Mock audits deliver value for healthcare    

Mock audits are an incredible tool for compliance officers to protect a healthcare organization’s revenue and add tangible value. They are time consuming, but they can dramatically advance your compliance program.  

Beyond protecting revenue, audits are effective ways to help organizations prevent fines. They’re also key to how compliance officers build relationships across the organization, shape the culture, and position Compliance as a true partner.   

 I’ll prove all of this by telling you about the $9 million in unbilled revenue I found in one mock audit. This success story is evidence of how Compliance brings value to leaders and influences culture, while helping the organization better manage and control risk.  

The Mad Dash in Revenue Cycle  

Revenue Cycle is a huge investment for any healthcare organization. It’s particularly true in behavioral health; many of our organizations were established from nonprofit work or federal grants.   

There wasn’t always a lot of money in the behavioral health field. But in recent years, with the Affordable Care Act and managed care coming in to cover services, it’s been a mad dash to figure it all out. How do we capture revenue? How do we bill for it, document for it and, of course, collect it?   

Behavioral health and many smaller healthcare organizations are working to put all the processes in place. Compliance should be involved because we’re integrated into all aspects of the organization, from HR and operations to clinical services and finance.

The Tough Questions  

With revenue protection, our role in Compliance is to be aware, ask questions, and determine which parts to monitor and audit. We need to be a fresh set of eyes for the organization, looking at all points of care.   

Compliance officers are responsible for asking the tough questions during audits: Do we bill that? Do we get paid for that?   

We’re usually distanced enough from the operational departments’ daily work that we can ask the questions no one else has the time to ask. Our questions may be ones that other people are afraid to ask because it’s not their role to look into it.  

As a former behavioral health surveyor with the Joint Commission, I’m comfortable with this role. A good mock survey covers all the aspects of a Joint Commission survey – the environment of care, HR, staff records, and client records.   

When I do mock surveys, I pretend to be with the Joint Commission. Everyone takes it seriously. My job is to find opportunities to improve because everyone in operational departments is so busy and distracted, putting out fires in their day-to-day work.   

For example, a lot of work in healthcare systems involves the documentation of services. During audits, compliance officers should ask questions like: are our payors going to ask for more details, deny claims, pull back money, or request refunds if it’s not documented?   

Anywhere Compliance can insert our help and expertise in the revenue process is useful to the larger organization.  

The Biggest Dollar Value Uncovered in an Audit   

My best and worst example of a mock audit is one I conducted with a former employer. It was the seventh or eighth mock survey I’d done with them.   

We did audits quarterly and discovered something new every time. But this was the biggest dollar value I’ve ever uncovered in an audit.  

We were going through our usual process of doing chart reviews and looking for any issues with documentation. We asked questions such as: does the documentation equal your utilization review?   

In the Billing department, it came to light that a tremendous number of services hadn’t been billed. They had piled up quickly over several months because the team wasn’t able to keep up.   

The clinical services had been delivered by the treatment team. But they simply put them in the record and assumed they would get billed from there; they didn’t have a process in place to monitor and audit services.  

We asked why they hadn’t been billed, and we found that it was simply because the Billing department had not done it. We were in the midst of taking on new patients and adding new programs, and the invoices were overlooked.  

We didn’t have the right systems in place to question how long an invoice can go without being billed. Without that system, other issues came up that people turned their attention to; it happens every day in all our workplaces.  

The unbilled services totaled $9 million.  

At first, people were shocked and embarrassed. There was definitely some frustration. But once we got past the initial shock value, everyone was grateful that we caught it so we could address it and move forward.   

Transparency is Key   

My goal with audits is to normalize whatever happens, so that regardless of what we find no one needs to be defensive.   

Transparency from leadership is critical for successful audits. When the CEO gives Compliance free reign for an audit, it trickles down to all sites and operational areas.   

Transparency helps ensure that operational leaders don’t prevent auditors from looking at an area. It makes sure there’s teamwork and individuals’ commitment and cooperation for fixing any issues identified. It also creates a healthy culture where people aren’t penalized for audit results. In this situation, nobody got in trouble. The unbilled services certainly were not due to any one person’s fault or incompetence.   

More Checks and Balances  

We reacted, obviously, by taking care of the billing. The payor also came and did additional audits.   

After that, we looked at our processes and asked some more questions. How did this happen? Where did this communication fail?   

We learned our issue was just in one program at one location in one state. But the discovery made us pause and wonder if there were other issues in the rest of the system. We checked everywhere and didn’t uncover additional issues, but we still put corrective actions in place across the system. Now the system is built to catch issues before they happen.  

We established more controls and added more checks and balances. One was a monthly billing report to identify what was and wasn’t billed – and why – and what’s pending. It improved the communication and oversight of the billing area. Another addition was a monthly meeting to review whether anything was missed. Before, an assumption was made that everything was fine. The monthly meeting strengthened collaboration and partnership and made us look at ownership of issues.  

That’s one of the beauties of uncovering such opportunities: it pushed us to look everywhere to see what else we could improve.    

It was a lesson learned, and everyone rallied as a team to fix the issues. After we put new systems in place, there was a sense of pride in building them. And we built a lot of confidence that we weren’t missing anything.   

We made sure $9 million would be our biggest dollar amount ever uncovered in an audit and that the problems that led to it would never happen again.  

Five Benefits Beyond Revenue Protection   

By giving everyone the opportunity to step away from their day-to-day tasks and look at the bigger picture, mock audits offer benefits beyond revenue protection. Audits are opportunities for compliance officers to:   

1. Build relationships across the organization and shape culture. Audits demonstrate that Compliance is part of the team. I find that when we do audits quarterly, operational leaders reach out more. They’re asking me more questions or challenging more things because we’re in conversations all the time. 
2. Prevent fines. Mock surveys certainly minimize the risk, and they improve the likelihood that you are meeting all relevant regulations because you’ve had a chance to talk through issues and problem solve across operational areas.   
3. Prepare staff to be comfortable in an actual audit situation. I can ask staff tough questions, and then we can practice the right answers. I can coach staff on how to answer certain questions because sometimes individuals are afraid of regulators. The biggest findings in actual audits tend to happen when people get nervous in the moment, and they blurt out something that’s not accurate.  
4. Give everyone a chance to ask questions. Why is that relevant, or why are we doing this in two different places? I love these opportunities where we find something to correct or improve. My goal is always zero citations for any kind of regulatory visit, and we accomplish that by practicing with quarterly mock surveys.  
5.   Change the reputation of Compliance as the bad guy and position us as a true partner. When I’m on site for an audit and I find something to fix, I do it. When I handle it, I’m taking it off their plate – not just saying, “You guys go fix these things.” I remediate anything that I can control on a survey visit. It builds trust and helps operational leaders see me as a valued partner.    

If you don’t conduct mock audits, my recommendation is to start with something that feels manageable – even if it’s just once or twice a year. Quarterly is ideal for really solving issues. But start by picking a time and putting it on the calendar a year ahead so people can prepare for it.    

In my experience, it can take a couple surveys before operational leaders see the value in them. They may be resistant, thinking, “I have to spend three hours talking to my compliance officer when I’ve got work to do!”   

As they realize audits make their work better – and that I’m engaged with them in problem solving – it becomes a true partnership.  

My success in uncovering millions of dollars in unbilled services demonstrates how revenue protection is a tangible way Compliance delivers value to healthcare organizations. It also underscores how compliance professionals make an impact across the business through building relationships, shaping culture, preventing fines, and positioning Compliance as true partner. Integrating all these activities enables Compliance to help the organization better manage and control risk.  

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Maeve O’Neill is the national compliance director for Circa Behavioral Healthcare Solutions and has worked in behavioral health for 35 years. Maeve has a passion for quality and safe care as well as happy and healthy staff. A former behavioral health surveyor with The Joint Commission, she is committed to excellence.   

The post Uncovering $9 Million in Unbilled Services    first appeared on YouCompli.

Use Education and Influencer Skills to Create Value

The stigma and complexities in behavioral health present compliance challenges that other healthcare organizations may not face. In this two-part series, I’m exploring how these challenges drive the need to minimize risk for behavioral health organizations through standardizations and building predictable processes. 

Read Part I, “Establishing a Strong Compliance Culture in Behavioral Healthcare: Minimize Risk and Add Value Through Standardization and Metrics”

In Part I, I examined why establishing a strong culture is critical for behavioral health organizations to minimize risk. I highlighted how using the Office of the Inspector General (OIG) ‘s seven elements and making the most of metrics can help behavioral health organizations build culture and show how Compliance adds value. 

Below are two more fundamental activities for creating a positive culture: being an effective influencer and emphasizing education. Prioritizing these activities – along with using the OIG’s seven elements and making the most of metrics – will enable you to build a culture that helps behavioral health organizations minimize risk.  

Behavioral health’s complexities

Behavioral health is unique in that we have the stigma that goes along with our work. The population we serve has mental health and addiction issues, plus co-occurring medical, legal, educational, work, and family issues.  

In addition to the lack of understanding around mental health and addiction, a big challenge in behavioral health is that we don’t have clarity yet on the differences between compliance, quality, risk, and safety. We’re still trying to define the differences and the commonalities and where they overlap.  

We also face a lack of consistency in behavioral health. We’ve come a long way in my 35 years, with more evidence-based practices and more research-based approaches. But we lack a common approach to measuring outcomes and what works as well as consistency from state licensing and accrediting bodies.  

Two more culture-building tips

In Part I, I explored how to successfully begin creating a healthy culture by using the OIG’s seven elements and making the most of metrics. Two more activities – being an effective influencer and emphasizing education – are key to navigating behavioral health’s complexities and building a culture that minimizes risk through standardizations and predictable processes. 

1. Be an effective influencer

Building solid relationships and being visible throughout the organization are crucial to building a strong culture of compliance. And acting with empathy helps you encourage others to proactively work with you to add standardizations and build in predictable processes. 

This comes from my belief that people want to be compliant. They want to do the right thing. Assume that employees are doing their best with what they have, and lead with that. 

If there’s an issue, it’s often because employees have not been given the right information, resources, or skills. Our job in compliance is to give employees the right information, resources, skills, and support they need – not to assume that they’re bad or lazy.  

Leading with empathy

At my old organization, we practiced lean management, and one of my favorite sayings was, “Hard on the process, easy on the people.” 

Being empathetic is more effective than blaming and pointing fingers. If I have a noncompliance issue, I approach it with employees as, “It’s my fault. Compliance failed you by not giving you a good enough policy, procedure, or training.” 

When I take this approach, you can feel the energy in the room shift. It transitions from a negative and fearful moment to a foundation of empathy and a healthy culture for compliance.  

It’s also helpful to have an open-door policy. If you’re new to an organization, have lots of conversations to assess what your colleagues’ previous experience was with Compliance. You have to be willing to hear things that are tough to hear and be responsive to that. 

“Hard on the process, easy on the people.”  

It’s key to building trust and being able to shape culture as an influencer. And it’s important to follow through on integrating their feedback into your compliance program. 

I like to tell new colleagues, “Here are the things I’ve heard that didn’t work, and this is what we want to do differently.”  

The change management process is a continual effort to build and make it better, and it takes time to get everyone’s buy-in. Resistance is absolutely normal and expected.  

To overcome resistance, communicate the why behind what you’re doing. Communicating and doing a lot of listening builds trust.  

If you’re changing policies or processes, explain why you have a better way to do it. Emphasize the importance of following the seven elements and integrating them into daily workflows.

Be confident that you have the knowledge, skills, and abilities to address the compliance issues the organization is facing. Be confident to push back, to question, and to challenge.

As compliance officers, we bring a specialization that is rare. Don’t be afraid to be a person of influence.

Being visible

It’s helpful to embed yourself into each operational area. Be part of each area’s initial orientation with staff, go to trainings, do mock surveys, and attend team meetings.  

When you’re embedded, you’ll start hearing about issues to look into. Then you can follow up with teams and say, “I wonder about this. Do you have any concerns in this area?” 

The more visible you are, the more that colleagues see you and trust you as a partner. They’ll appreciate what you bring, and in turn, they’re more likely to bring issues to you. This can help you catch a potential problem early to prevent it from becoming a bigger issue. 

2. Emphasize education

Education is closely related to using influence, and ongoing training is key to helping the organization minimize risks through standardizations and building in predictable processes. 

In an earlier role, I joined an organization where policies had not been updated in about 10 years. There were missing policies as well as conflicting and duplicative policies.  

I worked with each department – from nursing to medical directors to human resources – to review their policies and make sure they were aligned with their actual practices. This allowed each operational area to contribute to their policies and to secure any funding and training needed to resolve the discrepancy issues. 

Building cohesive policies across the organization was an opportunity for education around regulations and why they were in place. It also helped get employees’ buy-in and positioned them to champion compliance. They’re putting the policies to work every day and now they understand why. 

Monthly check-ins are also valuable for ongoing education and training. I do monthly phone calls with all our medical leads and nursing leads. It’s an opportunity for sharing and cross-training across different levels of care, or different settings; everyone can learn best practices from one another.  

Sometimes training becomes a check-the-box exercise. But effective training – testing for competence and making sure employees understand how to apply it in their daily work – is crucial.  

In behavioral health, we conduct trainings around critical care areas such as diagnosing substance and suicide prevention. We have to ensure that our training is updated and affecting care. 

Educate yourself on compliance industry resources

As you build a compliance culture, it’s helpful to get involved with the HCCA (Health Care Compliance Association).  

Using HCCA resources and asking for help from the compliance community – not normally people who we interact with in behavioral health – keeps you from having to start from scratch. Leverage existing programs and talk with people who are already doing the work. 

Also, using a tool like YouCompli gives you some of the structure you need for procedure development – the forms, trainings, whatever it might be. It will save you so much time and resources. 

Benefits of a healthy compliance culture

The stigma and the complexities we deal with in behavioral health present extra compliance challenges. Yet there are ways to effectively tackle these challenges to help behavioral health organizations minimize risk and show how Compliance adds value. 

Establishing a positive culture in behavioral health and showing how Compliance adds value includes four activities: 

1. Using the OIG’s seven elements
2. Making the most of metrics
3. Being an effective influencer
4. Emphasizing education

Prioritizing these areas will help give you the knowledge, resources, and confidence to address the organization’s compliance challenges. Compliance officers bring a specialization that is rare. Don’t be afraid to be a person of influence to build the culture you know will add value for your organization. 

Read Part I, “Establishing a Strong Compliance Culture in Behavioral Healthcare: Minimize Risk and Add Value Through Standardization and Metrics”

Maeve O’Neill, MEd, LPC-S, CHC, CDTLF, National Compliance Director for Circa Behavioral Healthcare Solutions, has worked in behavioral health for 35 years. Maeve has a passion for quality and safe care as well as happy and healthy staff. A former behavioral health surveyor with The Joint Commission, she is committed to excellence. 

How YouCompli helps

At YouCompli, we believe compliance professionals create value in healthcare organizations through standardization and metrics. That’s why we supply tools for our customers that they can be confident in using to educate and influence their stakeholders. YouCompli subscribers receive regulatory tools including primary research and regulatory alerts, practical analysis and impact, decision criteria and affected departments, business requirements, and model procedures. Every regulatory tool is validated by Horty Springer LLP, the nation’s top law firm. 

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The post Establishing a Strong Compliance Culture in Behavioral Healthcare: Part 2 first appeared on YouCompli.

Minimize Risk and Add Value Through Standardization and Metrics 

A strong compliance culture is important in healthcare organizations because so much of what we do is dependent on the people and the processes. Without standardized processes, there are greater opportunities for risks and problems to occur.  

During my 35 years in behavioral health, I’ve experienced how a compliance culture minimizes risk through standardizations and by building in predictable processes for organizations. Establishing a strong compliance culture in behavioral health and showing how Compliance adds value includes four activities: 

1. Using the Office of the Inspector General (OIG)’s seven elements 
2. Making the most of metrics
3. Being an effective influencer
4. Emphasizing education

I’ll explore these activities in a two-part series. Below, I discuss using the OIG’s seven elements and making the most of metrics. I’ll follow up with a look at being an effective influencer and emphasizing education.   

Stigma and complexities in behavioral health 

The stigma and the complexity of what we deal with in behavioral health present compliance challenges that other healthcare organizations may not face.  Because of these challenges, behavioral health organizations need to minimize risk for the organization through standardizations and building predictable processes. 

Stigma 

Behavioral health is unique in that we have the stigma that goes along with our work. The population we serve has mental health and addiction issues, plus co-occurring medical, legal, educational, work, and family issues.  

Everyone – our patients and their families as well as our staff and the regulators – has a judgment or a criticism of what we do. There’s a lack of understanding around mental health and addiction, which generates fear and uncertainty. 

Lack of clarity  

In behavioral health, our collective focus over the years has been on quality and risk management. The language of compliance is a little bit newer, whereas in healthcare it’s been a more long-standing process.  

The biggest challenge in behavioral health is that we don’t have clarity yet on the differences between compliance, quality, risk, and safety. We’re still trying to define the differences and the commonalities and where they overlap.  

Some behavioral health organizations think they have compliance covered because they do quality or safety. In reality, they’re duplicating efforts because they’ve built separate silos rather than truly integrating.   

Lack of consistency  

In behavioral health, we have higher acuity of patients, and we have more regulatory requirements. When I started in the field 35 years ago, we had the mental health unit, the alcohol unit, and the drug unit; now, they’re all one unit.  

We’ve come a long way, with more evidence-based practices and more research-based approaches. But we lack a common approach to measuring outcomes and what works as well as consistency from state licensing and accrediting bodies.  

There are millions of ways to do a behavioral health treatment, and everyone has a different set of rules to negotiate. Whereas healthcare, in general, has standardized practices and treatments, and therefore a common language and approach to compliance.   

Establishing a compliance culture in behavioral health 

Behavioral health’s unique challenges mean these organizations are ripe for a strong compliance culture. These two tips can help you start navigating behavioral health’s complexities and show how Compliance adds value by minimizing risk through standardization and building in predictable processes.  

1. Use the OIG’s seven elements 

Using the OIG’s seven elements in behavioral health is still pretty new. The reality is a lot of behavioral health programs are rather unsophisticated in their policies. 

Many behavioral health organizations still have their polices in big binders; they haven’t yet embraced technology to manage how they approach compliance. It’s partly because the focus in behavioral health has been on working with patients, not building infrastructure.

You can use the OIG’s seven elements almost as a checklist; think of the seven elements as building benchmarks. Start by assessing which of the elements you already have. 

Most behavioral health organizations find that they have the seven elements in some iteration. But they haven’t been organized in a work plan or an annual assessment.  

If you’ve met all seven elements – even if it’s minimally, as long as you have something in place for each of them – you have a good foundation for a compliance program. With the seven elements in place, you can build over time to create a strong culture. 

Start by taking a whole look at your organization. It’s a neat exercise to go through with your colleagues to look at all the things they’re doing – staffing, policies, standard operating procedures, documentation – and have them see the opportunities for simplification and standardization. 

2. Make the most of metrics   

We don’t always get the credit for the value Compliance adds. It’s partly because our job involves preventing, finding, and fixing issues. When we do our jobs well – preventing issues – nobody sees them.  

Yet our impact is tangible. By building in predictable processes, we’re creating healthier cultures that are more compliant and more financially stable, with fewer fines and lawsuits and less wasted money.  

To help show Compliance’s impact, remember that data is our friend. Several measurements can help gauge the effectiveness of your culture – and show how Compliance is making a difference.

An example is conducting a pre-test and a post-test. I always do this, whether it’s a new employee orientation or an annual training.

In my specific niche of behavioral healthcare, we’re accredited by the Joint Commission and their standards change twice a year. If you’re also accredited by CMS or other state regulatory agencies, that’s a lot to track.

I’m a big fan of building policies that embed the regulation into it. So, if there’s a rule on, for example privacy or drug testing or a medical process, the policy says, ‘Here’s what CMS says on that.’ It shows employees the regulatory rationale behind the policy to make it more motivating to comply than simply because it’s what Compliance said to do. 

Embedding regulations into the organization’s policies is also helpful if there’s an audit or a state visit. Employees can point to their process being aligned to a specific regulation and show how that alignment has led to fewer issues over a period of time. 

Leverage existing data 

Behavioral health organizations have existing data that can help assess the health of your culture. Look at our turnover. Are staff leaving? Are they staying? How long are they staying?  Also look at employee survey data and employees’ feedback. What could we do better? What do employees like, and how can we keep those things?   

Consider patient data and the surveys patients complete too. Are our patients coming back? Are they referring new patients to us?

You can also look at incident reports to see if incidents have gone down. The key is using data to help show Compliance’s impact and finding a trusted person in the organization to help sell your story.

It may be a board member, an executive, or a line person who really understands compliance. Having advocates outside of Compliance who support your efforts helps show the value you’re adding to the organization.

Value of a strong compliance culture 

The stigma and complexities of behavioral health underscore the need to minimize risk for these organization through standardizations and building in predictable processes. It can be challenging to navigate the complexities.  

Yet you can successfully begin creating a healthy culture by using the OIG’s seven elements and making the most of metrics to show how Compliance adds value. Prioritizing these two activities is critical to enabling behavioral health organizations to build standardized processes that help minimize risk.  

Watch for Part II, where I’ll examine two more key activities: being an effective influencer and emphasizing education. Together, these four areas can help you establish a strong compliance culture in behavioral health and show how Compliance adds value.  

Maeve O’Neill is the national compliance director for Circa Behavioral Healthcare Solutions, has worked in behavioral health for 35 years. Maeve has a passion for quality and safe care as well as happy and healthy staff. A former behavioral health surveyor with The Joint Commission, she is committed to excellence. 

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The post Establishing a Strong Compliance Culture in Behavioral Healthcare: Part 1 first appeared on YouCompli.