5 Ways to Improve CMS Compliance for Your Facility

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 requirements 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 to help ensure compliance at your facility.

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.

In general, these rules and regulations establish best practice standards that aim to improve care delivery across participating facilities. Standards provide guidance in a number of areas, including billing and documentation, quality of care, and fraud prevention.

Why Is CMS Compliance Important?

Facilities providing care to Medicare and Medicaid patients must follow all CMS regulations to avoid any legal and financial penalties. CMS administers several different programs for these facilities, so the specific type of penalty that can be incurred will depend on the situation.

In general, it’s also important to comply with CMS regulations to enhance care delivery at your facility. Since these standards are designed to support best healthcare practices, compliance can serve long-term benefits such as a more streamlined workflow and improved patient outcomes.

Compliance Tips for Your Facility

1. Become a CMS Provider

Before aligning your facility’s practices with CMS regulations, you should register with CMS as a provider to establish a formal relationship. Becoming a CMS provider allows you to participate in the Medicare and Medicaid programs, reap financial benefits through program compliance, and bill for services provided to their beneficiaries.

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

2. Ensure Transactions are Accurate and Secure

Healthcare transactions involve the electronic exchange of information between two parties to complete administrative or financial tasks. At the facility level, these transactions can include:

• Submitting billing claims to CMS
• Transferring patient enrollment forms
• Sending information on patient health plans
• Filling out eligibility information
• Making patient referrals

When submitting healthcare transactions, facilities must include a range of information. However, there are two key categories that facilities should familiarize themselves with in relation to CMS programming:

• 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 involves thorough, in-house reviews of any electronic documents that fall under areas of CMS programming. 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. You can enhance your professional development programs by regularly training your staff on relevant CMS rules that dictate their care delivery. This ensures your staff stays aware of what’s necessary for them to work at a CMS-participating facility, which can also help reduce nurse turnover.

4. Stay Up-to-Date With Operating Rules

Be sure to regularly review the latest CMS regulations, which can change from year to year. If you’re not sure where to look, CMS provides many direct resources to help you stay up-to-date with CMS programming and policies.

An all-in-one resource that can serve as a foundational starting point is the CMS Internet-Only Manual (IOM). This is a comprehensive repository of CMS-outlined programs and guidelines that have been published online for facilities seeking regulatory guidance. Each manual covers a different procedure or program administered by CMS, so you can select and read information that is most relevant to your operations.

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 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 outstanding questions or comments, you can email NSG using the contact information on their website.You can also consult with your CMS regional office for facility-specific questions or report suspected fraud through the CMS compliance hotline. It can 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 that only scratches the surface of information you might need to run a healthcare facility. Stay up to date on the latest industry insights and advice with our free newsletter.

IntelyCare editor Kayla Tyson contributed to the writing and research for this article.