The Compliance Imperative—The End of the Quality vs. Compliance Debate
No one expects to be investigated. Yet, the federal government recovers billions every year from healthcare providers, including mental health and addiction treatment organizations.
In the past, one visible area of vulnerability for behavioral health providers was the quality of our care. For some, the perception was that the community behavioral health centers’ culture of caring conflicted with the culture of compliance, and that money was better spent on care than on “overhead” such as a compliance program.
Now, through the Accountable Care Act, all providers that receive Medicaid or Medicare payments are required to have a compliance program. And we’ve learned that we can often define quality through compliance.
This is certainly the perspective the federal government takes when it uses treatment planning, medical necessity, staff qualifications, staff-to-client ratios, abuse, and the failure to provide prescribed medical and other therapies — real violations that have resulted in real penalties — to label a claim as false or fraudulent, with all the resultant miseries to the organization. Compliance enforcement extends well beyond coding.
Alert organizations have found that rather than pitting compliance and quality in a budgetary arms race that they should make every effort to combine resources and expand the perspective of the compliance effort.
The question to ask is “How can we provide quality care if we cannot ensure that we are a fully compliant organization?” And if you are fully compliant and can prove it, doesn’t that automatically make you a better care provider?
Some simple monitoring processes — that can often be implemented through your continuous quality improvement program, as long as it doesn’t hide the compliance violations — can help any behavioral health provider create a culture that is both quality-based and compliant.
Years ago before ACA implementation, NHS Human Services, a community-based behavioral healthcare provider caring for more than 50,000 children and adults, implemented monitoring strategies that combine quality and compliance; they even received national recognition as “Compliance Best Practices” from the Health Ethics Trust. The first is the Quality Call Back System that monitors offsite services such as targeted case management through after-service calls to patients to evaluate satisfaction with services provided. In addition to obtaining feedback about the service, NHS verifies whether or not the service was actually provided and provided for the length of time billed.
The second is global monitoring, which is an organized way to monitor 10 areas, including service record documentation, credentialing, program integrity, safety, satisfaction, and outcomes. Core indicators are identified for each of the 10 monitors, thresholds are established, and goals are set. You then monitor these indicators monthly, and the results are passed through the CQI and management processes and structures resulting in the identification of compliance failures and areas for improvement.
Each organization needs to fit a monitoring process to its service lines, areas of vulnerability and professional standards. However it is done, monitoring should be viewed as an improvement strategy that requires measurement and corrective action. And it requires understanding that compliance and quality are linked and not in conflict.