Don’t let processes overwhelm clinical colleagues

Helping our clinical colleagues feel the urgency of compliance monitoring can be a huge challenge. They’re busy seeing patients and doing the best they can to deliver care the best way they know how.  

Sometimes payers have specific requirements for care, though. And the Compliance team simply doesn’t have the clinical expertise to own the monitoring of these requirements. That’s why we work so hard to simplify and streamline regulatory change management: we have to take the busy work out of compliance so that our clinical colleagues can apply their subject matter expertise to compliance, rather than getting overwhelmed with process. 

Let’s now look at a real scenario that I encountered as a Compliance Officer that supports having Clinical leadership perform monitoring, document the monitoring, and report out the results.  

The net of it is this: Our Compliance Department performed a compliance audit related to sleep studies that resulted in a significant payback to the federal government that could have been avoided if monitoring was being performed by the Sleep Center Clinical leadership.  

Million-Dollar Payback 

In June 2019, the Office of the Inspector General (OIG) released findings and recommendations from a review of polysomnography [sleep] studies. The review found providers often did not meet the Medicare billing requirements – a whopping 83 of 200 were in error.

That’s a 41% error rate with an extrapolated overpayment of $269 million.  

The majority of the errors were due to: 

• Incomplete medical record documentation. The records did not contain face-to-face evaluations, attending physician orders and/or the technician’s report.  
• Technologist or technician lacked the required credentials or training certifications.  

In response to this report, my Compliance department initiated a statistical sample of sleep study claims to ensure the claims met the required billing rules and regulations. The initial results of the review were very good. The claims submitted had the required documentation to support the claim and the system received payment for the claims submitted.  

All good? Well, not exactly. While preparing for the audit, the compliance auditor researched not only the required billing rules and regulations, she also checked the National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). The auditor found an LCD that addressed polysomnography services.  

Armed with the LCD requirements, the auditor re-visited our sample of claims and found that 95% of the claims in the sample did not include the LCD requirements. As a result, the system initiated the required paybacks and we expanded our statistical sample to determine if prior claims failed to meet the LCD requirements.  

The results were similar, and when we extrapolated the error rate to our population, we arrived at a payback in excess of $1 million. We took immediate corrective action to ensure this would not occur in the future. Included in the corrective action plan was the establishment of an NCD/LCD subgroup. The subgroup included Clinical Leadership, Finance, Health Information Management and Compliance. The charge of the subgroup was to ensure the Clinical Departments were aware of NCDs and LCDs affecting their specific area and establishing a process to ensure they received the most up to date NCDs and LCDs.  

Painful LCD Monitoring Lessons Learned: 

This was a painful experience for the organization and the leadership. It definitely taught us some lessons. In the future, we made sure to: 

1. Ensure that clinical leaders are accountable for knowing the specific billing rules and regulations (including NCDs/LCDs) that impact their area. Much to our surprise the clinical leadership of the Sleep Study department was not aware of NCDs/LCDs. 

2. Ensure that clinical leadership conducts monitoring and can demonstrate that their monitoring encompasses all billing rules and regulations including NCDs/LCDs. Also, the results of their monitoring should be included in department metrics reported to their leadership and the Compliance department.  

3. Establish an NCD/LCD subgroup to aid Clinical departments in ensuring they have reviewed all applicable billing rules and regulations. Our subgroup shifted to quarterly meetings that the clinical department leaders actually look forward to attending.  

4. Conduct compliance audits of high-risk areas identified in the OIG’s Work Plan. The OIG now updates the work plan monthly. I recommend you sign up to receive the updates.  

5. Review the OIG Office of Audit Services final reports. They provide a wealth of information on findings for high-risk areas and how the OIG conducted their audit. It is a good roadmap to ensure your system targets the highest risk areas so if the OIG comes calling you can demonstrate the action your system has taken to be in compliance.  

Support Clinical Leadership Compliance Responsibilities 

You may run into resistance when you try to bring clinical leadership into an active compliance role.

Remember this: The Compliance, Finance, and Legal departments are not experts on the services that are rendered in a clinical area. Yes, you and these other departments can assist if there are questions about interpreting a regulation.

However, Clinical Leaders must take responsibility for  

• Keeping current with changes in rules, regulations, and laws appliable to their operational areas 
• Developing internal controls, policies, and procedures to comply with them 
• Training their staff on the written guidance  
• Actively monitoring and verifying the guidance is being followed.  

The best way you can help with this is to provide a scalable, repeatable process that takes the drudgery and busy work out of these responsibilities. From there, you can serve as a sounding board and thought partner, rather than trying to carry the clinical burden of compliance all by yourself. 

Where to Start Advising Clinical Teams 

The next time you’re meeting with a clinical team, ask how they approach monitoring. (Be mindful, they may not be calling it “monitoring.”) If you aren’t regularly meeting with clinical colleagues, I’d suggest finding a way to get closer to them before launching into a monitoring discussion. (Read Ken Zeko’s 12 key metrics for compliance officers looking to move their culture forward for tips on meeting with operational and clinical colleagues.) 

Start small. Choose a Clinical Department and ask the leaders how they receive specific information related to billing requirements. Be sure to include their awareness of NCDs/LCDs. If they ask you what an NCD/LCD is, you know where to start.  

Learn from the OIG. The OIG’s Office of Audit Services reports include the findings of their auditing of high-risk areas, and they provide a good roadmap on their sampling methods. You can use this to lay out your own steps for auditing and monitoring.  

Sampling. The Clinical Department can select a small sample on a random basis. If the sample results reveal a potential issue, expand the sample. In these situations, I would recommend involving your Compliance department. 

Survey to Expand. Consider developing a survey to find out how your clinical colleagues learn what documentation is needed to support a clean claim. This insight can help you determine how diligent your colleagues are about monitoring. 

As you move through this inquiry, you will start to embed yourself as an advisor to your clinical colleagues as they work to ensure clean operations. You can help them stay proactive by reviewing the OIG Work Plan with them regularly. Let them know if they are in a high-risk area as identified by the OIG and offer to help them with process and content to ensure clean claims.  

Your clinical colleagues may feel overwhelmed with this responsibility, especially if they haven’t been accountable for it before. Show them they are not on an island by giving them process support that helps them focus on applying their clinical expertise to compliance. 

YouCompli tackles regulatory change management with a one-two punch: qualified people to make sense of regulatory changes plus simple software to manage the rollout.  

Brian W. Kozik, CHC, CCEP, CHCP is a 25-year veteran of healthcare compliance and an expert in compliance monitoring and auditing. Most recently he served as Chief Compliance Officer at a major health system in Southern Florida. He is the author of The Healthcare Auditor’s Handbook and Ready, Set, Comply!: Compliance Games, Activities, And Tools to Train Your Staff. 

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The post A million-dollar healthcare compliance monitoring mistake  first appeared on YouCompli.

It’s tempting to focus all your time and attention on getting board and leadership support for a compliance program. The trouble is, the board and leadership aren’t the ones making the million decisions every day that affect patient care and compliant practices. In order for me to ever deliver a truly effective and robust compliance program, I also needed all employees and physicians to get on board. It was my job to help them fully understand the importance of our compliance practices and how our policies and procedures led to better patient care, better financial practices and a more compliant organization.   

To win hearts and minds, I needed to show up with my clinical and operational colleagues and make sure that my team was seen as a resource and not as punitive police force. In order to be a partner and resource, we need to practice a commitment to what I like to call the “four C’s of compliance.”   

• Communication  
• Collaboration  
• Credibility  
• Culture  

Let’s delve into each one further. 

Communication for healthcare compliance  

Communication is essential for ensuring the Board, your employees, your physicians and the community understand the commitment your system has to operating at the highest level of integrity. Maintaining ongoing communication helps ensure that all constituents are on the same page. As a Chief Compliance Officer, I looked for every opportunity to maintain open communication. For me, this starts with attending New Employee Orientation. I wanted employees to know compliance is so important the Chief Compliance Officer conducts the training. In addition, I worked with Marketing to develop a monthly Compliance newsletter. My Compliance staff visited various locations to introduce themselves. That way, stakeholders felt a connection to us rather than just hearing about the compliance staff and program.  

Collaboration for healthcare compliance  

There is no Compliance Officer who has the budget and staff to cover all of the risk areas within a system. This is why effectively collaborating with the employees and physicians is just as essential as communication. (Ken Zeko offers metrics for the amount of time you spend with your clinical and operational colleagues in 12 key metrics for compliance officers looking to move their culture forward.)  

I collaborated by helping employees and physicians see that they, too, are compliance officers.  They need to understand the regulatory environment they work in and to feel free to reach out to the Compliance Officer or Compliance department with questions and concerns. The Compliance department is there right beside them. I tell them that the regulations are not always as simple as “yes” you can or, “no” you can’t. Therefore, it is essential that you “team” up with the employees and physicians.  

Credibility for healthcare compliance 

Credibility is earned by the Compliance Officer. Employees and physicians will feel comfortable working with you when they feel you are credible. In some instances, this may be hard to obtain, especially if the prior Compliance Officer may have acted as more of a police officer. You need to be a good listener. Each person you work with will have had a unique experience with Compliance, so you’ll have to adapt your style to meet the individual where they’re at.  

In one of my compliance officer positions, access to the Compliance Department was restricted by badge and camera. To gain credibility, I knew the Compliance Department staff had to be accessible and transparent. So, on day two of arriving, I had the camera and badge access removed. I was surprised to receive more than 25 emails from employees I had not yet met. They told me how excited they were to see the camera removed thus, allowing them to come into the Department with any questions or issues. That was a little thing that went a long way!  

Culture for healthcare compliance 

Jay Anstine writes frequently about creating a culture of compliance. He has a great short definition: A culture of compliance is a commitment throughout all levels of an organization to do the right thing and do things right.  

There’s a pretty wide spectrum between what Jay describes – everyone lined up to do things right and believing that Compliance partners with them– and one where employees and physicians see compliance as a “forced” program. One important element of the culture is whether the Compliance program is seen as punitive. For example, as a new Compliance Officer I discovered that a privacy mistake like giving a patient someone else’s discharge instructions was considered a “serious violation.” This meant that someone who made this mistake would be written up. This was critical for the employee. A reprimand would have been placed in their personnel file and could have affected future raises. If she had made a similar mistake in the future, she could have lost her job. This seemed unnecessarily punitive and unlikely to lead to the psychological safety we needed in order for people to bring their mistakes forward to fix. 

So, I worked with Human Resources and adjusted the levels of discipline for privacy violations. This simple change resulted in employees and physicians being less afraid to report a mistake. Nurses were especially pleased. They are faced with taking care of several patients and working with Case Management in getting patients discharged. This is a fast-paced process as there are other patients waiting for the beds and patients wanting to leave for home. In the rush, taking one patient’s paperwork off the centralized printer may include others discharge papers. Do nurses do this on purpose? No. Do we want the nurses to feel safe speaking up about mistakes and asking for better tools? Yes.  

I love this discharge paperwork example because it incorporates all of my Four C’s. 

1. I had communicated with the clinical staff enough that they knew who I was, and a line manager was willing to bring me a problem. 
2. I collaborated with Human Resources and Nursing Leadership to change the policies around violations. I also collaborated with Nursing Leadership to change processes to reduce the risk of repeated violations. (One idea was to automate the process so printing paper was unnecessary. Another was to have managers meet with staff at the start of each shift and remind them to give themselves a few extra seconds to check the name on the discharge paperwork.) 
3. This incident helped me build credibility with my clinical colleagues. One of my best days at work was the day a nurse called to tell me this: “I work the night shift and have never met you but, my fellow nurses told me you are a good guy and I have an item I want to discuss with you.” I was so proud to have built that trust. 
4. We changed the culture around reporting incidents. We gave people more tools and more safety to do the right thing and to do things right.

I often tell this story as a win for the Compliance function, but of course it was a win for the organization. My biggest secret weapon in this work has been putting my ego aside and leading with empathy. A willingness to walk a mile in the nurses’ shoes – and then learn from that experience – was really the key to bringing these Four C’s to life. 

Brian W. Kozik, CHC, CCEP, CHCP is a 25-year veteran of healthcare compliance and an expert in compliance monitoring and auditing. Most recently he served as Chief Compliance Officer at Broward Health. He is the author of The Healthcare Auditor’s Handbook and Ready, Set, Comply!: Compliance Games, Activities, And Tools to Train Your Staff.

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27 Ungated Resources for Compliance Leaders and Teams 

Compliance professionals sometimes feel undervalued in comparison to other functions in their organization. They think leaders and colleagues don’t really understand what they do.  

These resources will help. Packed with ideas, tips and recommendations, these pieces were written by professionals with many years of compliance experience. 

You can quickly skim for articles that relate to your needs and interests. Bookmark this page as a reference for future questions or projects.

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The post The Four C’s of Healthcare Compliance  first appeared on YouCompli.