2024 Healthcare Compliance Trends: What Hospitals Need to Know

More than 60 million people across the nation are covered by the Centers for Medicare and Medicaid Services (CMS), and it plays a crucial role in offering healthcare services. If you oversee a long-term care facility, chances are you engage regularly with CMS in various transactions involving Medicare beneficiaries. It's natural to have inquiries about billing procedures, the appeals and grievances system, CMS requirements, and other relevant CMS categories.

In this article, we are going to discuss grievances and complaints in 2024, along with some other factors outlined by CMS. However, understanding these processes is vital in the realm of Medicare billing, as they play a key role in ensuring continued coverage for patient care.

CMS Definition Of Grievance

According to CMS, grievance means when you express dissatisfaction with any aspect of a Medicare health plan, like its operations, activities, or the behavior of its providers. This can include issues with getting appointments or experiencing long wait times, as well as disrespectful or rude behavior from doctors, nurses, or other staff in clinics or hospitals associated with the plan.

Deficiency citations often stem from challenges in meeting CMS grievance requirements. Acute hospitals find these standards outlined in the patient rights section of the Conditions of Participation manual. Even though Critical Access Hospitals (CAHs) lack a specific section, and acute hospital requirements don't directly apply to CAHs, it is essential for CAHs to establish policies and procedures addressing patient rights, encompassing grievances or complaints.

However, one can file a grievance verbally or in writing within 60 days of the event or incident that triggered the dissatisfaction. Some of the grievance examples are as follows:

• Difficulty scheduling appointments or long wait times.
• Disrespectful or rude behavior from doctors, nurses, or other staff.

Each plan must have effective procedures to resolve both standard and expedited grievances and complaints in 2024 in a timely manner. After receiving a grievance, plans must inform all involved parties about the investigation's completion promptly, typically within 30 days or sooner if the enrollee's health condition requires it.

If you have a complaint about the quality of care received in a hospital or another provider setting, you can report it through the plan's grievance procedures, the Beneficiary Family Centered Care - Quality Improvement Organization (BFCC-QIO), or both. The goal is to ensure that concerns about the quality of care are addressed promptly and effectively.

Why Hospitals Need to Follow Grievances and Complaints 2024

It's crucial for hospitals to remember that following up on grievances and complaints is not just a regulatory requirement but also an essential aspect of providing high-quality, patient-centered care. By taking concerns seriously and demonstrating a commitment to improvement, hospitals can create a safer, more positive environment for everyone involved.

Hospitals accepting Medicare or Medicaid reimbursement must comply with the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs) and other regulatory bodies like The Joint Commission (TJC) and DNV Healthcare (DNV). These standards mandate a robust grievance and complaint process, with failure to follow up potentially leading to deficiencies, fines, or even loss of certification.

Patient Safety and Quality Improvement

Grievances and complaints often highlight areas where patient safety or quality of care fell short. By following up, hospitals can:

• Identify and address systemic issues: Recurring complaints may point to broader problems within the hospital, allowing for proactive solutions to improve overall care.
• Reduce medical errors and adverse events: Addressing concerns related to medication errors, communication breakdowns, or other issues can prevent future occurrences.
• Improve patient satisfaction and loyalty: Taking complaints seriously and demonstrating a commitment to resolution fosters trust and positive patient experiences.
• Risk Management and Mitigation: Unresolved grievances can escalate into lawsuits or negative publicity, damaging a hospital's reputation and finances. Following up shows responsiveness and helps mitigate potential legal or PR risks.

Unheard staff concerns can lead to low morale and disengagement. Addressing staff grievances fosters a more positive work environment, potentially reducing turnover and improving overall performance. Grievances and complaints offer valuable feedback that can inform continuous quality improvement initiatives. By analyzing trends and patterns, hospitals can identify areas for improvement and strive for excellence in patient care.

However, there are many compliance trends in healthcare emerging in 2024, such as artificial intelligence, HHS cybersecurity framework, and many more. It’s important for hospitals to know about these emerging trends in order to prevent them from non-compliance consequences and provide robust healthcare services to patients.

Failure to follow up on grievances and address the underlying issues may result in citations from CMS or other regulatory bodies. These citations can lead to penalties, increased scrutiny, and potential adverse effects on the hospital's accreditation and reimbursement status. Non-compliance with patient-focused standards and regulations is a serious matter that can have far-reaching consequences for healthcare institutions.