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CMS Regulations – Top 4 Tips to Stay Compliant

CMS regulations are constantly evolving – and the risks of non-compliance are steep. As the backbone of numerous health plan payers, HealthEdge is responsible for adhering to CMS’s constantly changing regulations.

How do we do that? We have a team of 11 CMS subject matter experts. These Payment Policy Analysts have a wealth of knowledge and are deeply entrenched in CMS and its ever-changing regulations. They spend all year researching, prepping, and implementing CMS regulations to ensure that Source – our payment integrity platform – stays compliant.

When we asked the team – how can a payer stay up to date on CMS regulations? These were their top 4 CMS compliance tips.

  1. Understand the risks of non-compliance

CMS regulatory updates need to be completed accurately and on time. If this does not happen, it significantly impacts payers’ ability to process claims accurately and on time – which can lead to recruitment issues, overpayment, underpayment, increased member and provider abrasion, and decreased provider confidence in the payer.

Furthermore, CMS actively audits health plan payers to ensure compliance. Non-compliance with CMS regulations can result in fines and their star rating can be decreased.

  1. Plan & Prepare

CMS updates can be released multiple times a year. With every upcoming CMS change, they release a proposal outlining the upcoming change. The time between the release of that proposal and the final rule varies.

As soon as a proposal is released, our team reviews it with a fine-toothed comb and begins preparations. With this, the team fully understands the upcoming changes and lays the internal foundation to be able to implement the changes as soon as the CMS final rule is released. This is critical to ensuring on time implementation of new CMS regulations.

  1. Have Dedicated Resources

CMS regulations are complicated and specialized. HealthEdge manages this complexity with a team of expert Payment Policy Analysts. Having a dedicated team of experts is key to understanding, managing, and accurately adhering to CMS regulations.

  1. Leverage Automated Technology

CMS regulatory changes require constant vigilance. To maximize this, our team has implemented automated processes:

  • Website monitors: this technology automatically scans the CMS website to look for changes that our Payment Policy Analysts need to be aware of
  • CMS Notifications: Our team also subscribes to CMS notifications

The key here is to be proactive about looking for upcoming CMS regulatory changes.

Learn more

CMS regulatory compliance is a critical part of HealthEdge’s payment integrity platform Source. Source is a cloud-based platform that is the only prospective payment integrity solution that natively brings together up-to-date regulatory data, claims pricing and editing, and real-time analytics tools into a single IT ecosystem. This transformational approach allows payers to make payments with total confidence and make business decisions with real intelligence. Learn more here.

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