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By Lawrence A. Fogel and Joseph M. Watt Editor’s note: Lawrence A. Fogel, guidance documents for hospitals, including principal, and Joseph M. Watt, partner, the February 23, 1998, Federal Register and are both members of BKD Health Care the January 31, 2005, Federal Register. Group, a division of BKD, LLP, in Kansas City, Missouri, which serves thousands of health care providers nationwide. the OIG acknowledged that effective compli- In the OIG’s original compliance guidance, Mr. Fogel and Mr. Watt consult with ance programs provide the following benefits: clients on a broad spectrum of corporate ■ Enable hospitals to ensure that false or integrity solutions. Contact the authors at inaccurate claims are not being submitted lfogel@bkd.com or jwatt@bkd.com to government and private payors ■ Assist hospitals in identifying weaknesses United States hospitals cannot and internal systems and management blame the federal government for ■ Demonstrate to employees and the community that the hospital is strongly committed a lack of guidance on developing and maintaining effective compliance programs. To the contrary, the Office of ■ Provide a more accurate view of employee to honest and responsible corporate conduct Inspector General (OIG) has provided written guidance as a roadmap for hospitals to abuse and contract behavior related to fraud and operate effective compliance programs. ■ Identify and prevent criminal and unethical conduct Some hospitals seem unconcerned about effective compliance programs. Many hospitals program to meet the hospitals specific ■ Enable hospitals to conform the compliance assume just having a compliance program needs offers sufficient protection. In reality, ineffective compliance programs offer little or no ■ Create a centralized process for distribut- ■ Improve the quality of patient care protection to hospitals that commit compliance violations, detected or not, well after seri- rules and regulations pertaining to fraud ing information on relevant health care ous damage occurs. Effective compliance programs may enable hospitals to avoid compli- ■ Encourage employees to report potential and abuse ance violations or detect them early enough to problems mitigate serious damages. Furthermore, government agencies may be more lenient with gation of alleged misconduct ■ Provide for prompt and thorough investi- hospitals that operate effective compliance ■ Provide for immediate and appropriate programs even if cited for a violation. corrective action ■ Reduce the loss to the government Guidance is available and accessible. The from compliance violations through early OIG has published two primary compliance detection and reporting LAWRENCE A. FOGEL According to the OIG, the following seven elements should be included in compliance programs: 1. Develop and distribute written standards of conduct and written polices and procedures 2. Designate a chief compliance officer and compliance committee 3. Develop and implement effective education and training programs 4. Maintain a hotline or other processes to receive complaints 5. Respond systematically to allegations and improper or unlawful activities and enforce appropriate disciplinary actions 6. Use audits or other monitoring techniques to monitor compliance 7. Investigate and resolve identified systematic problems To evaluate compliance program effectiveness, the OIG recommends hospitals perform periodic reviews, at least annually, to determine if the seven compliance elements have been satisfied. Documentation supporting compliance activities should demonstrate the compliance program operated effectively. Reviewers should be independent of physicians and line management. The compliance review team should: ■ Conduct on-site reviews ■ Interview personnel involved in management, operations coding, claims development submission, etc. January 2006 38 Health Care Compliance Association • 888-580-8373 • www.hcca-info.org
JOSEPH M. WATT ■ Solicit staff and employees’ impressions using questionnaires ■ Review medical and financial records and other source documents ■ Review written materials and documentation prepared by the hospital ■ Analyze trends Despite the 1998 guidance, many hospitals have yet to perform periodic compliance effectiveness reviews. Consequently, the OIG published supplemental compliance guidance for hospitals in the January 31, 2005, Federal Register. In it, the OIG states there must be a commitment to active involvement of organizational leadership for every compliance program. The OIG expects a hospital’s leadership to promote a culture of values and rewards for prevention, detection, and resolution of compliance problems. Hospitals are expected to develop a culture that values compliance from the top down and fosters compliance from the bottom up. The OIG believes such an organizational culture is the foundation of an effective compliance program. The OIG recommends compliance program effectiveness be evaluated based on outcome indicators such as monitoring and evaluating billing and coding error rates and identifying overpayments. In addition to evaluating outcome indicators, the OIG recommends hospitals evaluate the seven elements through probing questions, including, but not limited to, the following: 1. Compliance officer and committee ■ Does the compliance department have a clear, well-crafted mission ■ Is the compliance department properly organized ■ Does the compliance department have sufficient resources ■ Is there an active compliance committee, comprised of trained representatives from each of the relevant functioning departments ■ Does the compliance officer have direct access to the governing body, CEO and legal counsel ■ Does the compliance officer have a good working relationship with other key operational areas ■ Does the compliance officer make regular reports to the board of directors and senior management 2. Development of compliance polices and procedures ■ Are policies and procedures clearly written ■ Does the hospital monitor compliance with internal policies and procedures ■ Have the standards of conduct been distributed to all members of the board of directors, officers, managers, employees, contractors, medical and clinical staff ■ Has the hospital developed and implemented a risk assessment tool ■ Does the risk assessment tool include an evaluation of federal health care program requirements 3. Open lines of communication ■ Has the hospital promoted a culture encouraging open communication without fear of retribution ■ Has the hospital established an anonymous hotline or similar reporting mechanism ■ Is the hotline or other reporting mechanism well publicized ■ Are all instances of potential fraud and abuse investigated ■ Are results of the investigation shared with the governing body and relevant departments 4. Appropriate training and education ■ Does the hospital provide qualified trainers ■ Does the hospital conduct annual compliance training ■ Is the training both general in nature and specific to pertinent staff responsibilities ■ Does the hospital evaluate the contents of its education program annually ■ Has the hospital kept current with changes in federal health care program requirements ■ Does the hospital seek feedback after each training session to identify strengths and weaknesses of the compliance program ■ Does the hospital administer post-training tests ■ Has the hospital’s governing body been provided with appropriate training ■ Has the hospital properly documented who has completed the training 5. Internal monitoring and auditing ■ Is the audit work plan reevaluated annually ■ Does the work plan address the appropriate levels of concern ■ Does the work plan include an assessment of billing systems ■ Is the role of the auditors clearly established and are coding and auditing personnel independent and qualified ■ Has the hospital evaluated the error rates identified in the annual audits ■ Does the audit include a review of all billing documentation, including clinical documentation Continued on page 40 Health Care Compliance Association • 888-580-8373 • www.hcca-info.org January 2006 39
Page 1 and 2: Volume Eight Number One January 200
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Page 5 and 6: Join us for the following HCCA Audi
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Page 9 and 10: By Susan C. L. Theuns Editor’s no
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