Kusserow on Compliance: Human resources management compliance jurisdiction

The great majority of internal investigations arise from complaints filed with the human resources management office (HRM) or through the compliance office hotline. Both functions have their own jurisdiction for dealing with sensitive issues, and this can raise tension and conflict if not addressed properly. HRM has a mission to assist employees in a host of ways, ranging from salaries and benefits to working conditions. It is therefore not surprising that the department is a front-line recipient of questions, concerns, complaints, and allegations related to the workplace. For all practical purposes, the primary responsibility for investigating and resolving personnel-related issues, including unfair labor practices, discrimination and harassment, lies with HRM.

Specific rules must be followed when conducting such investigations and the federal agency providing guidance and oversight is not the HHS Office of Inspector General (OIG) or the Department of Justice (DOJ), but the Equal Employment Opportunity Commission (EEOC). Furthermore, in some states, individuals conducting these types of investigations must undergo a designated number of hours of specialized training on the laws and rules governing employees in the workplace.

The sources of workplace complaints are varied, but their emergence is all but inevitable. With that in mind, it is important to have a clearly communicated and consistently applied policy detailing the specific procedure for reporting complaints. Many organizations encourage employees to utilize the “traditional” chain of command approach to reporting and resolution, while others have established more progressive open door communication policies to encourage unrestricted communication. Direct reporting to HRM is also an option for employees.  Allowing employees to report issues via an employee hotline, generally managed by the compliance officer, is yet another mechanism of reporting.  With most hotline calls have issues that fall under HRM primary jurisdiction, it requires careful coordination to guard against a matter falling between the cracks. This does not necessarily create a bright line of authority between the two functions, as many concerns raised may cross the line from being personnel issues to being compliance issues. It is essential that the compliance office and HRM maintain open communications and establish reciprocal reporting obligations for the purpose of ensuring the appropriate department is apprised of issues that are its primary concern. They must be able to coordinate investigative and resolution activity to avoid unnecessary duplication of efforts.

All of these reporting approaches provide a stream of information that can result in the need for internal inquiry or investigation. It is very important to note that, in order to have an effective reporting program that employees will actually utilize, it must be coupled with a clearly stated anti-retaliation policy. Employees must know that retaliation or attempted retaliation in response to lodging a complaint or invoking the complaint process is strictly prohibited by the organization. In August of 2016, the EEOC issued “Enforcement Guidance on Retaliation and Related Issues”, the EEOC’s first comprehensive review of retaliation since 1998. This was in direct response to the fact that retaliation is now the most frequently alleged basis of discrimination that EEOC receives.

The compliance officer focuses much attention on the Anti-Kickback Statute, Stark Laws, False Claims Act, and other fraud laws with considerable attention given to the OIG, DOJ, and state Medicaid Fraud Control Units. By contrast, the laws that most often occupy HRM interest include Title VII of the Civil Rights Act 1964; the Age Discrimination in Employment Act; the Americans with Disabilities Act; the Family and Medical Leave Act; the Fair Labor Standards Act; the Uniform Services Employment/Reemployment Rights Act; the Employee Retirement Security Act’s governing compensation and benefit plans; and the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) for employer-sponsored health benefits, among others.  The government agencies that oversee these areas are the U.S. Department of Labor, the Equal Employment Opportunity Commission (EEOC), and a variety of state agencies.  Violations can result in serious penalties.

Regarding matters that HRM must investigate and resolve, one area long overshadows (numerically) compliance matters raised to the compliance officer to handle: discrimination and unlawful harassment. Complaints to the federal EEOC and state counterparts number over 100,000 annually.  Many other complaints are received by HRM that never go so far as to be reported to outside authorities.   To meet the challenge of avoiding such complaints, HRM must implement a variety of compliance policies and train everyone on them.  These activities are familiar to compliance officers, who must do the same within their risk areas. However, in the case of some of the HRM-related laws and regulations, federal and state governments establish special rules for standards for related policies and mandatory training.  Special rules extend to the manner by which these types of cases are to be investigated and by whom, when there is a formal complaint.

One example of a compliance risk area requiring care relates to unlawful (sexual) harassment. In a series of Supreme Court cases, the High Court set forth the principle that no employer can mount an affirmative defense to allegations of unlawful harassment unless they can meet three standards: (1) they have zero tolerance policies and procedures in place; (2) all employees and managers are trained on these policies; and (3) the organization has taken steps to identify emerging issues and do not just wait until a complaint takes place.  On this last point, examples of action steps by management include screening hotline calls for any indications of emerging issues, conducting exit interviews and asking about employee work environment issues, and using training on the subject as a means to open discussion of potential problems.  In the latter case, having people stay behind to make further inquiries is more likely to open doors that public statement during formal training.

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.

Wolters Kluwer Announces White Paper Series on Healthcare Legislation

As federal lawmakers grapple with sweeping healthcare reform, Wolters Kluwer provides resources to help professionals stay ahead of reimbursement and compliance requirements

Wolters Kluwer Legal & Regulatory U.S. today announced the launch of an authoritative and timely white paper series to track updates and provide analysis on the American Health Care Act (AHCA) and Better Care Reconciliation Act (BCRA), the proposed replacements for the Affordable Care Act (ACA) under consideration in Congress.

The AHCA passed in the House of Representatives by a slim majority in May. A discussion draft of the BCRA was released in late June but the Senate has delayed any votes on the legislation until July. The first white paper in the series, entitled “How the AHCA Directly Impact Significant Parts of the ACA,” identifies and explains aspects of the ACA that are directly impacted by the AHCA. Wolters Kluwer’s white paper series will track the legislation as new versions of the bill become available.

“Considering the impending changes proposed by lawmakers, healthcare, legal and compliance professionals need to understand the evolving regulatory landscape,” said Paul Clark, Health Law Analyst for Wolters Kluwer’s Healthcare group. “Our series of white papers will help healthcare professionals to track changes in the legislation as they occur, measure the impacts, and manage compliance and reimbursement practices more efficiently.”

Download a free electronic copy of “How the AHCA Directly Impact Significant Parts of the ACA”

For those interested in daily, comprehensive coverage of the latest health law developments, Wolters Kluwer offers Health Law Daily providing in-depth analysis on new developments delivered directly to users’ device of choice every day. To learn more visit The Health Law Daily.

About Wolters Kluwer Legal & Regulatory U.S.

Wolters Kluwer Legal & Regulatory U.S. is part of Wolters Kluwer N.V. (AEX: WKL), a global leader in information services and solutions for professionals in the health, tax and accounting, risk and compliance, finance and legal sectors. We help our customers make critical decisions every day by providing expert solutions that combine deep domain knowledge with specialized technology and services.

Wolters Kluwer reported 2016 annual revenues of €4.3 billion. The company, headquartered in Alphen aan den Rijn, the Netherlands, serves customers in over 180 countries, maintains operations in over 40 countries and employs 19,000 people worldwide.

For more information about Wolters Kluwer Legal & Regulatory U.S., visit www.WoltersKluwerLR.com, follow us on FacebookTwitterand LinkedIn.


Linda Gharib
Director, Communications
Wolters Kluwer Legal & Regulatory U.S.
Tel: +1 (646) 887-7962
Email: linda.gharib@wolterskluwer.com

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Wolters Kluwer Holiday

We will not be posting on July 3 or July 4 in commemoration of Independence Day. The Wolters Kluwer Legal and Regulatory U.S. Health Law Editorial Team wishes you a safe and happy holiday. We will resume our regular posting schedule on Wednesday, July 5.

Kusserow on Compliance: EHR incentive program attestation is serious business

The American Recovery and Reinvestment Act of 2009 (ARRA) (P.L. 111-5) authorized providing incentive payments to eligible health care professionals, hospitals, and Medicare Advantage Organizations (“MAOs”) to promote the adoption and “meaningful use” of health information technology and electronic health record (“EHR”) systems. CMS established the Medicare and Medicaid Electronic Health Record Incentive Programs (EHR Incentive Programs) to make incentive payments to health care professionals and providers that meet specified requirements for the meaningful use of certified EHR technology (CEHRT). The EHR Incentive Programs are intended to bring about improved clinical outcomes and population outcomes, increase transparency and efficiency in health care, empower individuals to make decisions regarding their care, and generate additional research data on health systems. Program participants must report on their performance pertaining to certain clinical quality measures (CQMs) and objectives to CMS (for Medicare) or the authorized state agency (for Medicaid) through an attestation process. Since 2011, the EHR Incentive Programs have made incentive payments to numerous eligible professionals, eligible hospitals, and critical access hospitals (CAHs) that qualify as “meaningful users” by meeting the objectives and CQMs outlined in the various stages of the applicable programs.

Annual attestations required

Eligible providers must annually attest to meeting the specified objectives and measures in order to receive incentive payments under the EHR Incentive Programs. Once they have attested to meeting the identified objectives and measures, they are deemed to be meaningful users and eligible for incentive payments.  CMS, its contractor, and state Medicaid agencies conduct both random and targeted audits to detect inaccuracies in eligibility, reporting, and receipt of payment with respect to the EHR Incentive Programs.  Eligible hospitals may be selected for pre- or post-payment audits. CMS has required that eligible hospitals retain all supporting documentation used in completing the Attestation Module responses in either paper or electronic format for six years post-attestation. Eligible hospitals are responsible for maintaining documentation that fully supports the meaningful use and CQM data submitted during attestation. Those hospitals undergoing pre-payment audits will be required to provide supporting documentation to validate submitted attestation data before receiving payment.

Unsupported and false attestations

Making false statements, including attestations to the federal government, could implicate federal law (18 U.S.C. § 1001), which generally prohibits knowingly and willfully making false or fraudulent statements or concealing information. Although eligible hospitals receiving incentive payments under the Medicare and Medicaid EHR Incentive Programs are not required to follow any particular parameters when spending the payments, they must annually attest to meeting the relevant measures and objectives in order to be entitled to incentive payments. It is critical that eligible hospitals maintain documentation that supports their attestations.  Supporting documentation needs to make clear that the hospital is meeting the terms and conditions of the EHR Incentive Program. A checklist document by itself would be insufficient as supporting documentation. Failure to maintain such supporting documentation creates potential liability. Although no significant enforcement activity has taken place, compliance officers are advised to verify that proper supporting documentation is maintained.  In fact, the responsible program manager should be maintaining documentation as part of ongoing monitoring. As part of ongoing auditing, the compliance office should ensure that monitoring is conducted and validate that it is adequately meeting regulatory 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
Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

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