Mildred L. Johnson, JD, CPC - Health Care Compliance Association

unique in that it has two separate schools,
the Texas Tech University (undergraduate and
some graduate programs) and the Texas Tech
University Health Sciences Center. While
each School has its own President, they operate
under a single Chancellor and state Board
of Regents. The Texas Tech University Health
Sciences Center is a five-school university
located on four campuses and one academic
center, with a second academic center opening
in 2007. The four campuses are located
in Lubbock (the primary campus), Amarillo,
El Paso, and the Permian Basin. We currently
have an academic center in Dallas/Fort
Worth with one opening in Abilene, both
connected with our School of Pharmacy.
Since this is a new position for TTUHSC,
I can’t really address any change of scope at
this time.
JO: What are the unique compliance
challenges you face working in an academic
setting?
MJ: As you can see, with five schools, four
campuses, and two academic centers, one of
my challenges in the TTUHSC academic setting
will be dealing with the unique cultures
of each area. The goal is utilize the strengths
of each to develop common policies, procedures,
and practices to maximize our
resources while focusing of the risk areas that
are unique to each campus/academic center
and School.
One challenge in the academic setting
in general is the need to convince faculty
(especially those in the non-sciences) that
implementation of compliance oversight will
not interfere with academic freedom. Another
challenge is to avoid the “them” vs. “us” mentality
when implementing corrective action
plans, so that all members of the academic
community are treated in a uniform manner
when there is non-compliance.
JO: What are the biggest compliance risk
areas for your institution?
MJ: The compliance risk areas for TTUH-
SC are similar to those of other academic
medical centers, primarily billing activities,
especially when residents are involved, and
federal research grants as pointed out by the
Office of Inspector General in its compliance
guidance for PHS (public health service)
research facilities. The other risk, which I
think is relatively universal for all institutions,
is the break down of communication among
and between departments.
JO: Where are you in the development of
your compliance program?
MJ: TTUHSC is now poised to integrate
and consolidate its various regulatory
compliance activities under the “umbrella” of
the Institutional Compliance Office. This
is a work in progress, so you may have to
check in with me in a year to see where we
have grown. At this time, my focus in on the
billing compliance functions, to restructure
the current system to achieve efficiency and
centralization. One thing that I am working
on right now is to emphasize the role of the
compliance officer as a resource.
Jennifer O’Brien
JO: How do you go about getting
employee and staff support for your compliance
efforts?
MJ: I think that employees and staff want
to do the right thing and they will support
the compliance efforts IF they know that they
will receive support. By “support” I’m not
necessarily talking about financial support,
but leadership support. The compliance office
must not only inform leadership on what is
necessary to ensure compliance, but must
inform employee and staff of the risks and
assist them in developing the controls and
tools necessary to minimize those risks. In addition,
when necessary, the compliance office
needs to stand ready to justify the need for
increased financial support when it is necessary
to implement the compliance program.
JO: How do you respond to the challenge
of keeping education and training interesting
and effective?
MJ: Education becomes interesting and
effective when it becomes interactive rather
than a “lecture.” One way to do this is to
make the training department-and-job
specific; avoid a generic “one size fits all”
mentality. This is especially critical when
you are dealing with billing compliance risk
areas. A training module for anesthesiologists
should not have a heavy focus on E&M
(evaluation and management) documentation.
Conversely, training for cardiologists
should not focus on Medicare’s Primary Care
Exception, because it does not apply to them.
New information also creates interaction.
Bringing in new information should never be
a challenge as there are always new things to
address, whether they be OIG audits of an
area relevant to your institution, information
from the OIG’s Annual Work Plans, CERT
(Comprehensive Error Rate Testing) results.
I am anticipating that within the next year
(and maybe I’m being optimistic) there
will be reported results from the Medicaid
Integrity Program audits.
In addition to outside resources, your
internal monitoring and auditing activity
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Health Care Compliance Association • 888-580-8373 • www.hcca-info.org
February 2007
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