Business Processes with Compliance ControlsDetermine Patient Obtain Client’s Establish Download Patient Eligibility Compliance Y Electronically Verify Eligibility Eligibility Eligibility Eligibility Data Information for Control? Criteria Payment NA/P Reimbursement Determine Calculate Amount Type of of Reimbursement Compliance Y Provide Payment Reimbursement Control? NPharmaceutical/Medic al Management Formulate a Process Payment Medication Information on a Compliance Y Manage Generate Report Services Medication Treatment Plan Timely Basis Control? Inventory N
Steps to Create Business Governance Control Processes Employ a ReferenceProcess Model Map Reference Model Processes to Actual Identify the Processes in-scope Compliance Processes Define and Implement the Required Controls
Integrate the Four Compliance Processes via a Risk-Prioritized Process Foundation ASSESS EXECUTE MONITOR AUDIT MONITOR PROVE FIND GAPS REMEDIATE REMEDIATE COMPLIANCE RESULTS RISK-PRIORITIZED PROCESS FOUNDATION Prioritize all process activities based on relative risk • Perform quarterly, structured risk recalibration and adjust plans accordingly
Transition Steps/Considerations• Establish and Leverage Compliance Process Dashboards • Dashboards designed for each of the 4 process groups • Map current activities to one or more process groups • Appoint enterprise process leaders for each process group• Integrated Enterprise View of Compliance Process Data • Single data view of aggregated compliance –relevant data • Enterprise view of compliance risk vectors • External risk • Internal risk
Discussion: the Big Picture • What’s Missing? • What’s Wrong? • Anything Right? • Thank You!