Demonstrate effectiveness with automated tools
Demonstrating the effectiveness of compliance plans is an important task when the U.S. Department of Justice comes knocking on your door. But former Department of Health and Human Services’ Inspector General Richard Kusserow says that after a year or two of pumping resources into a compliance program, the much greater likelihood is that it will be the provider’s executive leadership that comes knocking on the door. In short, he says they want to see a return on their investment.
"They want to know if that investment has made a difference, and that is a hard question to answer," asserts Kusserow, president of Strategic Management Systems in Alexandria, VA. "Unless you are able to provide some empirical evidence that the organization has moved in a way that makes it less vulnerable to fraud and abuse issues, you have a problem."
Kusserow says one of the best ways for compliance officers to justify the increasing sums of money that have been invested in compliance programs over the last few years is through the use of automated tools.
"Technological solutions are no longer a mere luxury," agrees Joseph Russo, a partner with the law firm Russo & Russo in Bethlehem, PA. "They are an absolute necessity."
Russo says that’s because the OIG, as well as the Health Care Financing Administration and its fiscal intermediaries are increasingly utilizing software to find outliers and determine who is exceeding normative national averages. Moreover, he says, those programs are becoming increasingly sophisticated. Declining revenues and shrinking operating income as a result of the Balanced Budget Act of 1997 has made automation even more critical, according to Russo. "Compliance budgets have to get the biggest bang for their buck, and software systems can assist you in doing that," he says. "Oftentimes, rather than increasing cost, they decrease cost and at the same time minimize False Claims Act exposure and other risks associated with the compliance process."
The move toward integrated health care delivery systems and networks also has heightened the need for automated programs, says Russo. "It is absolutely critical to share information. Everyone has tons of data, but very few facilities really know what to do with it. Translating that data into useful information is one of the things technological solutions can accomplish."
According to Russo, most of the latest innovations responding to those trends are focused in three areas — auditing, monitoring, and education. He says auditing and monitoring tools for benchmarking that assist in the coding process and improve documentation is the first place providers should look.
He says the second area providers should look at is sanction- and compliance-monitoring tools. "Screening for sanctioned vendors and individuals has become very critical."
Interactive Web-based training is another area that can reduce costs and increase compliance awareness throughout a facility, according to Russo. In addition, there now is software that can ensure that medical necessity is validated, as well as new auditing and monitoring educational tools for managed care.
Kusserow says benchmarking to measure program effectiveness also can be automated. In fact, he reports that his firm now maintains a database that includes a surveyed population of nearly half a million. "That lets you benchmark yourself against yourself, as well as the universe."
He adds another important automated tool for maturing compliance programs measures the knowledge and experience of employees under the program. "Whereas the benchmarking survey is measuring perception and attitudes concerning the compliance culture as viewed by employees, the second survey measures their knowledge of the program as it has been implemented."
But Kusserow warns that compliance officers should not attempt to demonstrate effectiveness based on process. "Process leads to output,’ not outcome,’" he asserts. "Whenever you make the argument about effectiveness and outcome using process, you are doomed."
For example, while a large number of calls to a hotline can be used as evidence of an active compliance program, it can just as easily be used as evidence of numerous compliance problems. Likewise, while a scarcity of calls can be used as evidence that few problems exist that too can be turned on its head with the argument that employees lack confidence in the program.
Dan Roach, vice president and corporate compliance officer for Catholic Heath Care West in San Francisco, takes a similar view. "Providers need to do more in the way of automation," he asserts. But he also warns that automation is not an end in itself. "My concern is that I have seen a lot of people invest a lot of money on these tools and then only use a fraction of their functionality. I think an organization needs to assess its objectives and processes and then select tools that will help meet those objectives."
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