Put your CCP into action
Staff must understand processes, consequences
By Paula Swain, MSN, CPHQ, FNAHQHealth Care Management Consulting in Issues of Accreditation and Compliance
St. Petersburg, FL
When efforts to contain health care fraud began in the mid-1980s, the focus was on insurance companies, patients, and individual providers. As the amount of legislation to deter false claims has steadily increased over the years, the emphasis has shifted to include hospital providers. In educating staff, it may be useful to review the history of this movement. (See time line table, p. 31.)
Until more formal guidance is provided, it would be prudent to tailor your compliance program (CP) to meet your facility’s unique needs, using the seven elements set forth by the United States Sentencing Commission as minimum criteria. (See Compliance Observer in Hospital Peer Review, December 1997, p. 182, for the elements.) A common thread is incorporation of the code of ethics, which highlights minimally acceptable codes of conduct.
Move from theory to practice. While you put your CP in place, assess the work environment and the roles staff play. One way to educate staff is to have them apply components of the CP that are related to the service they provide. Assessing their activities for issues where compliance could be questioned will get them started.
There are two primary functions at the heart of a compliance program: detection of criminal conduct, and deterrence.
Everyone along the chain — from the administrator who sets policy, to the physician who orders services, to the clerks who handle the order — must know more about the compliance process than just the task at hand.
All work eventually appears in the form of a bill submitted for reimbursement. If payment is denied, everyone who provides services needs to know why, not just the billing manager. Deterrence begins with identification of a problem.
Most staff, including managers, do not know how the facility is reimbursed for services, nor do they know the criteria for that reimbursement. For example, consider this scenario:
A family wants the patient to go, at discharge, to the daughter’s home 50 miles away. The ambulance is ordered by the physician at the family’s request. Staff are unaware that the destination is out of the allowable mileage range. In addition, they are unaware of the rule stating that the beneficiary must sign an advance beneficiary notification form before the trip, thus assuming the additional transportation cost. These kinds of nuan ces create nightmares for the billing department. The next person hearing from this family could be the billing office’s complaint clerk, who has to try to answer the question, "Why is my mother being billed for her ambulance ride home?" Meanwhile, unit staff have no idea that all their effort resulted in no reimbursement for the facility. In fact, their work might be detrimental — it might place the facility in a red-flag situation with the government for overcharging.
Under generally accepted principles of agency, the actions or omissions of an agent or employee are linked to the corporate entity. This means that if an agent such as a physician, physical therapist, or employee breaks the law, the employer (hospital, home care company, network) may be held liable. Yet, a physician who improperly submitted 39 false Medicare claims for $550 was held by the court to owe the government $79,000.
It’s easy to see how multimillion-dollar settlements happen. The civil laws that are broken can give way to a more devastating criminal component if the government chooses to prosecute intentional false claims or statements made to Medicare or Medicaid. When the government successfully prosecutes those actions, they may result in a felony conviction, individual fine of $25,000, imprisonment for not more than five years, or both.
Examine all situations that contain potential compliance issues, and use the best measurement and assessment technique available in the facility. Follow lines of communication, document concisely, and carry out the instructions contained in your plan for transmitting findings and making recommendations. Remember: Everyone is involved in determining if there are fraudulent situations in your facility.
[Editor’s note: Priscilla Kibbee, RN, MEd, assisted in the preparation of this article.]
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