HCA compliance chief: Keys to successful compliance
HCA compliance chief: Keys to successful compliance
One of the greatest challenges of compliance officers is keeping the ethics and compliance message fresh, says Alan Yuspeh, who oversees ethics and compliance efforts at HCA’s 200 hospitals and 85 ambulatory surgery centers. However, Yuspeh argues this can be achieved by changing communication tools, adding new training materials, and addressing new issues.
He says that’s why HCA’s (formerly Columbia/HCA) recent revision to its code of conduct makes relatively minor substantive changes but alters the look and feel of the document completely compared to the first edition that Yuspeh prepared in late 1997. For example, the revised code includes a series of quotes from well-known individuals, which are intended to reinforce the mission and values statement for HCA hospitals.
Yuspeh adds that HCA views its overall effort as a "comprehensive compliance program" rather than just a "Medicare compliance program." Coding and billing pose some of the toughest challenges, he says. But getting them right won’t excuse problems that could arise in other areas of legal compliance.
Here are 10 key requirements that Yuspeh says hospitals should focus on to ensure effective compliance:
I. Formulate an easy-to-understand code of conduct. According to Yuspeh, hospitals are making a mistake if they fail to engage large numbers of their employees in the formulation of a code of conduct. When HCA created its original code and later revised it, the draft was distributed to various functional experts and management groups for comment and then placed on the company intranet so that staff at every level could comment.
Yuspeh explains that a legal compliance document, which had been prepared before he joined the company in October 1997, was a fair summary of some legal requirements but was difficult to understand. It was essentially a compilation of laws and regulations. The code of conduct now used at HCA reads at about a 10th-grade level.
II. Develop policies, procedures, and compliance aids for complex areas. According to Yuspeh, the second key requirement is detailed policies and procedures for technical areas that can’t be covered in the code of conduct, including comprehensive instructions in areas such as physician relationships, laboratory billing, and cost reports.
HCA’s inpatient coding manual is more than 400 pages, and its outpatient coding manual is about 200 pages. Yuspeh says both are intended to set a basic direction and establish internal standards. In addition, a set of overall coding policies includes an expectation that all inpatient coders have at least 30 hours of continuing education each year. Similarly, the cost report policies deal with the method of interaction between the department that prepares cost reports and the individual hospitals with financial management responsibilities.
III. Develop broad-based training. Yuspeh says a third critical requirement is some form of effective broad-based training. In fact, he says it should be standard practice to put core material in front of employees at least once a year. HCA’s videotapes are predominantly case studies on issues such as confidentiality that are designed to focus attention and teach people how to reach decisions.
Yuspeh reports that HCA is also expanding its use of the intranet to deliver training modules in specific areas. He points to a refresher course HCA is developing for hospital managers in the area of antitrust that will be placed on the intranet and delivered with an automated tracking mechanism in order to ensure that certain individuals receive the training. Numerous other additional modules will be developed or purchased for Intranet presentation.
IV. Utilize other communications tools on a regular basis. HCA also has employed other communication mechanisms, such as posters, that are designed to consistently reinforce compliance messages. There are also regular conference calls with various managers and e-mails with tailored messages. These are analogous to the OIG’s special fraud alerts. "These are used not necessarily because we’ve found a problem but more where we see an area of complexity," explains Yuspeh.
V. Establish internal reporting mechanisms that reflect proven elements. In order to establish intake coverage 24 hours a day, 365 days a year, Yuspeh says the only practical option is the use of an outside agency. But to make that effective, he says hospitals must provide the agency with detailed scripts explaining how to deal with people who might report a problem.
Yuspeh says that HCA has a team of people who triage cases and perform a case management function. Most matters are sent back to the hospital for investigation. If, however, a matter received by the ethics line were to involve senior management of the hospital, another means of investigation would be used. Eventually, a report is generated that determines whether or not the call was substantiated.
VI. Ensure effective employee discipline. One often overlooked area that Yuspeh highlights is employee discipline. He argues that employees will doubt the seriousness of compliance programs if questionable activity gets only a slap on the wrist. "That doesn’t mean that every time you find an error in performance that employment is terminated," he adds. When the cause of the error was negligence and not intentional, something short of termination may suffice.
VII. Carefully plan and execute extensive internal audit and monitoring programs. According to Yuspeh, the HCA information systems staff is increasingly developing data management tools that permit HCA to perform real-time monitoring in areas such as DRG coding. To the extent that hospitals can move toward automated monitoring, they should, Yuspeh argues.
However, Yuspeh notes that monitoring may only identify an area of concern but not confirm any type of error. For example, coding for DRG 79 and 89 might not be consistent with national averages. "In and of itself, that does not mean that you are coding incorrectly," he warns. "It just means that for some reason there is a differential from that national norm." Nevertheless, the monitoring tool points you toward where there may be issues of coding concern, and then you can devote further resources to investigate those possible problems.
VIII. Establish an effective organizational approach. According to Yuspeh, there is no single appropriate way to organize staff responsible for compliance. However, an effective organizational approach should always include an oversight committee, as well as some direction for the board of directors or trustees.
That structure should always include the concept of "responsible executives," he says, which basically means that responsibility for compliance should lie with those who are true functional experts. As an example, he says the head of health information management at HCA is responsible for coding compliance.
IX. Secure senior management support and involvement. Yuspeh says it goes without saying that hospital CEOs must understand that compliance reflects on their own stewardship. "If the CEO regards compliance as window dressing, that feeling will filter down through the organization and it will be difficult to get people to give it the necessary energy," he cautions.
X. Evaluate and assess failures, and correct problems. Finally, when problems are uncovered, Yuspeh says hospitals sometimes fail to do the two things required — return overpayments and fix the underlying problem. He says that he has heard of cases where an institution may only fix a problem for the future, and then notes: "I am sure that the government doesn’t regard that as sufficient." Alternatively, hospitals may repay the overpayment but fail to uncover the underlying problem. For example, there may be a chargemaster error that generated similar mischarges that must be corrected. "You obviously need to evaluate those problems and correct them both in terms of past mistakes and future correctness," he concludes.
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