Compliance & Mandates
Healthcare is one of the most highly regulated industries in the nation. Federal
and organizational mandates have become a consistent focus for all U.S. health plans.
Arcadia has managed vast compliance initiatives spread across many layers of payer
organizations, from national health plans to smaller, regional payers. From these
experiences, we have discovered that when investing in certain compliance initiatives,
there are many opportunities for health plans — both large and small — to attain
a much higher return on investment. This can be done by simply identifying specific
projects that align with their business goals and strategically implementing them
into their project plan.
ICD-10
ICD-10 represents the largest change that the United States payer community
has seen in the past 30 years. Affecting nearly all operational aspects of a health
plan, ICD-10 has substantial strategy, process and technology implications. Many
organizations are struggling to identify a strategic approach to ICD-10 compliance.
Arcadia sees ICD-10 as an opportunity to evaluate the topic of phased compliance
vs. full-system remediation, identify where ICD-10 changes will align with an organization’s
core strategic objectives, and leverage investment to derive the most business value
from the initiative.
Code Set Utilization
ICD-10 will introduce 8 times the codes of the current ICD-9 standard. The detailed
data that will be made available to payers represents tremendous value if used strategically
(e.g. opportunity for cost control, competitive advantage, etc.). Payers that efficiently
acquire a quality data set will create significant competitive and financial advantages.
The transition to the new code set will cause a number of business challenges related
to code utilization. For example, first-pass claims are expected to drop by approximately
30% due to incorrect code use. Also, the new codes will create a steep learning
curve for existing coders and cause attrition in more experienced coders. Through
conversations with at least 10 Payers, one gap clearly remains in the market — how
do you compel providers to utilize the codes properly?
- This is an ideal opportunity to leverage our payer and provider background to deliver
a service offering at the intersection of the two.
- The solution would need to go beyond basic outreach and education (e.g. webinars,
etc.), because others will be offering that. In fact, the Blues plans are starting
to collaborate on how to address this through their greater association. They do
not, however, have an answer for the "last mile" — actually reaching the providers
and investing in programs for the adoption of new codes.
- The service offering is not a way to generate revenue this year, or even next year.
It is, however, a much needed facilitator for discussions with payers.
HIPAA 5010
Many organizations see HIPAA 5010 as a sunk cost purely toward a compliance goal.
Arcadia sees HIPAA 5010 as an opportunity to leverage spending toward gaining a
business advantage. Arcadia has identified key areas with strategic return on investment
from this otherwise “sunk cost.”
Federal Mandates for Medicare/Medicaid
Arcadia’s Compliance Team employs forward-thinking process and technology experts.
We help maintain compliance with complex regulations for the service, sales, marketing
and operations of Medicare/Medicaid products, preserving valuable revenue while
helping avoid fines and penalties. An example of this can be found in our Medicare
Compliance Dashboard. It provides clients with capabilities such as management control
and monitoring of operational processes, with the end result being a compliant auditable
plan.
Blue Cross Blue Shield Association Mandates
Arcadia has a very long history and deep knowledge of the Blue Cross Blue Shield
association. We manage BCBSA mandates, initiatives and can ensure results and compliance
across:
- Blue Exchange
- Blue Squared
- ITS
- FEP