Anti-Kickback Statute Enforcement in Healthcare 

cj wolf anti kickback statute in healthcare

The recent surge in healthcare fraud has prompted heightened enforcement of the Anti-Kickback Statute (AKS). Government agencies are cracking down on illegal financial arrangements that jeopardize patient care. This article explores the significance of AKS enforcement, the impact on healthcare providers, and strategies for compliance in an evolving regulatory landscape.

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Establishing a Strong Compliance Culture in Behavioral Healthcare: Part 2

strong compliance culture in behavioral health

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.

strong compliance culture in behavioral healthcare

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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Telehealth expansion: Interstate licensure compacts benefit patients 

YouCompli Woman reviewing interstate licensure compacts for telehealth

Telehealth services and models have expanded rapidly during the pandemic. Healthcare employee burnout, the Great Resignation, and other factors are expected to further accelerate telehealth growth.  

Telehealth expansion has led to significant growth in the use of interstate licensure compacts. As more healthcare professionals obtain licensure under compacts, compliance officers need to be aware of interstate licensure requirements – and their effects on patient care. 

Increasing use of interstate licensure compacts 

The National Council of State Boards of Nursing (NCSBN) recently published its annual report on interstate licensure. It noted 43 states and territories have enacted licensure compacts for nurses, physicians, physical therapists, emergency medical technicians, psychologists, speech therapists/audiologists, occupational therapists, and counselors. 

The Nurse Licensure Compact (NLC) is an interstate agreement allowing nurses to practice in multiple states with one multistate license issued from their home state. The compact enables nurses to provide nursing services to patients located in other NLC states via telehealth without obtaining additional licenses. The NCSBN says this approach allows for greater nurse mobility, public protection, and access to care.  

In addition, use of the Interstate Medical Licensure Compact (IMLC) grew by 47% in the past two years. The IMLC Commission noted “more than 8,000 licenses were issued through the compact from March 2020 to March 2021.” This is compared with nearly 4,000 licenses issued during the previous 12-month period.  

With more healthcare professionals practicing across state lines, patients have more choices. And healthcare compliance officers have processes and procedures to update.  

Interstate licensure compacts benefit patients 

For patients, one benefit of licensure compacts includes licensing boards being able to ensure that physicians maintain professional integrity and medical standards – regardless of where they practice. As more healthcare professionals obtain licensure under compacts, patients gain greater flexibility in making care decisions.  

For example, rural patients can participate in a telehealth visit with a specialist or provider at home. This saves patients the time and expense of driving long distances to see the same provider in a facility setting.   

Another positive is the increased use of remote monitoring devices, such as glucose monitors, blood pressure monitors, and heart monitors. Patients can receive state-of-the-art monitoring remotely, instead of as a hospital inpatient. In turn, healthcare costs decrease and patient compliance increases.  

A significant patient benefit with expanded telehealth is the inclusion of mental health services. Under the provisions of the Consolidated Appropriations Act of 2021, services for the diagnosis, evaluation, or treatment of mental health disorders may continue as telehealth services. Per the Centers for Medicaid & Medicare Services (CMS), the previous restrictions limiting telehealth mental health services to patients residing in rural areas no longer apply.  

Compliance considerations 

Compliance officers need to help their organizations keep up as healthcare delivery models change. Organizations will need to update everything from billing codes to human resources policies and procedures to information technology (IT) practices.  

For example, compliance officers should partner with Human Resources to make sure out-of-state licensed professionals have been educated in facility policies and procedures. They also need to ensure that professionals working under licensure compacts understand the nuances of the rules and laws in the state they are working. 

Compliance officers also need to work with the IT department to ensure that remote devices have been securely connected to the network. They also need to collaborate with the risk department on making sure proper medical professional liability insurance coverage has been obtained for these licensed professionals.  

Compliance officers should work with Revenue Cycle on two crucial issues:  

  • Ensuring that the organization stays abreast of the changes to the CMS list of services payable under the Medicare Physician Fee Schedule when furnished via telehealth. 
  • Staying current on telehealth visit coverages and coding modifiers to decrease denials of patient charges.  

As your team manages your response to continuing regulatory changes, having a system to keep up with the moving parts can help. YouCompli can support your regulatory change management process. It provides regulatory analysis to help you know what changes are coming and decide whether they affect your institution. It also provides requirements, tasks, and deadlines, in clear business English, making it easier for you to manage changes and verify that you’ve taken the proper steps. 

Denise Atwood, RN, JD, CPHRM 
District Medical Group (DMG), Inc., Chief Risk Officer and Denise Atwood, PLLC 

Disclaimer: The opinions expressed in this article or blog are the author’s and do not represent the opinions of DMG.  

Denise Atwood, RN, JD, CPHRM has over 30 years of healthcare experience in compliance, risk management, quality, and clinical areas. She is also a published author and educator on risk, compliance, medical-legal and ethics issues. She is currently the Chief Risk Officer and Associate General Counsel at a nonprofit, multispecialty provider group in Phoenix, Arizona and Vice President of the company’s self-insurance captive.  

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Decide: YouCompli helps your organization make easy regulatory decisions

Before YouCompli, Compliance Officer Scott Borsuk said he “probably spent six to eight hours a week reading regulations, then copying and pasting them” to share with colleagues. Read the Western Maryland Health System case study.

“It’s not enjoyable reading,” Borsuk noted.

But he had to read closely to be sure he properly analyzed the regulation to see if it applied to him.

Simplify decision-making

“We were not confident that we were catching everything, we had the documents but didn’t know if we missed anything. At the end of the day, we didn’t know if we were making the right changes or not.” – Scott Borsuk, Chief Compliance Officer

Borsuk knew he needed a better system and a stronger approach to managing regulatory change. That’s where YouCompli came in. With YouCompli, Borsuk can easily decide if a regulation applies to his hospital system and how to comply.

YouCompli makes it easy for you to decide which regulatory changes apply to your organization and which tasks need to be performed in order to comply.

In this clip Scott Borsuk explains what regulatory change management is, and how YouCompli assisted his hospital system in achieving desired results.

Watch more videos on this topic here and see how YouCompli can help your organization

Regulatory analysis to help you decide

  • For each requirement associated with a regulation, YouCompli creates a few relevance questions. Users may be asked, for instance, “Is your organization a Medicare provider?” These relevance questions are followed by tips generated by YouCompli to help make your decisions easier.
  • We can do this because our analysts read entire regulations, flag relevant changes, and translate technical legal documents into easy-to-understand business requirements.
  • If you decide the regulation is not relevant, YouCompli marks it “complete” and removes it from your active tasks.
  • All our analysis is checked by Horty Springer, the nation’s leading health care law firm.
YouCompli’s simple interface makes it easy to decide if a regulation is relevant to your organization.

Get expertise from colleagues

Sometimes the relevance questions stretch beyond your expertise as a Compliance leader. In those cases, use YouCompli to get the answer from colleague with the right expertise.

  • Use the workflow tool to assign a complex relevance question to a subject matter expert
  • YouCompli allows you to maintain a directory of subject matter experts who provide compliance leadership within their departments
  • The workflow tool also tracks responses and lets your colleague decline or answer the question right in the tool.

A complete audit trail for your relevance decisions

YouCompli tracks all of your relevance decisions over time, so you can see which regulations and changes applied to your organization and why (or why not!)

  • All responses to decision criteria, including usernames and date stamps, are recorded in YouCompli to become part of the official record and the compliance audit trail
  • The log also captures the reasons for rejecting the requirement or proceeding to the next phase of the workflow.
  • YouCompli clients can access the complete audit trail at any time to review previous decisions and the reason for making that decision.

Great decisions help you manage regulatory changes

Once you know about a regulatory change and you’ve used YouCompli’s decision criteria to decide that a regulation applies to you, you’re ready to respond. YouCompli helps you manage the tasks necessary for compliance. And it helps you verify that your organization has put forth best efforts to stay in compliance.

Interested in how a healthcare system used YouCompli to decide which regulatory changes apply? Check out this case study from the Western Maryland Health System.