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Navigating Medicare Compliance: 7 Steps and Tips for Healthcare Providers

The cost of Medicare non-compliance is steep. In 2024, the Medicare Fee-for-Service (FFS) program reported an estimated improper payment rate of 7.66 percent, totaling $31.7 billion. While that figure represents significant loss of government funds allocated to healthcare, the consequences extend well beyond the Medicare budget. 

For healthcare organizations, non-compliance can result in denied claims, legal penalties, financial strain, and a loss of patient trust and privacy.

To minimize these risks, the Centers for Medicare and Medicaid Services (CMS) has established clear standards for how healthcare providers must operate within its programs. These rules protect public funds, support ethical care delivery, and ensure the integrity of the healthcare system. Beyond avoiding penalties, maintaining compliance helps practices build a culture of accountability, accuracy, and patient-centered care.

In addition to meeting general healthcare and Medicare standards, practices that participate in value-based care programs like Chronic Care Management (CCM) and Advanced Primary Care Management (APCM) must also adhere to each program’s specific compliance requirements. This adds another layer of responsibility around documentation, billing, and patient engagement. 

Partnering with a value-based care solution provider like ChartSpan helps practices stay aligned with these expectations, reduce risk, and operate with confidence across every aspect of care delivery.

What is Medicare compliance?

Medicare compliance is the effort of healthcare providers to follow all federal and CMS requirements designed to protect patient privacy and prevent fraud, waste, and abuse in healthcare. It’s the foundation for ethical and legal practice, accurate reimbursement, and an organization’s operational integrity.

Compliance requires an ongoing commitment to aligning every process, policy, and interaction with established regulations. This includes strict adherence to laws such as:

• Health Insurance Portability and Accountability Act (HIPAA), which protects private patient data.
• Health Information Technology for Economic and Clinical Health (HITECH) Act, which ensures the secure use of electronic health records.
• False Claims Act (FCA), which prohibits submitting false or fraudulent claims for payment to Medicare or Medicaid.
• Anti-Kickback Statute (AKS), which forbids offering or receiving anything of value to influence the referral of services reimbursable by federal healthcare programs.
• Stark Law, which restricts physician self-referrals for certain designated health services when there is a financial relationship involved.

Medicare compliance also requires a deep understanding of coverage requirements and billing codes, particularly for practices that deliver preventive care services through Medicare-funded programs like CCM and APCM. In these programs, thorough documentation and billing directly impact both regulatory compliance and reimbursements, making consistency and accuracy vital to program success.

Key elements of an effective Medicare compliance program include:

• Accurate billing and coding that reflect the care delivered
• Protection of patient privacy through secure data management
• Thorough documentation to support every claim
• Staff training on regulations and fraud, waste, and abuse (FWA) prevention
• Established compliance policies and procedures tailored to your practice
• Ongoing internal monitoring and audits to identify and correct potential issues early

When each of these components is functioning together, your practice stays compliant, strengthens its operations, safeguards patient trust, and sets your care programs up for success.

Why compliance is important for your practice

Compliance isn’t just a regulatory requirement; it’s a reflection of your practice’s commitment to ethical, patient-centered care. A strong compliance program builds trust with patients, strengthens internal operations, and protects your organization from financial and legal exposure. It ensures every interaction, process, and claim aligns with Medicare’s expectations, allowing providers to focus more on delivering quality care and less on managing administrative risk.

Benefits of compliance

For healthcare providers, the benefits of maintaining compliance extend far beyond avoiding penalties. It safeguards your reputation, promotes better outcomes, and supports a culture where every member of the care team is invested in doing what’s right for patients and the organization.

Protect patient privacy

A compliant practice protects patients’ personal health information. Following privacy regulations like HIPAA and HITECH ensures medical records are stored, accessed, and shared securely. This not only keeps your organization in line with federal standards but also reassures patients that their data is safe in your care.

Legal and reputational protection

Compliance serves as a shield against costly legal action and damage to your organization’s reputation. By meeting federal and CMS requirements, your practice reduces the likelihood of audits, penalties, or lawsuits. A strong compliance record also positions your practice as a trustworthy and professional healthcare provider.

Establish a culture of integrity

When compliance is part of daily operations, it creates a culture where providers and staff are motivated to uphold the highest standards of care. Everyone understands their role in maintaining ethical practices, from proper documentation and accurate billing to protecting patient privacy, strengthening the integrity of the entire organization.

Bolster patient trust

Patients are more likely to stay engaged in their care when they trust their provider. Demonstrating compliance through transparency, accurate billing, and secure handling of sensitive information builds confidence that your practice operates with their best interests in mind.

Learn more: Improving the Patient Experience in Healthcare: The Role of Care Management

Improved patient outcomes

Compliance and quality go hand in hand. When documentation is thorough and patients trust providers to handle health information responsibly, providers gain a clearer view of each patient’s medical history and current concerns, leading to more accurate diagnoses and more effective treatment plans. Patient trust also drives stronger engagement and adherence to recommended care.

Risks of non-compliance

Whether intentional or accidental, compliance lapses can have serious consequences for your practice. Releasing health records to unauthorized individuals, failing to secure patient data, denying patients access to their own records, or billing for services that were not actually provided can trigger costly audits, fines, and reputational damage.

Legal implications

Violating Medicare or federal healthcare laws can lead to civil or criminal penalties under regulations like the False Claims Act or Anti-Kickback Statute. Legal action can drain resources, disrupt care delivery, and permanently impact your organization’s standing with CMS.

Financial penalties

Improper billing, inaccurate documentation, or fraudulent claims can result in significant fines and repayment obligations. Even unintentional errors can be costly, emphasizing the need for consistent training, audits, and compliance oversight.

Medicare audits

Non-compliance increases the likelihood of a CMS audit. These reviews can halt reimbursements, consume valuable staff time, and, in the worst-case scenario, uncover deeper systemic issues within your billing or documentation processes.

Security breaches

Failing to protect patient data exposes your practice to both regulatory action and reputational harm. Breaches can erode patient confidence, result in financial loss, and require extensive remediation efforts to restore trust and compliance.

Exclusion from federal healthcare programs

Severe or repeated violations can lead to exclusion from Medicare programs, cutting off a critical revenue stream and limiting your practice’s ability to serve patients who rely on government-funded care.

7 steps to Medicare compliance

Creating and following a structured compliance program is the cornerstone of Medicare compliance. A well-defined program ensures that everyone in the practice understands expectations, adheres to federal and CMS regulations, and consistently follows established policies and procedures. This foundation not only helps prevent errors and audits but also fosters a culture of accountability and high-quality care.

Below are seven essential steps your practice can take to stay compliant and maintain operational integrity.

1. Establish policies and procedures

Policies and procedures define how your practice manages billing, documentation, patient privacy, and reporting, and they provide clear guidance for staff on handling sensitive situations in accordance with federal regulations. These should be specific to your practice’s operations; identify your practice’s compliance risk factors before writing the standards.

ChartSpan has built-in policies and procedures for CCM and APCM programs, particularly around patient enrollment and consent. By standardizing these workflows, ChartSpan helps practices maintain consistency, reduce errors, and ensure adherence to CMS program requirements.

2. Designate a compliance officer

A compliance officer oversees the program, ensuring that policies are implemented effectively, staff are trained, and issues are addressed promptly. Depending on the size of your organization, this role may be filled by a dedicated committee or shared by several staff members. Either way, it’s critical for monitoring adherence and maintaining accountability across the practice.

While ChartSpan doesn’t replace a compliance officer, our reporting and documentation tools provide structured, audit-ready records for CCM and APCM. This support makes it easier for compliance officers to monitor program adherence and review activities efficiently.

3. Provide compliance training

Staff training ensures that everyone in the practice understands regulatory requirements, documentation standards, and ethical practices. Regular training helps prevent errors, reinforces accountability, and ensures all team members are equipped to maintain compliance.

Before your program’s launch, ChartSpan provides comprehensive onboarding and training for the entire practice staff. This ensures everyone understands the requirements for CCM and APCM programs, from documentation standards to patient communication workflows, setting your practice up for consistent compliance from day one.

4. Maintain effective communication

Open, consistent communication across the practice and with third-party contractors ensures compliance expectations are clearly understood, policies are followed, and issues are addressed quickly. Communication also plays a key role in establishing transparency with patients.

ChartSpan maintains clear communication channels with practices, helping coordinate patient interactions, document care, and provide updates on program requirements. This level of information sharing between providers, practice staff, and care managers ensures consistent delivery of services in line with program requirements.

5. Audit and monitor regularly

Internal auditing and monitoring are essential to identify potential errors or gaps in documentation, billing, and workflows. Ongoing review helps prevent small mistakes from becoming major compliance risks.

ChartSpan maintains detailed, audit-ready records for each CCM and APCM patient interaction. In addition, data insights can help practices identify potential compliance gaps early, allowing staff to address issues proactively.

6. Enforce compliance standards

Enforcing standards ensures that policies and procedures are consistently followed and that staff understand the consequences of non-compliance. This step is critical for maintaining accountability and integrity across the practice.

By standardizing workflows and providing structured documentation, ChartSpan helps staff consistently adhere to compliance standards, reducing opportunities for errors or deviations from CMS requirements in the first place.

7. Respond to issues promptly

Even the most diligent practices encounter issues. Responding promptly helps prevent escalation, correct errors, and maintain both compliance and patient trust.

ChartSpan’s Quality Improvement team regularly reviews performance data, identifies areas for improvement, and implements interventions to address gaps. This proactive approach helps practices strengthen adherence to program requirements and respond quickly when issues occur.

How ChartSpan helps keep value-based care programs compliant

Maintaining a compliant value-based care program is essential for both regulatory adherence and quality patient care, but it can also add administrative burden and introduce new risks for practices on top of general Medicare compliance. Programs like Chronic Care Management (CCM) and Advanced Primary Care Management (APCM) require careful attention to enrollment, documentation, patient communication, and billing to meet CMS standards.

ChartSpan helps practices navigate these requirements while reducing the administrative load and supporting consistent compliance.

Managing enrollment

ChartSpan ensures proper enrollment from the very beginning. During the enrollment call, patients provide verbal consent to participate in CCM or APCM, which is then documented in their medical record. If patients sign up in writing, their consent is documented and saved as well.

Patients are informed about the services available, potential cost-sharing responsibilities, the rule that they can only be enrolled under one provider per month, and their right to discontinue CCM or APCM services at any time, effective at the end of that month. These procedures help practices meet CMS requirements and set patient expectations for participation in care programs.

Protecting patient data

Safeguarding patient information is a critical component of compliance. All ChartSpan software is HIPAA-compliant and SOC2-certified, and staff receive thorough training on privacy procedures. Patients have easy access to their care plan through an online patient portal and can request a copy from their care coordinator or provider at any time. During the welcome call, patients are given options for receiving their care plan, ensuring transparency and patient empowerment while meeting regulatory standards.

Providing thorough documentation

Accurate and up-to-date documentation is essential for both compliance and high-quality patient care. ChartSpan care managers update care plans after every patient interaction, track the time spent on care, revise care plans as needed, and record patient eligibility and consent during enrollment. For Chronic Care Management, this includes documenting the 20 minutes of care provided to each patient. This meticulous documentation supports audit readiness, accurate billing, and effective care management.

Meeting service requirements

ChartSpan helps practices consistently meet CCM and APCM service requirements while also maximizing patient engagement. Care managers contact patients monthly via calls, voicemails, texts, and emails, although CMS does not require direct patient interaction every month. 

ChartSpan ensures that the CCM 20-minute monthly care coordination requirement is fulfilled through a combination of patient outreach, reviewing and reconciling medical records, sharing relevant educational materials, and providing appointment reminders as needed. For APCM, ChartSpan ensures all service capabilities are available to each enrolled patient, each month. 

Assisting with billing

Proper billing is a critical component of Medicare compliance. When practices partner with ChartSpan, staff receive training on compliant billing practices. ChartSpan’s RapidBill™ technology also streamlines the review of claims, helping practices submit accurate claims efficiently while minimizing the risk of errors or rejected submissions.

Looking to launch or strengthen your value-based care program? Talk to an expert to learn how ChartSpan can help your practice establish and maintain fully compliant CCM or APCM programs.

You might also like:

• CCM Compliance Frequently Asked Questions
• Chronic Care Management CPT Codes & Billing Guide
• APCM Billing Codes and How to Use Them