Automating compliance checks per regulatory requirements

Purpose

1. Ensure anesthesiology billing and documentation meet healthcare compliance standards (e.g., HIPAA, CMS, local laws).

2. Minimize risks of penalties, audits, and claim denials by automating regulatory validation prior to claim submission.

3. Audit internal processes for accuracy of coding (ICD-10, CPT), provider credentialing, and patient consenting.

Trigger Conditions

1. New bill or clinical note is generated in the EHR/billing system.

2. Provider submits documentation for a completed anesthesia service.

3. Scheduled periodic compliance audit events (daily/weekly/real-time).

4. Change detected in regulation data sources or payer ruleset.

5. Claim moves from draft to ready-for-submission status.

Platform Variants

1. Epic EHR

• Feature/Setting: Interconnect API; Configure event webhook to export new anesthesia billings for compliance validation.
  

2. Cerner Millennium

• Feature/Setting: Ignition API for workflow event triggers; Use GET_DOCUMENT_EVENTS to detect new documentation submissions.
  

3. Allscripts

• Feature/Setting: FHIR API integration; Configure to push claim data at encounter closure.
  

4. Athenahealth

• Feature/Setting: Marketplace Compliance App; Enable webhook for when new charges are completed.
  

5. Meditech

• Feature/Setting: ClinicalBridge Interface Engine; Set HL7 feed to trigger compliance workflow on claim export.
  

6. Greenway Health

• Feature/Setting: API Billing Export; Set recurring job for nightly billing compliance review.
  

7. QGenda

• Feature/Setting: Schedule Change Notification API; Push anesthesia provider schedule changes to compliance audit process.
  

8. Salesforce Health Cloud

• Feature/Setting: Custom Apex flow; Listen to new record entry in billing module and push to compliance validation API.
  

9. SAP Health

• Feature/Setting: Integration Suite; Use iFlow to send billing events to compliance audit microservice.
  

10. Microsoft Power Automate

• Feature/Setting: Common Data Service Trigger; On new healthcare record entry, pass record to compliance validation flow.
  

11. Oracle Health

• Feature/Setting: HL7 Interface Trigger; Route billing messages through HL7 feed for compliance logic.
  

12. Google Cloud Healthcare API

• Feature/Setting: Pub/Sub Trigger on FHIR resource create; Send event to Dataflow pipeline for regulatory check.
  

13. AWS HealthLake

• Feature/Setting: EventBridge; Trigger Lambda to perform compliance audit when new claims added.
  

14. Redox Engine

• Feature/Setting: Data Model Event Subscription; Activate listener for new BILLING admin messages.
  

15. Experian Health

• Feature/Setting: Compliance Insight Service API; Validate claims pre-submission for regulatory mismatches.
  

16. Availity

• Feature/Setting: Claims Edit Service API; Push claim JSON for real-time compliance edit response.
  

17. Waystar

• Feature/Setting: Compliance Analytics API; Configure push of anesthesia claims for risk scoring.
  

18. Change Healthcare

• Feature/Setting: ClaimsXten; API trigger for compliance edits on anesthesia CPT combinations.
  

19. Trizetto (Cognizant)

• Feature/Setting: Claims Processing API; Send claim for compliance and regulatory check.
  

20. Flatiron OncoEMR

• Feature/Setting: Webhook for Billing Event; Trigger compliance check on anesthesia record creation.
  

Benefits

1. Eliminates manual steps, reducing time and compliance cost.

2. Flags errors in near-real-time, improving claim acceptance rates.

3. Rapid adaptation to evolving regulations via API or low-code configuration.

4. Eases audit preparation and reduces risk of costly billing penalties.

5. Enables scalable governance across multiple sites and providers.