2017 Healthcare Compliance Benchmark Study

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1 2017 Healthcare Compliance Benchmark Study Executive Summary and Results EXECUTIVE SUMMARY This report represents SAI Global s eighth annual survey gathering insights from compliance professionals in the healthcare provider industry. Respondents were asked questions relating to budget and priority areas of their compliance departments, as well as specific challenges and confidence in their ability to demonstrate program effectiveness. Survey respondents came from U.S. healthcare provider organizations representing nearly every state, ranging in size from large healthcare systems with over 1,000 beds, to critical access hospitals, and a variety of other healthcare provider organizations including physicians groups, clinics, home health providers, and long term care facilities. This report examines the results and includes detailed findings together with year-over-year trends.

2 TABLE OF CONTENTS KEY FINDINGS... 3 SURVEY RESULTS Compliance Program Budget... 5 Compliance Program Priorities... 6 Demonstrating Compliance Effectiveness... 7 Claims Audits and Denials Preparedness... 9 Cybersecurity and HIPAA Compliance Software Tools PARTICIPANT DEMOGRAPHICS Survey Participant Roles/Titles Organization Types and Size Geographic Scope CONCLUSION About SAI Global... 12

3 KEY FINDINGS COMPLIANCE RISK ASSESSMENTS Compliance Risk Assessments is the overall top compliance program priority. RISING CHALLENGES Confidence in the ability to demonstrate compliance program effectiveness around Monitoring and Auditing fell to the lowest level in the eight years of survey tracking indicating rising challenges. 41% of respondents expect an increase in budget this year, while 59% expect budgets to remain the same or decrease. Of those expecting an increase, the focus of the investment is in software technology, followed by additional headcount. COMMERCIAL PAYER AUDITS Commercial Payer audits now pose the greatest risk according to survey respondents, yet 48% are using manual or adhoc methods to manage claims denials, audits, and appeals. TOP DRIVERS Increasing focus and audits from CMS and Increasing focus from the OCR/HIPAA Compliance are the top drivers of compliance program priorities. 51% of respondents do not have a high level of confidence that their organization has all of the controls in place to prevent a data breach which is indicative of the complexity in managing cybersecurity risk today. EXTERNAL DRIVERS External drivers, such as the need to demonstrate compliance program effectiveness to external auditors or investigators, remain strong. However, internal drivers including the attention of the Board and Internal Audit continue to be influential. 39% of respondents indicated that Business Intelligence and Predictive Analytics Tools are a top or high priority for their organization. Enterprise Risk Management software followed closely at 34%. 3

4 COMPLIANCE CHALLENGES Respondents were asked: What do you expect to be the biggest challenges for compliance in your organization in the next 12 months? Audits, tracking and limited staffing for compliance resources are key challenges for many, as evidenced by the responses. Respondents were also asked: What has been the biggest change for compliance in your organization in the last 12 months? Finally, respondents were asked: What is your biggest barrier to success right now? Leadership/Management is a noted barrier to success. Some of the comments from participants were: Getting buy-in from the C-Suite Doctors reluctant to change Internal acceptance of the culture of compliance Lack of resources both in people and in dollars Lack of resources both in people and in dollars 4

5 2017 COMPLIANCE PROGRAM BUDGET EXPECTATIONS When reviewing the budget expectations for 2017, 46% of respondents view budgets as staying about the same. However, 28% are expecting budgets to increase slightly, with 14% of respondents expecting a significant increase. We also asked survey participants who were expecting to increase their budget this year which areas they anticipate allocating the additional budget, while comparing it to previous four years. Those planning to invest in software and technology, held steady at 41%. Additional headcount was also at 41%. The trend of investing less towards e-learning and education and consulting and legal services also continues this year. The shift towards technology the last few years indicates that Compliance departments understand the need to be more efficient and move away from a manual approaches which do not scale. 8 YEAR TREND: COMPLIANCE PROGRAM BUDGET AREAS FOR INCREASED BUDGET 5

6 2017 COMPLIANCE PROGRAM PRIORITIES 2017 COMPLIANCE PERFORMANCE PRIORITIES As in past annual surveys, we provided survey participants with a list of the top compliance program areas and asked them to indicate the priority level for each. A ranking of Top Priority indicates program areas that are most important and most urgent, therefore garnering significant dedication of time and compliance resources. A High Priority ranking indicates program areas that are very important, but not as urgent as a Top Priority these would receive adequate resources to address. A Medium Priority ranking indicates areas that are less urgent and less important with limited resources dedicated to them, while a Low Priority ranking indicates program areas that are not considered urgent or important and would have minimal resources addressed to them. 1 COMPLIANCE RISK ASSESSMENTS This year, Compliance Risk Assessments took first place as the overall Top Priority for compliance programs. This was followed closely by Compliance Training & Education and HIPAA Compliance/OCR Audit Readiness. With the ever-changing regulatory environment in healthcare, assessing compliance risk is a constant challenge. With a new Administration in place in Washington, DC, we are likely to see even more changes in healthcare regulation over the next few years. 2 TRAINING AND EDUCATION Keeping employees informed and educated on those new or changed regulations is a continuous process, explaining why Employee Training & Education continues to be a top compliance program focus area, ranking in the top three in seven of the last eight years. 3 HIPAA COMPLIANCE / OCR AUDIT READINESS For the fourth year in a row, HIPAA Compliance/OCR Audit Readiness is a top priority for compliance programs as the OCR continues to audit and investigate HIPAA violations with highly publicized settlement agreements. 4 CYBERSECURITY RISK Making its way into the Top 5 priorities this year is Cybersecurity Risk. In 2016, healthcare covered entities reported 329 data breaches exposing 16,471,765 records. This is much less than 2015 (113,267,174 records exposed), however, hospitals accounted for 257 of the reported breaches. As in 2015, the main cause of data breaches came from inside the organization - unauthorized access/disclosure of PHI. With the cost of a data breach averaging $355 per record in the healthcare industry 1 this explains why cybersecurity risk is top of mind. 5 DOCUMENTING AND INVESTIGATING INCIDENTS (CASE MANAGEMENT) Documenting and investigating incidents maintains a spot in the top priorities again this year. The proper documentation and investigation of compliance and ethics incidents has long been a focus of healthcare providers to root out potential fraud, waste, and abuse in the Medicare and Medicaid programs. Properly handled incident investigations may also help to mitigate the risk of whistleblowers, thus saving money and preserving reputation. In a recent Qui Tam case, the whistleblower, a former employee, alleged that the ambulance company falsified bills for ambulance services to fraudulently qualify for higher Medicare reimbursements. She claims she was fired afterwards for her continued questions and attempts to correct the fraudulent billing. 2 The company has since agreed to a $12.7 million settlement and a Corporate Integrity Agreement. 1 IBM 2016 Ponemon Cost of Data Breach Study 2 6

7 PRIMARY DRIVERS OF COMPLIANCE PROGRAM PRIORITIES PRIMARY DRIVERS OF COMPLIANCE PRIORITIES 2017 The top 5 drivers in 2017 are consistent with results from the last few surveys. The majority (63%) indicated Increasing focus and audits from CMS as their top driver, right in line with results from the last four years. As in 2016, in second place at 61% is Increasing focus from the OCR/HIPAA Compliance. Protection of reputation and brand was at 38%, down from 49% in We followed up this question by asking healthcare organizations: Is your organization currently under a Corporate Integrity Agreement? and 12% of our respondents indicated that their organizations are currently operating under a corporate integrity agreement which is less than 2016 (17%) and 2015 (14%). DEMONSTRATING COMPLIANCE PROGRAM EFFECTIVENESS HAVE YOU HAD TO DEMONSTRATE COMPLIANCE EFFECTIVENESS? Demonstrating Compliance Program Effectiveness to internal stakeholders (Boards, Internal Audit) as well as external entities continues to be a top compliance program priority for survey participants. External Auditors or Investigators were a key driver in this year s survey. We also see an increasing trend over the last few years on internal drivers, primarily Boards and Internal Audit, asking for evidence of compliance program effectiveness. 7

8 CURRENT METHODS FOR DEMONSTRATING COMPLIANCE PROGRAM EFFECTIVENESS In past years surveys, we asked survey participants to indicate the method(s) they use to demonstrate compliance program effectiveness. The results are consistent for the past 3 years with Hot line/ Incidents/Case Management Data and Internal Audit/ Assessment Results as the top methods. CONFIDENCE IN ABILITY TO DEMONSTRATE COMPLIANCE PROGRAM EFFECTIVENESS We also asked survey participants to indicate their degree of confidence in the method(s) that they use. As in previous years, most respondents feel moderately confident in the ability to demonstrate compliance program effectiveness. Thirty-eight percent indicated that their methods were already proven successful, continuing the slight downward trend of the previous 3 years. Policies & Procedures, Compliance & Ethics Training and Code of Conduct are still the top elements in which survey participants believe they can demonstrate effectiveness. Confidence in the ability to demonstrate effectiveness in Monitoring and Auditing fell sharply this year 49% from 69% last year. This is lowest level in the 8 years of survey tracking indicating rising challenges and perhaps explaining why Compliance Risk Assessments are the top compliance program priority for FOR WHICH ELEMENTS OF YOUR COMPLIANCE PROGRAM CAN YOU DEMONSTRATE EFFECTIVENESS TODAY? 8

9 CLAIMS AUDITS AND DENIALS The past 12 months have seen a shift in claims audit activity. While Medicare RAC audits have been back in full operation, the activity level seems to have moderated from the early years of the program perhaps as a result of the record limit changes put in the RAC contracts in The greatest increase in activity is coming from Commercial Payers including those participating in the Medicare Advantage program. With such potential for risk to revenue, it s surprising to find that 48% of respondents are using manual or adhoc methods for managing claims denials, audits, and appeals. AUDIT ACTIVITY INCREASE BY AUDIT TYPE IN THE LAST 12 MONTHS WHICH BEST DESCRIBES YOUR SYSTEM FOR MANAGING CLAIMS, DENIALS, AUDITS AND APPEALS? MEDICAL CLAIMS AUDITS POSING THE GREATEST RISKS Commercial Payer / Managed Care audits or denials now pose the greatest risk according to survey respondents. This replaces Medicare RAC audits which maintained the top position for the previous 6 years. 9

10 CYBERSECURITY AND HIPAA COMPLIANCE In 2015, there were 266 data breaches affecting over 500 individuals reported by healthcare organizations according to the Office of Civil Rights Breach Portal. In 2016, there were 329 data breaches. It s clear that breaches of protected health information are a big problem for the healthcare industry. We asked participants the following question: How concerned are you about data breaches in your organization? Forty-nine percent of respondents feel fully confident or strongly confident that their organization has all of the controls in place to prevent a data breach. This tracks closely to last year s result of 52% and is surprising given the industry statistics that show a steady upward trend each year of reported breaches. We also asked respondents How prepared is your organization for a HIPAA compliance audit from OCR? The majority of respondents, 78%, are highly or moderately confident that their organization is prepared for a HIPAA compliance audit. PRIORITIES FOR SOFTWARE TOOLS 2017 TOP PRIORITIES FOR SOFTWARE TOOLS We asked survey participants about their priorities for software tools in certain areas: Enterprise Risk Management, Regulatory/ Obligations Management, Business Intelligence/Predictive Analytics, and Managing Conflicts of Interest. 39% of respondents indicated that Business Intelligence/Predictive Analytics tools were a top or high priority for their organization. This was followed closely at 34% by Enterprise Risk Management software. With the growing complexity in managing risk across the enterprise, it appears that respondents are realizing the need for proactive, automated methods. 10

11 PARTICIPANT DEMOGRAPHICS SAI Global would like to thank all of the healthcare professionals that provided their valuable input to this benchmark study. Survey participants were comprised predominantly of individuals in compliance roles senior and mid-level compliance roles (CCO, Director, Manager) accounted for 45% of respondents and supporting compliance roles accounted for another 9%. Respondents representing Revenue Cycle roles accounted for another 20%. The remaining respondents were distributed across various roles; the 14% that comprised the Other category was mostly individuals that indicated their title or role was related to Audit, Information Technology, and clinical review. SURVEY PARTICIPANT ROLE/TITLE TYPE OF ORGANIZATION The majority of survey participants represented Healthcare Systems (63%), and most of these were over 250 beds: SIZE OF ORGANIZATION South 41% Midwest 29% North East 13% West Coast 17% 11

12 CONCLUSION As evident by the findings, auditing from regulatory agencies and payers is increasing and therefore driving the compliance program priorities. The requirement to monitor and audit internal compliance processes and controls has never been more important for organizations to be well prepared for the regulators. As indicated in the survey results, many healthcare organizations are looking to invest more in software to enhance their ability in these areas. Additionally, the focus on Business Intelligence and Enterprise Risk Management tools points to a more advanced approach to compliance risk. Cybersecurity and the potential for data breach is an ongoing concern for the healthcare industry. Highly publicized data breaches of hospitals and health insurance organizations indicate that current methods for protecting data are not adequate. As the Office of Civil Rights continues to audit and the fines for non-compliance with HIPAA increase, there will be more pressure on IT and compliance organizations to better protect health and other private information. ABOUT SAI GLOBAL SAI Global helps healthcare organizations manage risk across the enterprise. SAI Global Compliance 360 is an integrated, cost-effective Governance, Risk and Compliance platform, with applications designed to help healthcare providers manage the diverse set of risk and compliance challenges that they face today, including medical claims audits/denials, regulatory change management, 3rd Party Risk & contracts, and investigations of compliance incidents. SAI Global was recognized as a Leader in The Forrester Wave : Governance, Risk and Compliance Platforms, Q1 2016, with the independent analyst firm noting that Compliance 360 is a leading compliance solution among US healthcare companies. Further, SAI Global was called out for having an extremely diverse, extremely happy customer base. For more information visit SAI Global Limited ABN SAI Global Ltd. The SAI Global name and logo are trademarks of SAI Global Ltd. All Rights Reserved.

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