Is your compliance officer in place?
You may fit the role
Hospitals nationwide, large and small, are scrambling to install compliance officers (COs) to launch and oversee their new corporate compliance programs (CPs). Quality managers (QMs) and coordinators will likely be big players in developing CPs, and may well be called upon to serve as official or unofficial COs, depending on facility size. A QM’s role in assuring compliance with Medicare rules makes him or her a natural choice for the job. In addition, who’s best qualified to identify the key elements in a CP and be sure there are performance measures accuracy of coding, periodic review of standing orders, and so on that monitor the facility’s adherence to it? One of the CO’s responsibilities will be to aggregate those measures into a periodic report for administration.
If that’s not enough, here’s some news: The Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, has just come forward to state that fraud investigations may provoke a for-cause, unannounced survey. (See related story on p. 139.)
The Office of the Inspector General (OIG) of the federal Department of Health and Human Services in Washington, DC, has offered some direction regarding where a CO comes from and what the position’s responsibilities are. The duties, which closely parallel those of a facility’s QM, are outlined as follows:
• developing CPs with each department in the organization;
• reviewing and revising policies and procedures pertaining to professional fee billing, coding, and documentation;
• training physicians and other staff on billing and documentation rules;
• conducting concurrent reviews of records;
• providing one-on-one education of physicians based on weaknesses found in medical record reviews.
The OIG recommends that a CO understand the importance of compliance per se and be able to coordinate the plan throughout the institution. The person in that position should be senior-level management someone with direct access to the board of directors. A QM, nursing director, chief financial officer, or chief operating officer fits this model.
"A department head doesn’t qualify because that person would generally not have that kind of authority," says Sue Prophet, RRA, CCS, director of classification and coding at the American Health Information Management Association (AHIMA) in Chicago. "A vice president would be a fitting individual for the job."
Try for a full-time position
In a facility of any size, a QM is a likely candidate for the CO position. Make sure you get the right of first refusal if you want it. Demonstrate that you have a direct reporting relationship to your institution’s board. If your institution is large enough, your position as CO should be full time. That may not be feasible for smaller, 200-to-300-bed hospitals. In a facility of that size, though, a QM may be the perfect person for the job because that employee ideally should also be in charge of coordinating Joint Commission accreditation.
The CO has to see the big picture and be responsible for assuring the institution’s committment to compliance. COs can come from a variety of backgrounds. Because many CP issues deal with billing practices, including coding, it would help if the person either has personal knowledge of those issues, or works closely with people who do.
"But the CO doesn’t have to know all the ins and outs of quality management or billing and coding any more than any vice president would," continues Prophet. The CO should not be involved in the day-to-day billing issues that the CP is monitoring, because there are potential conflicts of interest.
"A CO can also come from the risk management arena," continues Prophet. "That individual’s been involved in keeping the organization out of trouble and looking for trouble spots."
The best minds in the industry advise that if your facility is not among those in the advance guard if it hasn’t yet initiated a CP you should make certain it follows suit now.
"The focus of the CP is proactive," says Paula Swain, RN, MSN, CPHQ, a health care consultant in St. Petersburg, FL, and a member of Hospital Peer Review’s editorial advisory board. "And so are the defining elements of quality and utilization management. The implementation of a CP should be no different from any other improvement project, except that this one has teeth."
CPs are your facility’s best hedge against the net that’s been cast by the federal government to snare fraud and abuse perpetrators. "Every health care entity should have a CP in place by now," says Robert Bacon, director of the office of billing compliance at the University of Pennsylvania Health System in Philadelphia. "However, there’s no greater danger than putting a CP on paper that has no teeth." The government has clearly stated that a shell program with no sanctions or monitoring is more detrimental than no program at all. Your plan has to be fully documented and include education, communication, and an internal hotline for confidential reporting. (See "Compliance Observer" column, p. 149.)
OIG recommendations: Good common sense’
The OIG released its model hospital CP in mid-September, shortly after this issue of Hospital Peer Review went to press, but most experts say key elements of the hospital version will be similar to those in the plan for clinical laboratories.
"A lot of the OIG’s recommendations are just good common sense," says Prophet. Swain agrees: "Initiating a workable CP is a move toward becoming better than we were before."
Swain goes on to say that complying with the OIG recommendation on CPs is "ten times simpler than dealing with the Joint Commission has ever been." The Joint Commission’s interpretations are sometimes ambivalent, and standards evolve. The federal government, on the other hand, says, "These are the elements. You have to conform to this."
"Some hospitals already have their CPs and COs in place," says Prophet, "because the OIG has stated that if you have a plan in place, and it appears you’ve implemented it well, that might well be a mitigating factor in an investigation." If you become the target of an investigation and you can say you’ve already addressed some issues and will make sure these problems don’t happen again, those positive moves on your part could alleviate any penalties or other adverse actions the government might take.
An institution is better off with a CP it has initiated itself than one the government has mandated as a result of a federal investigation and settlement. "The difference between the mandatory plans and those initiated voluntarily is monitoring," says Swain. "The government is regularly checking the mandatory ones. They’re on your neck, looking over your shoulder, and checking your paperwork and procedures to make sure you’re following the plan to the letter of the law."
CPs should be hospitalwide, says Karl J. Kuppler, vice president of operations and corporate CO for Trumbull Memorial Hospital in Warren, OH. They should address billing, ordering, physician recruitment, joint ventures, and reporting of communicable diseases, among other issues. Trumbull is developing its program in five tiers, with topics falling under these headings:
• billing and financial reimbursement;
• protection of tax-exempt status;
• physician relationship issues;
• patient care and employment laws;
• "everything else," including Occupational Safety and Health Administration (OSHA), environmental, and licensure issues.
After hearing representatives from the U.S. Department of Justice and the OIG speak at a recent meeting, Kuppler says he is convinced that the government’s interest in health care fraud and abuse won’t fade any time soon. "It’s evident that this isn’t a passing fad. In their minds they’re onto something, and they will stay with it until they’ve gotten as much as there is to get." (See chart, "By the Numbers," at left.)
Kuppler reminds those establishing a CP not to let themselves become overwhelmed by the prospect. Trumbull Memorial hired expert legal counsel to facilitate creating its program. Then the attorneys helped develop a knowledgeable in-house team to serve as a compliance committee. Members include Kuppler, the director of patient billing, the comptroller, the vice president of medical affairs, and others. "Ours is a broad-based team," he says, "so that someone knows what resources are out there and knows where to go."
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