Services

Health Insurance Carriers & Marketing Entities

Colleen McGuire Consulting (CMC) advises carriers and insurance marketing companies on the latest laws concerning federal and state regulations for marketing, advertising, and new product development. From Affordable Care Act (ACA) health insurance to Medicare plans, CMC stays on top of annual changes to regulatory requirements of the Department of Health and Human Services (HHS), the Centers for Medicare and Medicaid Services (CMS) and the National Association of Insurance Commissioners (NAIC). CMC also tracks the pulse of each presidential administration for regulatory updates to non-compliant ACA medical insurance options, including short-term medical and accident & sickness indemnity insurance. 

Healthcare Providers

The healthcare industry is extremely complex. Many small practices and institutional facilities have the best intentions to care for their patients but lack the administrative manpower to ensure procedures and protocols are followed. Some healthcare providers are unaware that the Office of the Inspector General (OIG) requires healthcare entities to have a compliance program in place. 

A few of the top risks providers and facilities need to be concerned with are third-party relationships, including the rules surrounding the use of outside contractors vs. employees, privacy and data security, and legal and regulatory compliance. 

CMC Areas of Expertise

Development and Drafting of Policies and Procedures

Your operating strategy is part of daily business decisions. Strategy also starts with documentation like policies and procedures, and a Code of Conduct. Having policies and procedures for compliance in place can help determine how a business will monitor and measure success. In addition, the Code establishes the perimeters for additional policies and procedures, and establishing training and communication standards. 

Development and Drafting of Code of Conduct

If a complaint arises, the OIG (and if involved, the Department of Justice) will ask, ‘does this organiztion have a compliance program and is it well designed?’ No matter the size of the practice or facility, a compliance program must be in place and have design elements like a Code of Conduct, which provides a guiding beacon for employee behavior, organizational management guidelines, and how misconduct is treated, remediated, and documented, should it arise.

Reference-Based Pricing Protocols

Reference-based pricing (RBP) protocol for healthcare providers ensures fair and transparent payments to healthcare providers while mitigating risks and maintaining compliance with relevant regulations. RBP can offer numerous advantages over traditional payment systems like Medicare or Medicaid, providing a fairer and more sustainable approach to healthcare reimbursement. Using RBO, providers can offer fairer reimbursement practices and reduce their administrative burden to become more efficient. Under CMC guidance, providers learn to go beyond ‘how little does the network compesate’ to ‘what is my payment percentage guarantee.’

Website Privacy Policies

Many states update their privacy laws annually or designate them for legislative action years in advance. Are your website and patient documentation current with 2024 laws? CMC helps providers and facilities ensure they are compliant with the most recent online privacy acts on any state level. 

Understanding of Employment Law

In January 2024, the Department of Labor (DOL) published new regulations for classifying independent contractors. Six new factors have come into play for employee vs. contractor status, which affects how organizations hire and maintain employment records in the eyes of the DOL. CMC can help providers and facilities determine the totality of the circumstances to uphold required compliance standards.

Overall Compliance Review Process for Healthcare Businesses 

CMC can help ensure that healthcare providers and facilities operate ethically, efficiently, and fully adhere to the regulations set forth by the OIG with a risk assessment of policies and procedures, training documentation and monitoring, and remediation steps to right any areas that need updating. CMC’s distinct knowledge of HIPAA, Stark, and Anti-Kickback Laws, and the False Claims Act helps review and assess organizational business models and build a compliance program unique to the practice or facility’s mission.