Legal Ease: Set parameters for fraud and abuse investigation

By Elizabeth E. Hogue, Esq.

Allegations of fraud and abuse from patients and their families should be treated very seriously. Case managers who receive such complaints should bear in mind two primary goals: 1) Case managers must demonstrate adherence to their internal compliance plans; and 2) Case managers must conduct a thorough investigation so that complainants are satisfied that there is no need to go to outside regulators and investigators because all that should be done has already been done internally.

The time for case managers to wonder whether they should have a fraud and abuse corporate compliance plan has long gone. These days, the reality is that case managers working for organizations that do not have such plans in place and effectively implemented are quite simply playing with fire. Among other things, corporate compliance plans should specify what is necessary to conduct a proper and thorough investigation of reports of possible fraud and abuse.

At a minimum, corporate compliance plans should specify a time limit for completion of investigations. Under most circumstances 60 days will be sufficient.

Corporate compliance plans should also require completion of written reports within the time frame specified above. Written reports of investigations should include, at a minimum, the following information:

  • Description of how the alleged fraud and abuse was identified and the origin of the information that led to the disclosure.
  • A detailed description and chronology of the investigative steps taken including: a list of all individuals interviewed, the dates of those interviews, the subject matter of each interview, business and home addresses and telephone numbers of each witness interviewed, and the positions and titles of those in the organization both currently and during the relevant time period.
  • A description of the files, documents, and records reviewed.
  • A summary of auditing activity undertaken and a summary of the documents relied upon in support of cost impact determinations, if any.

In addition to compliance with internal compliance plans, case managers should also take practical steps to ensure that those patients and their families who make allegations are satisfied insofar as believing sufficient internal steps have been taken. In doing so, case managers are protecting their agencies — patients and their families will be less likely to be tempted to go outside provider organizations and other investigative agencies. That said, it is at this point that it is necessary to sound a strong note of caution.

The experience of many case managers has demonstrated that allegations of fraud and abuse from patients and their families may often be based in a lack of understanding of reimbursement systems and inaccurate memories of events and/or applicable standards of care. Instances in which patients and their families claim that they never received services are classic examples of the need for caution.

So while case managers must take allegations of fraud and abuse very seriously, they must also keep an open mind until investigations are complete. Case managers must remember that staff and contractors have the right to a fair, impartial investigation as outlined above before adverse action is taken against them. Perhaps the real bottom line, regardless of conclusions reached, is to satisfy patients that such allegations are treated seriously and thoroughly investigated in order to avoid additional action by patients and their families.

[Elizabeth Hogue lives and works in Burtonsville, MD. A complete list of her publications is available. Telephone (301) 421-0143 or fax request to (301) 421-1699.]