All Medicare stakeholders need to know MACRA

Although the Medicare Access and CHIP Reauthorization Act (MACRA) (P.L. 114-10) is best known for changing Medicare provider payments, its true goal is improving the quality of care delivery across the health spectrum. As a result, according to Todd Gower and Lisa Alfieri from the Risk Transformation, Health compliance sector of EY, providers must enhance their relationships and contracts with providers. Gower and Alfieri, speaking at a Health Care Compliance Association (HCCA) webinar titled “MACRA: Not just for Providers,” explained that having the proper infrastructure to obtain and organize all necessary documentation is the key to surviving MACRA.

Gower and Alfieri stressed the need for new discussions within health systems, noting that MACRA has potential to transform the health care system “equally, if not far more” than the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148). As it implements MACRA, HHS is having new conversations with stakeholders including whether the shared risk will actually improve care, and whether the current proposed criteria (see Halfway through QPP ‘transition year,’ CMS proposes substantial changes , June 21, 2017) are too restrictive. They praised HHS’ website on the Quality Payment Program as a new way to communicate with providers and other stakeholders.

MACRA is a complex law with wide-reaching repercussions. Gower and Alfieri suggested infrastructure updates, and predicted that the most-advanced providers will be seeking commercial payer partners by 2019 to maximize incentives for value-based care (VBC) payment models. Therefore, payers should create or enhance existing VBC offerings now to meet that expected need. MACRA steering committees are important to ensure compliance and update risk management programs for providers, but also for non-provider groups.

Kusserow on Compliance: Free Webinar! Conducting Internal Investigation Interviews—Some Best Practices and Tips

Wolters Kluwer is hosting a complimentary webinar on January 26, 2017, entitled, “Best Practices for Conducting Internal Investigations.” The presenters are Richard P. Kusserow, former FBI executive and HHS Inspector General, and Kashish Chopra, JD. Both have extensive experience with conducting internal investigations. Today’s blog provides some tips on the most critical part of most investigations; conducting witness interview. This subject will be provided in more depth during the webinar.

Always project a professional image

This begins with how one is attired. An interview is a formal business meeting and those conducting them should dress accordingly. Dressing down in jeans or other casual clothing does not project a professional image. Those interviewed are not friends; and therefore investigators should not dress and act as if they were. The demeanor of interviewer is important to outcome of interview. If interviewer appears quietly competent and professional, it will encourage confidence in the individual being interviewed. It also reduces nervousness in innocent parties, increases nervousness in guilty ones. The manner should always be polite but firm. Cooperation is essential; intimidation is counter-productive and possibly disastrous in outcome. Treat those interviewed with dignity, respect, and courtesy; and avoid use of any investigative jargon or slang

Begin with why the person is being interviewed

Identify self and any others participating in the interview and explain the purpose of the investigation, along with the authority to conduct inquiry. Make it clear they have a duty to provide complete and accurate facts and explain their comments will be kept confidential to the degree possible

Take time to establish rapport

This is critical to the result of the interview. Beginning an interview with five or ten minutes of easy conversation has the advantage of reducing tension and increases better communication and cooperation. It also permits the investigator to observe the person and their behavioral patterns during this initial more relaxed discourse that often proves very valuable when assessing responses when questioning begins addressing more serious issue areas. Any rapport established can be easily lost by careless use of terms or phrases that may evoke negative connotations, or cause the person to become more defensive and less cooperative.

Best way to have a productive interview is to do one’s homework in advance

This means (a) knowing the objectives of the investigation; (2) having an investigative plan to achieve those objectives; (3) identifying facts needed to properly understand and assess the issues; and (4) what the person being interviewed may offer in terms of facts. It is useful to prepare the key points to be covered for use as a guide, but just going down a list of questions is a bad practice, as it turns the interview into something more akin to an interrogation. Use open-ended questions and allow the person to speak. Often they will cover many of the points on your guide in their discourse. At the end of the interview, review the guide to see if all the points were covered”.

Keep control of the interview by asking, not answering, questions

The interviewer is not the dispenser of information and, as such, they should not reveal the status of the work; offer opinions; indicate what has been found so far; or what has been said by others. Offer no opinions relating to the investigation. Losing sight of that principle often leads to losing control of the interview and is one of the major causes of bad outcomes in the process.

Always remember the interview purpose is to establish facts

It is critical that the investigator remain at all times focused on facts. It is common to have those being interviewed to drift off of facts, especially if they are uncomfortable with the direction of the interview. Therefore, always follow through on questions asked and not be diverted by other comments. Ensure basic questions such as who, what, where, when, how, and why have been addressed. Keep the questions simple and direct, avoiding compound sentences. Ask open-ended questions and allow the person to fully answer.

Take notes, discreetly

It is important to maintain the interview as much like a conversation as possible. Losing eye contact can throw the interview off and detract from results. As such, although it is critical to take notes throughout the interview, it should be done as discreetly as possible. This means writing only key words and phrases that can be filled out after the interview is over. Taking copious notes and losing eye contact risk turning the interview into something that may appear to the individual as an interrogation and makes individuals tighten up and be less forthright in their comments.

Click here to register.

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.

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

Kusserow on Compliance: Free Webinar! Best Practices for Conducting Internal Investigations

Channeling employees who wish to report allegations or complaints internally is critical to any effective compliance program, as well as to avoid the liabilities and other consequences to having them report externally. The HHS Office of Inspector General (OIG) and Department of Justice (DOJ), as well as other enforcement agencies, continue encouraging “whistleblowers” by offering great bounties for successes from their information. In 2016, recoveries totaled $3 billion with whistleblowers receiving as their share—$519 million. In addition, nearly a quarter-million whistleblowers contacted the OIG directly or through the agency’s hotline during the same period. Wolters Kluwer is hosting a complimentary webinar on January 26, 2017 from 1:00-2:30 PM EST, entitled, “Best Practices for Conducting Internal Investigations.” The presenters are Richard P. Kusserow, former FBI executive and HHS Inspector General, along with Kashish Chopra, JD. Both have extensive experience with conducting internal investigations. Today’s blog focuses on the predication of internal investigations that is also addressed in the webinar in more detail. There are many ways be called upon to respond to a complaint or concern raised by an employee, including compliance officers, human resource management (HRM), legal counsel, privacy/security officers, and risk managers, among others; however, only a few complaints would rise to the level of requiring an investigation.

An investigation is a search to uncover facts and seek the truth of an issue (who, what, when, where, why, how) and involves a detailed inquiry or systematic examination to gather facts and information to solve a problem, or resolve an issue. Other activities can meet this definition, including conducting audits, evaluations, and inquiries. All these other activities involve a detailed examination of facts. The fact is that vast majority of hotline complaints can be resolved fairly quickly—within hours or a day or two—without a formal investigation. Many complaints, allegations, and concerns are routine in nature and may be resolved through normal management procedures or through HRM. In determining how to respond to complaints and allegations properly, it should be a standard practice to, in effect, “triage” all the facts known, similar to what medical staff does when a patient arrives at an emergency room at the hospital. This involves an analysis of the complaint and any allegations to determine who is best equipped to resolve the issues. It may be the multiple functions may need to be involved. From this initial analysis, an investigative plan can be developed.

However, when it is determined that a matter requires an investigation, the key is how to do this properly, preferably using properly trained individuals to conduct the investigation. Anyone called to conduct an investigation must understand how to plan an investigation, conduct proper interviews, organize evidence, prepare written reports, and document management. Is unrealistic to have professional investigators in compliance offices, but certain basic principles should be taught to anyone taking on the role of an investigator, whether they come from the compliance office, HRM, legal counsel, privacy office, etc. Anyone who is likely to conduct an internal investigation should have as a minimum a basic understanding of best practices and methods. The upcoming webinar is designed to provide some of the basic principles in conducting a proper investigation in a timely manner.

Click here to register.

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: Is it an internal investigation, inquiry, audit, or evaluation?

In most organizations, there are many people who may be called upon to respond to a complaint or concern raised by an employee, however only a few of these would rise to the level of requiring an investigation. It can be important on how the response to the issue is labeled and convey meaning to people. Two leading experts on the subject were interviewed recently on this subject and provided useful tips, advice and suggestions.

Al Bassett, former FBI executive and a Deputy Inspector General, as well as extensive health care compliance consultant experience makes it a point that “calling something an investigation is using an emotionally ‘charged term’ that suggests a violation of law and enforcement action. This can have an impact on how individuals will respond when being questioned about a situation or issue. When people hear about an ‘investigation’ their imagination may be excited to infer a lot more about what is occurring than is factually correct.”

Emil Moschella, a career investigator and former FBI executive, observed that “Someone announcing they are conducting an investigation generally has the effect of making people more defensive and cautious in responding to questions. Many develop a very cautious attitude, if they believe they are being asked about something that may result in an enforcement action.” Both Bassett and Moschella believe, wherever possible, it is advisable to use neutral terminology to avoid unnecessarily exciting concerns and speculation among employees.

Investigation defined

  • Search to uncover facts and seek the truth of an issue (who, what, when, where, why, how)
  • Inquiring into something thoroughly and systematically
  • Detailed inquiry or systematic examination to gather facts and information to solve a problem, or resolve an issue
  • An inquiry into unfamiliar or questionable activities.

Steve Forman, CPA, has a long history of involvement in conducting a variety of inquiries. He was not only an executive at the HHS Office of Inspector General (OIG), but served many years as Vice President for Audit and Compliance at a major hospital system. He makes the point that “It is clear there are a number of other activities that could meet the general definition of an investigation, including conducting an audit, evaluation, internal inquiry, or internal review. I have found that characterizing the activity using these terms will avoid potential emotional response if using the term investigation.”

Most issues are resolved without a formal investigation

Carrie Kusserow, with over 15 years experience with reviewing literally thousands of hotline complaints, notes “The vast majority of these complaints and reports can be resolve fairly quickly within a day or two, without a formal investigation. Many complaints, allegations, and concerns are routine in nature and may be resolved through normal management procedures or through HRM. Those matters that may implicate a violation of law or regulation normally involve legal counsel. More complex cases may require a significant commitment of resources over a protracted period. In any case, the elements of any investigation or inquiry will include one or more interviews, gathering documents, and a case file.”

Be prepared

Suzanne Castaldo, JD, who has conducting investigations both in the capacity as an attorney and Compliance Officer, says “Some cases do require an investigation, real and in fact. When confronted with this, the key to resolution is how to do this properly. The real answer is having properly trained individuals to conduct the investigation. Professional investigators cannot be expected to be available for a compliance office to conduct an internal investigation, however certain basic principles should be taught to anyone taking on the role of an investigator, whether they come from the compliance office, HRM, legal counsel, privacy office, etc. These include understanding how to plan an investigation, conduct proper interviews, organize evidence, prepare written reports, and document management. It is advisable to have individuals undergo this basic training by experts. This can be done by participating in investigator training courses through Webinars, at conferences, or having experts provide training on site. If the latter, it is advisable to have all those who might be called upon to conduct an investigation participate (i.e., Compliance Officer, HRM, Privacy/Security Officer, Legal Counsel).”

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 © 2016 Strategic Management Services, LLC. Published with permission.