When it comes to revenue cycle management compliance, maintaining a compliant facility is non-negotiable. The healthcare industry requires strict adherence to laws and regulations that have been created specifically to establish fair and ethical treatment and billing. Additionally, when healthcare facilities and providers maintain revenue cycle management compliance, it helps to prevent cases of fraud and abuse.

What is Revenue Cycle Management?

Revenue cycle management, sometimes abbreviated to RCM, is a management process that healthcare providers use to handle everything surrounding the financial aspect of their facility. This is incredibly complex because it is not a simple exchange of a good or service. Ultimately, revenue cycle management takes into account the patient’s first contact with the practice for an appointment through their visit, treatment, and any testing, as well as through their final payments.

Health Insurance Portability and Accountability Act

What is Revenue Cycle Management Compliance?

Revenue cycle management compliance is when a healthcare facility engages in sound ethical medical and billing practices and are in agreement and follow all regulatory laws and requirements, including both state and federal legislation. Revenue cycle management affects nearly all aspects of the patient-provider interaction because nearly everything is regulated. Typically, a sound RCM will mean your practice is in compliance with those regulations, which is why you want to trust your RCM to providers who are experienced and knowledgeable.

What Regulations and Regulatory Bodies Impact Revenue Cycle Management Compliance?

There are a number of laws on the books that regulate everything from patient privacy to how claims are processed and even how medical services are billed. Let’s explore some of the more commonly known regulations that affect revenue cycle management compliance. Please note that the below list is not exhaustive, and a more extensive list can be found online through the United States Office of the Inspector General.

Health Insurance Portability and Accountability Act (HIPAA)

If you’ve ever been to the doctor or you’re a healthcare provider yourself, you’re likely familiar with the acronym HIPAA. This is a law that all healthcare providers must follow, and it impacts not only all of the patients’ interactions with the provider, but it also affects how their records, data, and even their billing is stored and treated. 

From the scheduling center to office personnel and the medical provider themselves, everyone in the office must adhere to HIPAA policies.  Essentially, HIPAA requires that everything related to the patient must be kept confidential, which means it’s imperative that safeguards are in place to maintain HIPAA and ultimately revenue cycle management compliance. 

False Claims Act (FCA)

Another important regulation that must be followed is the False Claims Act. The FCA comes into play when patients use government healthcare programs, such as Medicare and Medicaid. Any fraudulent activity with regard to these government programs could be deemed in violation of the False Claims Act. 

Regulatory Compliance Infractions

Compliance With Healthcare Common Procedure Coding System (HCPCS) and International Classification of Diseases (ICD)

While this coding system and disease classification aren’t exactly laws, they are so inextricably tied to them that they might as well be, and compliance with them is necessary. These two coding and disease classifications work hand in hand to ensure that there are standardized billing and diagnosis practices across healthcare providers. 

Affordable Care Act (ACA), Medicare and Medicaid

The ACA is legislation that affords all Americans the right to accessible healthcare, even if they don’t have a private insurance provider. By providing services in accordance with the ACA, as well as with Medicare and Medicaid government healthcare programs, your facility must stay in compliance with the regulations that guide these programs. It is absolutely necessary to have revenue cycle management compliance when it comes to these government programs. 

Impacts of Being Out of Revenue Cycle Management Compliance

If a medical provider or healthcare facility is found to be out of revenue cycle management compliance, the costs are significant. Having proper RCM means that you’re following ethical billing and medical practices. No one would want an unethical healthcare provider.

Not only could being out of compliance mean a loss of patients, loss of licensure and significant fines to the tune of millions of dollars potentially, but in some cases, it could even mean jail time in cases of fraud. For example, the United States Justice Department obtained $2.68 billion in settlements and judgments involving fraud and false claims against the government in the fiscal year ending September 30, 2023 alone

Furthermore, not being in revenue cycle management compliance also spells disaster from the provider perspective as well because it means that funds are not being properly managed and profits are not properly addressed.

revenue cycle management

How You Can Safeguard Against Regulatory Compliance Infractions

When working to stay in revenue cycle management compliance and safeguard your facility from infractions, it is important to keep in mind three major risk areas: patient, data collection and storage, and billing. Although this is somewhat of an oversimplification, the most common areas of risk fall into these categories. 

The ethical treatment of a patient, from the initial point of contact, scheduling, the patient visit and documentation thereof, and proper coding of the patient’s condition are all imperative not only from an RCM standpoint but from a patient care perspective. Additionally, confidential treatment of patient information, including data collection and storage of patient information, and proper billing can all fall out of compliance without proper attention. This is why RCM compliance is so complex — because it is affected by nearly every point of the patient experience.

Not only do healthcare providers need to ensure that they have adequate cyber security, but their office staff needs to be properly trained on regulations that could affect revenue cycle management compliance. Because the number of laws and regulations that affect this industry is voluminous, it is often necessary for healthcare providers to seek out professionals who can assist in maintaining compliance for the practice. 

Get Help With Revenue Cycle Management Compliance

If you’re struggling to keep up with changing regulations or simply need a new revenue cycle management process, it might be time to call in the professionals. Contact Credence Global Solutions to get a plan in place today!