Kusserow on Compliance: Use of temporary compliance and privacy officers

By now every health care provider is aware of the need for an effective compliance program under direction and management by a compliance officer, as well as a privacy officer to ensure HIPAA compliance. It is common these days for organizations to have compliance and privacy officer vacancies as result of a retirement, termination, someone changing jobs, or any other of a dozen reasons. Sometimes it may have been triggered by an audit or investigation by the HHS Office of Inspector General (OIG), Department of Justice (DOJ), HHS Office for Civil Rights (OCR), or a CMS contractor. In other cases, a board or new executive leadership may wish to use proven experts to promote and/or elevate the programs to a higher level. Regardless of the reason, the departure of a long time incumbent creates a vacuum that needs to be filled quickly for day to day management and responding to emerging issues to avoid serious problems and potential liability. The worst time to have a vacancy is when entering the holiday season and the end of the calendar year. For a variety of reasons, it is a time when many problems and issues arise needing prompt attention.

Steve Forman, CPA, is an expert on the subject with over 25 years as a healthcare compliance officer and consultant, including serving on multiple occasions as an interim compliance officer.  He notes that the sudden departure of a compliance or privacy officer makes the problem of finding someone properly qualified in a timely manner a serious issue. Confronted with a rapidly evolving regulatory and enforcement environment, health care organizations cannot afford to take the chance on having a gap in these positions. When such a gap occurs, engaging an expert on a short term engagement can hold the reigns of the program together, while a permanent replacement is found. Using a properly qualified outside expert presents a lot of advantages.  They can bring the experience of having served in other organizations and dealing with many of the same issues already addressed by prior jobs. It is also important that they have not been invested in any prior decisions, nor have they been aligned with any parties in the organization.  Most importantly, they bring “fresh eyes” to the program. They can provide objective assessment on the state of the compliance program, offer suggestions, and give guidance for improvements.

Suzanne Castaldo, JD, who specializes in providing interim compliance and privacy officers for healthcare clients, noted that clients to whom she has provided interim officers, usually take three to five months to find that hire a permanent replacement with necessary experience and qualifications. When they seek temporary officers, she provides experienced professionals with previous experience as a compliance or HIPAA privacy officer. Over the last 25 years, her firm has worked with over 3,000 health care organizations in building, evaluating, managing, and building compliance program that provide a unique level of knowledge and expertise. Using the right professional with a lot experience and technical skills can make significant improvements for any compliance program in a relatively short order.

Camella Boateng is another highly experience compliance professional who has served as an interim compliance and privacy officer for several organizations. She has found that organizations have a tendency to understate the needs in the vacant position.  In every case where she has been called upon to fill a vacancy, she has encountered serious problems that were hidden or not recognized by the organization. In fact, these unattended problems often were the reason for the departure of the incumbent. As such, those seeking temporary compliance or privacy officers require more than someone just to monitor and manage day to day work. They should look to added benefits and services an outside expert can bring, including providing an independent assessment of the status of the compliance program and high-risk areas warranting attention. Before leaving the engagement they can develop a “road map” for the incoming compliance officer to follow. All this can result in developing comprehensive briefings for management and board on the state of the program

Lisa Shuman is a consultant that has served as an interim privacy officer for organizations. She observed that the work flow is different from that of a compliance officer. She has found from her experience that most engagements can be part time with much of the work done remotely.  The first month usually involves focusing on reviewing adequacy of existing policies, procedures, controls, and training content. After that, the work focuses primarily on privacy violation investigations that arise, however, it is important that the interim privacy officer be available at any time to deal with issues



Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2017 Strategic Management Services, LLC. Published with permission.