A leading home healthcare provider implemented MetricStream's governance, risk, and compliance platform to strengthen audit management and regulatory compliance while protecting confidential patient information. The platform centralized audit tracking, improved RAC audit preparation, and automated workflows to ensure compliance with various healthcare regulations. It provided collaboration tools and reporting capabilities to help different teams conduct thorough audits and resolve issues efficiently. With MetricStream's solution, the organization now has stronger compliance controls and security of sensitive data.
BCBS Affiliate strengthens its Healthcare Compliance through Automation and I...MetricStream Inc
A leading healthcare coverage provider chosen MetricStream’s healthcare compliance solutions to automate and streamline critical compliance workflows, while providing a common platform to integrate compliance management across the enterprise.
Case Study - MetricStream offers a comprehensive GRC solution that addresses a wide range of health care regulations to reduce the overall cost of compliance management.
Solutions to Accelerate Compliance with Affordable Care Act (ACA) Mandates an...Lightwell
The healthcare payer ecosystem in the United States has changed dramatically over the last decade and is expected to evolve at an even faster pace over the next few years. Many world-class companies involved in healthcare payment processing are finding themselves constrained by their existing information technology infrastructure. The silos that they built around Business to Business (B2B) processing are constraining them, making it difficult to achieve governmental mandates and (more importantly) increase processing efficiency and competitive advantage.
The payers’ world today requires adherence to multiple industry standards, government regulations, and industry expectations. It is becoming more technical and payers need to become more agile (Figure 1). The IBM Standards Processing Engine Solution for Healthcare Payers is your answer to B2B enablement in today’s complex HIPAA/ACA (Affordable Care Act) world.
BCBS Affiliate strengthens its Healthcare Compliance through Automation and I...MetricStream Inc
A leading healthcare coverage provider chosen MetricStream’s healthcare compliance solutions to automate and streamline critical compliance workflows, while providing a common platform to integrate compliance management across the enterprise.
Case Study - MetricStream offers a comprehensive GRC solution that addresses a wide range of health care regulations to reduce the overall cost of compliance management.
Solutions to Accelerate Compliance with Affordable Care Act (ACA) Mandates an...Lightwell
The healthcare payer ecosystem in the United States has changed dramatically over the last decade and is expected to evolve at an even faster pace over the next few years. Many world-class companies involved in healthcare payment processing are finding themselves constrained by their existing information technology infrastructure. The silos that they built around Business to Business (B2B) processing are constraining them, making it difficult to achieve governmental mandates and (more importantly) increase processing efficiency and competitive advantage.
The payers’ world today requires adherence to multiple industry standards, government regulations, and industry expectations. It is becoming more technical and payers need to become more agile (Figure 1). The IBM Standards Processing Engine Solution for Healthcare Payers is your answer to B2B enablement in today’s complex HIPAA/ACA (Affordable Care Act) world.
Building Effective Denial Management DashboardsCitiusTech
In this whitepaper, we try to create dashboards from the lens of “Coding and Compliance Managers” – the real users who rely upon these dashboards regularly to help financially sustain a facility.
Powering SOX, NERC, FERC Compliance -Energy Industry MetricStream Inc
Case Study: The MetricStream solutions streamline financial control processes for SOX compliance and enable energy companies to comply with FERC and NERC.
Cutthroat competition and high regulation is squeezing bottom-lines of insurance companies. Moreover, if the claims processing is slow and document management is not seamless, the profits can dwindle further. One way to offset these impediments is to modernize claims processing and document management by collaborating with companies having deep domain expertise in these areas. HCL shows how this can be achieved.
10 Steps to Prepare for ICD-10
These 10 steps will help you get ready
for the transition to the ICD-10 code
sets. You may want to forward this
to those in your organization who are
working on this initiative.
For more information visit http://sites.mckesson.com/practiceconsulting/
The value of pre adjudication in healthcare claims processing - banc tec's wh...Jone Smith
BancTec provides Healthcare payers and benefit administrators with pre-adjudication technologies thus replacing error-prone human process and providing application for document management, PPO network management etc.
Governance, Risk and Compliance- Energy Industry MetricStream Inc
Case Study:Large Fortune 500 Energy Organization selects MetricStream's GRC solution to create a proper governance structure and GRC processes across the enterprise.
IT-as-a-Service Solutions for Healthcare ProvidersEMC
This white paper offers best practices regarding the technology infrastructure, business processes, and IT organizational structure to help healthcare providers maximize the value and impact of ITaaS across their organizations.
Information Quality and Metadata in Healthcare ManagementSeth Johnson
This presentation is targeted to department heads and frontline staff who produce provider, member and medical treatment information in a Medicaid Managed Care enterprise. It covers the quality approach to information, while fostering a work culture of information stewardship by clarifying information producer roles and how they can foster improving enterprise information and their own daily processes through updating and sharing of metadata in an annual process of completing the National Committee for Quality Assurance's Baseline Assessment Tool (now the HEDIS Roadmap).
Building Effective Denial Management DashboardsCitiusTech
In this whitepaper, we try to create dashboards from the lens of “Coding and Compliance Managers” – the real users who rely upon these dashboards regularly to help financially sustain a facility.
Powering SOX, NERC, FERC Compliance -Energy Industry MetricStream Inc
Case Study: The MetricStream solutions streamline financial control processes for SOX compliance and enable energy companies to comply with FERC and NERC.
Cutthroat competition and high regulation is squeezing bottom-lines of insurance companies. Moreover, if the claims processing is slow and document management is not seamless, the profits can dwindle further. One way to offset these impediments is to modernize claims processing and document management by collaborating with companies having deep domain expertise in these areas. HCL shows how this can be achieved.
10 Steps to Prepare for ICD-10
These 10 steps will help you get ready
for the transition to the ICD-10 code
sets. You may want to forward this
to those in your organization who are
working on this initiative.
For more information visit http://sites.mckesson.com/practiceconsulting/
The value of pre adjudication in healthcare claims processing - banc tec's wh...Jone Smith
BancTec provides Healthcare payers and benefit administrators with pre-adjudication technologies thus replacing error-prone human process and providing application for document management, PPO network management etc.
Governance, Risk and Compliance- Energy Industry MetricStream Inc
Case Study:Large Fortune 500 Energy Organization selects MetricStream's GRC solution to create a proper governance structure and GRC processes across the enterprise.
IT-as-a-Service Solutions for Healthcare ProvidersEMC
This white paper offers best practices regarding the technology infrastructure, business processes, and IT organizational structure to help healthcare providers maximize the value and impact of ITaaS across their organizations.
Information Quality and Metadata in Healthcare ManagementSeth Johnson
This presentation is targeted to department heads and frontline staff who produce provider, member and medical treatment information in a Medicaid Managed Care enterprise. It covers the quality approach to information, while fostering a work culture of information stewardship by clarifying information producer roles and how they can foster improving enterprise information and their own daily processes through updating and sharing of metadata in an annual process of completing the National Committee for Quality Assurance's Baseline Assessment Tool (now the HEDIS Roadmap).
CompliCheck - The Compliance Management SolutionRanjan Soni
CompliCheck is the next generation compliance management and tracking solution. It is designed for companies of all sizes help manage their compliance risks by identifying and tracking the statutory and regulatory responsibilities and risks associated with non-compliance. It is also powered by CompliPedia - A Compliance Knowledge base designed specifically for complicheck subscribers to stay informed and a platform to discuss compliance related queries.
An overview of software compliance management and how it relates to software asset management. Also, our services to address these issues are discussed.
360factors is a cloud based regulatory risk and compliance management Software Company. Our cognitive technologies to provide regulatory insights predict risks and improve operational excellence, sustainability and margins for Banking, Finance, Oil & Gas, EHS, Power and Utilities, IT and many other industries.
Stringent corporate governance, and accountability reforms, that
followed the corporate failures of the past, have dramatically
changed today's business environment - placing great responsibility
on the management and demanding seamless operations.
Organizations across the globe are constantly being challenged to
navigate through a proliferation of new standards and expectations
in a way that supports performance objectives, sustains
value, and protects the organization's brand. Whether we like it or
not, all corporations have to comply with regulations and at the
same time establish their credibility with investors, other stakeholders,
and the broader public. All these factors, brought together,
have fuelled the convergence of distinct, yet entwined
disciplines of the Governance, Risk, and Compliance (GRC).
This guide details common mistakes made by employees in Section 1 and by employers in Section 2 and Section 3 of the Form I-9 and best practices for avoiding such errors.
What is Money Laundering?
The act of concealing or disguising (laundering) of funds obtained through illegal activity
so that they appear to have been generated through legal, legitimate sources.
Types of Money- Laundering:
Structuring
Micro-Structuring
Cuckoo Smurfing
What is Structuring?
Structuring is one of the most common ways money launderers place money in the system
It is also known as smurfing. The individuals used to structure funds by organizations
doing money laundering are called Smurfs
Red Flags of Structuring:
Structuring red flags that banks and other financial institutions should look out for
include:
Cash transaction between $6,000 and $10,000
Frequent deposits for $9,000 or
Consecutive deposits that total $10,000
What is Micro-Structuring
Micro-structuring usually involves:
Checking accounts receiving cash deposits in amounts under $1,000 as infrequently as
several times a month
These deposits may be followed by ATM withdrawals in foreign countries
Red Flags of Micro-Structuring:
It has frequent deposits between $1,000 and $3,000
Makes it difficult to discern from normal account transactions
Easiest way to detect and prevent micro-structuring is to have accurate and up-to-date
Customer Due Diligence information is crucial to discover this type of structuring
Cuckoo-Smurfing
The term ‘cuckoo smurfing’ originated in Europe because of similarities between this
typology and the activities of the cuckoo bird
The perpetrators of this money laundering typology seek to transfer wealth through the bank
accounts of innocent third parties
Identity Theft Red Flags
opportunity to uncover identity theft is at the time of account opening
Examine the identification proof given by the customer carefully
Factors to look at carefully:
Does the picture on the ID match the person in front of you?
Does the year of birth match the person in front of you?
Does the identification match the state?
Is the identification real?
Use tools like Lexis Nexis to verify background information
Want to learn more about anti-money laundering process, its regulations, red flags and best
practices? ComplianceOnline webinars and seminars are a great training resource. Check out
the following links:
Red Flags of Money Laundering
Managing an Effective AML Compliance Program
Are You Doing Your BSA/AML Risk Assessment Properly?
How to Report under AML/BSA?
BSA/AML Compliance Checklist
How to Create Effective AML/BSA Compliance Program?
How to Develop Risk Models for AML Monitoring Program?
ComplianceOnline Virtual Seminar - IFRS and Effective Fraud Prevention Strate...ComplianceOnline
ComplianceOnline brings to you a full day virtual webinar session which will help you understand the IFRS basics and the risk areas and how to recognize the opportunities for fraud and develop strategies to deal with it. Whether you will be involved in preparing IFRS financial statements or analyzing those statements, come to this class to discover where the high-risk areas are and what you can do about them.
Case Study - Major health insurance provider in the US needed a central system with a highly flexible GRC software architecture for managing its compliance and audit programs.
MetricStream Regulatory Examination Management Solution has been widely adopted by banks and financial services organizations to streamline the entire regulatory examination process.
When the pandemic happened, this prominent healthcare provider from the Tri-State area couldn’t rely on their painfully slow and inflexible systems to create meaningful customer experiences. They partnered with TVS Next to rapidly modernize their systems and increase their appointment booking capability by 2000%, winning the hearts of the community they served.
Key Takeaways and Recommendations for Claims Software Adoption: DataGenixDataGenix
DataGenix claims software, fostering a more efficient, secure, and adaptable claims processing environment. The software's capabilities, combined with strategic implementation and ongoing optimization, position insurers to navigate the evolving landscape of healthcare and insurance with confidence and effectiveness.
Virima has helped many healthcare clients with post-merger woes especially those hospitals, clinics and imaging facilities don’t come together seamlessly, especially in the IT realm.
This KSA White Paper by Jason Oliveira, a Principal with KSA, discusses the intersection between the corporate onus of performance measurement and healthcare information technology. Planning towards and efficient and efffective performance measurement architecture.
This White Paper discusses the intersection of the corporate onus of performance measurement data collection and reporting with that of health information technology. KSA shares its thoughts on the planning for the future-state architecture for efficient and effective performance measurement.
Using Clinic Management Software to ensure compliance management.pptxMocDoc
Discover the importance of compliance management in healthcare and how Clinic Management Software (CMS) plays a vital role in ensuring adherence to regulations. Streamline operations, protect patient data, and enhance efficiency with CMS. Read more to elevate your clinic's compliance and efficiency.
Partnering With An RCM Management Company.docxtevixMD
Efficiency and accuracy in healthcare revenue cycle management are achievable with a specialized company. Maximize revenue and streamline processes by partnering with a trusted healthcare revenue cycle management partner.
How Technology is Revolutionizing Revenue Cycle Management in Healthcare.pptMatthew Clark
In the ever-evolving world of healthcare, technology has become a driving force behind the transformation of revenue cycle management (RCM). With the rapid advancements in technology, healthcare providers are now able to streamline their financial processes, improve efficiency, and enhance the overall patients experience. In this article, we'll explore the various ways in which technology is revolutionizing RCM in healthcare.
5 Reasons Why Coding and Documentation Audits are More Important than EverezDI
Auditing is an integral aspect of governance and quality management for organizations across industries. From a hospital in New York benefitting by $1.03 million, to recovering $214 million from medical insurance schemes, here are 5 reasons why auditing is important in healthcare today.
Visit Our Website:- https://www.ezdi.com/
Metricstream today announced the release of the next version of its Risk Management solution which will empower organizations to proactively assess, manage and monitor varied organizational risks.
A leading manufacturer of golf equipment selects MetricStream to strengthen supplier quality compliance through real-time monitoring of inspections and process capability.
Case Study: An Independent System Operator (ISO) selects MetricStream NERC Compliance and Issue Management Solution to ensure market participants are complying with the NERC reliability standards.
Case Study - A Fortune 500 & global leader in the production of cereal and convenience foods has chosen MetricStream to automate & streamline their quality audit management.
Case Study - MetricStream’s Audit Planning solution enabled the bank to create a risk-based audit plan with a well-defined objective and scope, in tandem with quality, compliance and risk management processes.
Global Bank Brings Compliance Risks under Control MetricStream Inc
Case Study - MetricStream has delivered the Bank a complete end-to-end workflow automation system for the compliance risk management process across its business units, geographic locations and product lines.
A Financial Planning Leader Streamlines Audit, Risk and Compliance MetricStream Inc
Case Study - A Financial Planning Leader selected MetricStream to automate and streamline audit, risk and compliance management (GRC) across the Enterprise.
A Financial Planning Leader Streamlines Audit, Risk and Compliance
Healthcare Audit Compliance
1. CASE STUDY
MetricStream A Leading Home Healthcare Provider Fortifies Audit and Compli-
ance While Maintaining Utmost Security of Confidential Information
Customer
The company is a premier home healthcare provider in the United States delivering personalizes
healtcare sevices.
Overview
With innovation as its forte, the company is constantly raising the bar of quality care and coordination
through state-of-the-art technology and programs. It offers a variety of home and hospice healthcare
service such as nursing, physical therapy and counseling.
Paramount importance is given to maintaining the highest standards of quality and process compli-
Customer ance. But operating in today’s regulatory environment is nothing short of complex. Healthcare provid-
A leading home healthcare giver in the United States ers are under constant pressure to meet a plethora of compliance regulations while caring for patients,
improving profitability, reducing costs and rising above the competition. The recent healthcare
overhaul has only complicated matters further by introducing newer, more stringent regulations.
Benefits
The introduction of Recovery Audit Contractors (RAC) and its permanent status have added to the
regulatory complexity for healthcare providers in the United States. In response, healthcare providers
Visibility into audit management, RAC audit prepa-
ration and compliance: MetricStream’s centralized have begun redefining their business strategy. Corporate governance has occupied center stage, and
dashboards enhance visibility into the company’s risk and compliance management have become key priorities.
audit management process and the preparation for
RAC audits, enabling managers to track their prog- Medicare Recovery Audit Contractor (RAC)
ress easily. The solution enables the company to gain The Centers for Medicare and Medicaid Services (CMS) started the RAC project to detect and correct
a complete view of the appeals at every stage. On the improper payments in the Medicare Fee-for-Service program. CMS hired Recovery Audit Contractors
compliance front, the central compliance library and
(RACs) who review, audit and identify improper Medicare payments.
issue tracking system present an accurate picture of
the company’s compliance quotient at all times.
Congress made RAC permanent across the United States from January 1, 2010. All healthcare provid-
ers that bill Medicare under its Fee-for-Service program require RAC Audits. They include hospitals,
Increased preparedness for RAC: With Metric-
Stream’s solution for RAC audit management, the physician practices, nursing homes, home health agencies, hospice agencies and durable medical
company’s readiness for RAC audits has improved equipment suppliers.
considerably. This has resulted in a significant
decrease in the number of improper payments and
denied insurance claims for the company. Challenges
Tracking of confidential patient information
Collaboration for foolproof audits: The solution With the wide-spread reach of the company and the enormous number of patients being served every
provides a common platform and centrally organized
day, the company found it challenging to track the confidential information of each patient, without
information. This helps the stakeholders in the com-
pany to collaborate effectively in billing adjustments, compromising its security. Each patient’s personal information, illness details, medical records, bill-
prepare better for RAC audits and run the audit integ- ing information, number of visits and payment details were recorded after each visit for future use.
rity function impeccably, with minimum issues. However, the company lacked a powerful and secure system to track this huge pool of information for
every patient and integrate each patient’s chart within its audit information.
Complete compliance: MetricStream’s ability to
track regulatory information applicable to the health- Increasing regulatory pressure
care industry, coupled with automated workflows,
The company, like most healthcare providers, has witnessed tremendous change in the regulatory
ensures complete compliance with regulations
and assures total protection of confidential patient arena over the past decade. Increasing compliance regulations, high regulatory scrutiny and non-
information. compliance penalties have become the order of the day.
The company had already established a system to manage these pressures. However, as the regula-
tions multiplied and changed, the system was unable to keep up. The company needed to manage a
variety of national regulations such as the Health Insurance Portability and Accountability Act (HIPAA),
the Gramm-Leach-Bliley Act (GLBA) and the Sarbanes-Oxley Act (SOX), as well as mandates that var-
ied across state, region and locality. Each regulation consisted of hundreds of requirements for which
strong IT expertise and focused attention to detail was required.
Manual processes
Most processes related to information handling and audit management at the company were chiefly
manual or semi-manual. Spreadsheets were used for auditing patient chart information, while phones
and emails were used as the primary channels of collaboration among different teams. These methods
were proving to be time consuming, expensive as well as unreliable, due to the large role of the hu-
man error factor innate to manual processes.
2. MetricStream
Insufficient collaboration
The various teams and stakeholders within the company were unable to collaborate in real time in
the absence of a common platform. This was particularly affecting the audit integrity function within
the company which required patient chart information and billing adjustments to be audited at regular
intervals. This in turn had a downstream impact on the preparation for RAC audits, where the claim
related information was audited.
Solution
The company needed to create a central system with a scalable governance, risk and compliance
(GRC) platform architecture for managing its regulatory compliance, ensuring the integrity of patient
information and preparing itself for RAC audits. MetricStream was selected as the solution provider
based on its track record as well as its functional and technical capabilities to meet the company’s
specific requirements.
MetricStream delivered a highly sophisticated and integrated GRC solution to the company, encom-
passing audit integrity, RAC audit management, issue management, and compliance management.
The solution is a comprehensive, Web-based application deployed on MetricStream GRC Platform,
and provides a common framework, automated workflows and an integrated approach to manage all
compliance and audit requirements in the organization.
MetricStream’s platform supports the company’s organizational model across all business divisions,
units and departments, as well as their mapping to different roles and reporting relationships. The
portal views are based on the user’s profile and organizational mapping. Users have a role-based
portal access with options required for initiating actions, scheduling tasks and viewing reports and
dashboards limited to their roles.
“MetricStream has implemented a rich solution to support our specific audit and compli-
ance needs. With clear visibility into audit status and complete automation in these areas,
we have achieved stronger compliance and secure audits across the organization. With
MetricStream Solution, we feel well-equipped to meet newer challenges in the health-
care space and serve our patients better than ever”
- says the spokesperson of the company
RAC audit management
MetricStream Solution helps the audit managers track and monitor improper payments and insurance
claims denied earlier. It also enables them to identify trends that can avoid future improper payments,
and to develop an internal process that streamlines the response to RAC audit requests.
MetricStream’s comprehensive solution automates, streamlines and integrates the company’s prepa-
ration for RAC audits. It has also introduced a proactive approach. The solution includes systematic
workflows that help the audit team complete record requests, submit them on time, send determina-
tions and appeals, and manage all aspects of RAC audit requirements on a single centralized platform.
Built-in status tracking and reporting, integrated document management, remediation action work-
flows and auto generation of letters allow the company to implement industry best practices for
regular self-assessments and internal audits.
In case of a complex review, the solution allows different stakeholders to collaborate and create,
compile and review claim data. Built-in workflows enable the automatic routing of information to vari-
ous stakeholders such as the Revenue Recovery department and the Appeals Coordinator. The entire
appeals process is simplified by automating the task of preparing, reviewing, approving and finalizing
appeals. Complex reviews usually involve several iterations which MetricStream Solution manages
seamlessly for the company.
3. MetricStream
When an automated review is required, MetricStream Solution helps the audit team manage the dif-
Why MetricStream ferent steps of creating, compiling and reviewing claims, collaborating with different stakeholders and
managing appeals in a smooth and efficient manner. The reporting capabilities of the solution provide
MetricStream offers a broad set of solutions on a trends and graphical charts based on a wide range of variables including the service that is being
Web-based platform with capabilities to address all audited, the physician associated with the service and diagnosis codes.
GRC and quality process within the company. Metric-
Stream’s solution provides a unified approach and an
Audit integrity
integrated solution to meet overall objectives, as well
as regulatory and compliance requirements. MetricStream Audit integrity Module helps the company’s audit team audit the vast amount of
patient-related information entered on patient charts. Multiple stakeholders are involved in completing
the audit: Audit Plan Owner, Audit Plan Approver, Patient Chart Auditor, Patient Chart Audit Reviewer,
MetricStream Solution is built and deployed on
MetricStream GRC Platform, a robust and scalable and Operational Reviewer.
infrastructure that contains powerful capabilities
such as automated workflows, configurable forms, The elaborate workflow built within the solution allows all these stakeholders to collaborate for the
collaboration, real-time exception tracking, email creation, review and approval of the audit plan. It also enables them to initiate patient chart audits,
alerts and notifications, integration, reports, executive and perform, approve and close the patient audits.
dashboards, business intelligence, analytics, and
secure access control.
Initiating, reviewing and approving patient billing adjustments is automated, and audits are performed
to ensure the accuracy of these adjustments. MetricStream Audit Integrity Module, along with RAC
MetricStream has deep domain experience in health- Audits Management Module, is integrated with the Issue Management Module for flawless tracking
care, as well as an in-depth understanding of issues
of incidents and fool-proof efficiency of audit integrity.
related to information security and prevention of fraud
and abuse.
Issue management
MetricStream Issue Management Module enables the company to identify and resolve documentation
discrepancies, gaps, coding errors and other issues that might result in a RAC audit failure as well
as non-compliance with applicable regulations. These issues are form-based and action owners are
assigned for particular issues related to audits and regulatory compliance. Each audit at the company
includes findings, recommendations, actions and issue owners.
The system assigns a unique ID to each issue, making it easy to track the issues from one stage to
the next. Issues are categorized based on predefined criteria with detailed information on each. Auto-
matic alerts and notifications are sent to the appropriate personnel for remedial action. Failure inves-
tigations are also conducted to determine the root cause of the issue. The investigation is conducted
using collaborative workflows, with each investigative task assigned to an appropriate individual.
Once a corrective action is initiated, the case closes only after the action plan is carried out.
Compliance management
MetricStream Solution captures and compiles requirements and regulatory information about industry-
specific controls, industry guidance, international and country-specific governance, laws and regula-
tions - all on a central platform.
Compliance managers at the company can access an exhaustive compliance library within the ap-
plication, identify relevant regulations, document specific requirements for the organization, and define
a monitoring process to comply with requirements.
MetricStream Solution provides a common framework and an integrated approach to manage all
compliance requirements faced by the company, including HIPAA/HITECH. Leveraging the solution, the
company can define and maintain a centralized structure of the overall compliance and control hierar-
chy including processes and assets in scope, risks for the processes and assets, controls to address
the risks and mechanisms to assess the controls.
For more information, visit
www.metricstream.com
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