JR - Health Care Compliance Association

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August 2002 James Roosevelt you see as the future of health care 14 development of the compliance program within Tufts Health Plan? JR: I am the senior corporate sponsor of the compliance program at Tufts Health Plan. I am not the compliance officer or the senior compliance officer but rather the next step above that because we take compliance so seriously. My role as a member of the most senior group of management is to sponsor the compliance program. So I am very heavily involved in the ongoing development of the program. There was a good program in place when I got there. We are working every day and every month to improve it and to respond to the changing demands of compliance in such areas as HIPAA. LM: Excellent. I actually have a question for you on that. Given the things that you’ve done within the context of the clients in your organization, what do you think is the single biggest dollar? JR: front, say $1,500, as an example, a I would say, first of all, the $1,000 personal care account that can most important thing in our compliance program is our people, both our people who design and implement the program. We have a great compliance officer, Anne Doyle, and a great senior compliance officer, Russ Kopp, who really take compliance seriously. But ultimately what makes a good compliance program is all 2,500 Tufts Health Plan employees. And in order to encourage that from day one, from orientation to annual quizzes to training during the year, keeping people aware of compliance and explaining what it means and adapting to changes in the working environment, are where we really get value. LM: compliance? Tufts Health Plan and I think has to be Oh, that’s excellent. The next an integral part of both every provider’s factor for the success of your program? question I’d like to ask you is what do and every insurer’s operation because JR: I think health care compliance is a dynamic field that keeps evolving. So, I’m not sure I can predict the future specifically other than to say that I think as the areas of both health care and health care coverage expand and change, so will compliance. New approaches in terms of assuring that law regulation and ethics are complied with will have to respond to the changing field and the changing market. Just to give you an example, there’s a lot of planning being done these days for offering defined contribution health care coverage. This is a plan where an employee is given a certain amount of money by his or her employer and he or she, first of all, Would it be the training, the monitoring? You know, where have you seen they’re going to have but, secondly, chooses the sort of coverage that the real bang for your compliance often has quite a high deductible up be used for traditional health care and also for things like wellness activities, complimentary medicine, everything from podiatry to massages. And the compliance aspect of a plan like that is probably going to be different from a traditional HMO or even PPO. The establishment of the network is going to present new challenges of avoiding conflicts of interest and things like that. LM: So you really believe that compliance has become an integral part of your operation? JR: Yes, absolutely. Compliance is an integral part of our operations at
there are so many issues that have to be determined on both a regulatory and an ethical basis. LM: What advice would you give to organizations to assist in prevention of fraud and abuse and exposure from government investigations. JR: The most important thing is to make people aware of what is permissible and what is not, not just the letter of the law, but what is in keeping with the spirit of the law. Now, some of that is just absolutely clear in black letter. For example, you may have noticed that Vermont has just enacted a statute requiring that all gifts of over $25 from pharmaceutical companies to providers have to be reported to the state. So there’s a new twist on compliance. Some of us have had internal policies similar to that but now here’s an absolute need for compliance to a regulatory approach. LM: As the general counsel of Tufts Health Plan, how do you work with the compliance department on compliance issues, particularly investigations, etc. JR: The legal department, which I head as general counsel, and the compliance department work together in several ways. First of all, as the senior corporate sponsor of compliance, together with one of my associate general counsels, Lois Cornell, we work with the compliance steering committee in drafting policies and adapting them to real-life situations. Lois also works on the gift and grant review committee to make specific determinations as to whether a particular gift or grant is in compliance with our corporate policies. When we reach an issue that is really in dispute in some way, the legal department becomes involved in a more, you might say, traditionally legal way. We might well have one of our litigators, Dave Abelman, conduct an investigation. We might advise both the operating department and the compliance department as to statutory and regulatory, as well as internal policy, requirements on a specific issue. LM: What do you see as the biggest compliance risk for health plans as well as for providers? JR: Currently the biggest compliance risk is probably meeting the HIPAA requirements and deadlines. That’s something that we can see on the horizon and therefore define. So that’s the greatest immediate risk. Long term, and ongoing, I would say the risk is trying to balance reality with our aspirations. We need to assure that our employees operate ethically and legally every step of the way. We also have to deal with a real world where things are not always absolutely clear as to what is the right thing to do. So the important thing I think is having people think about things in an ethical fashion. LM: And that would be both for health plans and providers? JR: That really applies to both health plans and providers. It’s not a whole lot different. The guiding principle actually is something that we think about and focus on a lot at Tufts Health Plan, which is basically to do the right thing and to put integrity before everything else. LM: Have you been involved in HIPAA implementation for Tufts Health Plan? And, if so, can you describe those efforts? Who is the chief privacy officer and where does he or she report? JR: We have many people including me involved in HIPAA implementation. Our compliance officer is also our chief privacy officer. One of her staff members, Jeannette Frey, who formerly worked on compliance generally has been detailed solely to privacy and HIPAA compliance. I have a legal department staff member who is devoted almost exclusively to HIPAA implementation and compliance. So at sort of every step of the way we’re finding HIPAA compliance to be not quite all consuming but a major task, certainly no less than Y2K compliance. LM: I have one more question for you. Is your organization combining compliance and HIPAA activities. JR: We do combine compliance and HIPAA activities in terms of the compliance side of the activities. Now in terms of staffing there are people who are dedicated solely on the IT side and the business processes side but in terms of compliance, we do integrate compliance and HIPAA activities because basically HIPAA raises to a regulatory level the issues of privacy that have had some legislative treatment in the past but have primarily been issues of internal policy in the past. LM: Thank you for your time today. JR: Thank you and we’ll see you in September at the Fraud and Compliance Forum. ■ 15 August 2002
Page 1 and 2: Volume Four/Number Eight August 200
Page 3 and 4: DON’T MISS OUT! ON THE CALENDAR U
Page 5 and 6: FOCUS ON ETHICS & COMPLIANCE Compli
Page 7 and 8: system. Other advantages include ea
Page 9 and 10: uation as unique. The divide and co
Page 11 and 12: By Norman Radies Editor’s note: N
Page 13: feature article Editor’s note: Th
Page 17 and 18: 3. Have a witness! Do interviews wi
Page 19 and 20: leagues. Physicians can hear the me
Page 21 and 22: Alyse Hutchinson, Associate Complia
Page 23 and 24: many tasks forces as they deemed ap
Page 25: Editor and Publisher: Margaret R. D

JR - Health Care Compliance Association

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