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The problem
The Risk Equation
- Regulatory Surprise
- Margin Compression
- Enforcement Exposure
For multi-state healthcare and workers’ compensation platforms, regulatory change is no longer incremental. States are increasing scrutiny of physician dispensing, expanding PBM transparency mandates, tightening TPA licensing requirements, and revisiting employer direction-of-care frameworks.
One state statute can:
- Alter reimbursement methodology
- Restrict repackaged drug markups
- Require new license filings
- Change network penetration dynamics
- Trigger enforcement exposure
Most organizations react after a change is enacted.
Risk Intelligence is designed to identify risks before they become operational disruptions.
What We Monitor:
50-State Regulatory Coverage Across Eight Domains:
1. CPOM—the Corporate Practice of Medicine
- Whether the doctrine is enforced and against which professions
- Permitted entity forms and who may hold equity
- MSO and management agreement limits—scope, term, indicia of control
- Fee-splitting and percentage-of-revenue compensation rules
- Board advisory opinions, AG guidance, and case law
2. HIPAA & State Privacy
- Where state law exceeds the HIPAA floor, provision by provision
- Breach notification triggers, deadlines and regulator reporting
- Patient access to records — response deadlines and permitted copying fees
- Sensitive categories: 42 C.F.R. Part 2, behavioral health, minors, genetic, reproductive
- Consumer health-privacy statutes reaching entities HIPAA does not cover
3. Physician Dispensing Rules
- Reimbursement caps and fee schedule limitations
- Repackaged and compounded drug restrictions
- In-office dispensing eligibility rules
- Mandatory generic substitution mandates
- Enforcement trends and litigation exposure
4. PBM Licensure & Regulation
- State PBM registration and licensing requirements
- Transparency and rebate disclosure mandates
- Audit authority expansion
- Anti-spread pricing legislation
- Reporting obligations to insurance departments
5. Direction of Care Laws
- Employer vs employee choice frameworks
- Initial provider selection restrictions
- Referral control limitations
- Network participation mandates
- Impact on pharmacy network penetration
6. TPA License & Regulatory Changes
- State TPA licensing requirements
- Surety bond mandates
- Claims handling compliance standards
- Regulatory changes affecting PBM–TPA relationships
- Multi-state operational risk alerts
- Impact on pharmacy network penetration
7. Nurse Case Manager Licensing Rules
- State NCM company licensing and registration requirements
- Professional entity and corporate practice compliance
- Scope-of-practice and delegation limits
- Insurance department and board reporting obligations
- Multi-state expansion and enforcement risk monitoring
8. Pharmacy fee schedules
- Brand and generic reimbursement basis
- Dispensing fees
- Lesser-of language and comparators
- Topical and compound caps
- Acquisition-cost transitions
Monitoring Infrastructure
- 50-state legislative and regulatory tracking
- State risk classification dashboard
- Effective-date implementation calendar
- Updated daily
Strategic Intelligence
- Executive impact summary
- Margin exposure analysis
- Jurisdictional risk scoring
- Identification of emerging enforcement patterns
Executive Advisory
- Monthly executive briefing
- Ongoing regulatory interpretation support
- State-specific implementation discussion
This is delivered through a structured monthly subscription model.
Accredation Risk Management
URAC, NCQA, SOC 2, and HITRUST don't just ask whether you're compliant—they require you to prove it. URAC requires organizations to actively track jurisdictional laws in every state where they operate and to maintain documented response protocols when those laws change.
Mid-cycle reviews can come at any time. Whether you're a PBM, TPA, nurse case manager, or any workers' compensation stakeholder operating across state lines, the burden is the same.
Losing accreditation doesn't just mean a missing seal on the website. It means lost contracts. That makes the RRM not just an accreditation tool but a revenue protection tool.
SRX Risk Intelligence is the operational infrastructure that satisfies those standards. The SRX Risk Intelligence provides real-time tracking across all 52 U.S. jurisdictions, organized by the regulatory domains that are significant to your business. When an accreditor asks how you monitor regulatory change, Risk Intelligence is your answer!