5 Ways to Improve CMS Compliance for Your Facility

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Written by Kayla Tyson Content Writer, IntelyCare
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Reviewed by Aldo Zilli, Esq. Senior Manager, B2B Content, IntelyCare
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Managing a healthcare facility requires knowledge in a range of areas, from hiring and marketing to management and billing. If you run a long-term care facility, it’s especially important that you understand CMS compliance to ensure that you’ll be able to continue to bill for Medicare services, which are likely a key component of your budget.

Preparing for a compliance review can be daunting. In this article, we’ll explain where these regulations and requirements originate and share general tips for improving your facility’s compliance.

What Are CMS Regulations?

The Centers for Medicare and Medicaid Services (CMS) outlines a set of rules and regulations that healthcare facilities must follow to participate in their programs. These compliance requirements are included in the Healthcare Insurance Portability and Accountability Act (HIPAA) of 1996 and in subsequent legislation like the Administrative Simplification Rules.

These administrative standards focus on the methods of using electronic communications to maintain patient confidentiality. Standards provide guidance in a number of areas, including billing and documentation, quality of care, and fraud prevention.

Compliance Tips for Your Facility

1. Become a CMS Provider

The first step in improving compliance is to register with CMS as a provider to establish a formal relationship between your facility and CMS. Becoming a CMS provider allows you to participate in the Medicare and Medicaid programs and bill for services provided to their beneficiaries.

The registration process includes a thorough eligibility verification process, which ensures that your facility meets specific criteria and has the necessary qualifications, licenses, and certifications to provide healthcare services. You’ll have to agree to follow specific billing requirements, as outlined by CMS, and your facility will undergo periodic audits and compliance reviews. Taking the step to complete this registration sets the groundwork for ongoing compliance and collaboration with CMS.

2. Accurately Document Transactions

Healthcare transactions exchange information electronically between two parties to complete administrative or financial tasks. These can include billing claims, enrollment forms, eligibility information, and referrals. When submitting healthcare transactions, facilities must include a range of information, but CMS focuses their regulations on the following two categories:

  • Unique Identifiers: Include your IRS-issued Employer Identification Number (EIN) in addition to the NPI number of the provider involved in the transaction.
  • Code Sets: Label medical diagnoses, procedures, treatments, tests, and supplies in transactions using CPT codes, as outlined in the Healthcare Common Procedure Coding System (HCPCS).

CMS guidelines also explain that facilities must maintain accurate electronic health records (EHRs) — digital versions of a patient’s chart. In addition, electronic billing transactions must maintain privacy through compliant direct data entry (DDE) screens that transmit billing claims directly to CMS.

3. Conduct Internal Audits and Staff Training

Improve compliance by conducting internal audits, which are self-assessments aimed at identifying areas of noncompliance. These areas might include coding errors, billing inaccuracies, or inadequate documentation. Use any errors you find to develop your own corrective action plan (CAP) as you determine next steps.

Consider including facility-wide CMS compliance training as part of your improvement plan. It’s a good idea for your professional development programs to regularly include compliance-focused training to ensure that your staff is aware of expectations, especially if your staff has a high nurse turnover rate and regularly hires new staff.

4. Stay Up to Date With Operating Rules

Be sure to regularly review the latest CMS regulations related to your facility’s operations. The Secretary of the Department of Health and Human Services (HHS) appointed CAQH CORE — a stakeholder group of more than 120 healthcare organizations — to collaboratively develop further operating rules to simplify medical transactions.

These guidelines set national standards that limit unnecessary paperwork and streamline administrative processes throughout the U.S. healthcare system. It’s helpful to familiarize yourself with these operating rules, which relate to infrastructure, high-volume transactions, claim adjustments, billing codes, and more. You might also consider becoming CORE certified, which prepares your organization’s systems and products for potential compliance reviews.

5. Utilize CMS Compliance Tools

CMS has developed a selection of tools to help your facility comply with regulatory requirements. The program is called the National Standards Group (NSG) Subregulatory Guidance and includes three main tools.

  • Guidance Letters: These letters share summaries of NSG’s interpretation of HIPAA Administrative Simplification laws, and share tips about how to apply them in the healthcare world.
  • Information Bulletins: Stay updated with NSG bulletins that address operational issues, highlight best practices, and share about successful initiatives.
  • Frequently Asked Questions: Use FAQ documents to access information about regulations, policy, and statutes as questions arise throughout your improvement process.

If you have ongoing questions or comments, you can email NSG at their dedicated mailbox. Additionally, you can contact your CMS regional office for facility-specific questions or report suspected fraud through the CMS compliance hotline. It can also be helpful to consult with legal and compliance experts who specialize in healthcare regulations, as they can provide guidance tailored to your facility’s specific needs.

Compliance Is Just The Start

We’ve shared some ways to improve CMS compliance in your facility, but frankly, that only scratches the surface of information you might need to run a healthcare facility. Stay up to date on industry insights and advice with the IntelyCare newsletter.