Making Your Agency Compliance Strong for 2015 and Beyond

Compliance Badge

There is a seemingly constant stream of grabbing headlines revealing yet another behavioral health or human services agency being penalized under payer take-backs or even accused of fraud, but for many providers these horror stories have not been enough to drive them towards compliance action.

In this post, we’ll take a closer look at compliance for behavioral health and human services providers, and reveal the best practices to guarantee that your agency is compliance strong for 2015 and beyond.

The Rise of the Take-Back

Providers not yet prioritizing compliance should tread carefully, especially considering the prevalence of payment reform causing payers to ramp up their compliance efforts in the form of persistent audits. This combined with the advent of incentive programs, means that payers are looking to minimize costs by enforcing take-backs whenever possible.

These take-backs or the mandatory repayment of overpaid funds continue to hit the healthcare industry hard, but for behavioral health and human services providers, take-backs can mean the difference between agency stability and a funding crisis.

The impact of take-backs is further amplified by existing funding issues which contributing to the extreme likelihood that overpaid funds have already been spent. This leads many providers to resort to desperate measures including layoffs in order to secure funds for repayment.

7 Steps to Guarantee Compliance Excellence

Providers can move closer to effective compliance measures and audit safeguards by following these key steps:

  1. Adopting a Leading EHR

    EHRs are one of the most effective compliance tools in a provider’s toolkit. The most effective EHRs make clinical documentation a part of the clinician’s workflow and require the completion of proper documentation for every service provided before a claim can be submitted. This level of checks and balances, makes documentation a natural part of the clinician’s day and integral to the billing process.

  2. Assigning a Point Person

    For behavioral health and human services agencies of any size, compliance starts with a point person, the Compliance Officer. This person manages and oversees all agency compliance efforts.

    Avoid: the Compliance Officer/Jack-of-All-Trades. Unfortunately, many agencies that already have Compliance Officers encourage them to priorities other responsibilities unrelated to compliance. These responsibilities usually take precedent over compliance and all compliance efforts are pushed further and further back. Avoid this common pitfall at all costs.

  3. Building Your Compliance Dream Team

    Establish a committee of stakeholders from across the agency to ensure that the unique compliance concerns of each department are represented. Compliance teams create greater accountability, build staff buy-in and result in stronger compliance initiatives.

  4. Getting the Rest of Your Agency On-Board

    Start with the message that prioritizing compliance is mandatory and essential to each person’s role. Incorporate this message into regular staff trainings on compliance and highlight how compliance will benefit the work they do on a daily basis. Educate the entire agency on the necessity of compliance, especially all members of the management, clinical and billing teams.

    Avoid: Take-backs and repayment will be too abstract for the larger agency and should not be the primary message of your compliance training nor should it be the primary goal of your compliance efforts. Providers often forget that the most profound impact of compliance is not avoiding penalties, but positively impacting quality of care, efficiency and overall cost management.

  5. Creating a Compliance Roadmap

    With help from the compliance committee, the Compliance Officer should create a compliance plan featuring the following components:

    > Identification of compliance committee members and Compliance Officer
    > Clearly defined compliance objectives and standards
    > Internal staff training programs
    > Enforcement standards for disciplinary action in response to instances of noncompliance
    > Standard guidelines to respond to noncompliance and prevent repeat offenses

  6. Monitoring for Signs of Noncompliance

    Continuously monitor for signs of noncompliance. High denial rates and incorrect billings are usually a dead give-away. Pay close attention to clinical documentation, which is consistently one of the highest contributors to noncompliance.

  7. Conducting Audits

    Perform regular internal audits to prevent noncompliance surprises and address issues in a timely manner after they arise.

The Compliance Power of an Effective EHR

Qualifacts’ certified Complete EHR, CareLogic Enterprise, enforces the necessary checks and balances to simplify the compliance process and safeguard against failed audits.

With CareLogic, providers can rest easy knowing that…

  • Proper and completed documentation is required for each specific service provided.
  • Completion of certain document fields is required and signature validation is enforced to reduce “documentation errors.”
  • Documentation forms can easily be adapted to changing regulations to ensure that providers are not using outdated forms.
  • Only “clean claims” are sent out.
  • The billing staff can mark services as “non-billable” if provided in error. Changing a service to “non-billable” no longer triggers a claim, but allows the documentation to remain in the client’s chart.
  • Providers receive reliable alerts to notify them of unkept appointments and the need for document completion or signature verification.
  • For convenience, documentation generates directly from the clinician’s schedule. This means that they do not have to recreate the information in multiple places which saves precious time and energy.

Qualifacts Named Fastest Growing Behavioral Health EHR

QSI-IncQualifacts Systems, Inc., the leading cloud-based electronic health record (EHR) provider for the behavioral health and human services industries, is proud to announce that it has been named to the Inc. 5000 as the fastest growing behavioral health EHR in America. This announcement marks Qualifacts’ third consecutive year ranking in the Inc. 5000 and highlights the company’s commitment to continued growth.

“Our growth is a direct result of listening to our customers, understanding their needs, and hiring smart, passionate people who know how to execute. I’m extremely proud of what we’ve accomplished, but even more excited about our future.” says David Klements, President and CEO of Qualifacts.

Qualifacts provides integrated clinical, financial and administrative software solutions to the behavioral health market through its single platform EHR, CareLogic Enterprise. The company has significantly increased its profitability from year to year and more than doubled its revenue from 2011 to 2013. In the past five years, the company has grown its workforce by 650% and customer base by 1,000%. With plans for future growth strengthened by a recent majority investment from private equity firm, Great Hill Partners, the company is on track to increase its workforce by an additional 40% by the end of 2015.

Qualifacts will continue to invest in sales and product development to further reinforce its position as a market leader and continue to support the complex healthcare reform needs of behavioral health organizations.

“Qualifacts’ single platform approach is the best solution for behavioral healthcare providers that either don’t want or can’t afford major software upgrades every few years and rightly prefer to dedicate their resources to serving more clients and improving care quality,” states Klements. He also adds that “at a time of rapid change in the healthcare market, Qualifacts is focused on ensuring that our customers can access and leverage the information and technology they need to not only compete, but thrive.”

What Do You Get When You Cross Technology and Community?

Nashville Skyline from Titans Stadium

You may have heard that Qualifacts recently secured a private equity investment from Boston-based Great Hill Partners, which presents a valuable opportunity for Qualifacts to create additional value for behavioral health and human services providers and strengthen product quality, but also continue to support local community.

The investment will help Qualifacts strengthen its importance in behavioral health technology and, along with a collection of local technology leaders, kick-start a rising technology community in the heart of Music City, Nashville, Tennessee. “The investment helps Qualifacts grow, but at the same time, having those resources in Nashville promotes tech community growth,” says Bryan Huddleston, President and CEO of the Nashville Technology Council (NTC), an organization dedicated to fostering and advancing the technology community in Middle Tennessee.

“I want there to be a change.”

Helping to lead this community progress and economic development is Qualifacts’ CEO, David Klements. Huddleston weighs in on Klements’ role in the Nashville community, saying that “Klements, from both a career and community-give-back perspective, has been very intentional about saying, ‘I want there to be a change.’”

Qualifacts is looking to deliver this change by recognizing the importance of community and helping behavioral health and human services providers deliver a higher quality of care to communities everywhere.

NTC interview and post by Cassidy McHose and Michael Norco

Qualifacts Strengthens Market Leadership with Majority Investment from Great Hill Partners

Qualifacts Systems, Inc. today announced that it has secured a majority investment from Great Hill Partners, a Boston-based private equity firm with more than $3 billion under management. The recapitalization, which was led by Great Hill Partners and existing Qualifacts management, will allow the company to accelerate product development and continue growth. The investment will also help the company identify strategic partnership and acquisition opportunities.

“Qualifacts has emerged as a recognized leader in behavioral health software, but there’s more we want to do to ensure that our customers are successful for the long-term,” said David Klements, President & CEO of Qualifacts. “To help us maximize our full potential, Qualifacts management wanted a financial partner with the right experience and resources. Great Hill was a perfect fit and we’ve already hit the ground running.”

In the past five years, Qualifacts has grown its customer base by 1,000% and workforce by 650%, repeatedly earning the company a place among the Inc. 5000 as one of the fastest growing private companies in America. The company’s single platform EHR, CareLogic Enterprise, supports more than 50,000 behavioral health professionals in 30 states and has supported the delivery of more than 20 million services to one million consumers within the past year.

“We are delighted to partner with David and the entire Qualifacts team,” said Mark Taber, a Managing Partner with Great Hill Partners. “Qualifacts offers a unique and powerful platform for behavioral health organizations to drive operational efficiencies, improve access to patient information, and quickly adapt to changing billing and compliance regulations.”

The investment will accelerate existing product initiatives which support the healthcare reform needs of behavioral healthcare providers. These include demonstrating clinical outcomes, coordinating care with other healthcare systems, delivering integrated primary care services alongside behavioral healthcare and efficiently handling new payment models.

Rafael Cofiño, a Principal with Great Hill Partners, added, “We believe Qualifacts has tremendous growth potential as behavioral health providers seek ways to manage increasing patient volume along with highly dynamic state and federal funding requirements.” Great Hill Partner’s prior healthcare technology investments include bswift, Passport Health Communications and SterilMed.

About Great Hill Partners

Great Hill Partners is a Boston-based private equity firm that manages more than $3 billion in capital to finance the expansion, recapitalization or acquisition of growth companies in a wide range of sectors within the business and consumer services, healthcare, media, communications and software industries. Great Hill targets investments of $25 million to $150 million.

For more information, please see

Qualifacts Helps Customer Cut Report Building Time by 500%

Recently, Generations/Gaither, a behavioral health service provider and Qualifacts customer, needed to build a particular report in Qualifacts’ report building system and wanted to learn more about the report building process. To address Generations’ reporting needs, a personalized one-on-one training was arranged through a statement of work.

Being so closely located to Qualifacts’ Nashville headquarters, we arranged for Generations to visit our office for the training day. Upon arrival Wayne Greer, Executive VP of Generations/Gaither’s Group, met one-on-one with Qualifacts’ reporting subject matter expert and gained invaluable answers to the questions hindering Generations’ essential reporting abilities.

The training day was tailored to target Generations’ specific needs and included discussion topics around methods of accomplishing a report detail and applying rules, and processes to accomplish reporting goals. In addition to tons of learning, the training also included a bit of fun and laughter for good measure.

Wayne ended the day with a fully functional report that he personally created and completed, and stated that the one-on-one training was well worth his time.

“Being able to sit down with Qualifacts staff in-person, I believe we were able to accomplish, in a very short time, work that would have taken much longer if we had tried to work over any kind of distance medium. Indeed, when I submitted the original request to have my report written, the estimated time to complete the report was 25 hours. Working together in person, we were able to complete the report in about 4 to 5 hours and spend additional time in general training. It was also nice to be able to see where the support staff worked and to meet the folks that I have been working with over the phone. It was a very productive and pleasant visit.”

- Wayne Greer, Executive Vice President of Generations/Gaither’s Group and Qualifacts Customer


Pilot Project Challenges Providers to Create Industry Benchmark

As a leading SaaS provider, Qualifacts is constantly driving innovation and employing user informed data to build solutions to complex healthcare reform needs. One example of this is our recently launched pilot project; through which, the Qualifacts team is encouraging organizations to play a greater role in future improvements to CareLogic IMPACT, our fully integrated outcomes management tool. The project will help leverage comprehensive benchmarking data to gain insight into several key areas including unmet implementation needs, access to outcomes data and much more.

The project includes ten participating organizations and will focus on:

  • Monitoring the implementation and use of CareLogic IMPACT in order to better identify strengths and opportunities for improvement
  • Developing and piloting a benchmarking process that is scalable for the entire CareLogic IMPACT system
  • Evaluating outcomes linked to CareLogic IMPACT for each participating organization

We look forward to sharing the project results with the CareLogic IMPACT family shortly and applying these findings to further streamline clinical outcomes measurement.

Want to learn more about  the pilot project and CareLogic IMPACT? Contact Christy Winter for more information.

Building Integrated Care Readiness through a Culture of Collaboration

As a promise to close the gap between the treatment of our bodies and our minds, Integrated Care seeks to standardize the collaboration of behavioral health and primary care providers. The Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Council for Behavioral Health, along with other leading behavioral health authorities, now suggest that integrated care “produces the best outcomes and is the most effective approach to caring for people with complex healthcare needs.”

Many behavioral health professionals are familiar with the importance of a better integrated healthcare model, but are struggling with the idea of creating a culture of collaboration that would enable a provider to participate in integrated care and therefore, holistically improve the lives and well-being of the clients they serve.

We must remember that, clinicians, social workers, counselors and other human service providers do not enter the behavioral health field because they love collaborative data sharing. They work in this field, because they are passionate about people. People who are too often stigmatized for the behavioral health challenges that they face everyday. To this extent, your staff’s passion and dedication are your greatest assets for truly adopting a culture of collaboration which serves as the backbone of integrated care. You can tap into this passion and use it to help facilitate the cultural shift needed to begin to tackle integrated care head-on by focusing on:

  1. Internal Education
    Ensure that your passionate staff members are fully informed on the importance of systemic integration. This is absolutely key to fostering a culture of collaboration, and internally building momentum and enthusiasm for integrated care.
  2. Investment Creation
    Foster a sense of investment by specifically identifying for staff members the direct link between their day-to-day tasks and care goals, and the vision of integrated care best suited for your agency.
  3. Champion Recruitment
    Often undervalued, is the active transformation of passionate staff members into champions of change internally. The impact of fellow staff members championing the cultural changes required to reinforce the value of integrated care and the role of knowledge sharing in supporting the overall mission of your practice should never be underestimated.

Once your staff understands the direct connection between the work they do and the role of integrated care in improving that work and the overall wellness of their clients, they will create a tangible investment in collaborative culture and become champions of care integration.

2014, marks a pivotal year for behavioral health providers to decide where they fit within the service delivery models of healthcare reform and along the integrated care spectrum, decisions that internal champions of change and a culture of collaboration can help guide. If agencies do not determine where they fit within the future of healthcare, it will be decided for them and with quality of service delivery increasingly tied to reimbursement in the form of pay for performance contracts, the stakes are too high to ignore.

By engaging passionate staff members and encouraging a culture of collaboration we can use integrated care to change the healthcare landscape, offer a higher standard of “customer” service and improve the link between the treatment of mind and body.

Mary Givens is a leading expert on healthcare reform, integrated care and meaningful use. She serves as the Product Manager of Healthcare Reform at Qualifacts Systems Inc. and is the primary contributor for the blog MUforBH, a comprehensive healthcare reform knowledge base for behavioral health professionals.


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