Act cautiously if you see a compliance problem

Take your information through proper channels

If case managers see a problem in their hospital, they have a responsibility to report it, asserts Alice Gosfield, JD, of Alice G. Gosfield and Associates, a Philadelphia law firm.

"Most institutions should have a compliance program. In addition, virtually every hospital has a quality improvement process. Case managers can report through that process," Gosfield says.

Case managers should be familiar with what constitutes a compliance problem and the steps they need to take to report an incident of noncompliance, overutilization, or underutilization.

The steps you should take will vary from facility to facility, but it is advisable for all hospitals to have a compliance program and a chain of command. Some areas where problems might occur are inappropriate care, under- and overutilization, kickbacks and rebates, and honoring patient choice of providers.

Look for patterns

Look for a pattern of conduct, not just isolated incidents, suggests Elizabeth Hogue, a Burtonsville, MD, attorney in private practice specializing in health care.

Don’t be tempted to investigate by yourself. Instead, take your information up the line to the appropriate people in the hospital. "If a case manager thinks he or she sees a pattern of inappropriate care or underutilization, he or she should go ahead and make the report to his or her supervisor and let someone else investigate. That’s what the compliance officer is required to do," she says.

Start by reporting your suspicions to the case management director, says Beverly Cunningham, RN, MS, director of case management at Medical City Dallas Hospital.

"If staff case managers see things that are going on they think may not be right, it is their responsibility to report it to me, and my responsibility as director is to study and see if it is happening or is an anecdotal incident, then to report it through the chain of command in the hospital," Cunningham says.

The organization is more likely to pay attention to problems if they are pointed out by the case management department as a whole, rather than by just one person, she adds.

When you do report a problem, make sure you approach the issue in a professional way and in a spirit of cooperation. Don’t sound like you have an ax to grind with whomever you are reporting, Hogue says. Emphasize that you know you have an obligation to point out the problem.

Most compliance plans promise anonymity when someone makes a complaint, but it’s not always possible to maintain confidentiality while you are investigating and taking action, Hogue adds.

"Part of any good compliance plan is protection of confidentiality. A good compliance plan should indicate that retaliation is not allowed," she explains.

If you report fraud and abuse and nothing happens, you have an obligation to go outside of the facility, Hogue says.

She suggests calling the federal Office of the Inspector General. "There again, there should be no ax to grind. Case managers should report what they see and say that they are satisfying their obligations to bring it to the attention of the authorities," she adds.