50/50 Just Won’t Cut It — You Have to Commit 100%. The Top 5 Components for Successful, Compliant, Committed Operations

If you weren’t able to make it to the Gorman Health Group 2016 Forum this year, you missed a dynamic time. More than just relevant topics, it included engaged participants who added a wealth of depth to our discussions. The topic garnering a lot of audience participation was “Can Operational Efficiencies and Compliance Co-Exist?”  The struggle to align the two is real and takes constant, diligent effort, but the success it can create is priceless.

I told a story about a recent vacation involving a shark swimming in the surf. At one point it started swimming towards a father and son. Those of us on the pier were yelling to warn the man to leave the water, but he couldn’t hear us. It wasn’t until the people on the beach carried the message to the man that they got out of the water. Oftentimes we rely on the Compliance Department to carry the weight of maintaining compliance, but like the people on the pier, that message only goes so far. To be effective and make a real change, the message has to be embraced by everyone in order to make a real difference.

Here are the five critical points to ensure operations entwines compliance in its core:

  1. Don’t Ignore the Human Factor — Our employees are the most critical factors in our department’s productivity and compliance. Make sure our employees are well trained on not only the technical components of the job but on the critical compliance requirements as well. Employee engagement, like member engagement, is critical to success. Our employees want to do a good job, but sometimes they don’t fully understand all that success entails.
  2. Know the “Why” behind an Action — What vision have you imparted to your staff?  Are they just keying in applications, or are they setting up and welcoming members into your plan? Do your employees think compliance is an obstacle to be circumvented or a process to be embraced? Making that transition occurs by showing the “why” behind the action.  How does what they do, both individually and as a department, impact our members? What is the logic behind why the Centers for Medicare & Medicaid Services (CMS) requires that activity? What they do is important, and making sure they understand all the reasons why makes your vision their vision.
  3. Have the Right Tools — Manual work-arounds and systems that have been duct taped to manage Medicare Advantage and Part D cause most of us the greatest headaches and compliance failures. There is no magic wand to resolve this—it takes diligence, documentation, and prioritization on a continual basis to raise up the next critical system needing to be resolved. Have your list of things needing to be fixed, the additional costs associated with the status quo, and the member impact ready and on the enhancement list.
  4. Provide Measurable Results of Success and Failure — Have a highly-visible way to measure individual and team success and failure. Successes should be celebrated.  Share the successes and bring the feedback to your team. Failures should be evaluated—it isn’t about the “who did it” but about the “why it happened.” Everyone should be focused on mitigation. One of the items the audience discussed is ensuring you eliminate a culture of fear so staff is engaged in reporting non-compliance so it can be addressed. When non-compliance is identified, embrace it and thank those who raised the issue. Let them know how this positively impacted the department, company, and members.
  5. Manage Up Sometimes we in management are the biggest barriers to compliant operations. We look at the production numbers and don’t focus on the compliance measurements.  We only give senior management what they ask for—it is our job to make sure the critical metrics and measurements go up to senior management. They often don’t know the right questions to ask or measurements to review, and it is our job to bring this forward—it protects the company and our members.

We all have a part to play to ensure efficient, compliant operations are in place for our members. It takes 100% commitment to make sure the vision is carried forward. At Gorman Health Group, we know how important it is to link compliance and productivity. We are available to join with you to ensure that vision is firmly established in your organization. Please contact me directly at jbillman@ghgadvisors.com.



At Gorman Health Group, we maintain the country’s largest staff of senior operations consultants.  Our team assists dozens of health plans every year in scrubbing their member data and can translate your business strategies into practical, efficient and rigorous work processes with the highest degree of compliance and accountability. Visit our website to learn more >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>