Five Essential Control Categories for Healthcare Compliance

Read time: 4 minutes

You’ve built your framework structure. Now you need to populate it with actual controls. But which controls matter most?

While every organization’s risk profile is unique, certain control categories are universally critical for healthcare organizations. The 2023 White & Case/KPMG survey found that third-party risk tops the list, with 59% of respondents, but healthcare faces additional regulatory pressures related to billing, relationships, and data security.

This blog outlines five essential control categories, each accompanied by concrete examples that you can adapt immediately.

1. Employee and Medical Staff Screening Controls

Healthcare organizations must ensure employees, contractors, and medical staff are qualified and free from regulatory exclusions that could create False Claims Act liability.

Initial Screening Controls

Before employment or privileges are granted:

• Education and training verification from accredited institutions
• Primary source verification of professional licenses
• Background checks through appropriate databases
• Federal and state exclusion list screening (OIG, SAM, state Medicaid)

Control objective: Prevent hiring or credentialing individuals who could expose the organization to regulatory violations.

Ongoing Monitoring Controls

After initial screening:

• Monthly sanctions screening: Catches exclusions that occur after hiring (automated alerts to compliance)
• Quarterly license verification: Identifies lapses in professional credentials
• Annual comprehensive updates: Reveals criminal convictions, malpractice actions, or status changes

Value driver: Automated monthly screening demonstrates audit readiness through systematic, documented compliance checks. Most healthcare organizations can’t manually track hundreds or thousands of employees on a monthly basis—automation is essential.

According to Gartner, embedded controls that guide employees within workflows reduce compliance obligations failures by 58%. Automated screening is a perfect example of this.

Pro tip for small teams: Start with monthly OIG/SAM screening for all employees. It’s free, required, and relatively simple to automate. Add state Medicaid screening once monthly federal screening is routine.

2. Billing and Coding Compliance Controls

Revenue cycle operations create significant compliance risk. The ECI 2023 survey found that 48% of organizations report a weak ethical culture—billing areas often face intense pressure to maximize revenue.

Documentation Standards Controls

Establish clear requirements:

• Documentation elements required for E&M levels
• Procedure documentation for surgical/diagnostic codes
• Physician signature, date, and authentication requirements
• Timely documentation completion standards

Control objective: Ensure medical records support billed services and comply with payer requirements.

Coding Validation Controls

Verify code accuracy:

• Pre-bill review: Sample high-risk or high-dollar claims before submission
• Post-bill audits: Evaluate coding accuracy after claim submission (minimum 5% sample)
• Focused reviews: Target specific providers, departments, or codes showing elevated risk

Value driver: Pre-bill review provides preventive control that stops problems before they become False Claims Act violations. This demonstrates proactive risk management to auditors and regulators.

Medical Necessity Controls

Ensure clinical appropriateness:

• Utilization management protocols review planned services before delivery
• Concurrent review monitors inpatient care for continued stay appropriateness
• Retrospective analysis identifies systematic patterns suggesting medical necessity issues

Billing Pattern Monitoring

Identify statistical anomalies:

• Provider-level analysis: Compare individual physicians to peer benchmarks
• Department monitoring: Identify systematic variations from expected patterns
• Procedure tracking: Highlight unusual frequencies or combinations warranting investigation

Warning sign: If the same provider consistently codes at higher levels than peers without clinical justification, detective controls should trigger focused audits.

3. Conflict of Interest and Disclosure Controls

Healthcare organizations must systematically identify and manage conflicts that could violate Stark Law and Anti-Kickback Statute provisions.

Disclosure Campaign Controls

Collect relationship information:

• Annual comprehensive campaigns: Baseline disclosure from all covered individuals (physicians, executives, board members)
• Quarterly updates: Capture changes between annual cycles
• Trigger-based disclosures: Immediate reporting when specific events occur (new consulting relationships, investment acquisitions)

Value driver: Customizable disclosure forms present only relevant questions to each role. A board member sees different questions than a referring physician, increasing participation through reduced burden.

Review and Approval Controls

Evaluate disclosed relationships:

• Multi-level review protocols route disclosures to appropriate reviewers based on conflict type/severity
• Documentation requirements capture approval/prohibition rationale
• Exception tracking maintains records of approved arrangements requiring ongoing monitoring

According to KPMG’s Chief Ethics and Compliance Officer survey, policy management and aligning policies to changing regulations rank among the top challenges. Systematizing review workflows addresses this by creating consistent, documented processes.

Ongoing Monitoring Controls

Maintain awareness of changes:

• Periodic re-verification confirms relationships haven’t materially changed
• Financial threshold monitoring tracks payments to ensure they remain within approved limits
• Relationship termination protocols ensure proper documentation when arrangements end

Pro tip for small teams: Start with an annual disclosure for physicians with referral relationships. Expand to quarterly updates once annual campaigns run smoothly. Add other roles (executives, board) as capacity allows.

4. Vendor and Business Partner Controls

Third-party relationships create significant compliance exposure. The White & Case/KPMG survey found 59% cite this as their greatest risk.

Vendor Selection and Onboarding Controls

Before relationships begin:

• Due diligence procedures verify vendor qualifications and compliance history
• Sanctions screening confirms vendor and key personnel aren’t excluded
• Contract review ensures agreements include compliance protections and business associate provisions

Value driver: Upfront due diligence demonstrates defensible decision-making to auditors. You can show that you evaluated compliance risk before entering relationships.

Ongoing Vendor Monitoring Controls

Throughout the relationship:

• Monthly sanctions screening: Identifies exclusions occurring after onboarding
• Quarterly performance reviews: Include compliance metrics alongside operational measures
• Financial stability monitoring: Identifies vendors at risk of failure that could disrupt operations

Vendor Relationship Disclosure Controls

Identify potential conflicts:

• Employee disclosure requirements capture financial relationships with vendors
• Approval protocols govern the acceptance of gifts, meals, and entertainment from vendors
• Family relationship tracking identifies situations where personal connections could influence selection

5. Technology and Data Security Controls

Healthcare organizations are increasingly relying on technology to manage protected health information. PwC’s 2025 survey found that cybersecurity ranks among the top compliance priorities, with 85% of respondents reporting increased regulatory complexity.

Access Control Mechanisms

Ensure only authorized access:

• Role-based access provisioning grants system access based on job responsibilities
• Periodic access reviews (quarterly minimum) remove access for terminated employees or role changes
• Audit logging tracks who accessed sensitive information and when

Value driver: Automated access reviews and logging provide documented evidence of HIPAA compliance for audits—without manual tracking burden.

Data Protection Controls

Safeguard information:

• Encryption requirements protect data in transit and at rest
• Backup and recovery procedures ensure availability despite system failures
• Incident response protocols enable a rapid response to suspected breaches

Business Associate Management Controls

Govern third-party PHI access:

• Business associate agreements establish compliance requirements
• Vendor security assessments evaluate third-party security practices
• Breach notification protocols ensure an appropriate response when business associates experience security incidents

Warning sign: If you can’t quickly identify all vendors with PHI access, your business associate management needs immediate attention.

Putting It All Together

These five categories provide your foundation. Within each category, prioritize controls addressing your specific risks:

Immediate priority (Months 1-3): Regulatory-required controls like monthly sanctions screening, exclusion list checks, and business associate agreements

Next priority (Months 4-6): Preventive controls for your top 3 risks identified in risk assessment

Ongoing (Months 7-12): Detective controls that monitor for emerging issues and best practices that strengthen your program

Getting Started This Week

Action 1: Map Current Controls
For each of these five categories, list controls you already have in place—even if informal. This shows your baseline.

Action 2: Identify Critical Gaps
Where do you lack required controls? These are your immediate priorities regardless of resource constraints.

Action 3: Choose Your First 3 Controls to Implement
Select controls that address high-priority risks and are feasible to implement quickly. Early wins build momentum.

What’s Next

You’ve identified essential controls for your framework. But controls only deliver value when properly implemented and maintained. In our final blog, we’ll explore how to move from framework to culture—implementing controls, measuring effectiveness, and maintaining long-term relevance.

About This Series: Building Risk and Controls Foundations for new enterprise risk programs. Coming next: “From framework to Culture: Implementation and Maintenance.”