As the pressure mounts for the healthcare system to detect and eliminate fraud, waste, and abuse, compliance officers are feeling equal pressure to ensure their organizations are remaining compliant in light of Medicare audits and new regulatory demands.
Two PYA experts, Lori Foley, Managing Principal of Revenue and Compliance Advisory, and Shannon Sumner, Principal and PYA Chief Compliance Officer, were recently asked by Healthcare Risk Management to share strategic insights regarding compliance in the era of increased scrutiny on fraud, waste, and abuse.
In the article, “Staying Compliant Can Be Challenging in 2025,” editor Gregory Freeman asks Foley and Sumner about the Trump administration’s goals for detecting and eliminating waste in Medicare, the expected increase in whistleblowing, the compliance risk with the 340B Drug Pricing Program, and cybersecurity risk with third-party vendors.
Increased Scrutiny and Whistleblowing
Foley discusses the planned increase in Medicare and compliance audits and fines. “They’ve expanded the hiring of auditors, particularly to go after the Medicare Advantage plans…to make sure [they] have been appropriately reimbursed…,” she says.
Foley notes the emphasis on detecting fraud and abuse will encourage whistleblowers to come forward, which can lead to all sorts of risks for healthcare organizations.
Compliance and Cybersecurity Risks
Sumner discusses the 340B Drug Pricing Program, which is a “significant source of revenue when done well…,” she says. As such, she says PYA is seeing more audits related to the program. Sumner recommends organizations employ comprehensive 340B auditing and monitoring programs.
Third-party vendors also bring new challenges, Sumner says. As large healthcare systems look to increase revenue while cutting costs, they often use third-party vendors, such as telehealth services, cloud providers, and medical device manufacturers. This practice increases compliance and cybersecurity risk. In fact, PYA is helping health systems and physicians address compliance and cybersecurity risks from third-party vendors more than ever before, Sumner says.
PYA’s experts in Compliance, Revenue Cycle Advisory, and Healthcare Technology and Cybersecurity are committed to helping healthcare organizations develop strategies to operate in compliance and respond to changing regulatory risk.
