Kusserow on Compliance: New CMS proposed outpatient rules

The 2020 annual rule cycle has been active for CMS with several proposed rules in the outpatient prospective payment system (OPPS) area. Hospitals and health system executives should monitor these annual rules carefully for provisions that will affect their organizations’ operations. Among the significant regulatory rule proposals for hospital and health system executives are the following:

  1. Mandated disclosure of negotiated charges between health plans and hospitals for all items and services for about 300 “shoppable” services
  2. Proposed penalties which would be over $100,000 a year for noncompliant hospitals
  3. The addition of several ASC procedures
  4. The removal of total hip arthroplasty from the inpatient-only list for 2020, allowing the procedure to be performed on an outpatient basis
  5. Reduction of supervision level for hospital outpatient department from direct to general for hospital outpatient departments
  6. A requirement for prior authorization of certain outpatient department services.
  7. Continued payment reduction for 340B purchased drugs
  8. Increased per-day cost threshold for separate payment for certain outpatient drugs
  9. The establishment a prior authorization process for five categories of services that often may be cosmetic: blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, and vein ablation
  10. Various updates to Hospital Outpatient Quality Reporting Program requirements

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: Choosing a location for investigation interviews

Regardless of whether you are conducting a debriefing of a complainant, interviewing a witness, or confronting a subject in an interrogation, determining the location and setting of the interview is important. The objective is to create privacy and eliminate any possible interruptions or distractions. It should be conducted away from any traffic or other distracting influences, or where others may observe or overhear what is occurring. Interviewing someone in their own office should be avoided in that it invites interruptions or reasons why the person may turn their attention to some other matter. It also gives the interviewee the advantage of being on their “own turf.” By interviewing someone away from their own area, the investigator receives an advantage. The following are some additional tips and considerations in deciding upon the interview location and setting:

1. Privacy. Fewer the people in the room, the better the results
2. Quiet. Don’t want external sounds or outsiders to hear
3. Room Size. Small enough to convey intimacy
4. Well Lighted. Permits closer observation of individual
5. Plain. Avoid distractions (e.g. window, pictures, wall clocks, etc.)
6. Telephone. Shut if off to avoid incoming calls/messages
7. Furniture. Avoid having furniture in between (barrier to rapport)
8. Seating. Interviewer should sit directly across from interviewee
9. Positioning. Avoid the person being able to look out a window and not at you

It is recognized that there are practical constraints that may necessitate compromise on these considerations. Also, most interviews will be persons who are witnesses or who otherwise provide limited information. As such, many of these tips may not be necessary. However, if the person to be interviewed is the subject of the investigation, applying these principles become important elements to successful outcomes.

 

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: 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.

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: 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.