Insights

Navigating the complex landscape of healthcare compliance

Cheryl Duva, Chief Healthcare Strategist, UST Evolve

Healthcare organizations face a daunting task in adhering to the intricate web of Medicare and Medicaid compliance regulations. The knowledge required to navigate this complex terrain often resides with a select few individuals, making it challenging to ensure consistent adherence across the enterprise.

“Maintaining compliance with all the policies, regulations, requirements, and disparate data sources is incredibly manual and arduous,” said Cheryl Duva, Chief Healthcare Strategist at UST Evolve.

Compliance rules span a wide range of requirements—from font size and reading-level specifications for documents to substantive healthcare policies, operational updates, and technical clarifications.

Noncompliance can happen “unbeknownst to anyone in the organization until an audit is conducted or when a member complains to CMS, Medicaid, or their federal/state representative. And that’s when you don’t want a surprise—because you can’t undo it.”

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Challenges of healthcare compliance

The recent CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) adds even more complexity. This rule, among others, requires organizations to follow over 50 new regulations.

Duva highlights five key challenges healthcare companies face:

• Limited knowledge sharing: Compliance knowledge is often concentrated within a small group of employees, making it difficult to disseminate and maintain across teams.
• Frequent regulatory changes: CMS (Medicare) and state Medicaid agencies often update forms and templates on their websites without notifying contractors (e.g., health plans, health systems, and providers).
• Disparate data sources: Requirements are scattered across multiple platforms—online portals, contracts, and emails—resulting in fragmented data and a lack of a single source of truth, which increases the risk of noncompliance and administrative burden.
• Steep penalties: Noncompliance can result in significant fines that impact financial health and brand reputation.
• Contractual implications and audit risk: Compliance lapses can hinder contract renewals, block new business opportunities, and increase the likelihood and frequency of audits.

Frequent updates to healthcare laws and policies demand continuous monitoring and adaptation. Left unaddressed, these challenges can result in healthcare organizations incurring hundreds of hours and millions of dollars in fines. Periodic audits alone are manual, time-consuming, resource-intensive, and simply not enough.

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Simplifying healthcare compliance

Duva envisions a highly automated, centralized “source of truth” to address these issues. This living repository would house all compliance information, updated in real-time using AI and machine learning.

“I want to turn the old, manually driven compliance culture from a burden into a benefit through tech-enabled modernization.”

Key components of this solution include:

• Compliance knowledge management: A centralized, AI-powered hub for all compliance-related information.
• AI-powered form retrieval: Automatic extraction of the latest Medicare and Medicaid regulations, policies, forms, and requirements.
• Template automation: AI-generated communication templates (e.g., for prior authorizations, appeals, grievances) to ensure ongoing compliance.

“When government contractors—or their first-tier downstream related entities (FDRs)—want to know what’s required for a specific topic, they can access the central repository and instantly view a summary of up-to-date requirements and their impact on various departments.”

The system also automatically alerts impacted business units about new or updated compliance requirements and tracks action plans to mitigate associated risks.

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Compliance as a service

By adopting a compliance-as-a-service model, healthcare organizations can realize the following benefits:

• Reduced costs: Improve operational workflows and avoid penalties.
• Improved efficiency: Free up employees to focus on strategic work instead of manual tasks.
• Enhanced member satisfaction: Prevent compliance-related issues that often drive member dissatisfaction.

“Being noncompliant causes tremendous member abrasion. Members complain and call their congresspeople and regulators, and it gets ugly real fast. This solution would lessen both the risk and the cost.”

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Proactive compliance monitoring

Duva emphasizes the importance of proactive compliance monitoring. Machine learning can analyze behavioral patterns and generate alerts—such as spikes in customer service calls—that flag emerging compliance risks.

For instance, a sudden increase in calls related to a specific complaint code can trigger an alert, prompting early intervention.

“And that’s the primary goal—finding out about an issue in near real-time so you can fix it right away.”

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Leveraging technological advancements

Ironically, the COVID-19 pandemic accelerated the adoption of tech-enabled solutions across the healthcare sector. As Duva notes, the crisis pushed healthcare organizations into the 21st century.

“COVID-19 finally put us in the 21st century with technology and forced us to become more technology-enabled,” said Duva, who has worked in healthcare technology for over 25 years. “Now we have to leverage that technology to improve performance and mitigate compliance risk.”

Technologies such as generative AI, machine learning, natural language processing (NLP), and advanced analytics are now critical enablers of smarter, faster compliance operations.

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Conclusion

Addressing healthcare compliance challenges demands a comprehensive, proactive, and technology-driven approach. By implementing a centralized, AI-powered compliance solution and embracing a compliance-as-a-service model, organizations can more effectively manage the complexities of Medicare and Medicaid regulations.

To stay updated on healthcare compliance best practices, visit UST Evolve and UST Healthcare.