Vālenz® Announces Strategic Partnership with Turquoise Health

Vālenz Announces Strategic Partnership with Turquoise Health

Database of negotiated hospital rates elevates consumer transparency and choice

PHOENIX, Ariz. (April 26, 2021) — Vālenz® announced today a partnership with Turquoise Health, a software solutions company that facilitates consumer transparency through its newly launched platform listing payer-negotiated hospital rates.

With new price transparency regulations requiring hospitals to share previously undisclosed rates for many services, Turquoise Health has created the first comparison engine for consumers to make cost-effective decisions about their care.

With full access to Turquoise Health’s database of hospital rates, Valenz will incorporate the comparison information into its concierge-level navigation program and self-service member portal. Valenz also will utilize the data to build highly efficient networks that drive quality care and customer satisfaction alongside cost savings.

“Our partnership with Turquoise Health aligns with our data-driven ecosystem and helps us take a significant step toward providing the transparency our clients and their members need,” said Rob Gelb, CEO of Valenz. “Not only can we share the cost structure of hospital services to help guide members’ decisions, but we can also help them gauge the quality of the service. It’s a key component of the Valenz promise to assure smarter, better, faster healthcare.”

As of Jan. 1, 2021, the federal rule requires hospitals to publish a machine-readable file listing their negotiated payment rates for hundreds of medical procedures, as well as a website where consumers can search for services and prices. Initial compliance has been mixed, with reports of some hospitals blocking their pricing from showing up on web searches – making the Turquoise Health platform all the more valuable in elevating transparency.

CEO Chris Severn says its database currently has more than 2,000 verified rates, and the list continues to grow as Turquoise painstakingly combs through and verifies hospital pricing data.

“This is just the beginning of making hospital billing more clear and patient-friendly,” Severn said. “Using both public price rates data and Turquoise participating provider data, we are showing there is a market for transparency in healthcare. We help put negotiating power where it belongs — in the hands of the consumer.”

 

About Valenz

Vālenz® enables self-insured employers to make better decisions that control costs across the life of a claim while empowering their members to lead strong, vigorous and healthy lives. Valenz connects cost and quality data from comprehensive care management services (Valenz Care), high-value provider networks (Valenz Access), claim flow management (Valenz Claim), complete bill review (Valenz ProteKHt), and solutions for payment integrity, revenue cycle management and eligibility compliance (Valenz Assurance) for smarter, better, faster healthcare. More information is available at valenzhealth.com. Valenz is backed by Great Point Partners.

 

About Turquoise Health

Turquoise Health launched in 2020 with a vision to simplify healthcare reimbursement through price transparency. CTO Adam Geitgey, formerly a Director of Engineering at Groupon, brings deep consumer marketplace experience to the healthcare sector. Turquoise invites providers and payers to become Turquoise Verified partners. Using the software suite, organizations create “price certainty” for patients while easing claims adjudication on the back end. Turquoise already counts major revenue cycle partners and hospital systems as satisfied clients. To learn more, visit turquoise.health or email info@turquoise.health.

Engaging Early and Often to Manage the Boomerang Effect of COVID-19

The COVID-19 pandemic continues to prompt many people to delay diagnostic testing and obtaining necessary medical care, leading to a decrease in both procedures and diagnoses. The result is the creation of unexpected utilization patterns, which the industry is only beginning to understand and attempt to reconcile.

While some patients delayed care for just a few months, others – including those with chronic conditions – have not yet returned for follow-up care and routine health screenings such as colonoscopies and mammograms. Researchers have predicted that patients will emerge with more serious health conditions, including later-stage diagnoses and more advanced stages of diseases such as cancer and certain cardiac-related conditions.

Consider these findings:

Engaging early and often to prevent long-term health consequences and increased costs caused by delayed care has never been more critical. Guided by insights from biometrics, utilization data and paid claims analysis, self-insured employers can identify gaps in care and engage members with real-time interventions, providing navigation to the right care path before serious issues occur.

Today’s technologies deliver insights from patient data, clinical drivers and social determinants of health to identify members at risk before their condition deteriorates. Once identified, care coordination to connect them with key resources 24 hours a day is possible. This level of continuous, evidence-based engagement guides better long-term health decisions while allowing self-insured employers to target the 5-15% of claims that drive up to 70% of health plan spending.

Self-insured employers will position themselves well to offer this level of support for their members through:

  • Concierge-level navigation for advocacy, education, and direction of quality care that results in positive medical experiences
  • Predictive analytics combined with member-centric services during the patient journey
  • Full-service care management programs that identify at-risk members and offer personalized services to improve health outcomes
  • Guidance and information on what is covered by a member’s benefit plan, managing co-pays, controlling out-of-pocket expenses, and accessibility to care
  • Using the power of data-driven solutions to provide the right care at the right place at the right time

But it is not just about engaging the member. Establishing a central point of contact for everyone across the care continuum, from members to care providers and payers, delivers comprehensive care with transparency.

With the right tools and information, delivered in real time, self-insured employers will find actionable information at each step in the life cycle of a claim. From high-performance network design through comprehensive and complete bill reviews, data-driven insights lead to health care costs that are fair, defensible, transparent and consistent for everyone.

Long before the current health crisis began, we have embraced the Vālenz® core promise of delivering smarter, better, faster healthcare. Although COVID-19 has created numerous challenges, maintaining the health and well-being of our clients and employees is more important than ever. We remain committed to early health engagement and ensuring the right care paths to keep everyone strong, vigorous and healthy.

***

Rob Gelb is Chief Executive Officer of Vālenz®, an ecosystem of data-driven solutions that creates new opportunities for self-insured employers to control costs while empowering members to lead strong, vigorous and healthy lives.

Portrait of Maurice Steenland, Vice President, Strategic Enablement at Vālenz

Maurice Steenland Joins Vālenz Leadership Team

As Vice President, Strategic Enablement, Steenland appointed to accelerate value for Valenz clients

PHOENIX, Ariz. (April 9, 2021) — Vālenz® is pleased to announce the appointment of Maurice Steenland as Vice President, Strategic Enablement.

In his new role, Steenland will be responsible for synchronizing departments to accelerate strategic initiatives that bring greater value to Valenz clients, fulfilling the company’s strategic vision and mission. He will continue to drive the expansion of the firm’s data engagement solution, v-Lens, to advance predictive modeling, data-driven decision enablement and transparency across the ecosystem.

“We are excited to welcome Maurice to this key strategic role on our senior leadership team,” said Rob Gelb, Chief Executive Officer of Valenz. “With deep expertise in uncovering operational efficiencies and enabling data and analytics to inform better decisions, Maurice is an excellent fit for the Valenz team. His highly strategic and analytical approach will no doubt add higher levels of transparency across our data-driven ecosystem to deliver smarter, better, faster healthcare.”

Steenland brings 20-plus years in executive roles for health-related organizations. Most recently, he was principal consultant for SISIX, LLC after serving as Vice President, Informatics for Optum, where he managed the Informatics and advanced analytics and data science teams that developed client outcomes reporting, predictive tools and methods to identify emerging risk and cost containment programs.

Steenland also has held leadership positions at CIGNA Healthcare, Coventry Health Care and Intracorp, with specialization in operations, utilization management, strategy and business development. He earned his master’s in business administration from the prestigious Wharton School of the University of Pennsylvania.

“I’m thrilled to join such a future-focused team at Valenz and have the opportunity to pave the way toward quality, utilization and cost transformation through transparency, efficiency and data-driven solutions,” Steenland said. “As we combine analytics-driven approaches with influencing skills to drive change and efficiencies, I look forward to providing greater savings and solutions for our clients in the self-insured industry.”

 

About Valenz

Vālenz® enables self-insured employers to make better decisions that control costs across the life of a claim while empowering their members to lead strong, vigorous and healthy lives.  Valenz connects cost and quality data from comprehensive care management services (Valenz Care), high-value provider networks (Valenz Access), claim flow management (Valenz Claim), complete bill review (Valenz ProteKHt), and solutions for payment integrity, revenue cycle management and eligibility compliance (Valenz Assurance) for smarter, better, faster healthcare. More information is available at valenzhealth.com. Valenz is backed by Great Point Partners.

Vālenz Announces Acquisition of Kozani Health

Kozani Health integrates as ValenzProteKHt™ for complete and comprehensive bill review solution

PHOENIX, Ariz. (April 1, 2021) — Vālenz® announced today it has acquired Kozani Health, integrating a new and innovative means for self-funded employers and the self-insured community to control costs across the life of a claim.

Kozani Health, which provides customized solutions to meet the challenges of paying medical claims appropriately, joins the ever-expanding Valenz ecosystem of data and solutions as Valenz ProteKHt™. The new solution offers detailed line-by-line bill reviews performed by nurses, certified coders and practicing specialists to uncover inappropriate billing and care provided.

With success rates averaging 70 percent, Valenz ProteKHt is the industry’s recognized comprehensive and complete bill review solution. Valenz ProteKHt offers clear, defensible, transparent and plan-specific reviews that deliver savings of 10-30 percent above the PPO allowable with a signed contract, agreed upon and authorized by the provider.

“We are excited to welcome Kozani Health as part of our data-driven Valenz ecosystem,” said Rob Gelb, Chief Executive Officer. “By bringing our teams together, we are providing self-funded employers and the self-insured community improved cost savings at each step in the life cycle of a claim, strengthening their ability to realize every opportunity to balance cost, quality and utilization under the Claim Cost ArcSM. Our solutions aside, which clearly align value for all, our cultures and the commitment to customer service and ‘customer love’ will be a continuing defining characteristic of our now, collective success.”

Valenz is focused on changing the trajectory of healthcare expenses, creating new opportunities for self-insured employers to control costs while empowering members to lead strong, vigorous and healthy lives. Valenz delivers a 20-40 percent improvement in savings from traditional health plan approaches by bridging the divide between robust analytics, care management, high-value provider networks, payment integrity and claim management.

“We are energized to begin our company’s next chapter as Valenz ProteKHt,” said Michael Scott, Chief Executive Officer and Co-Founder of Kozani Health. “Integrating our claim management solutions into the Valenz ecosystem will accelerate the growth and evolution of our services and bring value to our customers.”

“With this integration, we assure clients they will experience the same close partnership and personal attention as they have with Kozani Health,” said Heather Wilson, Chief Operating Officer and Co-Founder of Kozani Health. “Now, we can also offer the benefit of being part of the Valenz ecosystem. Together, we are committed to nurturing the same ‘customer love’ that has made Kozani Health a symbol of success in the market.”

 

About Valenz

Vālenz® enables self-insured employers to make better decisions that control costs across the life of a claim while empowering their members to lead strong, vigorous and healthy lives. Valenz connects cost and quality data from comprehensive care management services (Valenz Care), high-value provider networks (Valenz Access), claim flow management (Valenz Claim), complete bill review (Valenz ProteKHt), and solutions for payment integrity, revenue cycle management and eligibility compliance (Valenz Assurance) for smarter, better, faster healthcare. More information is available at valenzhealth.com. Valenz is backed by Great Point Partners.

About Kozani Health

Kozani Health, headquartered in Mesa, Ariz., provides customized bill review and bill review sign-off solutions to analyze pricing, coding and care provided to ensure appropriate payment. Since its inception in 2015, Kozani Health has forged long-term customer relationships and continuously improved solutions to solve customer challenges.

About Great Point Partners

Great Point Partners, founded in 2003 and based in Greenwich, CT, is a leading healthcare investment firm with approximately $1.3 billion of equity capital currently under management and 28 professionals, investing in the United States, Canada, and Western Europe. GPP is currently making new private equity investments from GPP III, which has $307 million of committed capital. Great Point manages capital in private (GPP I, $156 million and GPP II, $215 million of committed capital, and GPP III) and public equity funds. Great Point Partners has provided growth equity, growth recapitalization, and management buyout financing to more than 200 growing healthcare companies. The private equity funds invest across all sectors of the healthcare industry with a particular emphasis on biopharmaceutical services and supplies, pharmaceutical infrastructure, alternate site care, medical device and information technology enabled businesses. The firm pursues a proactive and proprietary approach to sourcing investments and tuck-in acquisitions for its portfolio companies. Reach Great Point at 203-971-3300 or www.gppfunds.com

Next Generation RBP Roundtable: Evolving Collaborative Approaches for a Balanced Reimbursement Strategy

The COVID-19 pandemic has had unprecedented impact on healthcare’s delivery, consumption and expense. While the use of virtual care has skyrocketed, 20 percent of U.S. households reported delaying care for serious problems during the pandemic, which can lead to major complications and catastrophic claims.

It is more important than ever for self-insured employers to have strategies in place that ensure their members are getting the right care, at the right time, from the right providers.

Vālenz® hosted a roundtable discussion focused on how the next generation of reference-based pricing programs focus on active collaboration between all parties to improve health outcomes while ensuring transparency.

Watch as Valenz CEO Rob Gelb and Adam V. Russo, Esq., Co-Founder and CEO of The Phia Group, discuss how innovative reimbursement strategies can bring balance to the quality-utilization-cost equation.

You will learn how the next generation RBP model integrates deep analytical insights with member-centric services to:

  • maximize plan dollars
  • improve health outcomes and the member experience
  • create positive, equitable relationships with providers
  • drive improved savings of 20-40% on your total healthcare spend

Click here to download a PDF of the slides.

Vālenz CaptiV: Reduce Risk, Gain More Control of Your Health Plan Spend

As health care costs rise exponentially, self-insured employers are facing greater risks of high-dollar claims. Recognizing the significant risk-reduction advantages and cost-effectiveness of combining employer plans in a medical stop loss (MSL) group captive program, Vālenz® has launched CaptiV to solve the challenges market volatility can pose for small to medium-sized employers.

Valenz CaptiV goes beyond risk sharing to provide a fully integrated, data-driven model for cost and risk reduction. By bringing together employers that are committed to managing their medical costs while improving health outcomes – and equipping them to engage early and often via its end-to-end analytics platform – Valenz CaptiV represents the next generation of MSL group captives.

“We operate at the center of the MSL group captive, actively engaging the group of employers and their employees in our proprietary ecosystem of data and service solutions,” said Rob Gelb, Chief Executive Officer of Valenz. “Our analytic and predictive capabilities uncover new strategies to drive a 20-40 percent improvement in savings by targeting the high-dollar claims that drive the majority of health plan spending. We continually integrate those learnings among Valenz CaptiV members to reduce the potential for catastrophic claims and create value for everyone.”

For self-insured employers with fewer than 1,000 employees, Valenz CaptiV leverages a larger and more diverse population to reduce plan level and catastrophic risk, while delivering exceptional cost-reduction strategies, increased underwriting credibility, and long-term rate stability.

“For captive members, our ecosystem offers unparalleled data-driven collaboration. from pre-claim loss to post-claim resolution,” said Gelb, explaining, “Valenz solutions build on one another, providing actionable information at each step in the life cycle of a claim.”

To accelerate its captive offerings, Valenz partnered with MSL Captive Solutions, the industry’s only platform dedicated to the development and delivery of comprehensive services exclusively for MSL captives. MSL Captive Solutions works with top insurance carriers and claims administrators to deliver market-leading results for Valenz CaptiV members.

“Properly structured group captives have proved to reduce costs and increase plan stability by effectively managing, diversifying and broadly diffusing risk,” said Phil Giles, Managing Director of MSL Captive Solutions. “By taking a discerning approach to membership and enabling more active, data-driven risk management, Valenz CaptiV promises superior performance.”

Together, the firms offer more strategic, proactive risk control and cost-reduction decision-making. And, as costs are contained, Valenz CaptiV members share in the profitability of the program.

For more information on Valenz CaptiV, call (866) 762-4455.

 

About Valenz

Through a complete health administrative ecosystem, Valenz connects cost and quality data on a single-source, end-to-end analytics platform for smarter, better, faster healthcare. Valenz solutions integrate data from comprehensive care management services (Valenz Care), high-value provider networks (Valenz Access), claim flow management (Valenz Claim) and solutions for payment integrity, revenue cycle management and eligibility compliance (Valenz Assurance) into the ecosystem. More information is available at valenzhealth.com. Valenz is backed by Great Point Partners.

 

About Great Point Partners

Great Point Partners (“GPP”), founded in 2003 and based in Greenwich, CT, is a leading healthcare investment firm, currently with approximately $1.8 billion of equity capital under management and 28 professionals, investing in the United States, Canada and Western Europe. Learn more at www.gppfunds.com.

 

About MSL Captive Solutions, Inc.

MSL Captive Solutions is the industry’s only platform devoted exclusively to the development of comprehensive (re)insurance solutions for group and single-parent medical stop loss captives.

MSL Captive Solutions provides consultative underwriting support to some of the industry’s leading stop loss carriers and operates independently to work with all qualified brokers, consultants, and captive managers. For more information visit www.mslcaptives.com.

 

Four Solutions to Support Employees’ Mental Health During COVID-19

This article is third in our series examining how the self-insured industry can respond to the long-term effects of COVID-19 on member health.

The COVID-19 pandemic has impacted almost every part of our daily lives, including physical, financial and emotional health. As the pandemic continues to worsen, we are gaining greater visibility into emerging mental health issues among the U.S. population. Consider these recent statistics:

  • According to a Kaiser Family Foundation (KFF) health tracking poll in July, 53 percent of U.S. adults say COVID-related stress has negatively affected their mental health – up from 39 percent in May.
  • Census Bureau surveys have found up to 40 percent of U.S. adults struggling with anxiety, depressive disorder or substance abuse since the pandemic hit.
  • More than half of behavioral health organizations are seeing higher demand for services, according to the National Council for Behavioral Health – but capacity is diminishing.
  • In addition, KFF found most U.S. adults think the worst of the pandemic is yet to come.

Mental health claims within our ecosystem are significantly on the rise, and clients are reporting increased concern about pandemic-related effects on their employees – adding new life to discussion about modifying care delivery models. The healthcare industry is acknowledging the significant correlations between physical and mental health, traditionally cared for as separate conditions. Integrated care solutions that treat the whole person could deliver improved outcomes with less expense.

To that end, in the face of continuing upheaval and stress from COVID-19, what resources can self-insured employers offer to support their employees? Here are four solutions to consider:

1: Use data to identify members at risk.

Employers are increasingly turning to data to identify employees at risk and proactively offering them the resources they need. Today’s technologies are providing new insights by leveraging real world data (RWD), which refers to health-related information collected and reported by diverse sources on patient health status, population trends and the routine delivery of care.

Within an ecosystem like ours, RWD come from multiple sources including electronic medical and health records, claims and case management databases – even from employees themselves. We anticipate self-assessments, social media and health-related wearables as emerging data sources that will soon be added into the mix to more precisely predict those in need of behavioral health services.

2: Offer a care management program with personalized support and navigation.

Poor mental health and behavioral choices make physical health and chronic care conditions more challenging and expensive to manage. To meet the patient’s physical and mental health needs, comprehensive care management involves the active monitoring of behavioral health to help prevent serious health events and navigate care across multiple providers and settings.

A full-service care management program with a nurse navigator as a central point of contact can personalize its services for employees who may benefit from more comprehensive attention. As they coordinate care and guide patients to an individualized treatment plan for better behavioral health, nurse case managers can help relieve anxiety and make at-risk patients feel more in control and proactively managing their health.

3: Ensure networks provide access to mental health services with telehealth options.

Demand for behavioral health services is expected to stay high for the foreseeable future. According to the National Alliance on Mental Illness (NAMI), however, many people do not have the same access to mental health specialists as they do for other medical providers – nor do they have as many available options. When they can find a mental health professional, they may be forced to go out of network to receive treatment.

This leads to higher out-of-pocket costs for mental health care compared with other types of primary or specialty care. When people face increased expenses, it may lead to seeking less care — or going without any care at all. Access to mental health services, clearly communicated to employees, is key to seeking and receiving treatment, which in turn improves productivity and retention.

A coordinated care team is better able to meet both the mental and physical health needs of the patient with improved outcomes.  Along those lines, the American Medical Association has established the Behavioral Health Integration (BHI) Collaborative with seven other physician associations to promote the integration of behavioral and mental health care into primary care practices. Such steps are critical for greater access and a robust telemedicine plan that addresses the issue of fewer available mental health providers by incorporating primary care into the solution.

4: Include an Employee Assistance Program in your benefits package.

People are struggling more than ever in the wake of COVID-19. An Employee Assistance Program (EAP) provides confidential support for numerous concerns, including mental health issues and personal, family or work problems. Counselors and other specialists can assist with stress, depression, substance abuse or financial issues. Identify an EAP that responds quickly when employees reach out.

The benefits of an EAP make such a program a worthy investment. NAMI estimates that untreated mental illness costs the United States up to $193 billion annually in lost productivity.

When employees are able to successfully manage their health, employers can expect to see improved job performance, productivity, engagement and retention; while minimizing the impact to their bottom line due to turnover, absenteeism, increased mental health services and higher insurance costs.

Data-driven solutions

The COVID-19 pandemic has forced all of us to find new solutions for improved health and access to the right care delivery. Through the mental, physical and financial implications of this global health crisis, Valenz remains committed to delivering on our core promise of smarter, better, faster healthcare – so our clients and their employees are strong, vigorous and healthy.

 

***

Amy Gasbarro is Chief Operating Officer of Vālenz™, one of the nation’s leading data-driven, medical cost containment and care management organizations offering an ecosystem of expanded data and service solutions to support the self-insured industry.

Portrait of Randy Dorshorst, Vice President, Ecosystem Success at Vālenz Portrait of Patty Onion, Vice President, Claims Operations at Vālenz

Vālenz Appoints Dorshorst, Onion to Leadership Team

New Vice Presidents Poised to Enhance Data-Driven Solutions, Cost Savings and Operational Excellence

PHOENIX, Ariz. (December 4, 2020) — Vālenz™ is pleased to announce the appointments of Randy Dorshorst and Patty Onion to the leadership team.

Dorshorst has joined Valenz as Vice President, Ecosystem Success, to advance the innovation behind the company’s health administrative ecosystem, combining data analytics with care service delivery to minimize claims costs for the self-insured industry and promote quality care.

“We are thrilled to welcome Randy to our senior team to oversee the continuing success of our product, data and client program solutions,” said Rob Gelb, Chief Executive Officer. “Randy offers 30 years of expertise in driving growth, technology and value through custom solutions, which makes him an outstanding fit to lead Valenz in the purposeful expansion of our ecosystem.”

Most recently, Dorshorst served as Vice President for AViDEL Medical Management in Irving, Texas. With his comprehensive leadership and management skills, he directed the successful launch of AViDEL as a sister company to Service Lloyds Insurance Company, where he was Vice President for Medical Management Service. Dorshorst also has held executive positions at HealthSmart Casualty Claims Solutions, Web TPA and CorVel Corporation.

Onion, who has more than 30 years’ experience in workers’ compensation, medical cost containment and managed care, joins Valenz as Vice President, Claim Operations.

“Patty’s proven success in setting strategic direction and implementing managed-care platforms and services makes her uniquely well-positioned for this role,” said Amy Gasbarro, Chief Operating Officer of Valenz. “She brings tremendous expertise in claim operations and process improvements that will help us go even farther to drive results for our clients and offer the highest possible level of service.”

Onion most recently served as principal for Milana Health Systems in Kansas City, Mo., specializing in workers’ compensation managed-care consulting. She was CEO of Berkley Medical Management Solutions and has held executive roles with numerous health-related companies including Coventry Health Care, Premera Blue Cross and Mercy Health Plan.

“I have been fortunate to know Patty and Randy for years, and most recently we have benefited from their guidance and counsel as consultants to Valenz,” Gelb said. “Today, I couldn’t be happier to have them on board full time, as they both bring outstanding leadership and deep expertise that will empower us to further deliver on our promise of smarter, better, faster healthcare.”

 

About Valenz

Through a complete health administrative ecosystem, Valenz connects cost and quality data on a single-source, end-to-end analytics platform for smarter, better, faster healthcare. Valenz solutions integrate data from comprehensive care management services (Valenz Care), high-value provider networks (Valenz Access), claim flow management (Valenz Claim), and solutions for payment integrity, revenue cycle management and eligibility compliance (Valenz Assurance) into the ecosystem. More information is available at valenzhealth.com. Valenz is backed by Great Point Partners.

 

About Great Point Partners

Great Point Partners (“GPP”), founded in 2003 and based in Greenwich, CT, is a leading healthcare investment firm, currently with approximately $1.8 billion of equity capital under management and 28 professionals, investing in the United States, Canada and Western Europe. Learn more at www.gppfunds.com.

Searching State Exclusion Lists: Why It Matters for Assured Compliance

If your profession involves compliance management, you know the Office of Inspector General’s List of Excluded Individuals/Entities (OIG LEIE) is the federal database for all Medicaid sanctions – and no doubt your team checks it regularly for sanctioned providers. However, many investigations are conducted by state Medicaid offices and do not always include federal participation. Is your compliance team checking for sanctions and exclusions at the state level as well? If not, they should be.

In fact, OIG Best Practices state that you should also search every state sanction and exclusion list that corresponds with your business or service delivery location(s) – meaning, all states where you operate or have a physical business presence. Some organizations are required to check all 41 state Medicaid sanction lists, but if yours is not one of them, our compliance experts recommend at least checking border states and any other state where the providers in your network or health system have practiced in the past.

Why? Because state actions may appear before federal listings, and in some cases, the states and federal databases do not fully synchronize their entries. But, to be clear, if a person or organization you do business with is excluded by your state, you will face the full threat of repercussions, for hiring and reimbursing them, even if they do not appear on the federal exclusion list.

What do those repercussions look like? In addition to the loss of your reimbursement funds plus interest, civil monetary penalties may apply – not to mention reputational damage and potential legal liability. When it comes to non-compliance, the risks and penalties can be great, so the time and costs associated with checking every applicable sanctions and exclusion list, including state lists, is well worth it.

Also worth noting: To screen thoroughly, you must search lists from state licensing and medical boards, as well as state and county disciplinary action lists and abuse registries (including state/local consumer affairs, addiction recovery lists and more). Checking all lists, not just the major ones, helps ensure compliance by alerting you to providers who may have had fines imposed or faced certain allegations but have not formally been sanctioned.

If you don’t have the internal manpower to ensure no stone is left unturned, good news: Affordable outsourcing options are available. At Vālenz Assurance, we offer a range of compliance software and support solutions to meet your needs and budget. To learn more about how we take the complexity out of compliance, call 888-395-9029.

Building an Effective Compliance Management Program: What You Need to Know

To help prevent fraud and abuse – and all the punitive setbacks that come with broken health care laws and unmet regulations – having a robust compliance program is key. There is no one-size-fits-all approach to compliance management, however, and it is most effective to tailor your program to your organization’s structure and type. The following FAQs are designed to help you understand the basics and formulate next steps for your compliance program.

What is a compliance program, and why do I need one?

A compliance program is a set of internal policies and procedures that helps your organization comply with the law in its daily operations. A proactive plan helps you maintain compliance with today’s regulations, as well as providing a framework for implementing future requirements.

What are the basic components every compliance program should include?

Effective compliance programs include these essential components:

  • Written policies and procedures
  • Effective training and communication
  • Internal monitoring and auditing
  • Enforcement and discipline
  • Prompt action/response times for issues detected

Why should I customize my organization’s compliance program?

Every organization is structured differently, has unique staffing and contracting programs, provides a different mix of services, and has a specific profile of patient demographics and payer mix. While the basic essentials apply to any compliance program, the specifics will vary based on your organization’s unique operations, structure, and areas of risk.

What resources are available to help me customize my compliance program?

To help you develop a compliance program that is most impactful for your organization, the Office of Inspector General (OIG) has developed a set of principles, called Compliance Program Guidance (CPG). These guidance documents are geared toward different segments of the healthcare industry, including:

  • Hospitals, Nursing Facilities, Physician Practices, Home Health Agencies, Hospices
  • Medicare+Choice Organizations
  • Third-Party Medical Billing Companies
  • Public Health Services (grants)
  • Pharmaceutical Manufacturers
  • Clinical Laboratories
  • Ambulance Suppliers
  • Durable Medical Equipment, Prosthetics, Orthotics, and Supply Industry

Use the CPGs as a starting point, and then tailor them for your organization. The OIG provides many additional compliance resources to encourage effective internal controls to monitor and manage adherence to applicable statutes, regulations, and program requirements.

Also, remember that a compliance program is never done – it evolves with your business and with changing regulations. It is forward-looking, and focused not only on risk containment, but also on best care and management practices.

This sounds like more than my small team can manage. Can I outsource my compliance program instead?

Yes! At Vālenz™, we offer a range of compliance software and support solutions to help assure you are not the “last to know” about a sanctioned provider or other compliance issue. With three tiers of service to accommodate any need and every budget, we take the complexity out of compliance and deliver peace of mind. To learn how we help you protect your organization from the risks of non-compliance, call 888-395-9029.