Articles on Compliance Strategies

Featured Health Business Daily Story, April 8, 2010

Workload, Responsibility of Compliance Departments Grow With Heightened Government Enforcement 

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@aishealth.com)

The growth in government audits and enforcement is changing the nature of the compliance program at MedStar Health, which includes nine hospitals and other entities in Maryland and Washington, D.C. In addition to expanding the volume and types of compliance audits performed by the compliance team at the nonprofit health system, the highly charged environment has raised the profile of compliance and intensified demand for its expertise on everything from audits to writing policies.

With the growth in compliance workloads, the compliance department has developed a system for tracking and analyzing requests for its assistance.

“Increasing regulatory enforcement has affected how the compliance program operates,” says attorney Susan Walberg, MedStar’s corporate compliance officer. “Back in the day, you’d look at the OIG Work Plan, do a risk assessment and then do your own work plan and go forward. Now we look at the OIG Work Plan as just one thing.”

Compliance Is Now on ‘Speed Dial’

There is much more activity to anticipate and/or respond to, including requests from the Comprehensive Error Rate Testing (CERT) contractor; reviews by recovery audit contractors (RACs), zone program integrity contractors (ZPICs) and Medicaid integrity contractors (MICs); and medical reviews by Medicare administrative contractors (MACs). “We are doing a lot more data analysis, a lot more tracking and trending, and have broadened the scope as we try to capture what is going on in real time,” she says.

In addition to generating significantly more responsibility for the compliance program, RACs, MICs and other auditors and investigators are a publicity juggernaut that put the compliance program on MedStar’s internal map. “There is heightened awareness across the organization,” Walberg says. MedStar executives will read an article about a Stark-related False Clams Act settlement, and wonder whether the compliance office should conduct a review at their hospitals for the same kind of potential liability. “People knew we existed but we weren’t on speed dial,” she says about the compliance program. That’s all changed. “We are spread much thinner because we are doing so much more.”

For example, MedStar’s compliance program used to do mostly planned, routine audits and coding reviews, with an emphasis on providers’ documentation and coding, Walberg says. Now the compliance team engages far more often in unplanned reviews in response to a MAC audit or a CERT request, or a concern raised by a MedStar hospital or other business unit. For example, if the MAC audits one MedStar hospital’s use of a particular code, that “gives us a lot of impetus internally to do our own review” of the other MedStar hospitals’ use of that code, she says. Training and education are part of the package to prevent problems at the other hospitals. “We tell them where to go look, give them parameters and a checklist and if there is a problem, we can try to get ahead of it,” Walberg says.

The compliance department has also been put in charge of managing RAC response for the system. The department is overseen by a RAC steering committee comprised of senior leaders (e.g., CFO, chief medical officer). However, each MedStar hospital has its own RAC team to pull and review medical records, with different people developing and managing different pieces (e.g., the appeals process). “Our role is to be overseer and coordinator at the corporate level,” Walberg says. “It’s more a herding process.”

All of these reviews “trigger a ton of work” compared to the standard audits that were performed before the federal government flooded hospitals with auditors.

And that’s just the compliance department’s response to outside demands from the audit and enforcement machinery. Compliance also receives far more “service requests” from MedStar entities and corporate leadership, Walberg says. MedStar staff may request audits, new policies or advice, among other things.

“People in other functional areas, such as finance, quality and risk management, now understand our role better and see more opportunities for collaboration,” Walberg says. “They are much more engaged and interactive with us and come to us much more frequently. As things heat up, compliance has become more visible at the corporate level and out in the field. It’s a very interesting shift,” she adds.

This is a big change from the days when compliance was generally perceived as “the ugly stepchild,” Walberg says. “We are getting involved in corporate-level projects that historically we were not involved in, like implementing an enhanced conflict-of-interest policy.”

In fact, the service requests are so abundant that the compliance department spent more than 800 hours fulfilling them in 2009, Walberg says. Requests are all over the map. They range from “audit this issue because we may have a problem” to “help us write a policy” to “we need a template for physicians to bill a certain service” to “come investigate this potential wrongdoing.” Walberg says it can be anything within the scope of compliance, but is beyond the scheduled internal compliance work plan topics. The compliance team has also been called to consult in areas beyond its expertise (e.g., durable medical equipment and pharmacy).

To document the service requests from intake through completion, Walberg and her staff created a service request checklist, including a spreadsheet to track the number of projects completed monthly per MedStar entity.

Service requests are a good way to show we are not just doing the reviews and projects on our work plan,” she says. The tracking form and spreadsheet are valuable to document everything that’s being accomplished because sometimes compliance will have to delay a project or find an alternate method for doing it (e.g., telling the department that compliance lacks the time to craft the policy, but is happy to review it). “Part of the service-request process is designed to show we have limits, and evaluate whether we can do it and negotiate with the internal client,” Walberg says. “Maybe we’ll say it won’t be before next month.”

The service request checklist also helps compliance verify that areas outside the department’s normal scope will still get addressed appropriately, Walberg says. For example, “our department isn’t typically involved in Joint Commission or licensure problems or conditions of participation,” but there might be overlap with more traditional compliance areas (e.g., billing). “Everyone comes to the table with their own lens, so we try to come up with possibly related things you might miss and drill it down,” she notes. If the issue implicates something outside the scope of the compliance team’s expertise, she coordinates with risk management or the legal department, for example.

“When we go through the checklist, we work with the people who have the greatest expertise rather than write a policy that addresses regulatory requirements but does not meet Joint Commission standards, for example. We want to make sure any work product coming out of our office will meet the customers’ needs and all the applicable standards,” Walberg says.

With the compliance focus increasing at MedStar entities and at the corporate level, Walberg expects it to attract more resources. That will be increasingly essential as compliance increases its interaction and collaboration with other departments, such as quality, risk management, legal and internal audit. “The movement is for compliance to operate cross-functionally,” Walberg says. “It has to have a broad scope.”

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