What do compliance officers do?

How facilities like yours are getting started

Helix Health in Baltimore had begun implementing several compliance processes when the Office of the Inspector General issued its Compliance Program Guidance for Hospitals in February. Helix Health was looking at issues prospectively as well as concurrently.

"We drafted our corporate compliance plan in spring of 1997," says Charlotte Kohler, RN, vice president and reimbursement compliance officer (CO) for the five-hospital nonprofit integrated delivery system. "It was relatively easy since we don't bill clinic time on a professional fee basis for our teaching physicians - that pretty much eliminated PATH concerns - and we were able to concentrate on other things." But Kohler's team had to work not only on one hospital's plan: They are creating a program for the entire delivery system, and five different hospitals have to agree.

Kohler previously served as vice president of a consulting company. She says that background stands her in good stead because there's a lot of consulting involved in acting as a CO. "For sure, the goal of reimbursement compliance is to make sure you're documenting with the right provider numbers and codes. But more so, it means you're meeting the right conditions of Medicare participation and that cost reporting is accurate. Reimbursement isn't always logical."

Kohler says model compliance plans can't be created with cookie cutters: "Going from writing the plan to its implementation is like saying, 'OK, we're 90% done, but we've got 90% to go.'"

What impact will all this have on the Joint Commission on Accreditation of Healthcare Organizations? "Compliance is tied to quality," she says. "My hunch is that this year, JCAHO surveyors are going to ask, `What are you doing about compliance?' to get a feel that something is happening. I think we're another year or so away from them actually considering compliance as a problem for recertification. They're feeling their way too, and to hold hospitals accountable today for something that we've just received guidance on - I think the Joint Commission is more reasonable than that."

Mary Beth Sorenson, director of utilization review and quality assurance at Buena Vista County Hospital in Storm Lake, IA, and the facilitator for the compliance team there, says her hospital's first priority was to educate itself because all this was new for them, as it is for most facilities.

"We read articles, viewed videos, and attended workshops," says Sorenson. "Our business office representative knew more than the rest of us in the beginning, so she presented an inservice to get us started. Home care had already started working on compliance since their model plan had been issued, and they shared their experience with us."

Last summer, Buena Vista formed a compliance team composed of about 10 members of the departments affected most by compliance requirements - home care, labs, X-ray, the business office, data processing, medical records, nursing, and pharmacy. "We knew we had to address the seven elements," Sorenson says, "so we split into subgroups and assigned roughly one element to each subgroup. We then put together an education program to take to the board, the medical staff, and department managers."

Buena Vista doesn't yet have a written plan, but they're close to it now that the OIG has issued its guidance. "We do internal audits once a month, and we've identified some projects that need attention. After reviewing records, we send reports with recommendations to the appropriate departments. We set up a plan for them and encourage each to do a more thorough and timely audit of their records."

How much time has all this taken so far? "It's hard to calculate," Sorenson answered, "but our 10-person team met twice a month for an hour, and the subgroups met in addition to that. We spent a lot of time doing several mandatory one-hour education programs. We also spent money and time on workshops and periodicals that we might not have subscribed to otherwise."

Nancy E. Richman, PhD, quality manager at Kewanee (IL) Hospital, says her facility has not put together an official compliance program yet. A team has begun educating executives, and the CEO, CFO, director of outpatient clinics, and quality managers have attended conferences to learn more. She says that a compliance initiative must come from the top of the organization and have board and CEO involvement. "A compliance plan cannot just be on paper," Richman warns. "It must be committed to from the top down, and an ideal beginning is to educate people at the top." Kewanee, a freestanding 75-bed rural facility, has not yet appointed a CO but probably will within six months.