Medicaid audits play a critical role in ensuring healthcare organizations meet compliance, quality, and contractual requirements, and this episode of Compliance Deconstructed breaks down what providers and health plans need to know. Hosts Jessica Zeff, Lorie Davis, and Elvan Baker explore how ECRO and ISCA audits function within Medicaid programs and why understanding them is essential for operational success.

Throughout this in-depth conversation, your hosts explain that ECRO audits, conducted by External Quality Review Organizations, focus on evaluating the quality of care, member services, and adherence to state and federal Medicaid standards.

ISCA audits concentrate on internal systems capability, including data integrity, IT security, and the reliability of systems used to manage Medicaid services and member information.

You will learn that Medicaid audit processes vary by state, with some states conducting comprehensive annual reviews and others using staggered or rotating audit schedules. Lorie, Jessica, and Elvan emphasize the importance of knowing state-specific requirements and timelines to ensure audit readiness and avoid compliance gaps.

The conversation also highlights the importance of contracts, protocols, and staff preparation in successful audit outcomes. By understanding contractual obligations, educating staff on their roles, and practicing audit readiness through mock interviews and data reviews, organizations can approach ECRO and ISCA audits with greater confidence and clarity.

Key Takeaways

• ECRO audits evaluate quality of care, member services, and compliance with Medicaid requirements.
• ISCA audits assess the security, accuracy, and capability of internal data and IT systems.
• Medicaid audit structures and timelines vary by state and require careful review.
• State contracts define the standards and protocols used during ECRO and ISCA audits.
• Staff education and role clarity are essential for accurate and effective audit responses.
• Proactive preparation, including mock audits and data reviews, supports stronger compliance outcomes.

Learn more about Healthcare Compliance and discover how Simply Compliance can help your company at simplycomplianceconsulting.com.

In this episode of Compliance Deconstructed, hosts Jessica Zeff, Lorie Davis, and Elvan Baker unpack why whistleblowing remains a critical pillar of effective healthcare compliance programs. They explore how speaking up about concerns - whether ethical, operational, or regulatory - helps healthcare organizations identify risks early and protect patients, staff, and reputation.

This in-depth discussion reframes whistleblowing as a proactive compliance tool rather than an act of disloyalty, especially within highly regulated healthcare environments. The hosts explain how fostering transparency and psychological safety strengthens compliance culture and supports long-term organizational integrity.

Jessica, Lorie, and Elvan also examine the tension between perceived loyalty and truth-telling in healthcare workplaces. They highlight how leadership attitudes and “all-or-nothing” cultures can unintentionally discourage reporting and increase compliance and regulatory risk.

This episode concludes with practical guidance for building safe, trusted reporting systems in healthcare organizations. From non-retaliation policies to multiple reporting channels, you’ll get an outline of actionable steps compliance leaders can take to encourage employees to raise concerns before small issues become systemic failures.

Key Takeaways

• Whistleblowing is about raising concerns in good faith to improve healthcare compliance and patient safety.
• A strong speak-up culture helps healthcare organizations detect risks early and prevent regulatory violations.
• Loyalty to an organization includes being willing to question processes and highlight compliance gaps.
• Fear of retaliation is a major barrier to reporting concerns and must be addressed through policy and practice.
• Multiple, well-communicated reporting channels increase trust and reporting effectiveness.
• Healthcare leaders play a critical role in modeling transparency and encouraging ethical accountability.

Learn more about Healthcare Compliance and discover how Simply Compliance can help your company at simplycomplianceconsulting.com.

In this episode of Compliance Deconstructed, hosts Jessica Zeff, Elvan Baker, and Lorie Davis continue to break down the complexities of the ongoing United Healthcare case through the lens of prior authorization and patient access. They explore how insurance-driven decision-making continues to impact healthcare delivery, compliance expectations, and provider operations.

Today’s conversation highlights how prior authorization, though positioned as a cost-control tool, can delay essential care and complicate compliance workflows. The hosts discuss real-world scenarios where automation, incomplete reviews, and non-specialist evaluators contribute to patient risk and provider frustration.

Jessica, Lorie, and Elvan will take you inside the peer-to-peer review process, explaining why mismatched reviewer expertise can derail legitimate medical requests. They outline how these flawed review structures not only hinder care but also challenge providers’ ability to maintain regulatory integrity.

The episode also includes a deeper look at how administrative burden, denials, and insurance network disruptions affect both compliance teams and patient outcomes. Your favorite trio of compliance professionals emphasize proactive communication, documentation, and advocacy as essential strategies for navigating an increasingly complex insurance landscape.

Key Takeaways

• Prior authorization often creates delays in medically necessary care despite its stated purpose of cost control.
• Automated or poorly reviewed denials can undermine clinical decision-making and erode trust between providers and insurers.
• Peer-to-peer reviews frequently involve non-specialists, leading to inaccurate assessments of complex medical cases.
• Administrative burdens tied to authorization processes place significant strain on healthcare providers and compliance teams.
• Network disruptions by insurers can severely limit patient access and destabilize established provider relationships.
• Strong documentation, patient advocacy, and early communication remain essential tools for navigating prior authorization barriers.

Learn more about Healthcare Compliance and discover how Simply Compliance can help your company at simplycomplianceconsulting.com.