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ONLINE WITH RESIDENCIES AT GW’s ALEXANDRIA, VA CENTER Graduate Certificate in Healthcare Corporate Compliance Acquire the compliance officer knowledge in demand today. Unique Format. Seven-month, 12 credit program, with two short residencies and online distance learning between residencies. Master the key concepts of high-priority healthcare laws including federal fraud and abuse law, governance and corporate responsibility, HIPAA, federal tax law, and more. Enjoy unparalleled access. Learn from a world-class faculty teamed with senior regulators, legislators, patient advocates and legal experts. Stackable Credentials. Apply this certificate toward a Master’s of Public Health degree. Program offered by the College of Professional Studies and School of Public Health & Health Services, in partnership with the law firm of Feldesman Tucker Leifer Fidell LLP. Information Sessions Wednesday, Oct. 29 1:00 pm ET Online Thursday, Nov. 20 1:00 pm ET Online Rsvp Today! 1.800.JoinGWU nearyou.gwu.edu/hcc CCB Accredited CCB Medicare’s medical necessity criteria: A mystery in the making ...continued from page 25 community standards do, in fact, support coverage of the items or services at issue. Conclusion Under the current system, Medicare is not prevented from infinitely expanding the sources of information upon which its contractors’ and adjudicators’ individual claim determinations are based. The fact that Medicare appeal adjudicators have begun to use articles posted on Internet Websites as bases to support adverse claim determinations only reinforces that conclusion. Challenging this practice based on Medicare’s limitation on liability provisions may or may not prove successful. In any case, that would provide only a temporary fix. A permanent solution to this problem is needed. Medicare’s formal written policies delineate the type of medical and scientific evidence NCDs and LCDs may be based on. Similar guidance should be applicable to contractors’ individual claim determinations. This would prevent contractors from resorting to Internet Websites to support their claim determinations, a practice which is detrimental to providers, suppliers, and the Medicare system as a whole. n 1 42 U.S.C. § 1395y(a)(1)(A). 2 See Heckler v. Ringer, 466 U.S. 602, 617 (1984) (acknowledging that the Secretary has discretion to either establish a generally applicable rule or allow claim adjudication on a case-by-case basis). 3 Centers For Medicare And Medicaid Services, Medicare Program Integrity Manual (Pub. 100-08), Chapter 13, §§ 13.3, 13.5.1. 4 Centers for Medicare and Medicaid Services, Medicare Claims Processing Manual (Pub. 100-04), Chapter 30, § 40.1.3. Be Sure to Get Your CHC CEUs Inserted in this issue of Compliance Today is a quiz related to the articles: n The 1-2-3s of claims sampling to resolve overpayment errors — By B. Bo Martin, page 32 n Quality of care and compliance: Existing challenges and first steps for hospitals — By Cheryl L. Wagonhurst and Nathaniel M. Lacktman, page 46 n Complying with the HIPAA Privacy Rule: What you need to know — By Rebecca C. Fayed, page 59 To obtain your CEUs, take the quiz and print your name at the top of the form. Fax it to Liz Hergert at 952/988-0146, or mail it to Liz’s attention at HCCA, 6500 Barrie Road, Suite 250, Minneapolis, MN 55435. Questions Please call Liz Hergert at 888/580-8373. 33170 www.gwu.edu/gradinfo THE GEORGE WASHINGTON UNIVERSITY IS AN EQUAL OPPORTUNITY/ AFFIRMATIVE ACTION INSTITUTION CERTIFIED TO OPERATE IN VA BY SCHEV. Compliance Today readers taking the CEU quiz have one year from the published date of the CEU article to submit their completed quiz. October 2008 26 Health Care Compliance Association • 888-580-8373 • www.hcca-info.org
Exploring the question: Does this really make a compliance program “effective” Editor’s note: Catherine Boerner is president of Boerner Consulting, LLC, a health care consulting firm in New Berlin, Wisconsin. Ms. Boerner was President of the HIPAA Collaborative of Wisconsin (HIPAA COW) for three years from 2005-2007 and helped revise the Hospital Payment Monitoring Program (HPMP) Compliance Workbook for the QIO community and acute-care PPS hospitals. She may be reached by telephone at 414/ 427-8263 or by e-mail at cboerner@boernerconsultingllc.com. From the US Sentencing Guidelines, the Office of the Inspector General (OIG) Guidance and Supplemental Compliance Program Guidance documents, American Health Lawyers Association (AHLA) and OIG resource documents as well as Corporate Integrity Agreements, I think we all have a pretty good idea what the government is looking for in a compliance program. The structures and processes outlined in these documents clearly show what is expected of the infrastructure of a compliance program, but still many people have questions, especially within organizations. Do all of these structures and processes really make the compliance program effective If we have these structures and processes, what outcome measures can we look to in order to demonstrate that the structures and processes are working or are effective And even if these structures and processes are working, based upon these outcome measures, is our compliance program, as a whole, really “effective” in detecting and preventing regulatory compliance risks By Catherine Boerner, JD, CHC Compliance culture If you want to make the argument that you do not need all of the structures and processes (otherwise known as the seven elements) outlined in the OIG Supplemental Guidance to be “effective,” you would need to start by demonstrating that you have achieved some of the most important outcome measures of the compliance program, perhaps despite the lack of certain structures and processes. The most important outcome measures involve demonstrating that a strong culture of compliance has formed and is sustainable. This strong culture of compliance needs to be evident not only throughout the workforce, but especially at the management level. I think it is important to explore what a strong culture of compliance means and explore how you prove it to an external auditor or the government. Cultures can be difficult to measure as they evolve. I like to quote Roy Snell, CEO, HCCA when he said “Many people get into trouble more often because of the way they deal with or react to their mistakes, rather than for the mistakes themselves.” This speaks directly to culture. How does your organization respond to mistakes or issues that it becomes aware of Many of you experience (even within a strong compliance culture) that as compliance issues get raised, a sense of urgency follows to investigate and bring the issue to resolution. However, you lose steam at the end of the process and weeks turn into months, and before you know it, Health Care Compliance Association • 888-580-8373 • www.hcca-info.org six months have gone by without obtaining the corrective action and follow-up necessary to prevent it from happening again; let alone putting it on next year’s compliance work plan to monitor the resolution (if you have an annual work plan) or putting it on next years compliance audit plan to actually perform a follow-up audit (if you have an annual audit plan). Other priorities present themselves and if you don’t have the structure and process to track the issue in your compliance log and have a compliance committee follow its progress and receive updates, the outcome of concluding the investigation appropriately will not be achieved. Here I would argue that the structure and process of the reporting mechanism is part of an effective compliance program and will help improve the outcomes of consistently resolving the issues promptly and following up on corrective action. I have seen evidence of a strong compliance culture measured through employee survey results; however, behind the scenes, the compliance program infrastructure lacked the Compliance department or management proactively addressing compliance risks. Serious gaps were identified with sustaining compliance with the changing billing regulations. If key managers are not engaged or, more likely, do not have the support and/or budget within their department to keep up with regulatory change and risk, a compliance culture alone will not keep you out of trouble. Therefore, even with the compliance culture being a main goal, you would have to concede that without the structures and processes, it is very difficult to keep up with the changing regulatory environment and continue to focus upon and proactively mitigate compliance risks in the organization. So, I would argue that the compliance culture is really not enough, by itself, to demonstrate compliance. Continued on page 29 27 October 2008
Page 1 and 2: Volume Ten Number Ten October 2008
Page 3 and 4: INSIDE Publisher: Health Care Compl
Page 5 and 6: which ensures that the understandin
Page 7 and 8: Table 1: 14 CLAS Standards U.S. Dep
Page 9 and 10: Scholarship Recipients The Four Dua
Page 11 and 12: and need emergency care (e.g., an i
Page 13 and 14: Court analyzes first case under Sta
Page 15 and 16: It was established in 1969 in respo
Page 17 and 18: and get linked up with e-newsletter
Page 19 and 20: Social networking Many compliance p
Page 21 and 22: Focus on Organizational Compliance
Page 23 and 24: Medicare’s medical necessity crit
Page 25: Is no notice enough notice Legal pr
Page 29 and 30: “Does this really make a complian
Page 31 and 32: Certification - the recognized mark
Page 33 and 34: suffice. This potential error can b
Page 35 and 36: Introducing Compliance & Ethics Soc
Page 37 and 38: who typically sell multiple plans o
Page 39 and 40: n State OIG that fight Medicaid fra
Page 41 and 42: Coordinating external requests for
Page 43 and 44: The what, why and how of Medicare C
Page 45 and 46: The what, why and how of Medicare C
Page 47 and 48: to hear the message first. Educatin
Page 49 and 50: COMPLIANCE ACADEMIES February 2-5 S
Page 51 and 52: or whistleblower lawsuit. Moreover,
Page 53 and 54: SEC Disclosure: Managing informatio
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New principles can help advance ind
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New principles can help advance ind
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When to use a monitor Although some
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ASKLEADERSHIP John asks the leaders
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Enforcement actions in health care
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Corruption enforcement actions targ
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“I am a compliance professional a
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n M. Michelle Walker, LifePoint Hos
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