SO - Health Care Compliance Association

Steven W. Ortquisthave moved into internal audit. BecauseJuly 200116OG:For the benefit of our readers,could you describe in a bit more detailhow your compliance office is set up?SO:Cathy Jacobson, our Chief ComplianceOfficer, is Associate Vice President forProgram Evaluation and SpecialAssistant to the President. In her role asSpecial Assistant to the President, shehas direct access to the President forany matter. Cathy is also usuallyinvolved in new initiatives, and so isoften able to incorporate compliancefrom the beginning. Cathy is officially amember of the President’s office atRush and has direct access not only tothe President but also to the threeSenior VPs who are responsible formanaging the organization on a day-todaybasis.Both Kelly Bireley, the Director ofInternal Audit and I, as Director ofCorporate Compliance, report to Cathyand we are both Assistant ComplianceOfficers at Rush. Kelly primarily takescare of the auditing and monitoringfunctions along with some investigationson the hospital side. She alsooversees some training and correctiveaction that is the result of her auditwork.I have been responsible for developingthe structural components of thecompliance program and overseeingtheir operation, for instance, institutingcompliance policies. My staff and Ihave compiled a policy manual thataddresses approximately 50 risk areas.Rush’s compliance policies go beyondsetting out a statement of policy. Ineach policy document we have includeda section titled Executive Summary thatdiscusses underlying laws and how thepolicy should work itself out in theorganization. Where relevant, we haveincluded hypothetical examples andmodel forms. So, it’s not just a policymanual, really, but it’s also a trainingtool and a reference.The training component of the complianceprogram is also my responsibility.Josie Corbett is Rush’s compliancetraining coordinator. Josie has a dualreporting relationship to me and to theemployee and organizational developmentsection of our human resourcesdepartment. While Josie spends 100%of her time on compliance training, shealso knows what’s going on elsewhere inthe organization because of this dualreport, and so, can coordinate the trainingcomponent of compliance withother organizational training requirements.OG:Well, it seems like it’s wellCoupled with this is the issue of whatof this they have a real good understandingof how Rush works–both itspliance office–do you self-disclose or doto do if a problem is found by the com-systems and politics of the organization–andthey are able to move throughk n ow that Rush recently did do a self-you try to work the problem internally? Ithose very effectively.d i s c l o s u re, which has gained some notori e t y. Could you tell us how the complianceprogram impacted that eve n t .SO:Yes. Actually the problem thatwas self-disclosed was discove red as theYes. As I mentioned earlier,compliance office was doing a risk assessmentof the organization–so discove ry ofthe problem was the direct result of havinga compliance program at Ru s h .OG:It might be helpful for ourreaders if you would generally describethe problem.SO:Sure. It was a billing problemin our abdominal transplant clinic. Ourtransplant physicians had developed astaff of nurses that they really trusted toprovide care for the patients. And theyhad gotten into the habit of not alwaysbeing present when those nurses wereseeing patients for routine post-operativecheck-ups.The transplant clinic at Rush is notprovider-based. It is a freestandingphysician clinic. So, had the physiciansbeen providing proper supervision, itprobably would have been possible forthem to bill for some of these visits aslevel one nursing visits using the incident-torule. But supervision was notoccurring consistently, and the clinicwas billing visit levels higher than levelone.OG:And what was the process ofself-disclosure that Rush took?SO:Pretty quickly after we hadthought out. One of the areas of concernconfirmed that there was a problem infor most compliance professionals this practice, our outside counsel wentis this idea of effective compliance. to the U.S. Attorney’s Office in the