How to Mitigate Compliance RiskAs the Centers for Medicare and Medicaid Services (CMS) increases its scrutiny and escalates enforcement, Compliance managers are on guard to ensure regulatory standards are met—and fines, sanctions, or even termination from CMS programs, are avoided. How can Compliance and Operations managers mitigate compliance risk and improve operations?

The best way to avoid compliance errors is to implement a fully integrated end-to-end solution that works across an enterprise. What constitutes an end-to-end approach? A comprehensive, holistic system should consider these key strategies:

Use Dedicated, Integrated Software:

  • Industry-specific software is paramount—NOT off-the-shelf generic software developed to accommodate multiple industries or various uses.
  • Integrated software is essential—modules that are engineering to integrate with your network and are highly adaptable, scalable, and designed to grow with you.
  • Use automated versus manual processes—wherever possible. Let the software drive the process. Put solutions in place that reduce or eliminate manual entry and decision-making.
  • Choose wisely—all products are NOT created equal. Search for solutions that are intuitive, easy to implement, and quick to learn—and require no need for onsite training, no IT involvement, and no hardware or software to install.

Centralize and Manage Plan Benefit Data Across the Enterprise:

  • Plan benefit information has a variety of uses—CMS bid review/approval, Medicare Plan Finder, member materials (ANOCs, EOCs, SBs), appeals and grievances, claims, call center benefit scripts, sales presentations/materials, and provider communications—however, it’s typically housed in multiple locations and managed independently. Find an automated solution that achieves a “single source of truth” by capturing and storing benefit data in one centralized location. It can then be transformed and used enterprise-wide—saving time and improving accuracy.

Utilize a “Single Source” Vendor to Create and Manage Member/Provider Communications:

  • Miscommunication between multiple vendor partners—document creators, website managers, translators, print shops, mail houses, 508 remediation specialists—increases risk, stress, and can cause delays—eliminate handoffs wherever possible.
  • Coordinate activities among departments to ensure all required actions are taken. For example, each year CMS issues an Evidence of Coverage (EOC) Corrections Memo through HPMS Memos, to fix errors discovered in the templates, issued at the beginning of the contract year. Use automation to flag and notify the EOC document developer of the changes required.
  • Does your Printer and Fulfillment vendor have redundancy and contingency planning? If not, they should. In the event of an equipment or system failure, your printer should have a contingency plan to ensure on-time delivery for critical mailings.

Consult Industry Experts:

  • Outsourcing collateral creation of mandated marketing materials to an experienced, cost-effective partner may make sense for those who are understaffed, undertrained, need to avoid penalties, reduce costs, improve distribution, and support star ratings measures.
  • For additional guidance, an experienced Compliance Consultant can help plans conduct mock audits, identify/assess risk, streamline workflows, manage complex investigations, cut costs, improve compliance, and help maintain a better standing with CMS.

Julie Hughes, Chief Compliance Officer at CODY, states that “The benefit of an end-to-end process from an operational point of view is that it reduces the potential for human error, makes the process more efficient, and gives plans more time to perform quality assurance on the materials being produced. CODY understands the impact that non-compliance can have on plans and focuses on aligning our internal operations with CMS’s guidelines to create systems and controls that manage compliance risks throughout the organization.”

CODY® exemplifies this end-to-end strategy to help plans mitigate compliance risk and improve operations across the enterprise. Our integrated suite of software is developed specifically for health plans—and includes the first-ever Centralized Source of Truth™ available in today’s market. Our Allied Services Division is a single-source solution created to manage the entire lifecycle of Member/Provider Communications from Plan Benefit Data and Collateral Creation through Print & Fulfillment, Translations, and 508 Remediation—literally from A-to-Z.

And for plans with limited resources, CODY’s Business Process Outsourcing (BPO) combines our Managed Care expertise and CodySoft® products to create and deliver more accurate mandated materials faster than you can do yourself with a manual process.


About CODY: CODY® works with more than 60 government-funded, commercial, and ACA health plans across 45 states and Puerto Rico. We help health plans improve regulatory compliance, manage plan benefit data, and streamline member/provider communications to maximize performance across the enterprise. CodySoft®, our proprietary suite of software, is designed specifically for health plans. www.codyconsulting.com.