Overcoming Regulatory Hurdles in Healthcare Risk Management in 2024

The healthcare industry thrives on intricate procedures, dedicated professionals, and, most importantly, patient safety. However, this very environment also breeds inherent risks, making healthcare risk management crucial for any healthcare organization. Compliance officers play a pivotal role in safeguarding patient well-being, ensuring financial stability, and navigating the complexities of healthcare risk management plans. This blog equips compliance officers with the knowledge and strategies to overcome the hurdles they encounter in this crucial domain.

The Operational and Financial Burdens of Risk Management in Healthcare

While healthcare risk management prioritizes patient safety and organizational integrity, it often comes at a significant cost.  In recent years, the healthcare sector has seen a surge in the level of operational and financial burden due to compliance. The American Hospital Association (AHA) reports that health systems, hospitals, and post-acute care providers spend nearly $39 billion a year on administrative activities related to regulatory compliance. This underscores the vital role of risk management in healthcare.

Essentially, each hospital spends an average of $7.6 million annually to ensure compliance, translating to $1,200 each time a patient is admitted. For smaller hospitals with fewer than 50 beds, the per-bed compliance cost can reach up to $1,500. This demonstrates the costly yet crucial nature of implementing a comprehensive risk management plan in healthcare.

Studies reveal that healthcare organizations dedicate substantial resources in Healthcare Risk Management:

• Developing and implementing compliance programs (15% of total budget on average)
• Training staff on regulations and procedures (estimated cost of $1,200 per employee or $47,000 per hospital bed annually)
• Conducting regular audits and risk assessments (can cost upwards of $100,000 per year)

Consequence of Failed Healthcare Risk Management  

Security Intelligence reported that data breaches in the healthcare sector are notably the most expensive compared to other industries. The typical data breach cost across various sectors is $4.45 million. However, this figure skyrockets to an average of $10.93 million for the healthcare industry, marking it as the sector with the highest data breach costs. Notably, over the past three years, the cost related to healthcare data breaches has witnessed a significant surge of 53.3%.

Hurdles to Execute Risk Management Plans in Healthcare

Without the expertise of a professional healthcare risk manager, healthcare risk management navigation becomes a riddle, compounded by the complexity and constant evolution of regulations. Some of the common challenges compliance officers face include:

• Keeping pace with regulation changes: The healthcare industry is subject to frequent regulatory updates from various governing bodies like the Department of Health and Human Services (HHS), the Food and Drug Administration (FDA), and state agencies. Staying informed of these changes requires constant vigilance and ongoing education.
• Understanding the intricate details of various regulations: Numerous regulations, such as the Health Insurance Portability and Accountability Act (HIPAA), the Affordable Care Act (ACA), and the Emergency Medical Treatment and Labor Act (EMTALA), govern different aspects of healthcare operations. Each regulation has its own nuances and complexities, demanding a deep understanding for effective implementation.
• Interpreting and applying regulations to specific situations: Applying broad regulations to specific organizational situations can be challenging. Compliance officers need strong analytical skills to interpret the intent and application of regulations in various scenarios.
• Cost of  Risk management in healthcare: Healthcare facilities, including health systems, hospitals, and post-acute care providers, are obligated to adhere to over 600 distinct regulatory mandates. Most of these requirements are concentrated in areas such as Conditions of Participation, Rules related to Privacy and Security, and Quality Reporting.

Specific Laws and Regulations Impacting Healthcare Risk Management  (HIPAA, ACA, EMTALA, PHI.)

• HIPAA: The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that sets forth regulations for using and safeguarding medical information. The primary aim of HIPAA is to ensure the confidentiality, integrity, and availability of all electronically protected health information (PHI) that a covered entity creates, receives, maintains, or transmits.
• ACA: The Affordable Care Act (ACA), sometimes referred to as “Obamacare,” was enacted to reform the healthcare industry in the U.S. Its main objective is to improve access to healthcare services, expand health insurance coverage, and emphasize preventive care. The ACA also aims to reduce healthcare costs for individuals and the government.
• EMTALA: The Emergency Medical Treatment and Labor Act (EMTALA) is a federal law that requires hospital emergency departments to screen every patient who seeks emergency care medically and to stabilize or transfer those with medical emergencies, regardless of health insurance status or ability to pay. EMTALA aims to ensure public access to emergency services and prevent patient dumping, a practice where hospitals deny treatment to patients or transfer them to public hospitals because of their inability to pay.
• PHI: Protected Health Information (PHI) refers to demographic information, medical histories, test and laboratory results, mental health conditions, insurance information, and other data a healthcare professional collects to identify an individual and determine appropriate care. The primary purpose of protecting this information is to prevent unauthorized disclosure of a patient’s sensitive health information, thereby upholding the patient’s right to privacy.

Strategies for Risk Management in Healthcare

Despite the challenges, proactive strategies can empower compliance officers to navigate the healthcare risk management landscape effectively:

Developing Effective Compliance Programs

• Establish a well-defined healthcare risk management plan that outlines risk identification, mitigation strategies, and ongoing monitoring procedures.
• Conduct regular risk assessments to identify potential compliance gaps and vulnerabilities proactively.
• Implement a centralized document management system to ensure easy access to policies, procedures, and regulations for all staff.

Implementing Training and Education Programs

• Regularly train staff on relevant regulations, policies, and procedures to ensure everyone understands their role in compliance.
• Offer ongoing educational opportunities for compliance officers to stay updated on the latest regulatory changes and best practices.
• Develop clear and concise communication channels to foster open communication and promptly address any compliance concerns.

Conducting Regular Audits and Risk Assessments

• Conduct regular internal audits to identify and address any potential compliance gaps or weaknesses.
• Utilize risk management information systems (RMIS) to streamline compliance tasks, manage risk data, and facilitate efficient reporting.
• Benchmark your organization’s compliance performance against industry standards and best practices.

A study by the American Society for Health Care Risk Management (ASHRM) revealed that organizations with a strong risk management program experienced 23% fewer compliance violations than those without one. This data emphasizes the effectiveness of regular audits and risk assessments in preventing regulatory hurdles.

The future of Healthcare Risk Management and Compliance is Likely to Involve

Upcoming Changes in Healthcare Regulations

• Increased focus on data security and privacy, driven by the growing adoption of telehealth and electronic health records (EHR).
• Evolving regulations address emerging technologies, such as artificial intelligence (AI) and machine learning, used in healthcare.
• Greater emphasis on value-based care

The Scope of Outsourcing in Navigating Healthcare Risk Management 

Outsourcing compliance and risk management aspects can be a viable option for healthcare providers. This can include areas such as compliance audits, staff training, and risk assessment.

OutsourceRCM is a professional Health Care Risk Manager in U.S. with over 15 years of industry leading experience. We specialize in Medical billing & Coding, Accounts Receivable, Insurance Verification and Healthcare Revenue Cycle Management services with precision and care.

In an era where effective healthcare risk management is paramount, partnering with OutsourceRCM ensures that your compliance programs are robust, your audits and risk assessments are thorough, and you remain agile amidst regulatory changes. Don’t let regulatory hurdles slow you down. Let us help you navigate the turbulent seas of healthcare risk management with ease. Visit Outsource RCM’s accounts receivable outsourcing services today and take the first step towards a more efficient and compliant future.