Make your CP the project of the year
Parts already could be in place
By Paula Swain, RN, MSN, CPHQ, FNAHQ
Swain & Associates
St. Petersburg, FL
(Dec. 18, 1996) Clinical Laboratory Agrees to Pay $10.1 Million for False Medicare Claims; (Jan. 23, 1997) Horizon/CMS Healthcare Corporation Pays $5.8 Million to Resolve Charges of False Medicare Claims; (July 29, 1997) Hospital Firm Pays $12.6 Million to Settle Kickback Allegations
Headlines like these are enough to send chills down the spines of even the most seasoned administrators. What kind of fraud are we talking about? Prescription fraud? Billing for services not rendered? False cost reports? Joint ventures and self-referrals? Providing unnecessary services or failing to provide necessary services? Patient dumping?
To enforce the federal False Claims Act, the government has only to demonstrate that errors occurred. It does not have to demonstrate management was aware of the errors, or that errors were intentional.
A corporate compliance program (CP) could reduce your exposure to fraud and abuse investigation. A well-implemented program also could significantly reduce penalties incurred if a violation is prosecuted. Writing your plan is not the hard part. The artistry is in evaluating and implementing it to ensure the avoidance of potential fraud.
Compliance officer oversees audits
In its model compliance plan for clinical laboratories, the OIG suggests appointing a compliance officer (CO). You have to put in place monitoring and auditing procedures to make sure billing problems or other concerns don’t arise again. You must take disciplinary action against staff found not to be following compliance standards. You also must have a hotline or other mechanism where employees can report any suspected compliance violations to the CO, anonymously and without fear of retribution. Any reported problems must be investigated.
The federal sentencing guidelines illustrate what is required for the minimally acceptable compliance program. In short, the OIG recommends that a CP should include, at minimum, the following key elements:
• written standards of conduct for employees;
• written policies that promote commitment to compliance and that address specific areas of potential fraud, such as billing, marketing, and claims processing;
• the designation of a CO a high-level official who is charged with the responsibility of operating the CP;
• the development and offering of education and training programs to all employees;
• the use of audits or other evaluation techniques to monitor compliance and ensure a reduction in identified problem areas;
• the development of a code of improper or illegal activities and the use of disciplinary action against employees who have violated internal compliance policies or applicable laws or who have engaged in wrongdoing;
• the investigation and remediation of identified systemic and personnel problems;
• the promotion of and adherence to compliance as an element in evaluating supervisors and managers;
• the development of policies addressing the nonemployment or retention of sanctioned people;
• the maintenance of a hotline to receive complaints and the adoption of procedures to protect the anonymity of complainants;
• the adoption of requirements applicable to record creation and retention.
Does much of this sound familiar? It should. Organizational leaders and key personnel who have been learning improvement methods over the past few years have been getting primed for the BIG project. This is no time to rest on your laurels. Dust off all the best practices, and weave them into the development of a well-coordinated program.
Assign your most skilled facilitators to create conduits between departments that have not worked well together before. Refresh your statistical tools training, and assemble data collection and analysis graph information so departments can plot points to be sure they are maintaining previous gains. Take another look around to see if you can piggyback your new endeavors on other efforts that already have a foothold in the organization.
Much of your program is in place. It just needs recognition and adaptation. Examples of this can be found in the work currently being done in groups such as your Ethics Committee, Safety Committee, and the group that supports the Information Management standards of the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL. These groups might be encouraged to include topics on their meeting agendas such as the code of ethics, physician relations, credentialing issues, employee feedback from suggestion boxes, hot lines, and so on.
In addition, the whole organization should have access to and understand Federal Alerts and payment information. They are available on the Internet at http://www.masalink.org/leg/ LEGMDAPF.HTM
The traditional surveillance functions utilization, risk, safety, and finance used to have well-marked demarcation lines. In the movement toward a more coordinated program, these have blurred around the edges. Everyone in the organization has a stake in the system.
• Risk management has always had a proactive side aimed at protecting the hospital’s assets. Departments are currently moving to take an active stand on issues of law pertaining to health care regulatory matters, environment, discrimination, sexual harassment, and antitrust.
• Utilization management (UM) has resources at stake and is accustomed to assessing for medical necessity. The UM organization looks here for Peer Review Organization compliance.
• Reimbursement and accounting offices require accuracy from suppliers for precise billing information. That means everything from tests such as lab and X-ray to outpatient visit charges.
• The quality management process oversees that the line people are involved in information flow. It supervises actions taken to improve patient care and looks for feedback on trends with a future potential negative impact.
• Administration has accountability for operations and provides resources.
Get together and make your CP the project of the year. There are numerous measures to establish, processes to flow, and people to teach. How an organization goes about facilitating this will be discussed further in an upcoming issue of Hospital Peer Review.
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