Compliance experts to establish effectiveness benchmarks
Architects of plan champion new key indicators as a leap forward in measuring success
When it comes to proving their worth to administration, compliance officers often face a steep uphill climb because, unlike most management functions, they can’t point to bottom-line cost-savings or other obvious sorts of outcomes as a measure of their success. But now, several important players in the compliance industry are seeking to change that by establishing an empirical set of benchmarks that hospitals and other health care providers can use to identify business risks and evaluate internal compliance controls.
Last week, PricewaterhouseCoopers (PWC) and faculty from the University of California-Los Angeles (UCLA) School of Public Health’s department of health sciences unveiled what they call "groundbreaking" techniques to identify best practices in compliance programs. These practices will be used to assess the effectiveness of a compliance program as a function of billing accuracy and employee awareness.
The goal, according to Lori Richardson-Pelliccioni, a former federal prosecutor and PWC’s principal investigator, is nothing short of an "industry standard" for measuring compliance. The architects of the new model want it not only to become a useful tool for institutions, but an instrument the U.S. Department of Justice (DOJ) will rely on to help determine criteria for prosecuting and sentencing.
Existing criteria used to detect fraud are weak, some experts say. Stuart Schweitzer, professor of health services at UCLA, says the "very crude" model compliance program developed by DOJ is not only "vague" but also "thoroughly untested." According to Schweitzer, a former researcher for the National Institutes of Health and the Health Care Financing Administration, there is "no evidence" that a compliance program consistent with DOJ guidelines is any less likely to have fraudulent billings than an organization with no such program in place.
Nobody doubts the importance of a tool that all sides have confidence in. "A good validation tool is something that would be of enormous use," says Joseph Truhe Jr., corporate counsel at Children’s National Medical Center in Washington, DC. He says demonstrating compliance program effectiveness internally is the paramount objective. "You want to know that you are closing the barn door before the horse has left and not afterward," he explains.
Bret Bissey, chief compliance officer at Deborah Heart and Lung in Browns Mill, NJ, takes a similar view. "We have to report to the board on a regular basis and validate our compliance efforts," he explains. Bissey says his organization attacks that challenge from several angles. In addition to an active educational program that is followed by open- and closed-ended questions, Deborah maintains scorecards on different types of audits and tries to compare performance by provider and department. The organization also is initiating a random survey process that will be administered by the compliance department or human resources.
The aim of the PWC/UCLA model is to formalize those types of measures in a consistent and thorough fashion. (See box, left.) Pelliccioni says the study now is finalized and available for hospitals to begin using. She says the next step is for the industry to use this model to establish compliance effectiveness standards.
To accomplish that, the developers of the new model are turning to the Philadelphia-based Health Care Compliance Association (HCCA), which is now in the process of establishing a steering committee that will develop parameters to examine the research. "HCCA will be the keepers of this research in the real world," explains Pelliccioni.
Numerous subcommittees representing a potential assortment of interests also will be established under the direction of HCCA second vice president Michael Hemsley. The committee will then prepare a report that makes recommendations about a possible effectiveness standard. According to Hemsley, vice president of corporate compliance and legal services at Catholic Health East, HCCA plans to invite participants to an organizing meeting shortly.
The next objective will be to gain the endorsement of at least two federal governing bodies, the Department of Health and Human Services (HHS) and the U.S. Sentencing Commission. Pelliccioni reports that informal discussions already have occurred. The HHS Office of Inspector General declined to comment on the new venture.
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