Articles on Compliance Strategies

Featured Health Business Daily Story Aug. 7, 2009

In-house Compliance Hotlines Can Provide a Wide Range of Assistance to Employees 

Reprinted from REPORT ON MEDICARE COMPLIANCE, the nation's leading source of news and strategic information on false claims, overpayments, compliance programs, billing errors and other Medicare compliance issues.

By Nina Youngstrom, Managing Editor,
(nyoungstrom@aispub.com)

When a retired physician walked into Carilion Clinic in Roanoke, Va., to order an X-ray for his spouse, an employee immediately called the compliance hotline to ask whether it was appropriate to provide the service. After all, the physician was not affiliated with the clinic and the patient was a relative.

The clinic employee had good instincts. Physician orders cannot be honored unless there is “a bona fide relationship” between the physician and the clinic and between the physician and the patient, says Jodie Caplan, director of corporate compliance at the nonprofit health system, which includes eight hospitals, 80 physician practices and 450 employed physicians. In this case, the physician was retired and therefore had no relationship with the clinic. He also had no professional relationship with his wife.

This is one example of the kinds of questions tackled by Carilion’s compliance hotline. Rather than outsourcing to a hotline vendor — a common practice in the health care industry — Carilion’s compliance department takes its own calls and keeps the hotline (called “ComplyLine”) open for all types of employee inquiries.

“Employees call if they have a question of any kind. We help them with regulatory research so we can be sure we’re in compliance with all laws and regulations,” Caplan says. If employees are concerned they’re not doing something correctly or need regulatory clarification for a new service line, compliance will track down the answer. Or perhaps employees picked up information at a conference but need it amplified. “They will call, and we fill in the picture for them,” she says.

Caplan, a CPA and certified internal auditor, has compliance liaisons in certain clinical departments (e.g., lab, health information management), and she brainstorms with them to get answers to the many questions that come into the compliance hotline. “We get a lot of calls about billing practices” — whether to use one CPT code or another, for example, or which modifier is appropriate for a particular procedure, or how a change in the regulations affects documentation and billing requirements. Though potential violations are also reported to the hotline, the majority of calls come from employees seeking information, feedback and problem-solving. “We’re not here to be punitive,” she says.

This approach is meant to reinforce Carilion’s efforts to avert compliance violations, Caplan says. “Our goal is to do it right the first time,” she says. “If employees need additional regulatory information, we are happy to do the legwork.” Apparently, the strategy is working because “over the past few years, we have gotten more proactive calls,” Caplan says. “Employees know they can call and feel safe calling us. We want to get it right from the beginning. And the myriad regulations are confusing.”

For example, a patient presented at a Carilion clinic with an order for services written by a physician who was excluded from Medicare. A clinic employee who recognized the physician’s name called the hotline. The employee, who remembered the physician had been excluded, wanted to confirm the clinic could not accept the order, Caplan says. Of course, the answer was “no dice.” (The reason the clinic employee was familiar with the physician was that he had previously tried to order services there.)

Confidentiality Is Popular Call Topic

Mark Pastin, president of the Council of Ethical Organizations in Alexandria, Va., is familiar with Carilion’s hotline and says employees have come to rely on it. That includes the physicians who are increasingly employed by the health system in a Cleveland Clinic-like model. These employed physicians are instructed to “plug into Jodie’s advisory system from day one, and that’s driven down the risk,” Pastin says. “It’s a preventive use of the hotline.”

The Carilion hotline is “totally in-house,” she says. Calls are generally answered on a monthly rotating basis by the four “compliance consultants” who work in the department, which has a total of seven full-time and two part-time employees, including compliance auditors. However, if a call is directed to a specific compliance auditor, he or she will take it. “We decided to do it in-house because we thought we would learn more,” she says. “We could talk to employees directly and [often] answer questions right on the spot.”

Caplan says she has noticed an uptick in the number of hotline inquiries and/or reports about employee confidentiality. For example, one department has a MySpace page and uses it to share information about staff meetings, research it is conducting, department procedures and other information that is not patient-related. It turns out that younger people are more responsive to MySpace and Facebook than to e-mail, according to Caplan. That was all fine, she says, as long as it doesn’t show patient information or other confidential data. However, another department e-mailed its department newsletter to employees, complete with their home phone numbers, home addresses and birthdays. “People are so used to having all this information out there, they don’t necessarily realize some people don’t like it,” she says. Caplan told the department manager to let employees opt out of the distribution of personal information.

Hotline callers are allowed to report issues anonymously, and there are two types of anonymous: (1) “pseudoanonymous,” where employees reveal their identity to the compliance staffer, but “we will protect their identity,” Caplan says; and (2) “superanonymous,” under which employees can refuse to reveal their identities when they call to ask a question or report a potential violation. “It’s frustrating when we need to ask follow-up questions or give feedback,” but there’s no way to reach this kind of caller, she says. Compliance is left hanging with partial information about something that may be important.

The compliance line has also become a sounding board for employees. “We get a lot of calls about interpersonal relationships,” Caplan says. “A lot of times we just listen.” For example, if the employee is angry about perceived unfair treatment by a manager, the compliance staffer will be empathic, encourage them to talk to their supervisor and ultimately refer them to human resources. “A lot of times people have just had a rough day dealing with patients. People can get frustrated and stressed,” she says.

Caplan notes that questions and complaints may come in through fax, snail mail, in-person contact and e-mail. The phone is not the only vehicle for communicating with compliance. The bottom line, though, is “hotlines give employees a way to ask questions where they feel they are not going to look foolish,” she says. “People may not want to talk to supervisors or other employees. We are a safe avenue.”

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