Even though the fiscal cliff was just kicked down the road for about 2 months the reality is that revenue will be tighter. The new buzz word I think will be "Medical Efficiencies". What does this mean? To me it says we need to better use our limited dollars in the most cost efficient way so by showing better "Quality" i.e targeting the right folks or showing the best results we can increase our income. Where does compliance come into it? Well we have an obligation to show in the most transparent manner that the systems work as designed and in compliance with governing regulations.
I'll do a real world example. Let's do a HEDIS measure Glaucoma Screening Older Adults(GSO). Your plan is trying to in increase the rates on this. Your score was originally a 78 and you've been wanting to increase this. You've made efforts increase the number optometrists and ophthalmologists who accept you insurance. You've made better efforts to process claims internally and have been able to maintain a 98% accuracy rate. However you've also been able to use HEDIS supplemental data this year to increase the score. This area since it is new for your plan will need extra scrutiny and review. You'll need to work with your HEDIS auditor to make sue you are in compliance with the technical specifications plus since you are using this data for reporting this may get reviewed by other external auditors. This is a tricky area since most compliance professionals aren't DBA's and rely upon the IT staff for support. Can this be smooth and work perfectly? Absolutely but it takes time planning and review.
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