Organizational Compliance

Our team of compliance, RAC and licensure experts can help you become a more compliant organization. By applying our “structure, process and people” methodology to systems, we assist your organization in making and maintaining improvement in an increasingly complex regulatory environment.  We customize our services to your  needs and have the ability to provide assistance both on-site and remotely.
Services include:

Utilization Management Compliance

Utilization Management compliance is vital to both meeting Conditions of Participation (CoP) for Centers for  Medicare and Medicaid Services (CMS) and margin protection. PACE has developed a methodology for a system  approach including scorecards that brings the hospital and medical staff together to ensure prudent use of resources. Educating and auditing physicians on proper utilization including readmissions, length of stay and documentation use Medicare and hospital dollars appropriately. The PACE system methodology of structure, process and people build lasting solutions.

Billing & RAC Compliance

Not only should healthcare providers be concerned about their standard billing processes being in place, but with the Recovery Audit Contractor Program (RAC) implemented by CMS, providers are at a much higher risk of claims, denials and recoupments for previously paid claims by CMS.  In order to avoid payment denials and recoupments, PACE assists providers with creating enterprise wide systems for compliance starting from bed placement and appropriate clinical documentation to coding and risk assessment. The PACE program can be customized to the fit of any organization with an initial assessment through implementation of necessary change.

RAC readiness and response begins with the Governing Board and CEO who are ultimately responsible for facility compliance and for the financial health of the organization. This approach has been proven successful in preserving the clients’ bottom lines by improving the internal processes around responding to audits and navigating appeals and by reducing total take backs over time. Our programs are based on real-world experience in helping healthcare providers prepare for and respond to RAC audits.PACE partners Elizabeth Lamkin and Amanda Berglund have written two manuals for healthcare providers to help them navigate the RAC Program from readiness to audits and appeals. The RAC Toolkit for Hospitals and Health Systems and The RAC Toolkit for Physician Practices are available at Amazon.com.

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Case Management

As a part of utilization and billing compliance PACE assesses the case management department for effectiveness. Case Management marries clinical and financial operations for a compliant continuum. The PACE team evaluates both utilization and discharge planning for compliance with CMS and makes recommendations for improvements.

Physician Advisor

Physician Advisors can assist any organization in becoming more efficient and effective in billing, documentation, and quality metrics.  Physician Advisors serve alongside case management staff to minimize audits for medical necessity on claims, while instituting clinical documentation programs to medical staff in an organization with knowledge of patient-centered best practice and evidence based medicine. Physician Advisors serve to complement CMOs and VPMAs while taking on non-tradition roles where a physician can impact billing, compliance and reimbursement. PACE will assess existing PA programs for effectiveness or assess the need for a PA program. PACE partners with leaders in PA training and services to design solutions for any size or type of hospital. Our clients have implemented internal, outsourced and a combination of both or hybrid program to work with medical staff and case management on appropriate utilization and documentation for billing compliance.

RAC/Billing Committee

In order to successfully bring stakeholders together to build and maintain a compliant and effective continuum, facilities need an interdisciplinary approach beyond the UM Committee. PACE assesses how a facility manages compliance and denial appeals to develop a practical and functional committee to oversee this crucial function.

Documentation Compliance

PACE will perform chart audits to assess how well a facility and medical staff are documenting for compliance. PACE partners with leaders in documentation training to assist with education as well as audits of improvements.

Licensure Compliance and Mock Surveys

In addition to CMS deemed organizations such as Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the newly approved Center for Improvement in Healthcare Quality (CIHQ), hospitals are increasingly being surveyed directly by CMS for validation surveys or patient complaints. Some of these CMS surveys are leading  to System Integrity Agreements (SIA).

PACE has experience with hospitals under an SIA and with hospitals wishing to prepare for or require assistance during a CMS surveys. PACE also assists hospitals prepare for all types of surveys including JCAHO and CIHQ.

PACE has developed a rapid one-week mock survey system to identify and mitigate vulnerable areas. The PACE team educates the facility while surveying and provides a comprehensive report including recommendations for improvement.

HIPAA Compliance

HIPAA Compliance has become an increasingly more important portion of a provider structure in place within a hospital or physician practice. PACE Healthcare Consulting provides a risk assessment and plan of correction that includes an internal technology audit and  legal advisors. We provide the resources to both assist with HIPAA Audits, comply with all HIPAA Rules and Regulations, and implement a HIPAA program customized to best suit your organization given its financial, technological, staffing, and IT constraints.  To read more about HIPAA Compliance, please read our article here.