Breaking the Incompatibility Barrier — Four Keys to Merging Operational Productivity and Compliance

Can compliance and efficiency co-exist in Operations?  Is there a “right” balance between the two, or could it be more of an intertwining of the two?  If you have been in Operations long enough, you have been told you have to increase efficiency, reduce staff, and improve handle time or auto-adjudication rates.  What you probably have not been told is to be more compliant, except maybe by the Compliance Department.  Widgets in, widgets out, is the name of the game.

It’s a lot of plates to keep in the air, trying to balance more with less, and now we add in compliance.  What if compliance and productivity cannot only co-exist but can cause a department to thrive?  Here are the four critical keys to an intertwined compliant, productive Operations team.

1. Don’t Ignore the Human Factor — Productivity and compliance are both reliant on employees.  All the best tools, reporting, and systems can be in place, but if well-trained and engaged employees aren’t on the team, we won’t have well-run productive and compliant processes and teams.  Employee engagement, like member engagement, is critical to success.
2. Know the “Why” behind an Action — We need to change compliance from an obstacle to be circumvented to a process to be embraced.  We do that by showing the relevance to the process — the “Why.”  Have you asked your team what the critical Centers for Medicare & Medicaid Services (CMS) requirements are for the activities they perform?  Does the Claims staff know the time frames for processing a claim or the requirement for a clear and understandable denial reason?  Even more important, do they know why those requirements are in place and how they impact the beneficiary?
3. Have the Right Tools — Do you know how many manual work-arounds your team completes on a given day?  How many member communications must be manually completed?  How much manual research is needed to adjudicate a claim? Does your management know?  IT changes are costly and take time, but we must get things on “the list.”  That’s why a current prioritized list of enhancements is needed.  Make sure to document the productivity and compliance loss due to the work-arounds.   Include team member’s input — their voice is important to understanding the true issues. Spearhead the top critical needs on the earliest IT release possible.
4. Provide Measurable Results of Success and Failure — How do you and your teams know when you are successful or when you failed?  Do your reports show both your production and compliance goals?  Typically, Operations has lots of reports, but how are they aligned — with commercial or Medicaid metrics or the unique Medicare metrics?  Is this shared with your team?

In the Medicare world, Operations can’t be a balancing act — it’s all about intertwined compliance and productive Operations teams.  At Gorman Health Group, we know how important it is to link compliance and productivity.  For actionable advice on this topic and best practices, join us at our annual Gorman Health Group 2016 Forum, April 19-20, at the Worthington Renaissance Fort Worth Hotel in Fort Worth, Texas.

During this year’s information-packed two days, our elite team of experts, operators, clients, and partners will help you figure out what matters and what doesn’t. We will share proven tactics to cut costs, increase member satisfaction, and manage and drive sustainable growth. Register now >>

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