How to screen applicants for fraud, abuse violations

Put policy in place, then apply evenhandedly

By G. Michael Barton, SPHR

Vice President of Human Resources

Regional Medical Center

Madisonville, KY

To validate the effectiveness of a corporate compliance program, it is critical to know if the prospective applicant has a history of questionable performance or inappropriate conduct. This can best be accomplished by utilizing the services of an objective data retrieval system to determine if the applicant has any current Medicaid, Medicare, or licensure sanctions. Most of these systems are easy to access via desktop computer programs, which are easy to install and use.

Key provisions of the U.S. Sentencing Commis sion Guidelines require organizations to monitor and audit illegal activities:

"The organization must have used due care not to delegate substantial discretionary authority to individuals whom the organization knew, or should have known through the exercise of due diligence, had a propensity to engage in illegal activities."

The commission goes on to state specifically that organizations must utilize monitoring and auditing systems to detect criminal conduct:

"The organization must have taken reasonable steps to achieve compliance with its standards, e.g., by utilizing monitoring and auditing systems reasonably designed to detect criminal conduct by its employees and other agents and by having in place and publicizing a reporting system whereby employees and other agents could report criminal conduct by others within the organization without fear of retribution."

The above provision also points to the need for an objective system, such as an employee hotline, to be provided to report workplace violations. It also directs employers to protect the organization from potential problems before they occur. This is the basis for screening applicants for fraud and abuse.

The organization must establish employee standards, which generally are delineated in the code of conduct. An important standard would be:

"We shall employ individuals who perform their work duties in accordance with legal requirements and accepted professional standards."

To ensure conformance with the above standard, it is imperative to screen job applicants thoroughly. In the past, most organizations relied heavily on employment interviews or personal profiles to determine an applicant's potential honesty quotient. In the era of corporate compliance, health care organizations must take a much more aggressive approach to screening applicants. Building an effective screening program involves taking a fresh look at existing app roaches and investigating the applicant's work background completely. This is a new, and in some cases distasteful, departure from previous employment methods. The organization must be careful to construct a screening program that can be communicated and meet the needs of the organization, including satisfying compliance standards.

These are the steps necessary for screening applicants effectively:

· Step 1: Implement a policy on fraud and abuse screening.

This policy should detail the screening process. It should be specific about what the organization's official stance will be if current sanctions exist:

"Any applicant with current Medicaid, Medicare, or licensure sanctions will not be eligible for employment with XYZ Medical Center."

The policy should be discussed with the applicant and widely available to all employees. It should be in the employee handbook and posted on the bulletin board outside the human resources department along with current job openings. (See sample policy on fraud and abuse screening, p. 58.)

· Step 2: Obtain written authorization from the applicant.

Written authorization to complete the fraud and abuse screening can be secured when the employment application is completed. In fact, a statement of authorization can be added to the back of the application.

"I authorize a background check to be completed on all aspects of my previous employment history. I understand this includes a review of my work record by an independent source(s) to determine if there are current professional, licensure, or criminal sanctions. I hereby grant permission to complete such a review and will not hold any former employers or data sources liable for issuing or obtaining this information."

That authorization may seem exhaustive, but it is necessary to describe the screening process in detail. As an extra precaution, someone in human resources should discuss the authorization and policy on fraud and abuse screening with the applicant.

· Step 3: Conduct a screening search.

The organization should select a database service that can provide information on sanctioned health care personnel, institutions, and vendors. Most of these services provide software that can be accessed easily and managed internally. In selecting a database service, keep these factors in mind:

1. Select a broad database. The database should report sanctions from a number of sources. Some examples include disciplinary actions or sanctions by the Office of the Inspector General, Health Care Financing Administration, Drug Enforcement Agency, state Medicaid fraud control units, state health departments, and licensing boards.

2. Make sure a comprehensive list of clinical providers is represented. Some examples include physicians, nurses, pharmacists, social workers, psychologists, lab technicians, imaging and radiology consultants, and chiropractors. Institutional providers such as hospitals, nursing homes, hospices, rehabilitation centers, and psychiatric facilities also should be available.

3. Select a database that is easy to install and train others on its use. The database should be capable of being installed on an existing desktop computer. Avoid any database systems that require the organization to purchase special hardware or additional programming from the vendor. Most of the available database systems can be installed easily on a computer with the Windows operating system. Access to the data generally is via modem using the organization's name. Training usually is provided on site by the vendor when necessary. The vendor should provide an easily accessible troubleshooting service.

4. Determine whether any future service expansions or database enhancements will be communicated and offered at a nominal charge. Most of these services will continue to expand as screening becomes ingrained in the health care culture. It is important that enhancements be provided at little or no additional cost. Remember, this process adds to the cost of recruiting and employing applicants.

5. Verify that the database system can ensure accuracy of data before acting on it.

There are a number of nurses named Sarah Jones, for example, so it is important to ensure the one being screened is the applicant. The database should have several data checkpoints (such as the Social Security number, driver's license number, birth date, or hire date) that can ensure the credibility of the data.

6. See how widely the database is used. In short, how many other health care organizations are using the system? That indicates how other health care organizations view the credibility of the system. It also may indicate how aggressive the vendor is in providing new services or maintaining the existing system.

After a database has been selected, it is imperative to restrict access to the system to as few individuals as possible. This generally means one individual will have direct responsibility for most searches, perhaps with another individual cross-trained to use the system. It is important to restrict the system to maintain confidentiality and prevent tampering with the database. More individuals having access increases the likelihood of system downtime.

· Step 4: Verify the data with licensing boards.

Licensure sanctions should be verified with the appropriate licensing board. This makes the credentialing process more palatable when reviewed by an outside source such as HCFA or the Office of the Inspector General. It also is a good idea to verify licensing data with the licensing board in case the database service does not have any record of current licensure sanctions against the applicant.

· Step 5: Conduct a criminal background check.

This is usually a separate screening from the database search. A criminal background check can provide local, regional, and even state information about the applicant that generally is not available from any other source except court and police records.

· Step 6: Review interviewing techniques.

The job interview should include questions to determine the applicant's commitment to corporate compliance. The following are some sample questions:

- "How comfortable would you be in reporting a compliance violation?"

- "Do you understand the importance of keeping patient information confidential?"

- "How comfortable are you in telling your supervisor that you made a mistake?"

- "When is it appropriate to take a gift from a patient, family member, or vendor?"

- "What would you do if you witnessed unsafe patient care being provided by a co-worker, physician, or nurse?"

- "What type of information should be shared with a competing medical facility?"

- "What should you do if your supervisor asks you to do something that is unsafe, unethical, or illegal?"

· Step 7: Refine the employment process.

This also is the time to review other aspects of the employment process. For example, how can the reference-checking process be changed to provide more meaningful data? Many employers have all but given up on receiving useful feedback from other organizations. The best approach may be to obtain data that can verify dates of employment and the type of work the applicant performed for the organization. Those data could be helpful if a discrepancy on the application exists or the database yields a performance sanction during the dates of employment.

Other aspects of the employment process to consider include the pre-placement physi -cal screening, which should be conclusive enough to determine if the applicant can perform the job physically. Note that this is a pre-placement screening, not a pre-employment physical. The physical screening should not be conducted until the job offer is made. This protects the organization against claims of discrimination from the applicant if a physical impair - ment exists.

· Step 8: Emphasize corporate compliance in orientation.

The importance of maintaining an environment free from fraud and abuse should be discussed at length during each employee's orientation. Comprehensive training on the organization's compliance program should be provided to all new employees.

Watch for opportunities to improve

The long-term effectiveness of the screening program is dependent on all involved players, including interviewers, data analysts, supervisors, trainers, vendors, and applicants. Those individuals should be asked how the program can be improved or made easier to use.

That input, along with the needs of the organization, can be used to keep the program fresh and vital. Fraud and abuse screening is more than the next component of corporate compliance that must be in place to satisfy legal and regulatory requirements. It also is essential to meeting other customer expectations for quality health care services provided by a qualified and compassionate staff.