INSIDE - Health Care Compliance Association

Volume Five
Number Seven
July 2003
Interview
with
Britt
Crewse
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Leadership letter
On the calendar
Corporate
responsibility
Academic Research
CFG
Home Care
Compliance CFG
CHC Congratulations
Payor/Managed care
CFG
Meet Britt Crewse
15 new opportunities
The no-show
Liability issues
CEO’s letter
Your HCCA staff

“In the near future,
we will begin the
process of electing
several members to
the HCCA Board
of Directors. I want
to encourage those
of you who have a
commitment to
HCCA’s long-term
success to consider
applying to serve on
our Board, or, if you
prefer, nominating
someone else to
serve.”
Dear Fellow Members:
ALAN YUSPEH
HCCA President
I am writing this as we have
completed a fabulous Annual
Compliance Institute in New
Orleans. We had some 1,000 people
in attendance, and everyone
agreed that the quality of the
program was exceptionally high.
For those who attended, thank
you for making this such a success.
And for those who could not
be with us this year, please try to
come next spring. It is clear that
if you can attend one national
compliance meeting a year, this
is the one to attend!
I wanted to recognize the extraordinary
job that was done by our
Conference Program Chair, Dan
Roach, the compliance officer for
Catholic Healthcare West. Dan
showed great vision in creating a
program that had both depth and
breadth. We should all be grateful
to him for providing such an
excellent educational opportunity.
I want to also recognize the
excellent support provided by
Roy Snell, Erin O’Donnell,
and the HCCA staff in making
the conference run so
smoothly.
The other facet of this program
about which I’m so excited is that it is truly a celebration
of the constantly increasing professionalism of our work
as health care compliance officers. Increasingly, as we get to
know one another, these meetings are like a family reunion.
They are a chance to network with our colleagues and to
continue to professionalize the field of health care compliance.
The next major HCCA program is our joint effort with the
American Health Lawyers Association (AHLA) in late
September. This promises to be an exceptional session as well.
Please try to be there.
Finally, in the near future, we will begin the process of electing
several members to the HCCA Board of Directors. I want
to encourage those of you who have a commitment to
HCCA’s long-term success to consider applying to serve on
our Board, or, if you prefer, nominating someone else to
serve. We have an enormously qualified Board at this time,
and we want to make certain that it remains strong and
reflective of HCCA’s membership. ■
Forget the HCCA password?
Email HCCA with your password questions at
info@hcca-info.org. Always check the bottom right
corner on page 2 in Compliance Today.
July 2003
2
HCCA’S
HCCA exists to champion ethical
practice and compliance standards
MISSION in the health care community and
to provide the necessary resources for compliance professionals and
others who share these principles.
Key through 6/30/03 hiphop from 7/1/03 fforum3

NewsFlash
HCCA’s call for nominations
The Health Care Compliance Association (HCCA) has sent
to each member it’s annual call for nominations. HCCA
nominates from the membership to fill positions on its Board
of Directors.
Any member wishing to be considered for nomination or
wishing to nominate another member should complete a
nomination cover sheet and return it to the HCCA national
office in Minneapolis, MN, with a nomination statement and
full curriculum vitae. If you did not receive this information
with the June issue of Compliance Today, please call HCCA
at 888/580-8373. All nominations must be received by June
30, 2003, at 5780 Lincoln Drive, Suite 120, Minneapolis,
MN 55436.
HCCA’s new logo
Yes! The Health Care Compliance
Association has changed its logo.
It will soon appear on our Website
and HCCA materials, books,
notices, brochures, and educational
program flyers. It’s not an
HCCA event if you don’t see
this logo!
This Week in Corporate
Compliance–HCCA’s weekly
news update!
Subscribe Today! Each Friday the
HCCA publishes This Week in Corporate Compliance on the
HCCA Website. An email version is also available:
To subscribe go to: http://www.hcca-info.org/email_news
To unsubscribe go to:
http://www.hcca-info.org/email_news/html/unsubscribe2.html
To change your subscription email address, first unsubscribe
with your old email address, then subscribe with your new
email address. ■
HCCA
ON
THE
CALENDAR
Mark your calendars for the following
HCCA sponsored events:
2003
CONFERENCES:
ANCHORAGE, AK
■ JUL 17-18, HCCA Region IX
Conference
SAN DIEGO, CA
■ JUN 16-19, Academy for
Advanced Compliance
Practice
■ DEC 10-12, HIPAA Forum
DENVER, CO
■ AUG 25-26, HCCA Region VIII
Conference
WASHINGTON, DC
■ SEPT 21-23, AHLA/HCCA
Fraud and Compliance Forum
KANSAS CITY, MO
■ AUG 1, HCCA Region VII
Compliance Conference
LAS VEGAS, NV
■ NOV 6-7, HCCA Region IX
Conference
DALLAS, TX
■ NOV 3-6, Academy for Health
Care Compliance
REDMOND, WA
■ OCT 1-3, Corporate
Responsibility Conference ■
RESOURCES
For more information about events or resources, check out the
HCCA Website, http://www.hcca-info.org or call 888/580-8373.
Be sure to ask about your member discount.
■ Monitoring & Auditing Practices
for Effective Compliance–
HCCA’s newest book offers
guidance and advice from
national experts
■ HCCA’s Compliance, Conscience,
and Conduct , a video-based
compliance training program
■ HCCA’s book, Compliance 101
■ Individual & Small Group
Physician Practice Compliance:
What every physician should
know, HCCA’s audio training
program designed specifically
for physicians
NEW!
■ Privacy Matters–HCCA’s
video-based HIPAA Training
Program
HCCA’s CD Videos -
■ Alice Gosfield-Unplugged
(with 2 HCCB CEUs)
■ HIPAA Forum Digital
Reference CD (with 20 HCCB
CEUs)
■ Physician Group Practices
Compliance Conference (with
3.6 HCCB CEUs) ■
3
July 2003

July 2003
By Gabriel L. Imperato, Esq.
Editor’s note: Gabriel L. Imperato, Esq., consistent with the Department of
is a partner in the law firm of Broad and Justice’s recently announced intentions to
Cassel. He may be reached in Fort hold business organizations subject to
Lauderdale, FL at 954/745-5221 or by criminal charges. See Memorandum
email at gimperat@broadandcassel.com from Larry D. Thompson, Deputy
Attorney General to the Department of
Anot-for-profit community Justice Components and the United
hospital in Western Michigan States Attorneys re: “Principals of Federal
was found criminally liable for Prosecution of Business Organizations”,
fraudulent activity in a case which is a dated January 20, 2003.
first of its kind involving corporate
responsibility for hospital conduct The consequences of this increased
involving the actions of its medical staff. emphasis on corporate accountability
The indictment, plea agreement, and and its ramifications for the health care
conviction of the hospital is clearly industry are no better reflected than in
intended by the Federal government to the circumstances surrounding the conviction
of UMH. The key factual com-
convey the message that corporate health
care providers will be held accountable ponents of the basis for the conviction of
for criminal and civil fraud in the health the hospital clearly signal the end of
care industry. The conviction of United those days when the Board of Directors
Memorial Hospital (UMH) in
and Officers of a hospital could afford to
Greenville, Michigan, is perhaps only act in deliberate ignorance or deliberate
the first reflection of the effects of the disregard of the activities taking place
Enron/Arthur Andersen case and passage within the corporate organization.
of the Sarbanes-Oxley laws and the government’s
efforts to hold health care corporations,
such as hospitals, responsible hospitals has also recently been reflected
This type of corporate accountability for
and accountable for fraud and abuse in the announcements of Federal, criminal,
and civil fraud investigations involv-
activity of its employees and agents.
ing a Tenet health care hospital in
The enforcement of the health care fraud California and an HCA hospital in
and abuse laws against individuals and Florida, involving allegations related to
organizations is not novel in the health the nature and utilization of medical procedures
in the hospital’s cardiac catheteri-
care industry, but the investigation, prosecution,
and conviction of corporate zation programs.
providers for crimes, whether they be
hospitals or other health care facilities The salient facts in the UMH case are
and/or profit or not-for-profit entities, is instructive and are as follows:
4
GABRIEL L. IMPERATO
1. The hospital was governed by a Board
of Trustees (Board), which characteristically
had relied upon its medical
staff, in particular the Medical
Executive Committee (MEC) and
the Professional Activities Committee
(PAC), to oversee the practices of
physicians who have privileges at
UMH. The Board, which serves voluntarily,
relied upon its administrative
management team, particularly the
CEO and the CFO, to manage the
day-to-day operations of the hospital.
2. The MEC and the PAC are accountable
to the Board for making decisions
about whether to grant, deny,
restrict, or suspend a physician’s privileges
and to generally review the
physician’s practices to ensure the
quality of patient care.
3. The hospital was apparently struggling
financially in the early ‘90’s and
it recruited an anesthesiologist to provide
full-time anesthesia services for
surgical procedures. This anesthesiologist
apparently had no training or specialized
experience in pain management,
but commenced performing
pain management procedures upon
arrival at the hospital, which were in
addition to the traditional anesthesia
services. This doctor was also chairman
of the anesthesia department at

the hospital and apparently approved
income for the hospital and that they
would antagonize him or cause him to
his own application expanding his
should keep their concerns to them-
take his practice to a competitor. The
clinical privileges, to include “manage-
selves or leave the hospital.
CEO of the hospital had apparently
ment of problems and pain relief”.
8. There were also complaints expressed
stated during 1996 to a board mem-
4. The number of surgical procedures
by physicians on the medical staff who
ber that the anesthesiologist’s practice
performed by the anesthesiologist rose
also noted that the anesthesiologist
constituted approximately one-third
dramatically from 24 in January of
repeated procedures on patients who
of the hospital’s income and that “we
1994 to 230 in December of that
were apparently not benefiting from
would not want to hurt him would
same year. The number and pace for
those procedures. A physician on staff
we?” The revenue for the hospital
the procedures being performed by
apparently recommended that the
from 1993 to 1994 increased by near-
this doctor alarmed the operating
anesthesiologist not be given expanded
ly $2 million dollars, which is due in
room medical staff, a number of
pain management privileges.
large part to income generated by the
whom described the situation as an
9. There were apparently also complaints
anesthesiologist’s pain management
“assembly line” or “mill”.
received from patients, one of which
practice.
5. The record also reflected that begin-
advised one of the doctors who was a
12. The anesthesiologist apparently also
ning in late 1994 a management team
member of the hospital’s PAC that the
formed joint venture financial rela-
at the hospital began receiving com-
anesthesiologist admitted doing proce-
tionships with two other doctors on
plaints about the anesthesiologist from
dures simply for purposes of increased
the medical staff of the hospital, one
nurses, operating room staff, and
reimbursement. There was no action
of which was the Chief of Staff and
ultimately physicians on the medical
taken by that particular doctor or the
the other who was the Chief of
staff at the hospital.
PAC to investigate this complaint.
Emergency Medicine. These three
6. The nurses complaints were numerous
10. The Board of the hospital was
physicians also incorporated “PCS
and included allegations that the anes-
advised of these concerns about the
Greenville” with the goal of negotiat-
thesiologist performed repeated proce-
anesthesiologist as early as May of
ing with the hospital to increase com-
dures on the same patients, even
1995, but was advised by the CFO
pensation from the hospital. These
though the patient showed no
that the anesthesiologist’s practice “had
doctors continued to sit on commit-
improvement; that the anesthesiologist
a favorable financial impact on hospi-
tees responsible for reviewing and reg-
described himself to the medical staff
tal operations when compared to the
ulating the anesthesiologist’s pain
as the “Sam Walton” of pain manage-
budget”. The Board, nevertheless,
management practice, notwithstand-
ment; that he freely admitted he was
drafted a letter to the PAC directing it
ing their mutual financial interests
at the hospital to make money and
to examine the anesthesiologist’s prac-
and the recommendation of at least
intended to double his “stats” every
tice of using a dorsal column stimula-
one other doctor that the Chief of
month; and that he rewrote a poster
tor (a surgically implanted device
Staff and the Chief of Emergency
to read “Quantity over Quality”. The
designed to block pain) and to deter-
Medicine recuse themselves from
nurses also reported that the anesthesi-
mine the appropriateness of this pro-
review of the anesthesiologist’s prac-
ologist often operated on “walk-in”
cedure at the hospital. The PAC never
tices because of a conflict of interest.
patients, apparently without conduct-
responded to the Board’s inquiry and
13. The proliferation of these complaints
ing a history and physical examination
apparently took no further action.
apparently had little or no impact on
to even remotely determine whether
11. The Chairman of the Board, contem-
the management of the hospital which
the procedure was medically necessary.
poraneously with this examination,
did virtually nothing to restrict the
7. These complaints were apparently
apparently stated at a board meeting
number or type of procedures the
submitted to supervising nurses who
that, while the hospital wanted to find
anesthesiologist was performing over
were advised by UMH Administra-
someone to review the anesthesiolo-
the course of the time period in ques-
tion that the anesthesiologist was
gist’s practices, it was important to
tion and, instead, took actions to
responsible for generating significant
ensure that it was not someone who
Continued on page 6
5
July 2003

CORPORATE RESPONSIBILITY...continued from page 5
discourage complaints against the
anesthesiologist. For example, one
doctor who continued to voice concerns
about the anesthesiologist’s practice
was told by the then CEO that
after the death of one of the anesthesiologist’s
patients. The PROM issued a
report in November of 1996 (three
months after the anesthesiologist left
the hospital), noting the following:
commission of a corporate crime is, of
course, imbedded in the collective and
aggregate activities of individuals who are
representatives and agents of the corporation.
The hospital was not the only party
his comments were not welcome. The
“There were several themes that were
convicted of a crime in this case.
same doctor saw his medical referrals
recurred in the records examined:
dwindle after voicing these concerns
Specifically, the evaluative process pre-
The case also included conviction of the
and after noting the Chief of Staff and
sented was uniformly inadequate.
Chief of Staff and the Chief of
the Chief of Emergency Medicine’s
Results of the testing data, and find-
Emergency Medicine on state misde-
financial conflicts of interest regarding
ings either within history or on physi-
meanor charges of aiding and abetting
the anesthesiologist. The Chief of
cal examination that supported the
larceny. The anesthesiologist was convict-
Staff, acting on behalf of the MEC, in
purported diagnostic impressions were
ed of thirty-three counts of mail fraud
fact, suspended the privileges of one of
consistently absent. There was an
after a two-week trial, including allega-
the doctors who had challenged the
apparent routine over use of invasive
tions of the performance of unnecessary
anesthesiologist’s qualifications to per-
techniques without clear indications.
procedures at UMH. The former CEO
form continued procedures.
The Pain Management activities
at the hospital is still facing charges in a
Furthermore, the anesthesiologist
seemed to have proceeded without
related case, including three counts of
complained to the then CEO about
evidence or [Sic] efficacy, quality
perjury before a Grand Jury concerning
these doctor’s complaints and the
assurance, or outcome evaluation...
his involvement with contractual negoti-
July 2003
6
CEO shortly thereafter left the hospital
to work for the anesthesiologist.
14. An outside medical expert was eventually
retained by the hospital to
review the medical necessity of the
anesthesiologist’s surgical procedures.
This expert reported that he was
unable to render such an opinion,
given the lack of medical documentation
in the anesthesiologist’s files.
However, the PAC took no action for
eight months and when it did only
counseled the anesthesiologist to
improve the documentation of his
work. The anesthesiologist, in fact,
continued to perform pain management
procedures at the hospital in an
unrestricted fashion up until August
of 1996 when he voluntarily resigned
from the medical staff after meeting
with the Board’s attorney.
15. The Board eventually submitted
eighty patient charts from the anesthesiologist’s
files to the Peer Review
Organization of Michigan (“PROM”)
Continuing to allow invasive procedures
without objective evidence of
improvement in pain level, narcotic
use, functional improvement, or
return to work is not warranted.”
16. The hospital continued for several
more years after this report from the
PROM to collect fees generated by
the procedures performed by the anesthesiologist,
including fees for services
performed on the patient who died.
There was no effort on the part of the
hospital to quantify the extent to
which the medically unnecessary procedures
resulted in the receipt of
unauthorized revenue from Federal
health programs and/or third-party
commercial payors, let alone return
such overpayments.
The developments in this case could be a
harbinger of things to come as corporate
responsibility and accountability assert its
place even more profoundly in the health
care industry. The underlying basis for
ations between the hospital and the anesthesiologist.
The conviction of the hospital of a crime
raised the issue of whether or not it
would be subject to mandatory exclusion
from Federal health programs. The
United States Attorney’s press release in
the case, in fact, stated that if the hospital
were to have been convicted at trial, it
would have been subject to mandatory
exclusion from the Medicare and
Medicaid programs. The hospital’s plea
agreement includes a stipulation that the
plea will be suspended by the court while
the hospital serves a three year probationary
period during which time it will
be subject to an obligation to implement
a compliance program designed to
ensure that it will comply with all
Federal and state laws and that its coding
and billing practices will be audited on
an annual basis.
Continued on page 10

COMPLIANCE
FOCUS
GROUP
ACADEMIC/ RESEARCH
Data to
further research and discussion.
larly using color as guides for recom-
information:
mending priorities–green for good, yel-
Getting the
A major aspect of your job is to select
low for caution, and red to indicate
best value for
the appropriate elements that will test
urgency.
your investment
the important issues and capture the
By Nina W. Tarnuzzer
data in a way that they will “roll up”
Gathering data is expensive
into summary reports. The goal is to
While some Academic Health Centers
Nina W. Tarnuzzer, MHA, CPA, CPC is
design a system that gives an individual
may enjoy on-line medical records,
the Associate Director for the University
details, plus consolidate the informa-
many have the traditional hand written
of Florida’s College of Medicine, Gainesville,
tion to provide governance with a glob-
progress notes and paper records in the
Florida. She has been with the Office of
al picture.
clinic. This makes gathering data for
Compliance for five years. She can be
self-audit a substantial investment. But
reached at 352/265-8359 or via email at
Target your audience
it is the most valuable educational tool.
nwt@ufl.edu. [The views expressed in
If your audience is a physician or a
Reviewing each provider’s documenta-
this article are Tarnuzzer’s personal views
group of physicians, you are trying to
tion periodically provides a very power-
and do not represent the views or opin-
communicate with a busy person.
ful and rewarding feedback. It works.
ions of the University of Florida.]
Present a concise report–try to keep it
to one or two pages, then be prepared
It’s easier now to build your own
This article was submitted to Compliance
to produce your supporting documen-
database
Today by the Academic/Research Focus
tation quickly.
ACCESS 2002 and 2000 are more user-
Group (CFG). Please contact Marti Arvin
friendly than older programs. You can
to learn more about the Academic Health
The objective is to generate a report
design your own database to meet pres-
Centers CFG.
that guides the user. For example, a
ent needs and adapt to future develop-
report on an individual will target what
ments. Investing time in learning about
Your audience is data driven
that individual needs to know to
database design can reward you with an
Some individuals are more responsive
improve or provide positive feedback
array of customized reports. Flexibility is
to data than others. Certainly the place
for good performance. Alternatively, the
important. It is key to be able to add
to find them are Academic Health
Board will need reports much broader
additional categories as rules, codes, and
Centers where there is a large popula-
in scope to guide, and will likely be
regulatory focus change.
tion of highly educated persons well
presented in the form of overheads or
versed in measurement and statistical
PowerPoint. Keep it brief and to the
Avoid comment boxes for any informa-
analysis. Methodical gathering and
point you wish to convey.
tion that may require grouping. They
presentation is inherent in research and
are cumbersome, do not lend them-
decision making.
Academic Health Centers have a wide
selves to sorting, and are very limited in
array of specialties. It is also important
utility.
Your data must credible and relevant
to develop perception of consistency
You won’t be credible if your data isn’t
and fairness in reporting. Consider a
It’s important to be able to generate
consistently accurate. Personal account-
standard format for reports to individu-
reports free of (HIPAA) protected
ability for the quality of your work
als, and for departmental summaries.
information
product and constant diligence is essen-
Be sure to strip off protected information
tial. Careful review and confirmation
You may wish to consider alternative
from correspondence and reports that
by a physician within the specialty is
methods of guiding your audience
will not be treated with the same security
important. It’s an opportunity to learn,
other than totals and percentages.
measures as your medical records.
and identify questions that will require
Ranking can be very effective, particu-
Continued on page 8
7
July 2003

ACADEMIC HEALTH CENTERS CFG...continued from page 7
There’s also opportunities to gather
information to monitor HIPAA
effectiveness and risk management
issues
While you are reviewing the medical
records, are there other opportunities to
gather information for other compliance
purposes? Is there a Notice of
Privacy Policy, after April 14, 2003?
How would you note a potential quality
of care or risk management issue?
Track outcomes both as number of
outcomes within the sample, and the
dollar value
Reporting based on dollar values may
either add emphasis or offer an alternative
perspective. Be sure to identify the
reasons for overpayments and underbilling.
There may be several comments
about a specific encounter, but its very
helpful to be able to quickly identify
which ones have the most significant
financial impact.
It’s also important to track based on
specific findings. You may also want to
be able to quickly identify findings that
mirror prior issues or are a current regulatory
focus.
Compliance continues to evolve into
ever increasing complexity
Data elements captured will change as
new issues and focus areas arise. Rules
will change, so adding effective dates
may be helpful. Tracking education,
refunding, and follow up testing by
provider can also be a useful tool in
managing your compliance efforts and
measuring effectiveness. ■
Database fields for physician services audits:
Tracking the audit:
Control number assigned to the audit
Name of individual performing the review
Name of individual providing supervision and review
Provider information:
Name of provider
Provider number
Physician, ARNP, or PA?
Division
Department
Medical record:
Name of the patient
Medical record number
Invoice number
Date of service
Type of documentation
The bill:
Was the encounter form signed?
The service:
Rendered by physician alone
Resident involved in service
Teaching physician documentation
Site of service
ARNP/PA involved in service
ARNP/PA performed service alone
Incident to
CPT code(s)
E&M service or procedure?
ICD-9 code(s)
Inpatient/Hospital-based/Outpatient setting
Name of clinic
Payor and payment:
Payor
Amount Charged
Findings:
Compliant or non-compliant?
Corrected CPT code?
Refund required?
Full refund?
Partial refund?
Amount of refund?
Reason for refund?
Underbilled?
Administrative or physician error?
Description of error (additional tables can be added
including extensive descriptors) ■
July 2003
8

COMPLIANCE
FOCUS
GROUP
HOME
CARE
CMS
clarification
on homebound
criteria for
home care industry remains unclear
By Lisa M. Silveria, RN
Editor’s note: Lisa M. Silveria, RN, is
Home Health Care Compliance Officer
with Catholic Healthcare West (CHW).
She may be reached at 209/956-2608.
This article was submitted to
Compliance Today by HCCA’s Home
Care Focus Group Chair Chris Anderson,
Vice President & Chief Compliance
Officer, Gentiva Health Services. He may
be reached in Melville, NY at 631/501-
7390.
When asked to write an article for
Compliance Today, I racked my brain
to find a topic that is controversial, fairly
subjective in nature, and still remains
unclearly defined in the eyes of CMS
and Congress. I didn’t have to search
very far. I have also recently been
approached by many of our CHW
agencies, since the release of Transmittal
302, as to how they should approach
this from an educational perspective
and still remain objective and clear in
definitions and examples of homebound.
After all, as this is one of the
qualifying criteria for home health services,
providing such services to the nonhomebound
patient can result in submission
of a false claim. With varied
clinical practices amongst same clinicians
by trade, let alone different disciplines,
this is clearly a hot topic area
and therefore no wonder a continuing
focus of the OIG.
In short, additional language was added
to HIM 11 under Section 204.1 in an
attempt to further clarify the definition
of homebound. It is worth noting that
we are pleased from an industry perspective
to see CMS recognize such
events as family and religious endeavors
as vital to a beneficiary’s recovery. For
so long this patient population was not
allowed to attend these functions for
fear that the home health agency may
be required to terminate medically
needed services as the patient was able
to leave the home setting and therefore
could receive these services somewhere
else. The problem was that there was
usually not that somewhere else to
which they might go. Home health
agencies, still to this day, take homebound
very serious and literally out of
fear of non-reimbursement and now
false claim submission. I believe this
will also ease the physician’s mind more
as he is required to certify in writing,
by signing the Plan of Care, that the
services are medically necessary and
that the patient is homebound.
It is refreshing for CMS to also look at
this issue from the patient’s complete
and lengthy health status and not just
during the brief home health episode of
care. Chronicity of illness is indeed a
factor in the patient’s overall health status
and response to care.
Why do our national and state organizations
have continued issue with it
then? For the same reasons many Home
Health Directors and Compliance
Officers still do. Transmittal 302 clearly
“muddies” and bends the interpretation
even more. Subjectivity is more prevalent
a consideration then before. It also
hasn’t gone far enough. It addresses specific
diagnosis (s) and degenerative
chronic illness conditions but what
about everyone else? Technology alone
has allowed us more ability to care for
people we haven’t been able to before.
With these advancements come personal
freedoms that enhance our patient
population recovery and hopefully ward
off exacerbations of illness.
And of course we have our regional
home health fiscal intermediaries to
deal with along with state surveyors.
Consistent training industry wide for
interpretive guidance is essential. The
GAO has chimed in also and has concerns
that these changes along with
others recommended by Congress, not
yet approved, will increase Medicare
cost. So, are we looking at an expansion
of the regulation and at the same time a
denial of services to cut cost? What is
considered too many absences now
under this ruling?
Then we have the case where services
are required but cannot be provided in
the home setting based on equipment
or treatment needs. The home health
agency is then expected to make
arrangements for such services under
PPS and for those not included in PPS
payment but part of the patient’s Plan
of Care. How does homebound fit
here? Same way. This homebound
patient will generally require the use of
an assistive device, potentially special
transportation, and the assistance of
another person to travel with them.
Their condition is usually a bit more
precarious so justifying homebound
becomes a little easier.
Continued on page 10
9
July 2003

HOME HEALTH COMPLIANCE CFG...continued from page 9
What does the agency needs to
do....DOCUMENT, DOCUMENT,
DOCUMENT. We must not ignore the
fact that a taxing effort is still required
along with the assistance of others to
make the infrequent departures from
the home even possible. Charting to the
physical and mental effects of the
absence on the next visit is essential.
Did the patient miss any required treatments
or medications? Did the outing
aggravate their condition?
Quality review of cases on an ongoing
basis is vital to assure that no patient’s
care is billed for that doesn’t meet all
the criteria for receiving home care
services. This review needs to include a
sampling of all clinicians. Recently at
the HCCA Institute held in New
Orleans, quality was a topic at several
sessions. Quality and Compliance must
be intertwined in considering all practices
and auditing performed and
reported.
Education of staff, physicians, and the
patient population is also needed.
Documentation of these encounters is
recommended. Use of newsletters,
inservices, and Patient FACT sheets are
helpful tools to establish a consistent
and defendable standard of practice. We
must also remember however that no
two patients are alike and individual
considerations and decisions will always
be expected, based on that particular
patient’s condition. ■
CORPORATE RESPONSIBILITY...
continued from page 6
July 2003
10
This type of sentence ordinarily would
not, by itself, fall outside the definition of
“conviction” for purposes of application
of the mandatory exclusion authority
under Federal health care programs.
However, the plea agreement to a count
of wire fraud against private payor programs,
is not one of the categories for
mandatory exclusion, which only relate
to convictions involving Federal health
care program (Medicare and Medicaid)
related crimes; convictions involving
abuse and neglect of a patient; convictions
involving controlled substances; and
convictions involving financial misconduct
in other Federal health programs.
Furthermore, the Office of Inspector
General of Health and Human Services
ordinarily does not impose mandatory
exclusion as a practical matter until after
sentencing in a case. The sentence in this
case has not been entered and will not be
entered (and in fact the case will be dismissed)
as long as the hospital successfully
completes the three-year probationary
terms under the plea agreement. ■
The Healthcare Compliance
■ Terri B. Graham, CHC
Certification Board (HCCB)
announced that the following individuals
have recently successfully
■ Deborah K. Harder, CHC
completed the Certified in
■ Mia G. King, CHC
Healthcare Compliance (CHC)
examination, thus earning the CHC
■ Michael S. Klueh, CHC
designation:
■ Donna J. Montmeny, CHC
■ Charles T. Bent, CHC
■ Tammy E. Nichols Ripa, CHC
■ Janis W. Cogley, CHC
■ Stephanie Coleman, CHC
■ Janice A. Ortiz, CHC
■ Alberta N. Craven, CHC
■ Barbara J. Wolf, CHC
■ Kent C. Fosha, CHC
■ Eric B. Zimny, CHC ■
Update your Member Information!
Check your information on the HCCA Members Only section of the HCCA
website, http://www.hcca-info.org, and email your update information to
info@hcca-info.org.

COMPLIANCE
FOCUS
GROUP
PAYOR/ MANAGED CARE
Conflicts
of interest
in payor and
managed care
organizations
by Robert A. Freeman and Vickie
McCormick
Editor’s note: Robert A. Freeman is
Associate General Counsel and
Compliance Officer with Blue Cross and
Blue Shield of Massachusetts, Inc. He can
be reached at robert.freeman@
bcbsma.com. Vickie L. McCormick is
Special Counsel with Halleland, Lewis,
Nilan, Sipkins & Johnson. She can be
reached at vmccormick@halleland.com
This article was submitted to
Compliance Today by the
Payor/Managed Care Compliance Focus
Group (CFG). Please contact Vickie
McCormick to learn more about the
activities of the Payor/Managed Care
CFG.
One common thread running among
the corporate scandals exposed during
the past few years is that the tainted
companies failed to guard against conflicts
of interest. It has long been best
practice among payor compliance programs
to educate employees about conflicts
of interest and resolve conflicts
that inevitably arise. The importance of
addressing conflict is even greater now,
where government actions have ranged
from enactment of the Sarbanes-Oxley
Act 1 to a series of investigations of
health plan business practices by the
Minnesota Attorney General. 2
This article will summarize some questions
to consider in designing a compliance
program to address conflicts of
interest, and will present some tips on
how to resolve conflicts identified by a
compliance program.
What is a conflict of interest?
The simplest definition of a conflict of
interest for these purposes is when one’s
personal interests are inconsistent with
the best interests of the organization.
Employees’ duty of loyalty to their
employer arises out of corporation
statutes, common law, tax-exemption
rules for non-profit organizations, and,
in some cases, employment contracts,
codes of conduct, and employee handbooks.
This duty requires employees to
act with the interest of their employer as
the uppermost guide for their conduct. 3
Types of conflicts of interest
Conflicts can be divided into the following
somewhat arbitrary categories:
■ Actual conflicts of interest. These
are direct and immediate conflicts
between an individual’s and an organization’s
interests.
■ Potential conflicts of interest.
These are situations where there is
no immediate conflict, but the
prospect of a direct conflict can be
readily foreseen.
■ Apparent conflicts of interest.
These are situations where there may
not in fact be a direct conflict, but
people unfamiliar with all the facts
and circumstances of the situation
may reasonably believe an actual or
potential conflict a exists.
■ Indirect conflicts of interest. These
are situations where there is an actual
or potential conflict between the
interests of the employer and an
employee’s close family or friends.
ROBERT A. FREEMAN
Why are conflicts of interest
problematic?
Conflicts of interest can expose payors
to liability in a number of ways.
Depending on the nature of the conflict,
and how it is handled, a payor
could face liability under federal
statutes, such as the Anti-kickback Act,
the False Claims Act, and ERISA. They
could also face liability under analogous
state statutes as well as under claims
alleging bribery or a breach of fiduciary
duties. Enforcement could include
shareholder derivative actions and challenges
to a non-profit organization’s
tax-exempt status.
Just as important, revelation of a conflict
of interest can harm an organization’s
reputation and public image.
Trust built up over years can disappear
in moments when a scandal erupts.
Firms may expose themselves to all
sorts of external criticism–from derogatory
views of the company’s integrity to
allegations from jilted vendors that they
were denied opportunities because they
lacked equal unfair access to decisionmakers.
Moreover, companies that fail
to deal with conflicts of interest may
Continued on page 12
11
July 2003

PAYOR MANAGED CARE CFG...continued from page 11
tolerate other forms of inappropriate
conflict disclosure process, at least
conduct that can further erode the
for boards of directors and officers.
company’s reputation and result in
■ Educate employees about the com-
additional legal exposure.
pany’s policies and procedures.
Finally, conflicts of interest undermine
internal credibility. Imagine the effect
widespread self-dealing or favoritism
has on employee loyalty and trust. The
result likely would be either sharp alienation
from the company’s goals or a
sense that “anything goes.”
Conflicts of interest should be
addressed in any code of ethics or
compliance handbook and, as indicated
above, merits a stand-alone
policy. Reminders can be included
in employee newsletters or other
compliance communications, and
the issue should at a minimum be
VICKIE MCCORMICK
How to deal with conflicts of interest
Payor organizations should establish a
process to address conflicts of interest.
The process will help protect both the
company and individuals from the risks
associated with conflicts of interest.
Any program to address conflicts of
interest should include the following
elements:
■ Adopt corporate-wide policy on
conflicts of interest. The content of
the policy can be as strict as the
organization feels is appropriate, but
should clearly spell out the company’s
position and should alert
employees at all levels to their respective
obligations. The policy should
address high-risk areas such as gifts,
nepotism, and funding from pharmaceutical
manufacturers and device
makers.
■ Adopt reasonably detailed procedures
for handling conflicts of
interest. These procedures should
detail what situations need to be dis-
included in overall compliance training.
Organizations should consider
delivering specific training on conflicts
topics–whether by way of a
stand-up presentation, on-line
course, or custom-made or off-theshelf
video–particularly if there is
doubt as to the depth of employees’
understanding of the issues.
Whatever the format, education
should give concrete examples of
conflicts and how they should be
handled.
■ Document the process by which
situations are evaluated, resolved,
and communicated to employees.
Although conflicts can come in a
dizzying variety, documentation will
help payors strive for consistency,
and will enable them to demonstrate
that they have taken serious steps to
address the risk.
There are many other questions to consider
in designing a compliance program
to deal with conflicts of interest.
These include:
■ Should disclosure of conflicts or
potential conflicts be made part of
the vendor selection process? Some
firms include questions about known
conflicts in their RFP boilerplate to
elicit information from vendors at
the earliest possible time.
■ What types of information need be
disclosed? Typical questions include
outside employment, employment of
spouses, board memberships, and
financial interests. Should disclosure
forms ask about significant charitable
or political activities? With regard to
financial interests, disclosure obligations
should be phrased in terms of
both percent of ownership and
absolute value. For example, a policy
could ask the employee for information
about any investment that is
equal to or greater than 10% ownership
of the other firm or valued at
more than $50,000.
■ How much information should be
requested concerning family and
friends? One rule is to seek equivalent
information (i.e., employment,
closed, to whom disclosures should
■ Who should complete periodic dis-
board membership, substantial finan-
be made and in what fashion, and
closures? It is common practice to
cial interests) about all relatives with-
July 2003
12
what process will be followed for
evaluating disclosures. Serious consideration
should be given to mandating
a periodic (typically annual)
require officers and directors to complete
disclosure forms, but should the
process be extended to senior management,
or to the entire company?
in “one degree of consanguinity” -
that is, parents, spouses, and children.
What about siblings?
■ Should disclosure forms be com-

pleted annually? More frequently?
Probably the most important question
legal disputes and loss of reputation by
Upon employment or joining the
to consider, however, is the appearance
implementing a tailored conflicts of
Board? Likely disclosure should be
required any time there is a change
in situation newly creating a conflict.
■ Who is responsible for managing
the process? Who collects disclosure
forms? Is the process for board directors
and officers the same as for
lower level employees? Can an online
disclosure process be maintained?
How will reports be recorded,
stored, and retained?
■ Who is responsible for making deci-
of the conflict. This is true regardless of
the category into which the conflict
may fit. The perception or appearance
of a conflict can be just as damaging as
the existence of an actual conflict.
To assess the appearance, use the common
“headline” test: how would it look
if the situation was plastered across the
front of the business section of your
local newspaper? Think about how the
local tabloid could spin the situation to
interest program. As organizations
change, conflicts of interest programs
may also need to change, so programs
should be reviewed periodically. Also,
compliance officers should make sure
their approach to conflicts of interest is
multi-disciplinary. Organizations need
to involve Human Resources and management
in the process. In the end, a
strong conflicts of interest program will
strengthen payors now and in the
future. ■
sions? Options range from managers,
the compliance officer, human
resources, and senior management.
Typically the general counsel or corporate
secretary will review disclosures
by officers and directors. Is the person
responsible for evaluating conflicts the
same as the person responsible for
managing the process?
make your company–and the individuals
involved–look bad.
Consider also the companion to the
“headline” test: the “water cooler” test:
how would senior management feel if
the situation was the main topic of discussion
at the proverbial water cooler.
1 Sarbanes-Oxley Act of 2002, Pub. L. 107-
204.
2 See http://www.ag.state.mn.us/consumer/health/
Law_Legis.htm#Law Enforcement Efforts
3 This article will not address those rare situations
where employees are at liberty, or even
required, to act contrary to their employers’
interest.
If embarrassment would result, it is
How to resolve conflicts of interest
Up to this point, this article has skirted
probably a signal that something should
be done.
Your physician compliance
training just got easier...
the toughest question of all: how to
address a situation when a conflict–
When a conflict is discovered without
actual, potential, apparent, or indirect–
voluntary disclosure, the full array of
arises. Resolving conflicts is difficult,
disciplinary measures should be avail-
and fact-specific. Still, here are a few
able. When a conflict is disclosed in
guidelines to help compliance officers
advance, measures could include:
evaluate situations that arise.
changing an employee’s job responsibili-
First, any review must consider the law.
Potential exposure to legal risk is a fundamental
question to answer in every
case. Next, consider whether the conflict
is likely to have direct adverse con-
ties, forbidding an employee from participation
in certain activities (for Board
members, this is akin to recusal from
participation in discussions and votes
related to the conflict situation), or simply
making sure decision makers are
With HCCA’s 39-minute
audio-training program:
Individual & Small Group
Physician Compliance: What
every physician should know
sequences for the organization, such as
disadvantageous terms for a business
deal. A related inquiry is whether the
situation has or is likely to lead to the
disclosure of confidential or proprietary
aware of the conflict so they can take
into account the possible competing
interests in making decisions. There is
no single approach to conflicts of interest
that is appropriate for all organiza-
An essential resource for every
compliance department. Visit
HCCA’s Website, http://www.
hcca-info.org, to order.
information.
tions. But, payors can reduce the risk of
13
July 2003

July 2003
feature
14
Editor’s note: This feature interview with
Britt Crewse, MBA, MHS, HCCA
Region IV President and Associate VP
and Chief Compliance and Privacy
Officer with Duke University Health
System, was conducted in the Spring of
2003 by Debbie Troklus, CHC, Assistant
Vice President for Compliance and
Privacy, University of Louisville School of
Medicine. Britt may be reached at
919/668-6250 and Debbie may be
reached at 502/852-0758.
DT: Tell me about your background
prior to compliance? What in your
background do you feel prepared you
for life as a compliance professional?
BC: My background and masters
degrees are in business and in the hospital
administration field. I became a
CPA while working as a senior manager
in a Big 5 accounting firm, where I
learned a great deal about compliance
while helping health care organizations
implement compliance programs. I
have been consulting or in the compliance
officer role since 1997.
DT: Tell me a little about your position,
what your title is and what do
your responsibilities include?
BC: I am the associate vice president
and chief compliance and privacy officer
for Duke University Health System.
My primary responsibilities include
oversight of DUHS’s compliance activities,
ensuring the evaluation and
demonstration of program effectiveness.
article
Meet Britt Crewse, MBA,MHS
Associate VP and Chief Compliance
and Privacy Officer,
Duke University Health System
I oversee the implementation and execution
of the annual DUHS compliance
workplan that audits and monitors
compliance risk areas. I work in collaboration
with the Duke Private Diagnostic
Clinic and the Duke School of
Medicine to ensure compliance
throughout all of Duke.
In 2001, I was designated DUHS’
Privacy Officer. As Privacy Officer, I
was charged with overseeing all ongoing
activities related to the development,
implementation, and adherence to privacy
policies and procedures related to
patients’ protected health information.
DT: At Duke, are there separate compliance
officers or contacts for the hospital,
clinics, etc? Do you work on a
compliance liaison approach?
BC: Duke’s organizational structure,
like many academic health systems, is
unique. The health system consists of
three hospitals, 70 employed primary
care physicians, home health, and hospice.
The Duke Private Diagnostic
Clinic is the multi-specialty teaching
physician group consisting of 850
physicians and 200 non-physician
practitioners. Finally, we have the Duke
University School of Medicine that
primarily consists of our 2,400 clinical
trials and research components of
Duke. When you combine these with
the support areas (finance, IT, etc.)
there are approximately 20,000 health
care workforce members at Duke.
Each of the three components of
Duke has separate compliance officers.
The School of Medicine and Duke
PDC compliance officers have a dotted
line reporting relationship to me.
With-in Duke University Health
System, we have compliance liaisons at
each of the facilities. Each of the compliance
liaisons reports directly to me
for compliance-related issues.
DT: What does the compliance
organizational structure look like? Also

would you tell me how many staff do
you have and what positions they hold?
BC: Our compliance structure begins
with the Audit and Compliance
DT: What impact has HIPAA Privacy
implementation had on your office?
BC: HIPAA implementation had an
enormous effect on my office and con-
Committee of DUHS. This committee
meets twice a year. I report directly to
DUHS’s president and CEO, who is
also the chancellor of health affairs for
Duke University. I have four staff
reporting directly to me. The employees
reporting to me are not specialized in
one particular area. They have great
understanding of all compliance issues
and enjoy being involved in the many
aspects of compliance. I have found this
approach to be best for the professional
development of our staff. In addition,
several Duke employees spend a significant
amount of their time dedicated to
compliance activities and report directly
to me on these activities. I have been
very fortunate to be surrounded by such
talented individuals.
DT: What are the top challenges
when dealing with physicians in regards
to compliance, and how do you deal
with them?
BC: I would have to say the top challenges
with physicians are the following:
a) Physicians are not incented the same
way as hospitals. Getting physicians
to understand the importance of
appropriate documentation for the
hospitals is challenging because
physicians are not paid by Medicare,
Medicaid, insurance companies, etc.
based on how they document the
hospital records.
b) Training residents as to how
documentation should occur in
the medical record is difficult
because residents are spending
tinues to be a large focus for the compliance
office. As Privacy Officer, I was
given the task of ensuring HIPAA
compliance for DUHS, the Duke
University School of Medicine, and
the Private Diagnostic Clinic. The
complexities of our organization created
several challenges for us to become
HIPAA-compliant, but at the same time,
we have several experts in our organization
that made becoming HIPAA compliant
much more manageable.
We are now in the process of developing
audit methodologies to ensure
HIPAA compliance in key areas.
DT: Did you find that HIPAA implementation
seemed very similar to compliance
program implementation?
BC: There were several similarities
between HIPAA implementation and
compliance program implementation.
Compliance training is something we
take very seriously at Duke. All new
employees are required to participate in
a 1-1/2 hour compliance and HIPAA
orientation course. For existing employees,
we required HIPAA training via
on-line, video, or self-study packets.
To date, 96% of our 20,000 workforce
members have completed compliance
and HIPAA training.
In addition to training, we developed
approximately 50 new policies
and procedures related to privacy and
security. Key employees have been
trained on these policies and procedures.
We are very excited about our
HIPAA compliance program and
DEBBIE TROKLUS
DT: Are you involved with research
compliance?
BC: Although most of our research
compliance activities fall under the
Duke University School of Medicine
Compliance Office, I have been very
involved in reviewing clinical trial
compliance and investigational devices.
At Duke, there are very few issues that
come to our attention that do not affect
DUHS, the Duke University School
of Medicine, and the PDC.
DT: Do you find that the Research
area has both unique compliance and
HIPAA-related issues?
BC: Academic research definitely has
unique compliance and HIPAA issues.
One of the first things I had to learn
was that research consists of human
subjects, not patients. The review of
conflicts of interest issues in research is
a very sensitive issue that requires very
careful handling. I believe the single
biggest HIPAA concern for academic
medical centers is the accounting of disclosures
for reviews preparatory to
research. We must now account for
those disclosures to outside companies
that we work with every day. Although
we have stressed to our researchers the
most of their time learning how
believe it is a model for academic med-
importance of accounting for these
to treat patients.
ical systems across the country.
Continued on page 16
15
July 2003

July 2003
16
Britt Crewse
disclosures in our accounting of disclo-
learn
sure database, this is a culture change
that will require some time to take root.
DT: I have heard many compliance
officers talk about the stress of the job.
How do you deal with the everyday stress
of being the compliance officer for such a
large academic medical center?
BC: First of all, I am fortunate to
work at a place that places such a high
emphasis on integrity and doing the
right thing. This starts at the top of our
organization and flows throughout
Duke. This certainly has put me in a
more comfortable position to help correct
those processes that are not working
in a compliant manner. But the
most stressful thing in my life is being a
full-time father of a soon to be fouryear
old son and a six-year old daughter!
I am a huge sports fan and am still
an avid basketball player and runner.
Duke is a pretty fun place to be during
basketball season.
DT: What do you see as the next big
agenda item for compliance?
BC: I think we will see more quality
of care and compliance stories. Associate
U.S. District Attorney Jim Sheehan
spoke at length about this at the
Compliance Institute. Our recent tragedy
at Duke related to the Jesica Santillan
case is one that has sent waves across the
United States. I am proud that we were
very forthcoming about the events that
occurred in the case. Many people have
asked how this case has affected me and I
tell them that it deeply affected all Duke
employees. At Duke, our reporting
model consists of a patient safety compliance
officer that reports to me on financial
compliance issues but reports to the
chief nursing officer on patient compliance
matters. I have heard many discussions
about another model in which the
chief compliance officer holds the
responsibilities related to patient safety as
well. I believe you can make a case for
either model.
DT: What is it about your role as
compliance officer that you most enjoy?
BC: I really enjoy being involved in
so many different activities in an amazing
health care organization. I am a
health care professional first and a CPA
second. I love the health care industry
and think compliance allows an individual
to see the entire health care
organization. I enjoy being able to help
lead teams that improve processes and
help our patients. In addition, I have
grown very fond of academic medicine
and the unique compliance challenges it
brings. Finally, Duke is a great place to
work where I have been able to make
great strides professionally.
DT: I know you are President of
HCCA Region IV. What would you say
are the benefits for members of being
active in the HCCA regions?
BC: I think regional and state events
are an important offering to HCCA’s
membership. The Compliance Institute
event is a tremendous gathering that
educates the members on national compliance
issues such as HIPAA. Each
state and region has unique regulatory
issues that may be different than
national compliance issues. In Region
IV, we have had successful regional conferences
dating back four years. We are
already deep into the planning stages of
this year’s fifth annual regional meeting
that is going to occur in November. In
polling our regional membership, we
have found that most members like to
about the enforcement and regulatory
issues related to our region. The
same can be said for the state events.
DT: What words of advice do you
have for individuals seeking positions
as compliance officers?
BC: First, get involved in HCCA.
The network that I have been able to
develop through HCCA is incredible.
It’s nice to be able to pick up the phone
and call a fellow compliance officer
halfway across the country when I have
an issue. I have been to several HCCA
conferences over the past five to six
years and every time have been able to
bring back something that I use as a
compliance officer.
Second, read everything you can
on compliance. Compliance Today
and HCCA’s weekly e-mailed newsletter
have been great resources for me to
learn more about the compliance
industry.
Last, practice your problem solving
skills. Most compliance issues are not
solved immediately and probably are
related to processes that involve multiple
departments. In addition, practice
patience. There are so many compliance
issues occurring at one time that
there is no way you will be able to solve
them all at once. ■
HCCA Contact Information:
Telephone: 888/580-8373 or
952/988-0141
Fax: 952/988-0146
Mail: 5780 Lincoln Drive
Suite 120
Minneapolis, MN
55436
Website: http://www.hccainfo.org

By Frank Sheeder
Frank Sheeder is a principal of Sheeder &
Welch, a Dallas-based law firm that focuses
on healthcare compliance and complex litigation
matters. He may be reached at
214/747-9900 or at frank@sheederwelch.com
The Department of Health and
Human Services’ Office of
Inspector General (OIG) and
the American Health Lawyers Association
(AHLA) recently announced the
release of a collaborative educational
resource entitled Corporate Responsibility
and Corporate Compliance: A Resource for
Health Care Boards of Directors. This document
(the Educational Resource) should
come as no surprise, considering the current
corporate accountability crisis and
the recently enacted Sarbanes-Oxley Act.
The Educational Resource, which can be
found at http://oig.hhs.gov/fraud/docs/
complianceguidance/040203CorpRespRsce
Guide.pdf, is intended to promote corporate
compliance in the health care industry
by educating boards of directors on
how they might meet their oversight
responsibilities. The Educational
Resource offers specific guidance to
directors in the form of 18 questions
(plus sub-questions) that boards should
ask their management teams.
The OIG and the AHLA have indicated
that the Educational Resource is not
intended to set any specific or mandated
standards. Nonetheless, in its April 2,
2003 press release, the AHLA reported
that Lewis Morris, Chief Counsel of the
OIG, stressed the document’s significance
by encouraging health care organizations
“to provide this pamphlet to incoming
board members so that they understand
not only their fiduciary duties but also
the corporate compliance challenges of
the organization.” 1
Summary of the Educational Resource
The Introduction of the Educational
Resource:
■ Refers to the current corporate integrity
crisis and the resulting widespread
scrutiny of corporate directors.
■ Makes it clear that health care organizations
will be held to the same standards
as other companies, regardless of
whether they are publicly-traded or
for-profit.
■ Reminds directors of their fiduciary
responsibilities and describes those
duties in detail. Directors’ duties
include:
• The basic fiduciary duty of care
principle, which requires a director to
act in good faith with the care an ordinarily
prudent person would exercise
under similar circumstances.
• The concept of “reasonable
inquiry,” which is embedded in the
duty of care.
■ Describes the personal liabilities that
directors can have when they do not
meet their duties.
■ Discusses the Caremark 2 decision,
which is the seminal lawsuit against
the board of directors of a health care
organization for alleged breach of duty.
■ Explains that the purpose of the document
is “to help health care organization
directors to ask knowledgeable
and appropriate questions related to
health care corporate compliance.”
FRANK SHEEDER
The Duty of Care section of the Educational
Resource, which contains a thorough
description of a director’s duties:
■ Defines the duty of care that a director
owes to an organization. This duty
involves:
• Acting in good faith. This means
making sure that a matter or transaction
does not involve any improper
financial benefit to an individual, and
does not take advantage of the entity.
This entails “reasonable inquiry,”
which is conducting the appropriate
level of due diligence to allow an
informed decision. Directors are not,
however, expected to know all details.
They are allowed to rely on the advice
of management and outside advisors.
• Acting with a level of care that an
ordinarily prudent person would exercise
in like circumstances.
• Acting in a manner that the director
reasonably believes to be in the
best interest of the organization.
■ Explains that the duty of care arises in
two distinct contexts:
• The decision-making function.
This applies to board actions.
• The oversight function. This
includes overseeing the organization’s
day-to-day business operations and
exercising reasonable care to assure
Continued on page 18
17
July 2003

15 NEW OPPORTUNITIES...continued from page 17
that managers carry out their responsi-
ance information about the health care
aimed at them?
bilities and comply with the law.
industry:
■ Compliance infrastructure. Does the
■ A recent HCCA survey that found
compliance officer have appropriate
The Caremark decision, which is viewed
that in just three years, providers with
authority, autonomy, and resources?
as being applicable to all health care
active compliance programs have
Are compliance responsibilities
organizations, states that directors have
grown from 55 percent in 1999 to 87
assigned appropriately? Is there
two principal oversight obligations:
percent in 2002. 3
employee accountability?
■ To insure that a corporate information
■ In support of industry compliance
■ Measures to prevent violations. Has
and reporting system exists.
efforts, the HHS-OIG has issued
there been adequate training and
■ To insure that the reporting system is
provider-specific, voluntary compliance
measurement of its effectiveness? Is the
adequate to assure the board that
guidances. 4
board kept apprised of pertinent regu-
appropriate information about compli-
latory and industry developments?
ance with applicable laws will come to
The final section of the Educational
■ Compliance program effectiveness. Is
the board’s attention in a timely man-
Resource is called Suggested Questions for
conformance with and effectiveness of
ner as a matter of ordinary operations.
Directors. It is divided into structural
the compliance program evaluated?
questions and operational questions.
Are there remedial measures to address
It is sometimes challenging for directors
Structural questions that directors should
shortcomings?
to gain comfort that they are discharging
be asking are aimed at the following
■ Measures to respond to violations.
their duty of care with respect to their
themes:
How does the organization evaluate,
oversight functions. As discussed below,
■ How is the compliance program struc-
respond to, and resolve instances of
this area presents an opportunity for com-
tured, and who is responsible for its
suspected or reported non-compliance?
pliance professionals to “step into the gap.”
implementation and operation? Does
Are relevant documents and informa-
the program address the organization’s
tion preserved? Does the organization
The third section of the Educational
specific existing and emerging risks?
protect whistleblowers? How are com-
Resource, entitled The Unique Challenges
■ How is the board structured to oversee
pliance violations reported to the
of Health Care Organization Directors, sets
compliance issues?
board or government authorities?
forth well-known realities in the health
■ How does the compliance reporting
care industry:
system function?
The implications and opportunities
■ The industry is heavily regulated under
■ What are the compliance program’s
Much of the contents of the Educational
a voluminous and complex set of rules.
goals and limitations, and what are the
Resource will be axiomatic to compliance
■ Non-compliance with government
procedures for addressing its limita-
professionals. The question will then
health care program rules can result in
tions?
become, however, whether the board is as
substantial risks.
■ What resources are dedicated to the
acutely aware of its intent. In light of the
■ The current “corporate responsibility”
compliance program, and are they ade-
Caremark decision, it is clear that the
environment should cause directors to
quate?
directors of health care organizations need
be diligent about their oversight func-
to be extremely mindful and vigilant in
tions.
Operational questions that directors
matters relating to compliance. 5 Indeed,
■ Government enforcement resources,
should be asking relate to other themes:
the failure to establish an adequate com-
and the fines and penalties resulting
■ The organization’s Code of Conduct.
pliance program may constitute a breach
from their utilization, have grown dra-
Has it been incorporated into corpo-
of the duty of care under Caremark.
matically.
rate policies, communicated well, and
Moreover, since the Caremark decision is
accepted across the organization?
particularly highlighted in the
The fourth section of the Educational
■ Policies and procedures. Are there poli-
Educational Resource and apparently
Resource, entitled Development of
cies and procedures that address risk
used as a reference in crafting some of the
July 2003
18
Compliance Programs, includes compli-
areas and establish internal controls
Suggested Questions for Directors, it would

e prudent for compliance officers and
boards of directors to pay special attention
to that decision. The Educational
ment with a summary of the organization’s
risk areas and applicable statutes
and regulations. Your in-house or out-
12. Nonprofit health care organizations
should review the Corporate
Responsibility Guidebook published by
Resource should also provide compliance
side counsel should be able to provide
the Coalition for Nonprofit Health
professionals with an excellent opportuni-
appropriate supplemental material.
Care in November 2002. 6 One of its
ty to heighten directors’ awareness. Here
are some ideas as to how to make the
most of this opportunity:
1. Share the Educational Resource with
directors and senior management. Let
them know that the OIG and the
AHLA (comprised of lawyers who
would represent them in instances of
compliance lapses) have formulated
and issued voluntary standards that
apply directly to them.
2. Explain that government “suggestions”
and “guidances” become expected
behavior. It is interesting that there is
no law or mandate that requires health
care providers to have compliance programs–just
OIG “guidance.” The
Caremark decision would indicate that
some form of corporate information
and reporting system, such as a compliance
program, should be implemented
in order for a corporate board
to satisfy its obligations. While the
6. Have a “compliance retreat” for your
board of directors and senior management.
Invite a multidisciplinary team
that can immerse them in the various
facets of the compliance program.
7. If your compliance program needs a
“jump start,” consider using the promulgation
of the Educational Resource
as the spark. Ask for and obtain “tone
at the top” by having the board and
senior management reiterate the organization’s
commitment to compliance
to everyone in the organization.
8. Share a copy of the Caremark decision
with directors and senior management.
Review the Caremark decision and
incorporate the principles it stands for
into your overall compliance program.
9. Use the Educational Resource as a
rationale for shoring up areas of your
compliance program to which your
board and senior management have
not been receptive in the past.
recommendations is that nonprofit
health care organizations consider
implementing selected Sarbanes-Oxley
provisions now.
13. If applicable, review the New York
Stock Exchange and the NASDQ
Stock Market’s proposed new corporate
governance standards.
14. Ask your counsel to review board and
management indemnity agreements
and consider making them consistent
with the guidance in the Educational
Resource as to board and management
responsibilities.
15. If you are in the 13 percent minority
that does not have an active compliance
program, design and implement
one promptly. If you already have a
compliance program, have it reviewed
by outside counsel. In order to avoid
even the appearance of a lack of independence,
use counsel that does not
generally represent the organization. ■
Educational Resource is voluntary,
boards that are faced with instances of
non-compliance will likely be held to
its standards.
3. Answer the questions posed in the
Educational Resource and arrange to
have the answers communicated to the
board. Consider having this done by
or under the auspices of legal counsel.
4. Create a broader report that assesses
your organization’s current compliance
with the suggestions in the Educational
Resource. Offer a cohesive plan for
fixing any shortcomings. Consider
having this done by or under the
auspices of legal counsel.
5. Provide directors and senior manage-
10. Help the board to develop policies
and procedures aimed at complying
with the Educational Resource, including
descriptions of board, management,
and compliance officer responsibilities.
Develop a Statement of Purpose and
Responsibilities for the board so it can
more effectively discharge its oversight
responsibilities. Recommend that, at a
minimum, at least one director be
charged with the responsibility of overseeing
compliance efforts.
11. Review the composition of your
board and its audit or financial committee
to ensure that the requisite
“independence” exists and that there
are no conflicts of interest.
1 See, Office of Inspector General and American
Health Lawyers Association Release Educational
Resource for Health Care Board Members (April 2,
2003) http://www.healthlawyers.org/oigahla/
OIG-AHLA-PressRelease-CorpResp
CorpCompl.pdf
2 In re Caremark Int’l., Derivative Litig., 698
A.2d 959 (Del. Ch. 1996).
3 See HCCA’s 5th Annual Survey, 2002 Profile
of Health Care Compliance Officers,
http://www.hcca-info.org/documents/
HCCAsurvey9_02.pdf
4 See http://oig.hhs.gov/fraud/
complianceguidance.html
5 In Caremark, 698 A.2d at 970, the court held
that as a part of its duty of care, a board had
an obligation to “exercise a good faith judgement
that the corporation’s information and
reporting system is in concept and design
adequate to assure the board that appropriate
information will come to its attention in a
timely manner as a matter of ordinary operations
so that it may satisfy its responsibility.”
6 See http://www.cnhc.org/pdf/
CNHCguidebook.pdf
19
July 2003

By Phoebe Moore, BA, CPC, CPC-H
July 2003
20
Editor’s note: Phoebe Moore is a Project
Manager and Senior Consultant with
HP3’s Coding and Audit Group. In her
role, she conducts onsite medical record
reviews, mentoring, and coding training
programs. She has managed pre-billing and
concurrent coding audits and conducted
coding in-service education for both coding
staff and physicians. She may be reached at
610/332-2990.
Physician practices are often
confronted with the difficult
circumstance of dealing with a
patient who fails to show up for a scheduled
appointment. Missed appointments
cost the practice money. Particularly for
small practices, appropriate staffing and
scheduling are critical to ensure a profitable
enterprise. Practices may feel
compelled to develop a policy to charge
patients for these missed appointments.
What are the options and how can we
implement such a policy? Does Medicare
permit this? If patients are charged will
the monetary benefits outweigh the risk
of losing the patient to a more flexible
practice?
A Medicare provider may bill a beneficiary
for a missed appointment.
However, Medicare does not provide
any type of benefit for missed appointments.
Thus, the charge for this missed
appointment would be considered a
non-covered service and is therefore the
responsibility of the patient. Several
important steps must be taken so that
the practice is certain that the policy is
clearly understood and applied without
discrimination.
First, patients should be notified in
advance. A written no-show policy
should be provided to all new patients.
Established patients should receive a
notice by mail including information
about fees, the number of hours in
advance when cancellations will be
accepted, and any exceptions to the policy.
The policy should be posted in the
office or clinic so that patients are
reminded of the consequences of missing
a scheduled appointment.
The policy must be standard and must
apply to all patients equally. It would be
inappropriate to exclude any particular
group of patients based upon the type of
insurance coverage, as this could be
viewed as discriminatory. Prior to standardizing
the policy, all managed care
plans should be reviewed. Some
providers’ contracts may contain restrictions
prohibiting the provider from
charging for an appointment that is not
kept. If this is the case, then the policy
could not be applied equally to all
patients.
The approach to billing patients for
missed appointments is a matter of personal
choice. The ramifications may be
significant and should be carefully considered.
Patients may be offended by
such a policy or may decide to leave the
practice. Before implementing a charge
for the no-show visit it may be wise to
consider a less drastic approach. If the
true intention is preventive as opposed to
punitive, then there are other options.
One suggestion is to call the patients a
PHOEBE MOORE
day or two before the scheduled appoint
with a reminder, confirming the date and
time. It is easy for patients to forget
appointments that have been scheduled
weeks and months in advance. If the
patient has a conflict at the time of the
call and needs to cancel, there may still
be an opportunity for the practice to fill
the open appointment. This method
allows the practice to accommodate
emergencies and urgent cases as well as
promoting a positive, caring relationship
with the patient.
Patients who have missed previous
appointments may be scheduled at the
end of the day to avoid inconveniencing
the physician and staff in case the situation
occurs again.
For habitual “no show” offenders, it may
be necessary to legally terminate the
physician-patient relationship. In this
case, the following steps should be taken:
■ A 30-day notice in writing via certified
mail should be sent to the
patient.
■ A return receipt should be requested
and kept on file.
■ The notice should include an explanation
of the reason for the termination.
■ The practice should assist the patient

in locating another physician.
■ The practice should offer to transfer
medical records to the new physician.
■ The practice should continue to provide
care if the patient is sick.
The physician-patient relationship is a
complex one. It is both a personal relationship
and a business arrangement.
Physicians often spend years of hard
work and hours of communication to
establish the trust and confidence of their
patients. For this reason physicians may
try to divorce themselves from the business
aspects of the practice, such as collecting
money, discussing fees, and
explaining policies.
Office administrators and practice managers
may need to account for a drop in
revenue or a decrease in the number of
patient visits. A no-show policy may
seem like a reasonable solution. But policies
and procedures that appear to be
inflexible or insensitive can damage one
of the office’s most valuable yet intangible
assets; the patient’s perception of the
office. Patients need to feel that they will
receive quality care in a sensitive and
compassionate atmosphere. It would be
wise to consider all alternatives and to
seriously weigh the possible outcomes of
implementing a no-show policy. A policy
which is initially developed to resolve a
financial concern might ultimately cause
the opposite to occur. ■
SAVE THE DATE!
AHLA/HCCA Fraud and
Compliance Forum
September 21-23, 2003
Washington, DC
For more information, call:
888/580-8373
By Joseph J. Russo, Esq.
Editor’s note: Joseph J. Russo, Esq., is ■ Allegations of “under documentation”
or “insufficient documenta-
President, HP3 Inc., which is located in
Bethlehem, PA. He may be reached at tion”
610/882-2200.
■ Claims of medically unnecessary
services being provided
Compliance and Health ■ Poor continuity of patient care
Information Management ■ An impact on quality of patient care
professionals often tell stories overall
about attending physicians who have
handwriting that is difficult to understand.
Poor handwriting results in illeg-
often review medical charts to ensure
Medicare carriers and intermediaries
ible documentation creating liability that the documentation is consistent
and risk issues for hospitals and physicians.
These include False Claims Act audits and medical chart reviews are
with the reimbursement received. The
issues, quality assurance issues, risk performed by medical record professional
and/or clinicians. These auditors
management issues, JCAHO accreditation
issues, increased audit potential will not spend an inordinate amount of
from public and private payers, as well time attempting to decipher the handwriting
of the attending physician.
as medical malpractice risks. In addition,
illegible documentation can have a When handwriting is illegible, the auditor
will not give any credit to that por-
direct negative impact on patient care
resulting in improper medical treatment tion of the documentation. Although
or the dispensing of the wrong medication.
the illegible documentation creates a
the service was legitimately provided,
substantial legal risk. Illegible documentation
is of no value in verifying
More specifically, illegibility can lead to:
■ Improper treatment of the patient medical necessity or coding accuracy
■ Negligence on the part of the physician
and the health care organization Manual, DOC-1, “Documentation of
for services billed. (Medicare Policy
■ Medical malpractice on the part of Services”, Para. 2, Rev. 3/97.)
the physician and the health care
organization
In addition to issues of illegible documentation
and their impact on reim-
■ Dispensing of wrong medications
■ The assumption that the service was bursement, JCAHO Hospital
not provided
Accreditation Standards also address
■ High error rates in documentation issues of medical record legibility.
and coding audits
Indeed, IM.7.10.1 states that the review
■ No payment for services provided
Continued on page 22
21
July 2003

LIABILITY ISSUES...continued from page 21
sive procedures, tests, and their
dence.”
results
■ Reports of any diagnostic and thera-
A second excellent example of illegible
peutic procedures, such as pathology
physician documentation is the case of
and clinical laboratory examinations
Balmir v. DeBuono, Commissioner of the
JOSEPH J. RUSSO
and radiology and nuclear medicine
examinations or treatment
■ Records of donation and receipt of
transplants or implants;
■ Final diagnosis(es)
■ Conclusions at termination of
hospitalization
New York State Department of Health,
et.al., 237 A.D.2d 648, 655 N.Y.S.2d
113 (1997). There, the Bureau of
Professional Medical Conduct charged
Dr. Balmir with 19 specific acts of misconduct
in an effort to revoke his
license to practice medicine.
July 2003
22
of medical records must address the
“presence, timeliness, legibility, and
authentication” of the following:
■ Identification data
■ Medical history, including the chief
complaint; details of the present illness;
relevant past, social, and family
histories (appropriate to the patient’s
age); and an inventory by body system
■ A summary of the patient’s psychological
needs, as appropriate to the
patient’s age
■ A report of relevant physical examinations
■ A statement on the conclusions or
impressions drawn from the admission
history and physical examination
■ A statement on the course of action
planned for the patient for this
episode of care and of its periodic
review, as appropriate
■ Diagnostic and therapeutic orders;
■ Evidence of appropriate informed
consent
■ Clinical observations, including the
results of therapy
■ Progress notes made by the medical
staff and other authorized staff
■ Consultation reports
■ Reports of operative and other inva-
■ Clinical resumes and discharge
summaries
■ Discharge instructions to the patient
of family
■ When performed, results of autopsy
Case law has been very informative on
the issue of illegible physician documentation
in the areas of Social
Security Income (SSI) benefits and
physician disciplinary and licensure
issues. For example, in the case of Holle
v. Barnhart, Commissioner of Social
Security, 2002 WL 1770535 (N.D.Ill.),
the court denied plaintiffs Social
Security Disability claim based in part
upon illegible medical record documentation.
The court stated:
“Plaintiff’s medical records do not
indicate any objective medical evidence
supporting Plaintiff’s complaints
of disabling pain. This court
also notes that the treatment notes
submitted by Dr. Johnson were illegible.
This court attempted, mostly
unsuccessfully, to decipher the notes
and was unable to make out any
diagnosis or find any evidence supporting
Plaintiff’s allegations. Dr.
Johnson’s opinion that Plaintiff is
totally disabled is therefore unsubstantiated
as it is not otherwise supported
by objective medical evi-
In upholding the physician’s revocation
of his license to practice medicine, the
court noted that Dr. Balmir failed to
maintain adequate medical records.
This included “making terse, incomplete,
and often illegible notations of
physical findings...”
In conclusion, it is very critical for
Compliance and Health Information
Management professionals to understand
the liability and risk areas related
to illegible physician documentation.
Moreover, it is critical to review physician
handwriting legibility as functions
of internal compliance monitoring and
external compliance auditing. ■
NEW!!
A Corporate Responsibility
page has been added to HCCA’s
website (http://www.hccainfo.org/html/cr.html).
Please take a moment to review
the slide presentations by
Vickie L. McCormick and by
Karen Schnatterly, Assistant
Professor, University of
Minnesota

a tremendous amount of understanding
of the law through our
outside legal counsel and by
attending conferences.
85% of
surveyed
compliance
professionals
do not have a
law degree
ROY SNELL
Long arm of the law
We have surveyed compliance professionals
each of the last five years looking
for interesting trends. One number
I found to be very interesting is that in
each of the last five years less than 20%
of those surveyed have a law degree.
The number did not change much
from year to year. Most assume that
that number would be higher. Many assume that the law
degree is a “natural prerequisite” for compliance professionals.
Why?
Why don’t all compliance professionals have a law degree.
The answer to that question could be that compliance
professionals are often hired from within, and smaller
organizations have few candidates
with a law degree. When hiring
from the outside we often go
after billing or administrative
experience. What ever the reason
for this is, in compliance, a basic
understanding of the law is very
helpful.
Do we need a law degree?
In the early days of health care compliance billing was
a major focus of our attention, legal experience was less
important. Facilitating change was and has always been the
tough part of compliance. As the compliance role expands
beyond billing a law degree may not be mandatory, but a
basic understanding of the law is very helpful. I have gained
AHLA/HCCA Fraud and
Compliance Forum
September 21-23, 2003
WASHINGTON, DC
Benefits of a basic understanding
of the law
Here are some concrete advantages
for possessing a basic understanding
of the law:
■ Communicating with outside legal counsel
■ Communicating with inside legal counsel
■ Highlighting legal issues for administration and the Board
■ Monitoring risk areas
■ Increasing job opportunities
■ Greater credibility with staff
■ Tracking enforcement activities
What is HCCA doing to help?
HCCA’s biggest commitment to provide legal education to
compliance professionals is our fall HCCA/AHLA Fraud and
Compliance Forum in Washington, DC. We are in the planning
process right now. We partner with the American Health
Lawyers Association and have a planning committee made up
of experienced lawyers and compliance professionals.
Allison Maney, Al Josephs, and
Suzie Draper have worked with
several attorneys to develop a
comprehensive agenda. From the
“Legal Primer” pre-conference to
the breakout sessions on False
Claims, Attorney Client Privilege,
Stark, and HIPAA, attendees
will get an opportunity to hone their skills. This is our
third meeting together. It is an effective partnership. A
good understanding of the law can make a difference.
Conferences and networking are some of the best ways to
cover a lot of material in an effective way. I hope to see
you all there. ■
Compliance Today wants you!
Please email your article or topic ideas to Compliance Today editor, Margaret Dragon, at mrdragon@ziplink.net.
Be sure to include your telephone number. Or call Margaret at 781/593-4924 to discuss your article ideas. Some
topic ideas to consider: compliance and the Board, HIPAA compliance education and training, EMTALA compliance,
conflicts of interest, and attorney/client privilege. ■
23
July 2003

Margaret Dragon
Director of Communications
Erin O’Donnell
Operations Manager
Kim Davis
Controller
Tracy Hlavacek
Stephanie Lentsch
April Kraft
Conference Planner/
Regional Coordinator
Accounting Manager
Database Administrator/
Member Relations
July 2003
24
Darin Dvorak
Conference Planner
Wilma Eisenman
Receptionist/Member Relations
Renae Hines
Project Specialist

Editor:
Margaret R. Dragon, Director of Communications, HCCA, 781/593-4924,
mdragon@hcca.attbbs.com
Publisher:
Health Care Compliance Association, 888/580-8373
Consulting Editors:
Alan Yuspeh, President, HCCA, 615/344-1005
Roy Snell, CEO, HCCA, roy.snell@hcca-info.org
Design & Layout:
Robin Taliesin, Raven Creative, 781/631-4639, robint@raven2.com
Advertising:
Erin O’Donnell, HCCA, 888/580-8373, erin.odonnell@hcca-info.org
HCCA Officers and Board of Directors:
Alan Yuspeh, JD, MBA
HCCA President
Senior Vice President
Ethics, Compliance and Corporate
Responsibility
HCA
Al W. Josephs, CHC
HCCA 1st Vice President
Compliance Officer
Hillcrest Healthcare System
Odell Guyton
HCCA 2nd Vice President
Director for Compliance
Microsoft Corporation
Allison Maney, CPA, CHC
HCCA Treasurer
Director for Claims Research and
Resolution, Pacificare
Daniel Roach
HCCA Secretary
VP and Corporate Compliance Officer
Catholic Healthcare West
Sheryl Vacca, CHC
HCCA Imme. Past President
Director, National Health Care Regulatory
Practice, Deloitte & Touche
Shawn Y. DeGroot, CHC
VISN 23 Compliance Officer
Department of Veterans Affairs
Suzie Draper, BSN, RN
Corporate Compliance Officer and Privacy
Officer, Intermountain Health Care
CEO/Executive Director:
Roy Snell, CHC
Health Care Compliance Association
Rory Jaffe, MD, MBA
Chief Compliance Officer
U.C. Davis Health System
Vickie McCormick
Special Counsel
Halleland Lewis Nilan Sipkins & Johnson
F. Lisa Murtha
Chief Audit and Compliance Officer
Children’s Hospital of Philadelphia
Steven Ortquist
Chief Compliance Officer
Banner Health System
Teresa L. Mullett Ressel
Deputy Assistant Secretary
U.S. Treasury
John Steiner
Chief Compliance Officer
The Cleveland Clinic Health System
Debbie Troklus, CHC
Assistant Vice President for Compliance
and Privacy
University of Louisville, School of
Medicine
L. Stephan Vincze, JD, LL.M, CHC
Ethics and Compliance Officer
TAP Pharmaceutical Products, Inc.
Greg Warner
Director for Compliance
Mayo Foundation
Counsel:
Keith Halleland, Esq.
Halleland Lewis Nilan Sipkins & Johnson
Compliance Today (CT) (ISSN 1523-8466) is published by the Health Care Compliance
Association (HCCA), 5780 Lincoln Drive, Suite 120, Minneapolis, MN 55436. Subscription rate
is $357 a year for non-members. Periodicals postage-paid at Minneapolis, MN 55436. Postmaster:
Send address changes to Compliance Today, 5780 Lincoln Drive, Suite 120, Minneapolis,
MN 55436. Copyright 2002 the Health Care Compliance Association. All rights reserved. Printed
in the USA. Except where specifically encouraged, no part of this publication may be reproduced,
in any form or by any means without prior written consent of the HCCA. For subscription information
and advertising rates, call HCCA at 888/580-8373. Send press releases to M. Dragon, PO
Box 197, Nahant, MA 01908. Opinions expressed are not those of this publication or the HCCA.
Mention of products and services does not constitute endorsement. Neither the HCCA nor CT is
engaged in rendering legal or other professional services. If such assistance is needed, readers should
consult professional counsel or other professional advisors for specific legal or ethical questions.
25