The end of the year often brings a flurry of activity, and for those of us in behavioral health, it’s not just about holiday planning—it’s about preparing for the compliance demands of a new year. Whether you run an IOP/OP, PHP, RTC, or Medically Monitored Withdrawal facility, the truth is that compliance isn’t just a regulatory burden; it’s a cornerstone of patient trust and quality care.
At Alleva, we know this firsthand. Our team includes compliance experts who have walked in your shoes, managing the complexities of Governance, Risk, and Compliance (GRC) while keeping the focus squarely on the people you serve. We understand that the last thing you need is a cold, clinical checklist. Instead, think of this as a supportive guide to help you close out the year strong, ensuring your EMR is set up for success in January and creating a culture of compliance year-round. (We’d love to show you how Alleva can support your GRC needs!)
Here are five essential Governance, Risk, and Compliance tasks to tackle before the ball drops on December 31st.
1. EMR Access Control Audit: Securing PHI and Patient Trust
In the behavioral health space, patient privacy is paramount. Every person who accesses your EMR—from the clinical director to the billing specialist—holds a key to sensitive information. As staff roles shift, new hires join, or team members transition, access permissions can become outdated, creating unnecessary risk. A year-end audit is a chance to reset and reinforce that sacred trust with your patients.
- Review User Accounts: Go through every active user in your EMR and other systems (like RCM or CRM).
- Verify Role-Based Access: Ensure each user’s permissions are strictly limited to what their current job requires (the principle of Least Privilege). For example, does a former intern still have access to discharge summaries?
- Deactivate Dormant Accounts: Immediately disable or delete accounts for any staff who have left the organization.
- EMR Focus: Utilize your EMR’s administrative tools to generate an access report. A robust EMR should make this process transparent and auditable, providing a clear trail of who has access to what.
2. Prepare for 42 CFR Part 2: Finalizing SUD Consent Documentation
The Substance Use Disorder (SUD) community has long been protected by the strict privacy rules of 42 CFR Part 2. While the recent updates (as of April 16th, 2024) aim to improve care coordination by aligning more closely with HIPAA, they introduce new complexities. December is the critical month to ensure your consent forms and EMR workflows are ready for the February 16, 2026, compliance deadline. Getting this right is about facilitating whole-person care without compromising patient confidentiality.
- Update Consent Forms: Ensure your patient consent forms reflect the new allowance for a single, global consent for all future Treatment, Payment, and Healthcare Operations (TPO) disclosures.
- Train Staff: Conduct mandatory training for all staff on the updated consent process, emphasizing when and how information can be shared under the new rules.
- EMR Focus: Confirm that your EMR (like Alleva) has updated its Part 2 flagging and consent management features to support the new TPO disclosure rules. Your EMR should be your partner in managing the nuances of this critical regulation.
3. Proactive Security Risk Assessment (SRA) for Behavioral Health HIPAA Compliance
We know that a data breach isn’t just a technical failure; it’s a profound violation of the therapeutic relationship. The start of a new year is a prime time for cyber threats. By conducting a thorough SRA now, you’re not just checking a box for HIPAA; you’re proactively protecting your patients’ most vulnerable information and safeguarding your organization’s future. At Alleva, maintaining our customers’ safety and trust is paramount. Visit our trust center and read about our robust security features to learn more.
- Identify Vulnerabilities: Systematically review all areas where Protected Health Information (PHI) is created, received, maintained, or transmitted. This includes your EMR, email systems, and physical security protocols.
- Document Gaps: Create a clear, prioritized list of security gaps and a plan for remediation in Q1.
- EMR Focus: Pay special attention to EMR-related risks, such as encryption status, multi-factor authentication (MFA) enforcement, and the security of remote access for telehealth services.
4. Update Business Associate Agreements (BAAs) for Regulatory Changes
Your facility relies on a network of trusted partners—from billing services to cloud storage providers. These Business Associates (BAs) are an extension of your care team, and their compliance is your compliance. December is the perfect time to ensure that every BAA is current, signed, and reflects the latest regulatory requirements, especially concerning the updated Part 2 rules. This simple step protects you and your partners, ensuring a seamless continuity of care. This topic also reflects Alleva’s drive to provide a unified experience within a single platform for your peace of mind.
- Inventory BAs: Create a complete list of all vendors who handle PHI on your behalf.
- Verify Current Agreements: Check that you have a signed, up-to-date BAA with every single one.
- Address Part 2: Ensure your BAAs specifically address the new Part 2 regulations, clarifying how your partners will handle SUD records under the updated consent rules.
5. CMS Billing Changes: Preparing Your EMR for January 1st Reimbursement
The financial health of your program—whether you’re running a small PHP or a large RTC—directly impacts your ability to provide life-saving services. With the Calendar Year (CY) 2026 Medicare Physician Fee Schedule (PFS) Final Rule taking effect on January 1st, there are new opportunities for reimbursement, particularly for expanded behavioral health services. Your December task is to translate these regulatory changes into smooth, compliant billing operations. Reach out to learn more about Alleva Billing, our integrated RCM.
- Identify New Codes: Review the CY 2026 PFS Final Rule for new or modified CPT codes relevant to your behavioral health services.
- Update Fee Schedules: Ensure your RCM system and EMR fee schedules are updated with the new rates and codes.
- Train Clinical Staff on Documentation: The key to compliant billing is compliant documentation. Train your clinicians on the specific documentation requirements for any new services or codes to prevent denials in the new year.
- EMR Focus: Ensure your EMR is well-positioned for these critical compliance updates, like Alleva billing. Use December to test and verify that your system is ready to submit claims accurately on January 1st.
Moving Forward with Confidence
Compliance doesn’t have to be a source of anxiety. By tackling these five essential GRC tasks in December, you are not just meeting regulatory mandates; you are demonstrating an unwavering commitment to the safety and privacy of your patients. This proactive approach is key to creating a culture of compliance year-round.
At Alleva, we build our EMR with this empathy and expertise in mind. Our platform is designed to seamlessly support your entire GRC framework—from governance and risk management to daily compliance activities—ensuring that the technology supports your mission, rather than complicating it. We’re here to help you move into the new year with confidence, so you can focus on what matters most: providing exceptional behavioral healthcare.
If you’d like to learn more, we’d love to hear from you!
Disclaimer: This content is for informational purposes only and does not constitute legal advice. Always consult with your organization’s legal counsel and compliance officer.