Kusserow on Compliance: Debriefing complainants—24 question tips

It is very important to fully debrief any complainants and act in a very timely manner to avoid having them go elsewhere with their information—such as an attorney, government agency, media, etc. Any of these other channels could result in serious problems and possible liability. In many cases the information may come anonymously from the hotline, underscoring the importance that those answering the calls be trained on properly debriefing callers and be familiar with health care related issues.

Also, time is not a friend once information is received that may warrant immediate action. Complicating matters is that frequently a single complaint may include several different allegations, each of which needs to be addressed independently. In the debriefing process, once the story is told, specific clarifying questions need to be asked in guiding the person back through the information. This should be done by asking the standard WHO, WHAT, WHEN, WHERE, and WHY questions. These should be designed to expand on the factual details and to test and corroborate the information and be sure the chronologies of events are established.

It is important also to look for avenues and leads that will provide direction by which to either substantiate the allegations or dismiss them. Inasmuch as the allegations may relate to a specific event, something personal or organization wide, an ongoing process problem, etc. It is impossible to draft a set of question that would apply in every circumstance, however the following gives an idea about the types of questions that can be asked in a formal debriefing.

 

DEBRIEFING QUESTIONS

 

  1. What happened that led to the making of the complaint?
  2. Why are you coming forth with it now?
  3. What occurred, where, when, and how?
  4. Did the person who engaged in the conduct engage in similar conduct with anyone else?
  5. Has anyone else complained to you about similar conduct?
  6. When did it occur (date and time)?
  7. Where did it take place?
  8. How did you respond when it occurred?
  9. Who did you discuss it with and when? 
  10. What did you say? What did they say?
  11. How has this incident affected you?
  12. Has your job been affected in any way?
  13. Who else was present when the act occurred? 
  14. Where were they in relation to you? 
  15. Who else has any knowledge of the act? 
  16. Has anyone else discussed it with you? 
  17. If so, who and what did that person say? 
  18. Did anyone see you immediately after the act?
  19. Who else was involved, knows about, or witnessed it?
  20. Who else have you told (employees, supervisor, attorney, media,)?
  21. Why do you think it happened?
  22. What documentary evidence would help in the investigation?
  23. What do you believe should be done to resolve this matter?
  24. Has is happened before (an isolated event or part of a pattern)?

 

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.

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

Kusserow on Compliance: Hospital insurance trust fund will be exhausted by 2026

This year’s Medicare Board of Trustees Annual Report found that the  hospital insurance (HI) Trust Fund will be able to pay full benefits until 2026. The Medicare Program is the second-largest social insurance program in the U.S., with 59.9 million beneficiaries and total expenditures of $741 billion in 2018. By comparison, in terms of size, the Department of Defense entire budget during this period was $686 billion.

The Trustees projected that total Medicare costs (including both HI and SMI expenditures) will grow from approximately 3.7 percent of Gross Domestic Product in 2018 to 5.9 percent of GDP by 2038, and then increase gradually thereafter to about 6.5 percent of GDP by 2093. The SMI Trust Fund, which covers Medicare Part B and D, had $104 billion in assets at the end of 2018. Part B helps pay for physician, outpatient hospital, home health, and other services for the aged and disabled who voluntarily enroll. It is expected to be adequately financed in all years because premium income and general revenue income are reset annually to cover expected costs and ensure a reserve for Part B costs.

However, the aging population and rising health care costs are causing projected costs to grow steadily from 2.1 percent of GDP in 2018 to approximately 3.7 percent of GDP in 2038. Part D provides subsidized access to drug insurance coverage on a voluntary basis for all beneficiaries, as well as premium and cost-sharing subsidies for low-income enrollees.  The President’s Fiscal Year 2020 Budget, if enacted, would continue to strengthen the fiscal integrity of the Medicare program and extend its solvency.

CMS has already introduced several initiatives to strengthen and protect Medicare that includes increasing choice in Medicare Advantage and adding supplemental benefits to the program; and offering more care options for people with diabetes; providing new telehealth services; and lowering prescription drug costs for seniors. CMS is continuing to advance policies to increase price transparency and help beneficiaries compare costs across different providers.

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

Kusserow on Compliance: Questions board-level compliance committees should be asking

HHS OIG compliance guidance calls for a Board-level committee to oversee the Compliance Program (CP). The HHS Inspector General noted that the best boards are those that are active, questioning, and exercise (constructive) skepticism in their oversight, asking probing questions about the compliance program. Boards need to know what type of questions they should be asking, and compliance officers should assist them with this problem. However, compliance officers in turn should be prepared to provide full and complete answers to them. The OIG and American Health Lawyers Association developed specific suggested questions that Board’s should be asking in their jointly produced “Corporate Responsibility and Corporate Compliance: A Resource for Health Care Boards of Directors” and “Corporate Responsibility and Health Care Quality (2007): A Resource for Health Care Boards of Directors”. The following are drawn from these advisory documents:

  1. Does the compliance officer have sufficient authority to implement the CP?
  2. What is the level of resources necessary to properly implement and operate the CP?
  3. Has the compliance officer been given the sufficient resources to carry out the mission?
  4. Have compliance-related responsibilities been delegated across all levels of management?
  5. What evidence is there that all employees are held equally accountable for compliance?
  6. How has the code been incorporated into corporate policies across the organization?
  7. What evidence is there that the code is understood and accepted across organization?
  8. Has management taken affirmative steps to publicize importance of code to employees?
  9. Have compliance-related policies been developed that address compliance risk areas?
  10. Are there policies/procedures for CP operation and how they should be reviewed/updated?
  11. What kind of document management ensures compliance-related documents are up to date?
  12. What is the scope of compliance-related education and training?
  13. What evidence is there of the effectiveness of CP training?
  14. What measures enforce training mandates and provide remedial training?
  15. What evidence is available that employees understand compliance expectations?
  16. How are compliance risks identified?
  17. What is the evidence that identified compliance risks are being addressed?
  18. Is the board being kept up to date on regulatory and industry compliance risks?
  19. How is the compliance program structured to address such risks?
  20. How are “at risk” operations assessed from a compliance perspective?
  21. Is conformance with the CP periodically evaluated?
  22. Does the CP undergo periodical independent evaluation of its effectiveness?
  23. What is the process for the evaluation and responding to suspected compliance violations?
  24. What kind of training is provided to those who conduct investigation of reported violations?
  25. How do the CO, HRM, and legal counsel coordinate in resolving compliance issues?
  26. What are the policies to ensure preservation of relevant CP documents and information?
  27. What policies address protection of “whistleblowers” and those accused of misconduct?
  28. What are the results of ongoing compliance monitoring by all program managers?
  29. How is ongoing compliance auditing being performed and by whom?
  30. How often is sanction-screening conducted and with what results?
  31. Are results from sanction-screening included in a signed report by the responsible parties?
  32. Has the CP been evaluated for effectiveness by a qualified independent reviewer?
  33. What evidence regarding effectiveness of hotline operation and follow-up investigations?
  34. What are the metrics being used to evidence CP effectiveness?
  35. What are the results of an independent review and assessment of the CP?

 

More information regarding available tools and resources available to assist in answering these questions, contact Daniel Peake at (dpeake@complianceresource.com) (703-236-9854).

 

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

Kusserow on Compliance: Tips on finding the right hotline vendor

One of the critical elements of an effective compliance program outlined by OIG compliance guidance is the establishment and maintenance of communication channels with employees and management. Such communication permits employees to report sensitive matters outside the normal supervisory channels. Both the U.S. Sentencing Commission and DHHS Office of Inspector General (OIG) call for a hotline. Results from the Ninth Annual Healthcare Compliance Benchmark Survey conducted by SAI Global and Strategic Management Services found that 55 percent of organizations outsource their hotline. Daniel Peake of the Compliance Resource Center provides hotline services and explained there are many reasons why so many choose to outsource their hotline. Although there are benefits of maintaining the function in-house, it is far outweighed by the advantages of outsourcing it to a professional vendor service. He cited some of these reasons why so many decide to use a professional vendor service, including the following:

  • Cost of staffing with qualified people in-house is prohibitive
  • Systems must blocked and “backstopped” to prevent anonymous caller identification
  • Those answering the calls in house should not be highly visible to the work force
  • Calls should never be answered in an area where they can be overheard by others
  • Hotline vendors have the training and experience to handle complainants
  • Callers are nervous and speaking with an outside party generally is reassuring

TIPS FOR EVALUATING HOTLINE VENDORS

  1. Cost of operation. Vendor’s services should be a set fee under $2/employee/year.
  1. Contract. Avoid contracts not permitting cancellation by 30 day written notice. Client should be held by good service, not by contracts.
  1. Industry expertise. Seek vendors knowledgeable of health care issues.
  1. Hotline services. Must include both live operator and Web-based reporting. Either approach alone has its deficiencies and is not a best practice.
  1. Policies and procedures. Vendor should assist with developing operating protocols for following up an allegations and complaints received through the hotline.
  1. Timelines. Insist on a provision of a full written report within one business day of receipt of the call. For urgent matters, it should be immediate.
  2. Reports provided. Written reports must clear, concise, and of high quality.
  3. Report Delivery. The manner the report is delivered is important. There is security problems with reports provided either by facsimile or email. Insist on secure web-based reporting with notification of a report being provided via email.
  1. Insurance. Like any other vendor, the company should have at least one to three million dollars liability coverage.

 

For more information, Daniel Peake can be reached at (dpeake@compliancereource.com or (703)-236-9854)

 

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 © 2018 Strategic Management Services, LLC. Published with permission.