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Part 2: Compliance by the Data – Identifying Risk Gaps

June 12, 2019

Areas of Risk Can be Addressed Systematically

In order to remain in compliance, health care organizations must be diligent in creating and sustaining transparency through screening, verification, and continuous monitoring of every staff member—from the board and C-Suite, to licensed providers, volunteers, and everyone in between including contractors, vendors, investors, and supplier entities.

Identifying Data Risk Gaps

Having established and scalable systems in place that follow an audit blueprint can create a culture of compliance and situate an organization inline with the massive growth the U.S. health care industry is experiencing.

For the first time in history health care surpassed manufacturing and retail as the largest employment sector in the US:

  • 2 million general health care workers, 8 million more are licensed
  • 20% growth rate
  • 37% growth rate of both nurse practitioners and physician assistants

Compliance audits are important because we spend more than $3.5 trillion annually on health care and more than $90 billion of that is spent on improper payments. Worse still, an estimated 10 percent of the overall spend—equaling $350 billion—is lost to fraud with only 1 in every 6 dollars recovered, and much of what is recovered requires many millions of dollars to be spent in the act of recovery.

Historically, 1 in every 20 health care providers will have negative information in their records. These noncompliant situations mean greater (a) risk to patient safety, (b) exposure to liability for negligent hiring, (c) probability of State and Federal civil monetary penalties, (d) restricted practice through sanctions, and (e) loss of patient population or customer relationships through reputational damage.

With quality measures driving reimbursement, providers have a positive motivation to demonstrate quality of care. Only through thorough screening can an organization make informed hiring decisions. Following hiring, continuous monitoring against thousands of data sources can provide near real-time red flags on compliance issues. This information provides organizations the information to mitigate noncompliance risks for the business and for patients.

Given the risks, striving for compliance seems simple enough until you look at the obstacles common to so many organizational structures in the health care sector.

Currently, many health care organizations still have decentralized paper systems where portions of a credentialing file can be scattered across departments. Talent acquisition, human resources, medical staff services, and network management often each have different protocols and data sources for screening. As a result, critical decisions are often based on incomplete facts, leading to critical gaps that expose an organization to potential fraud and abuse.


When a hospital recruits a physician, relocation costs can easily reach the $100,000 mark. Without technology automation, it takes on average two to four months to complete credentialing and enrollment for the new hire of a licensed medical professional at an average cost of $7,000 per year based on 20 or more hours of administrative time. Some 75-85% of credentialing applications are incomplete at submission, requiring even more time from medical staff services, the board and committee members.

The time and expense incurred during this onboarding cycle cannot be offset by billed services until a provider is fully onboarded, which can take up to 18 months. If it is later discovered that the professional represents a compliance risk, the process must begin anew—duplicating the expense while adding an additional year before billing can occur.

The same fundamental issues, albeit with minor variations, occur across the landscape of organizations in health care. Utilizing technology does not always solve the data gap. There is equal opportunity for gaps to occur when running processes on separate spreadsheets using disparate software in separate departments. The decentralization of data undermines the compliance audit process whatever form the data takes.

Health care leaders must elevate the conversation around the credentialing process and shed light on the ways gaps in compliance can be debilitating to a health care organization. Thankfully, the issues can be addressed by understanding critical gaps and how they can be resolved. Closing these gaps provides a 360-degree view of each provider, employee, and entity, thereby paving the way for improved outcomes, quality of care, patient safety, and compliance in billing practices.

Best practices for closing the data risk gaps involve technology that aggregates data sources, contains name matching algorithms, links data to the proper identities, and bridges the lack of cross-State and State-to-Federal reporting by pulling data from board, county, state, and federal levels.

 Susen Sawatzki Written by Susen Sawatzki
Healthcare Industry Expert
Muse. Writer. Publisher. Producer. Creator of Inspiring Narratives.
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