Kusserow on Compliance: Measuring compliance program effectiveness using validated and reliable knowledge surveys

The OIG from its earliest compliance guidance documents has recommended the use of “[q]uestionnaires developed to solicit impressions of a broad cross section” of the workforce. Evaluating effectiveness through the use of questionnaires or surveys can measure the compliance culture and/or knowledge of the organization. Such surveying of employees are one of the two methods suggested for evidencing compliance program effectiveness by the HHS OIG in its Compliance Guidance for Hospitals and Supplemental Guidance for Hospitals. The agency noted that “as part of the review process, the compliance officer or reviewers should consider techniques such as…using questionnaires developed to solicit impressions of a broad cross-section of the hospital’s employees and staff.” It further reinforced this by stating it “recommends that organizations should evaluate all elements of a compliance program through “employee surveys.”   The OIG also stated that “[t]he existence of benchmarks that demonstrate implementation and achievements are essential to any effective compliance program.”

Steve Forman, CPA, has 35 years experience as a compliance officer and health care compliance consultant. He has used compliance surveys for over 20 years to measure program effectiveness and has found them to be an extremely inexpensive method to provide great insight into the compliance program’s effectiveness. However, he notes that it is critical that the survey being used has been professional developed, as well as validated and tested over many organizations. In addition, it is necessary for employees to have confidence in the fact that their scoring will not be attached to them. This means that the survey needs to be independently administered that ensures the confidentiality and anonymity of participants. It is very useful for organizations gaining feedback from employees by querying them on their knowledge of the compliance program elements drawn from their general observations and personal experiences. Results from a survey can evidence employees’ knowledge; awareness and understanding of the compliance program are used to identify positives and weaknesses of the compliance program.  It can provide empirical evidence of the advancement of program knowledge, understanding, and effectiveness.

Jillian Bower has been overseeing administration of knowledge surveys with health care organizations for more than 6 years at the Compliance Resource Center (CRC). The CRC has been employing compliance surveys since 1993.  The most popular survey for Compliance Officers is the Compliance Knowledge Survey© that tests the knowledge of the compliance program’s structure and operations, including the understanding of the role of the Compliance Officer, how the hotline functions, etc. It specifically focuses on the OIG’s seven elements of an effective compliance program and uses simple closed-ended questions with “Yes and “No” answers choices that requires no more than 20 to 30 minutes to complete. Reports from this survey runs 30 pages or more that includes tips for addressing weaknesses and benchmarks results against the universe of those who have used the same survey three ways; (a) overall results, (b) by topic, and (c) individual questions. The biggest benefit of the Compliance Knowledge Survey© is being able to benchmark the results of an organization with the universe of those that have used the same survey by overall results, topical areas, and by question.

Carrie Kusserow with 15 years experience as a compliance officer and consultant has found that reports of survey results can evidence both strengths in the compliance program, as well as areas opportunities for improvements in the Compliance Program. It is one way that compliance program effectiveness can be objectively measured with credible metric evidence. Using the same survey over time, permits measurements that can benchmark progress in Compliance Program development and in tracking improvements.

Al Bassett, JD, has assisted in building and evaluating compliance program effectiveness more than just about anyone in the country over the last 20 years. He has routinely employed employee surveys as a tool to obtain the most out of a compliance effectiveness review. He has found that a compliance knowledge survey parallels and reinforces his findings from document reviews, observation of program operations, and interviews of key staff. In addition, he has surveys administered to provide the foundation for focus group meetings. Findings from a survey can identify potential weakness, but does explain the “why” for the issue. He cautions that for reliable and credible result, the survey should be professionally developed and administers.  From experience he notes that internally developed questionnaires naturally raise employee suspicion that the questions are being designed to bias the results in favor of the organization.  There is also the concern that if administered internally, anonymity in responding to questions would be lost. Another issue is that the credibility of the results is not likely to provide convincing evidence to any outside authorities. A properly developed survey will also address a response-set bias, where respondents may always answering the questions as “yes” or “no”. It is therefore important to have a few reverse scored questions included.

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.

Keys to successful contracting and credentialing: honesty, questions, compliance

Contracting and credentialing are critical aspects when it comes to providers and payment. Insights and suggestions for avoiding missteps and getting the best agreement when it comes to contracting and credentialing were presented by Anna Whites and Nathan Moore, Compliance Officer at Premier Tox Laboratory, in a Health Care Compliance Association (HCCA) webinar on September 13, 2017.

Contracts

Whites defined a contract as an agreement that contains every aspect of what each party is required to do, noting that state and federal law outline contractual terms. Because different states have different laws, she recommended ensuring that the state law relied upon in the contract be the state where the individual or entity is located. She stressed the importance of reading the contract, understanding what it contains, and asking questions before signing. “Contract terms govern,” she said, and once the contract is signed, the parties can’t take the conditions back unless the contract provides for modifications as part of the terms. She also warned that the contract may require compliance with terms in other documents, for example, a provider manual.

  • Payor contracts. Provisions of payor contracts usually include services covered, provider types covered, frequency of services, and term and termination. Whites recommended providers pay close attention to these terms to ensure that they are able to meet the specifics of the provisions. Terms in payor contracts also address claims management. Providers should focus on the details of how, when, and where to submit a claim as well as how payment is made (electronically or paper), how medical necessity is defined, and how denials and appeals will be handled. In addition, providers must be aware of fee schedules included in the contract to ensure they know what they will be paid and if they are comfortable with the amount of the payment.
  • Provider contracts with health care entities. Provider contracts include the scope of services, reporting and oversight requirements, licensure and/or credentialing requirements, hours and payment, liability and insurance, and behavioral health carve-outs. Whites pointed out that when entering into a contract, parties must be aware of who is responsible for mistakes and whether tail coverage is provided. She recommended asking many questions about liability and obtaining coverage.
  • Entity provider contract with physicians and other staff. Under these contracts, the terms will include scope of services, who is in charge, who is liable, cost of services and whether the contract is with an employee or independent contractor. Providers need to determine whether employees or independent contractors are better for their organization.

In negotiations of contracts, there should be a discussion between the parties. The discussions should allow for changes and modifications. Parties should consider proposing pilots and new services. White highly recommended engaging an attorney to provide legal oversight of the contract and review the terms and provisions as well as the state and federal requirements.

Moore addressed the compliance oversight component in contracting and provided the following recommendations.

  • Ensure processes are in place to identify nonstardard terms or terms that would not be fulfilled in the organization in day to day operations.
  • Clarify any requirements that seem too rigorous prior to executing the contract.
  • Create awareness and make recommendations on how to fulfill any new requirements by coordinating with the appropriate department head.

Credentialing

Credentialing generally takes place when joining a new practice, becoming a participating provider, adding new providers to an existing group, updating information for carriers, and at the start of a new practice, Whites said. Credentialing involves collecting and verifying information about a provider’s professional qualifications, such as relevant training, licensure, certification and/or registration to practice in a health field, and academic background. Information collected before the process begins includes such documents as a copy of state licensure, a copy of board certification, proof of current malpractice coverage, a statement of disclosure of ownership and control interest statement, and a summary of any prior malpractice or disciplinary action. During the credentialing process, payors assess whether a provider meets certain criteria related to professional competence and conduct, Whites explained. Relevant factors may include location, cultural diversity, ability to speak other languages, treatment provided to children, availability, crisis training such as ability to provide care in emergency and address behavioral issues, and ability to refer and admit (to other hospitals or entities).

Whites recommended providers to be aware of specific degree requirements of the payor or network, state requirements regarding credentialing, and billing regulations that may limit reimbursable services to certain provider types. When permitted, Whites suggested submitting a resume. She also stressed that it is a provider’s right to: (1) request a status of the application, (2) review information that the payor used to deny or defer credentialing, and (3) correct any inconsistencies between the information obtained by the provider.

Credentialing issues

Whites and Moore identified issues and areas providers must be aware of to ensure that they are in compliance with requirements. Some of those areas include:

  • Cooperate in CMS audits and sites visits to ensure providers are properly enrolled, credentialed, and operating. Not cooperating may result in revocation of provider agreement.
  • Maintain compliance with payor requirements, good intentions are irrelevant to CMS.
  • Regularly review credentialing and licensing to ensure they are up to date.
  • Screen for excluded providers on available sources, prior to employment of individuals or contracting with vendors and maintain screening records for seven years. Develop a removal and notification process.
  • Ensure that providers are properly enrolled in Medicare and Medicaid enrollment systems.
  • Be aware of billing issues such as out-of-network denials, nonpayment for new provider types, and services that payors will not pay for because they were provided by a noncredentialed provider.
  • Ensure that providers are aware of coverage and payment rules regarding telemedicine.

Conclusion

Whites emphasized transparency and clarity in responses in contracting and credentialing. She stressed that providers must be honest because information is much more readily available to parties seeking it, for example, from the national databank. She noted that there are severe penalties for errors in credentialing and pointed out that CMS can exclude providers for multiple years. On the other hand, she said there are unintended negative consequences related to credentialing that arise from such things as not updating an address, not disclosing working with an excluded entity, and being responsible for a prior owner’s bad actions.

Kusserow on Compliance: Extending and economizing compliance programs—tools, services and tips

Compliance officers are confronted with a host of ever increasing external regulatory and internal demands with most having inadequate resources to meet all the challenges.  Furthermore, it is becoming increasingly common to add responsibility for HIPAA Privacy to the portfolio of compliance officers’ duties. All of this results in ongoing efforts to find ways to extend capabilities, while being sensitive to limited available resources. There are finite options available. Of course, the preference is to handle all this with internal staff. However, unfortunately for most compliance officers, limitations on increased office staffing limits this option. In some cases, organizations turn to Out-Sourcing their compliance program. This is most often done as a measure to temporarily fill gaps with an Interim Compliance Officer (ICO) when an incumbent leaves, or smaller organizations contracting the function out to an individual or firm to assume responsibility by providing a Designated Compliance Officer (DCO). Co-Sourcing is a third option and “middle ground” between hiring new staff (In-Sourcing) and Out-Sourcing and may prove to be the best strategy available for compliance officers to take huge pressures away, if implemented correctly. It involves using limited vendor services and tools to address key elements in the compliance program.

Co-Sourcing Compliance Services/Tools

The key factor that separates Out-Sourcing from Co-Sourcing is the maintaining control and direction under the compliance officer. It involves using a third-party on an ongoing basis to supplement limited staff resources by carrying part of the workload. It can help bridge the gap without compromising the ability to easily return to a structure where the compliance officer reassumes full operation when staffing issues are resolved. This approach is also recognized by the OIG as a useful solution to where an organization is limited in-house compliance expertise and resources. Compliance Officers are increasingly employing this as a means as a practical solution when confronted with a staffing shortage and offers the advantage of using limited, rather than full time services. It also may permit gaining access to a range of specialist without having them full time on payroll.

Common Types of Co-Sourcing Tools/Services

Co-Sourcing Expert Services

There are a number of advantages of engaging outside experts for limited scope of work, especially to address staff shortage or obtaining technical skills that do not exist in-house. Careful use of vendors to supplement the Compliance Office can not only gain access to experts not available in-house, but can save time, money, and effort; while maintaining flexibility to end an arrangement at anytime, when no longer needed. The following are common examples of Co-Sourced services:

Co-Sourcing Tips

  1. Clearly define duties, tasks, responsibilities, and methodology for vendor to follow.
  2. Ensure the agreement is flexible to expand or contract levels of service as needed.
  3. Look for providers that have industry specific expertise.
  4. Check experience and seek references of the firm.
  5. Ensure individuals provided have the needed skills, experience, and expertise.
  6. Bigger is not always better, as smaller niche firms are more likely to provide better, less expensive services.
  7. If planning to Co-Source for multiple tools and services, consider seeking discounts for a “bundling” arrangement.

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 Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

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

Essential resources for health care providers & attorneys during hurricane season

Hurricane season has arrived and health care providers in affected areas are focusing on providing services to injured individuals and rebuilding damage to facilities, but not necessarily on compliance with Medicare and Medicaid laws and regulations. To assist providers, federal and state agencies are temporarily waiving some regulatory requirements and providing other emergency services. While active hurricane recovery efforts are underway, Health Law Daily will feature links to federal and state resources.

Federal information:

State- and commonwealth-specific information: