Compliance & Ethics for Health Plans
Compliance & Ethics for Health Plans
David A. Gregory
Principal
Darren R. Jones
CIA
Principal
Michael J. Patti
Principal
John Romano
CPA, CIA, CFE, CITP, CSM
Partner
Mark Scallon
Principal
A well-developed and effective enterprise compliance and ethics program is essential to adhere to complex government regulatory requirements and enforcement initiatives. At Baker Tilly, we understand that your compliance program is never stagnant. It is constantly developing and addressing new regulations and business needs. Baker Tilly’s professionals are here to help our clients navigate the compliance life cycle at each step of the way by providing innovative, cost-effective solutions to meet their unique business needs.
Compliance life cycle solutions
Guiding you through the compliance life cycle
The most effective compliance programs are those that can adapt.
Compliance programs are often designed to establish a company’s policy, as well as culture around compliance and an ethical behavior for the organization. Historically, these compliance programs were reactionary and solely focused on complying with current government regulations. However, with a shift for health plans to focus on a more consumer-driven approach that is reliant on innovation, traditional compliance programs must be reviewed and updated to adapt to the healthcare industry’s rapidly shifting regulatory environment that focuses on both current and emerging governmental regulations.
Baker Tilly’s compliance and ethics program development strategy utilizes a proactive approach, focused on your organization’s unique risks as well as compliance-based auditing to transcend today’s and tomorrow’s regulatory needs. This includes fraud, waste and abuse; the ethical utilization of patient health information while promoting information privacy; and transparency regarding network pricing standards. Our solutions include comprehensive compliance program development and implementation, including program auditing and monitoring, compliance operations, program evaluation and advisory, and workforce compliance training.
Implementing appropriate processes, solutions and support tools is crucial to the long-term success of organizations, and compliance adds another layer of complexity that must be addressed. Baker Tilly’s compliance operation services are able to generate measurable results and support all compliance requirements in your day-to-day operations.
Health plans face a more stringent and volatile regulatory environment than most industries, and a well-developed compliance and ethics program is essential for an organization’s operational success. Baker Tilly’s team of professionals can evaluate your compliance and ethics program to confirm that it encompasses organizational risks, partners with reliable third parties, and takes a proactive approach at mitigating existing or potential risks and concerns. Whether you are planning a complete operational overhaul or starting a needs assessment, we are here to assist you in making informed decisions.
Baker Tilly has a breadth of experience in audit and compliance monitoring. However, we also understand the unique and specific needs of health plans. An effective monitoring program is never a one-size-fits-all solution, and our experienced specialists work with you to develop an approach that suits your organization’s specific needs. Whether you are in need of exam preparation services, provider directory audits or third-party monitoring solutions, we will work with you to ensure your compliance program meets state and federal regulations.
Creating an effective compliance and ethics training program is vital in the long-term success of every healthcare organization, and ensures that all team members are cognizant of standard compliance procedures and general program knowledge. Baker Tilly’s training program development services can assist your organization with the development of an educational solution that best suits your organization’s compliance needs and objectives.
Compliance training content development
Availability of the appropriate tools and knowledge is the best approach for organizations educating their team members on compliance matters. Our experience developing content for compliance training can provide your organization with the necessary knowledge and skills. Our program is adaptable to your needs and ensures that every team member receives the most up-to-date and accurate compliance information available.
Compliance training execution
Conducting compliance training is a challenging task and our skilled training professionals keep team members engaged throughout each learning session. The training methods utilized provide participants with the confidence and knowledge necessary to proactively understand and identify compliance-related issues in the workplace.
Featured insights
Large health plan develops QPA methodology to comply with the No Surprises Act
This case study discusses how Baker Tilly helped a large payer organization develop a methodology for calculating QPAs and comply with the No Surprises Act.
Risk assessment for health plan’s member letters and notifications
Baker Tilly performed a risk assessment for a large, multi-state health plan to help the company understand the various risks associated with the member letters and notifications distributed throughout the year.