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.

Kusserow on Compliance: Effective hotline programs

All healthcare organizations need confidential compliance communication channels. First and foremost among them is a hotline. By definition, all effective compliance programs should have a hotline. It is an important avenue of communication between employees and management, in that it permits employees to report sensitive matters outside the normal supervisory channels.  The reality is that developing and monitoring a hotline is a critical part of any effective compliance program. It provides an avenue of communication that permits employees to report sensitive matters outside the normal supervisory channels. The compliance officer bears the responsibility of constantly reviewing and improving the effectiveness of the hotline operation.  The US Sentencing Commission, the HHS Office of Inspector General (OIG), and Department of Justice (DOJ) all call for having a hotline, as well as other authorities, including the Sarbanes-Oxley Act for publicly traded companies and the federal courts in connection with unlawful harassment. Failure to establish positive internal compliance reporting channels often results in reporting externally to the OIG and DOJ from “whistleblowers.” The challenge is establishing effective internal compliance communication. Today, it is the exception to find organizations trying to manage a hotline function internally. The fact is that any advantage of internally operated hotlines is more than off-set by the disadvantages.

From a practical standpoint, it simply is not cost effective to operate a hotline 24/7 internally.  Even those that decide to operate and manage the function in house are confronted with a number of challenges—it is extremely inefficient, costly and seldom meets any minimum standards. Hotline numbers will need to be “backstopped” against tracing and all caller identification systems have to be blocked. People answering the calls in house should not be highly visible to the work force. Confidence comes from neither party being known to the other. Hotline vendors have the training and experience to handle complainants. Callers are generally nervous and afraid and knowing they are providing information to an outside party generally is reassuring. They always raise the question of whether anonymity is truly offered and whether employees will ever sufficiently trust calling an employee. It has become the standard practice for organizations to outsource their hotline to a vendor.  However, evaluating those providing the best service at the right price is a challenge. The following are questions that can be used to determine a properly qualified vendor. Those failing key tests should be avoided as they may prove to be a future liability.

 

Questions for hotline vendors

  1. Cost of Service. Does the vendor charge an established fixed rate or sliding rate based upon number of calls? Seek a fixed, not a variable rate, based upon number or time of calls. A good rule of thumb is that the cost of a hotline service should not exceed $1-3 per employee per year.

 

  1. Industry Focus. Can the vendor evidence having understanding and expertise of issues related to the health care industry? Failing to understand healthcare standards and regulatory matters limits the ability to properly debrief callers. Ask for a breakdown of the types of clients they serve by industries.

 

  1. Hours of Service. Does the vendor provide 24/7 service? If not, don’t use them.

 

  1. Call Centers. Does the vendor provide call services? If so, avoid them completely. Call centers provide outbound calls used to promote services and products. Others answer after hour services for businesses (doctors, plumbers, electricians, etc.) and relate messages to their clients. The people doing this are performing a clerical function and answering hotline calls requires more professional expertise. Furthermore, there is the risk of having calls interrupted by a call for some needing emergency service.

 

  1. Hotline Service Types. Does the vendor provide multiple levels of service for (a) receiving live operator calls and (b) a web-based reporting system that prompts individual complainants? One level alone is not enough.

 

  1. Avoiding Vendor Contract Traps. Does the contract permit cancellation at any time with a simple 30 day notice? If not, don’t use them. Staying with a vendor should be because of good service, not because of being locked into them by contract terms. If you have a current contract, check the termination clauses to see if cancelling a contract is cumbersome. If it is, ask to renegotiate the termination clause. If they decline, then take steps to follow termination procedures in the contract.

 

  1. Hotline Number. Does the vendor want to use their phone number? This is a common vendor trap to lock in users to their service. You advertise their number everywhere and to change would necessitate changing all the places you have advertise the number. Always use and own your own hotline number that can be pointed to a vendor.

 

  1. Language Translation. Does the vendor provide a language translation service to address non-English speakers?

 

  1. Check Vendor Background. What is the level of hotline experience among the ownership, management, and operation of the service?

 

  1. Length of Hotline Experience. How many years of experience can the vendor evidence in the management of hotline operations?

 

  1. Policies, Procedures, and Protocols. Does the vendor provide advice on developing operating protocols for following up an allegations and complaints received through the hotline?

 

  1. Business Associate Agreement (BAA). Does the vendor offer to sign a BAA to meet HIPAA protected health information (PHI) requirements for any patient related information received through the hotline? If they don’t know what that means, forget them.

 

  1. Timelines. Will the vendor agree to provide a full written report within one business day of receipt of the call and for urgent matters, immediate notification?

 

  1. Report Delivery Security. Does the vendor deliver call reports by the most secure means? It is critical to establish a secure call report submission process to a specific responsible party and to an alternate should the primary contact be unavailable? Any delivery of reports via fax or email lack necessary security. It is critical that reports are secured to protect those filing the report, as well as those who are subject of the report or mentioned in them. HIPAA PHI, proprietary and confidential data, and personnel information must be protected. Web-based reporting is the most secure with notification of a report being provided via email.

 

  1. Routine vs. Urgent Reporting. Does the vendor assist in establishing a process that alerts the primary contact to any urgent report received? A delay in reporting a serious issue could result in potential liabilities.

 

  1. Insurance. Does the vendor provide at least one to three million dollars liability coverage? If your vendor does not have this insurance, consider changing over to one that provides this assurance.

 

  1. Caller Contact Information. Does the vendor have procedures for providing callers with a means to call back without disclosing their identity?

 

  1. Personalized Service. Does the vendor provide the identity or identities of individuals available to respond to any issues or question that may arise, whether it relates to call reports, invoice issues, or providing general advice? Not having easy access to someone or having to go through a phone system moving you from one office to another before you find a stranger who may or may not be able to answer your questions can be frustrating. If possible, seek an identified accounts manager who will be responsible for any and all issues that arise under the contract.

 

  1. Training and Assistance. Does the vendor provide guidance on the best way to promote understanding of the hotline?

 

  1. Other Useful Benefits. Are there any other services or benefit provided under the contract? This would include such things as supporting policy and procedures for hotline management, poster templates, newsletters, etc. For smaller organizations, these benefits may exceed even the service fees paid to the vendor. Find out what they offer.

 

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.

Kusserow on Compliance: Defending against ransomware threat

Cyber attacks have risen to dramatic levels over the last two year and are likely averaging one attack a day, with the most disturbing trend involving ransomware. A survey by the American Health Lawyers Association indicated that virtually all healthcare lawyers believe they will be involved with cyber security matters with their client and the threat will continue to increase over the coming years. Data breaches include actions by those inside the organization, as well as external attacks including phishing, hacking, and ransomware. Ransomware typically involve a sophisticated computer virus introduced into a victim’s system that encrypts the system’s data.  The attackers threaten to delete the private key needed to decrypt the files unless the owners of the information pay a ransom, typically in an untraceable digital currency such as Bitcoin. The healthcare industry, particularly hospitals, have proven to be a soft target, as they need to have immediate access to their patient information and many have paid the ransom to regain control over it. The healthcare sector is considered a “soft target” for Ransomware attacks, particularly hospitals that are the perfect mark for this kind of extortion in that they provide critical care and rely on up-to-date information from patient records. As such, compliance officers need to consider this a compliance high-risk area where ongoing monitoring and auditing applies.  Simply assuming that someone in IT is addressing this problem area can be a big mistake. At the same time, the compliance office is not responsible for the program, but is responsible to ensure that those that have that responsibility are doing their job, including IT and human resource management (HRM).

According to new studies reported, healthcare now ranks as the second highest sector for data security incidents, after business services. The “2017 Internet Security Threat Report” found that in healthcare (a) over half of emails contained spam; (b) one in 4,375 emails being a phishing attempt; and (c) email-borne ransom-ware spiked 266% over the previous year.  The Ponemon Institute further found breaches could be costing the healthcare industry $6.2 billion annually. All these studies indicate that the biggest vulnerability to cyber attacks is employees that let-down their guard when opening or responding to emails from unknown sources. Often “scammers” create the appearance of legitimate sites, including using similar names, emblems of companies and even government agencies, etc. (including the OIG and IRS). Once someone opens the door, all kinds of bad things can happen.

Practical Tips

  1. Implement policies and procedures on taking precautions against malware and train all covered persons on them.
  2. Ensure ongoing (repeated) training of employees to keep them aware and being on guard against allowing software breaches by clicking on an email link or attachment, or responding to “pfishing” inquiries.
  3. Don’t entirely rely upon employees to always do the right thing and provide assistance by configuring email servers to block zip or other files that are likely to be malicious.
  4. Restrict permissions to areas of the network by limiting the number of people accessing files on a single server, so that if a server gets infected, it won’t spread to everyone.
  5. Limit employee access to systems on a need to know standard.
  6. Security efforts should focus on those files that are most critical, patient records.
  7. Conduct a risk analysis to identify ePHI vulnerabilities and ways to mitigate or remediate these identified risks.
  8. Maintain disaster recovery, emergency operations, and frequent data backups to permit restoring of lost data in case of an attack.
  9. Move quickly on any report of an attack to prevent the malware from spreading, by disconnecting infected systems from a network; disabling Wi-Fi, and removing USB sticks or external hard drives connected to an infected computer system.

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.

 

Kusserow on Compliance: CMS to issue new Medicare card to 60 million beneficiaries

New cards will no longer contain Social Security number

Over 2.5 million beneficiaries are victims of identity theft incidents

CMS is readying a fraud prevention initiative that removes Social Security numbers from Medicare cards to help combat identity theft, and safeguard taxpayer dollars.  This is being done to meet the congressional deadline for replacing all Medicare cards by April 2019 that followed the passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). CMS will assign all Medicare beneficiaries a new, unique a Medicare Beneficiary Identifier (MBI) number which will contain a combination of numbers and uppercase letters. Beneficiaries will be instructed to safely and securely destroy their current Medicare cards and keep the new MBI confidential. Issuance of the new MBI will not change the benefits a Medicare beneficiary receives and will be designed to help protect against personal identity theft affects a large and growing number of seniors.  According to the DOJ, people age 65 or older are increasingly the victims of this type of crime that now are estimated to affect 2.6 million seniors a year. Two-thirds of all identity theft victims reported a direct financial loss with also the problems associated with disrupting lives, damage credit ratings, and result in inaccuracies in medical records and costly false claims.

New card will be mailed beginning in April 2018 and will use the unique, randomly-assigned MIB number to replace the Social Security-based Health Insurance Claim Number (HICN) currently used on the Medicare card.  Providers and beneficiaries will both be able to use secure look up tools that will support quick access to MBIs when they need them. There will also be a 21-month transition period where providers will be able to use either the MBI or the HICN further easing the transition.

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.