Kusserow on Compliance: Health care waste estimated at $760 – 935 billion

25 percent of health care costs are due to fraud, abuse, and wast

More waste than the Department of Defense budget

The estimated cost of waste in the U.S. health care system ranged from $760 billion to $935 billion, accounting for about one quarter of the of total health care spending of 3.82 trillion, according to a study published in Journal of the American Medical Association by researchers from the Institute of Medicine. The study was based on 6 previously identified domains of health care waste. These waste estimates are larger than the entire U.S. Department of Defense budget of $693 billion.  The researchers further projected potential savings from interventions that reduce waste of 25 percent, equaling about $191 billion to $282 billion. The six factors included in their focus of waste were: (1) failure of care delivery; (2) failure of care coordination; (3) overtreatment or low-value care; (4) pricing failure; (5) fraud and abuse; and (6) administrative complexity. The study noted that the United States spends more on health care than any other country, with costs approaching 18 percent of the gross domestic product (GDP)—more than $10 000 per individual.

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 © 2019 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: Conducting effective investigative interviews

Obtaining facts from witnesses is a critical part of any successful investigation. The witness interview process involves determining how the investigation is defined and scoped; understanding the facts and issues at play; and assessing the accountability of individuals. When conducting interviews proper preparation is important, as is remembering that even honest and disinterested witnesses can be concerned about being interviewed. Their level of cooperation often depends on their assessment of the professionalism, experience, and trustworthiness of the interviewer.

 

  1. Plan the interview. Know what information is needed from the person and proceed in a logical order to obtain it. If not organized, there will be gaps in the interview and lead to failure to ask something important.

 

  1. Take time to establish rapport. It is very important to take the first couple of minutes to establish rapport with the witness. This can be done by asking routine questions about their duties and who they report to, etc. This will help make the witness more comfortable and lead to better responses to substantive question.

 

  1. Treat those interviewed with dignity, respect, and courtesy. Don’t treat witnesses as subjects to be interrogated; and never intimidate or make threats. Witnesses are mostly those that are neutral on the matter being investigated. Their cooperation is needed and should not alienated by an investigator’s bad manners.

 

  1. Be professional. It is important to dress and act professionally at all time, including demeanor and tone. Avoid investigative jargon picked up from movies. A witness will offer much more meaningful information if they trust the interviewer’s professionalism.

 

  1. Interviews are conversations with a purpose. Successful interview conversations require maintaining eye contact and responding to what is being said, as you would do in any conversation. It also means avoiding distractions which can be caused by referring to notes, reading questions, or taking extensive notes.

 

  1. Ask short, simple questions. Avoid the long, unfocused questions typical of an inexperienced or unprepared investigator. Cover a topic by asking short, simple, and direct questions which easy for the witness to understand. It also allows for better evaluation of the answers and provides opportunity to seek clarification or elaboration.

 

  1. Open-ended questions. Use open-ended questions that permit the witness to tell what they know in their own way. Witnesses will often in their narrative address many of the questions that are on the interviewers list. Also, it may also open new lines of inquiry or issues that were not previously considered.

 

  1. Don’t accept what the person says as facts. What is being said may be colored by several factors, such as knowing the people involved, concerns about personal involvement, and simply the fog of memory. In some cases, the person may not be telling the truth, whole truth. Therefore, responses must be substantiated before they can be accepted as fact.

 

  1. Talk less, listen more. During an interview the investigator should talk about 20 percent of the time and the person being interviewed 80 percent. Therefore, questions should be brief and, whenever possible, elicit a narrative response. Avoid interrupting a witnesses’ answer unless they don’t understand the question.

 

  1. Insist on complete, responsive answers. Think about the answer to a question before asking the next one to be sure it was answered completely. Often even well-intentioned witnesses stray from what is being asked. Stay on an issue and seek clarification until fully answered.

 

  1. Ask, not answer question. Don’t lose control of the interview by answering witness questions, stay in control of the process. Many inexperience investigators will give out more information at witness interviews than they receive.

 

  1. Never offer any opinions relating to the investigation. Inexperience investigators may leak out their opinion on matters under investigation or respond to witness questions in a way that suggests their opinion. This can create a host of problems later.

 

  1. Press for details. Follow the journalistic “who, what, where, when and how”. Always get dates of key events, persons present at important meetings, what was said by whom, whether any record of the meetings, exist, and so on. Don’t be afraid to ask sensitive questions directly.

 

  1. Basis of witness knowledge. The focus needs to be on obtaining direct knowledge of facts. Therefore, witnesses need to be asked about how they became aware of their information. This is to assist in evaluating reliability of the information and to expose possible uncorroborated information from a third party.

 

  1. Recapping the interview. In concluding the interview, the investigator should recap the information with the witness to ensure accuracy and to permit additions and clarification.

 

  1. Close out of interview. In bringing the interview to a close, the witness should be asked if there was anything not covered; whether they know of others that might be able to add useful information; that there may be a need to recontact them later to clarify points; and request they contact the investigator should they think of anything.

 

  1. Promptly prepare a memo. Take only limited and abbreviated notes during the interview to avoid distractions and losing the conversation tone. However, immediately upon conclusion, a detailed set of notes should be created before memory begins to fade.

 

Richard Kusserow has over 40 years investigative experience including eleven years as HHS Inspector General and twelve years with the FBI. He authored “Conducting Internal Investigations in Health Care Organizations (ISBN 979-1-936230-60-8). His firm provides investigator training for clients.

Connect with Richard Kusserow on LinkedIn.

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Copyright © 2019 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: CMS issues final rule on affiliation disclosure requirements for the provider enrollment process

CMS issued a final rule on September 10 that sets forth requirements mandating providers and suppliers who submit an application for enrollment or revalidation for Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP) disclose current or previous (up to five years) affiliations with a provider or supplier who has uncollected debt; has been or is subject to a payment suspension under a federal health care program; has been excluded from participation from Medicare, Medicaid, or CHIP; or has had billing privileges denied or revoked. CMS said a history of bad actors trying to escape the ramifications of inappropriate or fraudulent behavior by re-entering the program in some capacity, and/or shifting their activities to another enrolled Medicare provider or supplier with which they are affiliated, provided the motivation for the rule. In addition to furnishing the disclosure information, the provider must submit: (a) an organizational diagram identifying all of the entities listed in this section and their relationships with the provider and with each other; and (b) if the provider is a skilled nursing facility, a diagram identifying the organizational structures of all of its owners.

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.

Connect with Richard Kusserow on LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2019 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: Tips for reducing the risk of cyber-attacks

Tim Murphy, former FBI deputy director stated that he rated cyber-attacks as the number one threat facing the country. Threats come from both inside organizations and outside. Insider threats may involve current or former employees or vendors. They may be motivated to steal intellectual property, funds, or simply to cause problems. The danger of employee-related crimes is that they have inside information concerning how things work and have access to data and computer systems. One of the best ways to combat attacks by insiders is to maintain a continuous monitoring of an individual’s public, online activity as well as the internal, network activity to detect changes in behavior. Often, cyber-attackers have patterns of detectable behavior and network activity which can provide indicators of risk, assist in early detection. It is important to know at any given time what are employees doing on the network; who are they dealing with; if they are leaving with data and files; and whether they are violating policy by sharing sensitive information with outsiders. Employee engagement in careless practice is far more common than engagement in malicious practice. Oftentimes carelessness takes the form of simple negligence by clicking on a link in a random email. However, there are ways to mitigate the threats, which can reduce the risk of cyber-attacks by as much as 80 percent, including:

  1. Provide ongoing employee and contractor training on what to do and not to do
  2. Conduct a risk assessment to understand threats presented by an insider
  3. Continuously monitor employee and vendor networks
  4. Update and upgrade software
  5. Use encryption to guard against information being read by unauthorized parties
  6. Establish multi-factor authentication

For more information health care provider cyber-security, contact Dr. Cornelia Dorfschmid at cdorfschmid@strategicm.com or at (703) 535-1419.

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.

Connect with Richard Kusserow on LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2019 Strategic Management Services, LLC. Published with permission.