Reporting: Who, what, how much, and when?
Once you engage that track, you can’t return
You’re following advice and running twice-yearly credentialing checks at Internet sources. What should you do if you hear that a member of your medical staff is the focus of a review by the feds or by a state Medicaid fraud investigation unit? Whom should you tell? How much should you share? When should you blow the whistle?
"The feds came out with guidance on self-reporting late last fall," says Fay Rozovsky, JD, MPH, president of the Rozovsky Group, a consulting firm in Richmond, VA. "Its advice was not to self-report unless you absolutely have to. Once you engage that track, you cannot return. You’re opening Pandora’s Box."
Get legal advice, she says. If the OIG or FBI calls you or you receive a subpoena, immediately call your hospital attorney or compliance officer. Make sure the medical staff know what to do if they are approached, too. Everyone there should know an appropriate response, whether the tack of the investigator is, "If you don’t cooperate, bad things will happen . . . " or "I’m just here to have a friendly chat . . . "
Who should be involved in this compliance-credentialing crosswalk? The quality professional is generally directly involved in taking this action, but it depends on the size and nature of the organization, says Rozovsky. Some quality directors are in charge of medical staff services; others are not. In today’s environment, the quality professional probably is also doing credentials verification for the health plans at her hospital. How should you transfer information among two or more entities? Instruct middle management staff how to report information up the chain.
For many years, people in credentialing have felt frustrated: They did their work well, and yet decisions they disagreed with were being made by people above them. Now, with compliance at the top, credentialers have another venue in which to raise their concerns.
Under most compliance programs, if a staffer sees something aberrant — for example, she finds a report on the Federal Register saying a doctor at her facility has been excluded from Medicare — she should bring the information to a medical executive or the credentialing committee. If the entity says, "We’ll let him carry on — we won’t worry about that," the staffer might feel her job is on the line if she proceeds further. But now, most CCPs empower her in that case to go above those to whom she ordinarily reports and register her concerns via internal 800 hotlines. If an internal number is not available, the OIG’s hotline [(800) 447-8477 (TIPS)] is available to the staffer, so it is best to have the internal line available.
How peer review looks at these issues is going to change over the long haul. "This is an interesting new landscape," says Rozovsky.
Will a finding of abuse, fraud, or waste of Medicare or Medicaid funds now be deemed unprofessional conduct by a licensing body under state law? Even if the abuse has nothing to do with care, if it’s "just" a billing error, will that be grounds for taking away or suspending a license?
"This will have a tremendous impact on health care," she says. "A light bulb has gone on: Some thing driven by a concern for ethical issues and fraud and abuse matters has profound operational and risk issues at other levels."
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