Quality of the estimate. December, p. 47 - Health Care Compliance ...

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Mail call: How to respond to a regulatory investigation ...continued from page 9 December 2011 10 harm. There is potentially a risk for reputational harm, but if there is nothing truly sensitive in the medical information, it is likely not a significant risk of harm. If you need to contact the patient for any reason, such as to offer credit monitoring, verify that the investigator has no objection to you doing so. Response Look at what the notification letter asks you to provide and the due date. Write a clear letter that includes the case reference number, provides a succinct description of the occurrence, and whether you agree with the allegation. List the documents you are sending in support of your response and include them in a well-ordered attachment. These attachments should include copies of the authorization form, both fax cover sheets and confirmation sheets, the phone note, disclosure log, and applicable policies. Also, make an entry in the new disclosure log in the file related to sharing PHI in response to an agency investigation and make a copy of the submission for your records. If for some reason you cannot submit the response in a timely fashion, you must contact the investigator and ask for an extension of time. If you identified any actions you need to take or policies that need to be adopted or revised, either do so and send proof or indicate what you have done and provide a date for anticipated completion. It is likely that OCR will want to see the items completed. Once you have completed your response, let the investigator know that it is being sent and reiterate the delivery method as determined in the earlier conversation. E-mail: If sending by e-mail, the e-mail should be encrypted. Do not put the patient name in the subject line, but the reference number is a convenient indicator. If you do not have an e-mail encryption system, there are several free zip technologies that enable attachments to be zipped and encrypted. Again, when the file is zipped, the patient name should not be the file name, but the reference number works fine with the patient’s last name as the password. Please note that password-protected only files are not encrypted—only the zipped and encrypted files. If you use the patient’s last name as the password, then in the e-mail, you can indicate that the attached file’s password is the patient’s last name and the investigator can look up the name by the reference number. Otherwise, the password should be sent in a separate e-mail or provided over the phone. Fax: If sending the file by fax, please confirm the fax number Health Care Compliance Association • 888-580-8373 • www.hcca-info.org and use a confirmation sheet. Once sent, check the fax number against the confirmation. Mail: If sending by mail, use a mail service that offers delivery confirmation with a signature. This may cost a little more, but the peace of mind and proof of delivery is priceless. Final determination Now all you can do is wait for further contact. There are four responses you may get back: n No regulatory action taken (which can mean either no violation or voluntary compliance) n Request for more information n Completion of identified actions n Regulatory action in the form of a violation found with or without a penalty If the investigator asks for more information, provide that in a timely manner. If the investigator asks for proof of completion of an action you identified in your response, either provide it, if completed, or discuss with the investigator your time frames and plans for completion. You may have a constraint around policy adoption, implementation, or training. Additionally, the investigator may require you to take some action, such as revising a form or policy. If so, you should clarify the rationale behind this request and which rule mandates this action.
If you disagree with the requested action, you can offer a counter solution. The agency will consider the counter and provide explanations if it is unacceptable, as long as the requirements and the patient’s interests are met. If you receive a notice of violation, you will also be provided the mechanism to appeal the decision. Determinations may take some time, but if two months have passed without receiving a letter, you should contact the investigator. The letter may have been misdirected. Additional considerations In some instances, patients may file complaints with multiple agencies, either concurrently or after receiving notice that you were not penalized. You may be required to undergo this process with a state agency and this is when your meticulous record-keeping will be helpful once again. You can provide copies of your response to OCR to the state agency and OCR’s final determination if it has been received, especially if the determination was no violation. Under HIPAA, there is typically nothing wrong with allowing a state oversight agency to have access to patient records—however, there is also nothing wrong with requesting it to be in writing. You should be clear with the agency that you are not opposing their right, but that you need something in writing so that you have a record of the disclosure, when, why, how, etc. Discuss with the agency what they require to conduct their investigation and provide the minimum necessary, but if they require the full chart, then provide the full chart. Once again, make an entry in the disclosure log for the file and document, document, document. Conclusion Any investigation is likely to produce a fair amount of consternation and worry. However, with proper procedures in Health Care Compliance Association • 888-580-8373 • www.hcca-info.org place, responding to a request from a regulatory agency can be merely a matter of compiling the documents, providing appropriate information, and communicating clearly with the investigator. Regulators are not our enemy; they are the fact finders of whether the rules are being followed. They are there to ensure that patients’ rights are protected, and most entities do not deliberately set out to purposefully violate those rights. n Help keep your program fully staffed List Your Job Openings Online with HCCA Basic Classified Ads Our basic ads are listed on our website for 90 days and cost just $400 per position. In addition, for each month you advertise with us, your listing is included in our monthly HCCA Jobs Newsletter, which we send out to over 24,000 email addresses. Premium Listings Want to make sure your job listing gets noticed first Try a premium listing. For just $100 more, your job listing is placed in the top section of the site, and it is also featured in the top section of the newsletter, making it stand out. LIST MY JOB OPENING: hcca-info.org/newjobs HCCA_JobBoard_thirdpagead_2c.indd 1 11 11/14/2011 4:41:34 PM December 2011
Page 1 and 2: Volume Thirteen Number Twelve Decem
Page 3 and 4: INSIDE 5 The rising tide: Recognizi
Page 5 and 6: The rising tide: Recognizing your c
Page 7 and 8: Legal function of any consulting ar
Page 9: side and show that proper actions w
Page 13 and 14: n Starting from Scratch o I just re
Page 15 and 16: CFO was particularly timely in ligh
Page 17 and 18: territory in the early years. The m
Page 19 and 20: Social Networking John Falcetano Ed
Page 21 and 22: y the federal and state agencies th
Page 23 and 24: People on the Move Former Medicaid
Page 25 and 26: may find themselves in a netherworl
Page 27 and 28: Losing sleep over health care marke
Page 29 and 30: Editor’s note: Jeffrey N. Joyce i
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Page 35 and 36: Community Relations. A process to r
Page 37 and 38: With the implementation of the EMR
Page 39 and 40: showed that the company viewed its
Page 41 and 42: Healthcare facilities that are seri
Page 43 and 44: CCB The Compliance Professional’s
Page 45 and 46: Legislators viewed the Medicare RAC
Page 47 and 48: Confidence and precision in claims
Page 49 and 50: universe is no less than $9,650. No
Page 51 and 52: Accountability is the key to compli
Page 53 and 54: Accountability is the key to compli
Page 55 and 56: Regulatory compliance for research
Page 57 and 58: Occupational Fraud and Abuse, it is
Page 59 and 60: offenses, including modification of
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Publisher: Health Care Compliance A
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New HCCA Members Alabama n Patricia
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