BCBS Affiliate strengthens its Healthcare Compliance through Automation and Integration

CASE STUDYMetricStream A MAJOR BCBS AFFILIATE STRENGTHENS ITS HEALTHCARE COMPLIANCE THROUGH AUTOMATION AND INTEGRATION Customer The customer is an independent licensee of the Blue Cross Blue Shield Network and is one of the largest providers of healthcare coverage in a US state. The company is committed to improving the wellbeing and health of its community through affordable health plans, employee benefit services and wellness programs. Overview The healthcare industry has witnessed sweeping regulatory reforms over the last few years. From the Affordable Care Act to the Model Audit rule (NAIC MAR) to mandates from the Centers for MedicareCustomer & Medicaid Services (CMS), compliance regulations have only increased in scope and number. HealthA LEADING HEALTHCARE COVERAGE PROVIDER plans cannot afford to slack as regulatory scrutiny is intense and noncompliance penalties are high. However, compliance is not only a matter of appeasing regulators. A robust compliance program can lower the incidence and impact of risks, help overcome crises and build higher brand loyalty.Benefits Fueled by the desire to offer access to top quality healthcare, the company is committed to develop- ing a world-class risk and compliance management framework. It has already incorporated a numberAssured compliance of standards and procedures to reward quality healthcare and minimize medical errors. However, en-MetricStream’s enterprise-wide compliance frame- suring compliance with complex regulations such as NAIC MAR and CMS can be daunting especiallywork along with regulatory alerts integration and with regard to tracking regulatory updates and monitoring compliance.automated control management enables the companyto ensure complete compliance with the plethora of As the number of compliance requirements increased, the need of the hour was for a robust systemregulatory requirements extending across NAIC MAR that could strengthen the company’s existing compliance strategies, mitigate risks and protect theand CMS. MetricStream Solution eliminates compli-ance gaps and inconsistencies at every step, ensur- interests of patients and stakeholders.ing a fool-proof approach to compliance. It also helpsthe company seamlessly evolve with the compliancelandscape and respond readily to future changes in Challengesregulatory requirements. Manual tracking of regulatory updates With external regulations frequently changing, the company had to consistently keep abreast of allAutomation of critical workflows updates and alerts. Most of the time, these alerts were tracked through manual spreadsheets andMetricStream Solution eliminates the need for manual paper-based processes, and then forwarded to the respective managers across the enterprise. Theprocesses, spreadsheets and paper-based applica-tions. The solution is equipped with the business entire process was time-consuming and laborious. Besides, it was impossible to ensure that allintelligence to automatically track regulatory updates, updates across all required regulations were being tracked at all times.monitor internal controls and raise alerts when issuesoccur. This way, the company will be able to improve Increasing compliance requirementsthe efficiency of compliance management processes As a health plan, the company is confronted with a growing number of compliance regulations includ-and save valuable time, costs and effort. ing NAIC MAR, HIPAA, the Affordable Care Act and other CMS regulations. Each regulation comes with an enormous list of requirements and demands. For NAIC MAR alone, the company needs toEnhanced collaboration and visibility demonstrate compliance with over 500 requirements. It’s an extremely cost-intensive, time-consum-MetricStream Solution helps the company shift froman ad hoc compliance approach to an integrated, ing and laborious process – one that is prone to errors especially when conducted manually.one. It extends across business silos to streamlinecompliance management across the enterprise and Ad hoc compliance Initiativesimprove collaboration. Powerful dashboards deliver Being a large organization, the company managed its operations – including compliance – in func-enhanced, real-time visibility at every stage, enabling tional silos and ad hoc systems. There was not much collaboration across units, departments andthe company to make informed decisions regarding locations. As a result, compliance activities would often result in redundancies and duplicities. Thecompliance. same risk across two departments would have multiple controls. This was costly, inefficient and un- necessary.Improved accountabilityMetricStream Solution helps the company embed aculture of accountability and compliance. It supports Building a culture of accountabilityindependent management of assignments and has In addition to external regulations, the company has its own policies and ethical Standards such asthe capability to roll information back up to higher monitoring employees’ use of social media. Ensuring sustainable compliance with these standardsmanagement for enhanced visibility and decision and building a culture of accountability requires a centralized view of enterprise-wide compliance.making. This way, the company will be able to closely Without this, the company would find it complex to consistently monitor compliance at every turn andmonitor loopholes in compliance and apply the ap- resolve sensitive issues.propriate remediation measure.

MetricStream Lack of a centralized repository for policies and documents Like other health plans, the company is required to manage a large amount of documentation related to company policies, compliance requirements, control assessments and more. Sifting through these documents and extracting the required information at the right time is difficult when each department functions independently and stores their own documentation. Solution The company wanted a solution that could help embed and sustain a compliance-focused work culture. The solution was required to automate and streamline critical compliance workflows, while providing a common platform to integrate compliance management across the enterprise. After considering several compliance solution providers, the company selected MetricStream based on its domain expertise and rich solution capabilities, as well as its successful track record with several other BCBS affiliates. MetricStream provided the company a comprehensive healthcare compliance management solution, equipped with capabilities for regulatory alerts tracking, policy and document management, and issue management. Using the solution, the company will be able to assure compliance with regulatory requirements, thus enhancing stakeholder confidence and protecting the interests of its customers. Regulatory alerts tracking MetricStream Solution seamlessly integrates with regulatory sources such as CMS and the Health Plan Management System (HPMS). This helps the company track regulatory updates through vari- ous channels such as the Web, e-mail and RSS Feeds. The solution captures all relevant regulatory information and stores this in the form of a centralized repository that can be accessed by the relevant stakeholders. Subsequently, the solution helps in interpreting these alerts and updates, keeping stakeholders informed and initiating an issue and action plan. Compliance Management MetricStream Solution enables the company to comply with the complete spectrum of healthcare regulations, including NAIC MAR and CMS mandates. The solution provides a centralized structure of the overall compliance and control hierarchy, including processes in scope, risks for the processes, controls to assess the risks and mechanisms to assess the controls. At each point, control assessments are easily scored, tabulated and reported. They are also monitored based on predefined criteria and checklists. The solution contains powerful reporting capabilities to aggregate control assessments and compliance data into comprehensive reports. It enables the company to track compliance patterns, study and analyze compliance trends, and focus on those areas that require immediate attention. Issue Management MetricStream Issue Management Solution helps the Compliance & Ethics group track, investigate and resolve sensitive noncompliance issues. All issues including potential noncompliance issues trigger the issue management and remediation mechanism. The system then investigates, analyzes and documents the issue, and routes it to the required personnel for further investigation. Automatic alerts track the progress of the issue remediation process and ensure that the company re- solves each issue before it is closed. At every stage, executive dashboards allow managers to closely track the issue as it moves from one stage to the next. Policy and Document management MetricStream Compliance Management Solution is equipped with a centralized repository for all policies, compliance requirements, control assessments, regulatory updates and other critical information. It provides the company with a single, secure data location for easy access and storage. Rights to view, modify, distribute, or print are granted based on roles and user groups.

MetricStream Enterprise GRC PlatformWhy MetricStream MetricStream Solution is built on a GRC platform which meet’s the organization’s objective of extending the solution across business units, operations, departments and geographies. The platformMetricStream’s vast domain experience of imple- provides built-in tools such as a Form, Process Flow and Data Designer that can be configured to suitmenting GRC solutions for some of the largest health specific business requirements. It helps the company streamline and integrate compliance manage-insurance companies and BCBS affiliates ment across the enterprise.The solution’s ability to track regulatory changes andfollow them up with an appropriate action plan The platform also enables the company to adopt a clear, unambiguous approach to compliance by breaking down restrictive silos and building more collaborative workflows. It provides a centralizedThe solution’s ability to comply with a spectrum of framework to manage all compliance processes ranging from control assessments and monitoring, toregulations such as NAIC MAR, HIPAA/HITECH, and risk analysis, to reporting, to documentation.other CMS regulationsThe solution’s ease of use and scalability whichenables it to be extended across the enterpriseThe solution’s flexibility to be configured to thecustomer’s specific requirements with minimum needfor programmingAutomated workflows ensuring collaboration withvarious stakeholdersFor more information, visitwww.metricstream.comCopyright 2011. All Rights Reserved.

BCBS Affiliate strengthens its Healthcare Compliance through Automation and Integration

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BCBS Affiliate strengthens its Healthcare Compliance through Automation and Integration Document Transcript