Blog

How QHR Health Compliance Supports Independent Hospitals

Lisa Boston
Compliance Officer

Chances are if you are a regular reader of the QHR Health blog, you know my peers have been sharing client success stories on our website.

Just last month, Susan Dorsey, the Associate Vice President of PLUSTM Supply Chain Solutions, wrote a blog about some of her many success stories, such as Coffeyville Regional Medical Center and Bear Valley Community Healthcare District. Likewise, Wanda Wright, QHR Health’s Vice President of Managed Care, wrote about a small hospital in the Southwest that was facing significant financial challenges that threatened the ongoing viability of the organization.

Now, it’s my turn – with the caveat that our compliance client hospitals, understandably, are reluctant to name their organizations in success stories.

How QHR Health Compliance Supports Independent Hospitals

As QHR Health’s Compliance Officer, my team and I support independent hospitals and healthcare systems by partnering with them to prevent, detect and respond to fraud, waste and abuse. That means staying current with guidance and information from, including but not limited to, the Office of Inspector General (OIG), Department of Justice (DOJ), Office for Civil Rights (OCR) and the Centers for Medicare and Medicaid Services (CMS) and having a formal compliance program that includes eight elements:

  • Compliance officer and oversight
  • Code of conduct and policies/procedures
  • Education and training
  • Monitoring and auditing
  • Reporting and communication
  • Response and corrective action
  • Enforcement and discipline
  • Program effectiveness

The OIG’s Compliance Program Guidance is:

  1. Designate a Compliance Officer who is a member of the leadership team and the Compliance Committee with direct access to Executive Management and the Board.
  2. Develop and distribute standards of conduct, as well as substantive, written policies and procedures that promote the organization’s commitment to compliance with relevant laws and regulations and:
    – Address specific areas of potential fraud and abuse
    – Are clearly written and available to all workforce members
    – Are re-evaluated on a regular basis
  3. Provide compliance education and training to all workforce members that:
    – Is factored in the annual performance evaluations of employees
    – Is a condition of continued employment
  4. Conduct ongoing evaluation of compliance through a proactive auditing and monitoring plan that includes, but is not limited to:
    – Coding, physician contracts, medical necessity, quality of care, Conditions of Participation, refunds of overpayments and HIPAA privacy and security
  5. Develop open lines of communication between the Compliance Officer and workforce members that include:
    – Maintenance of a process, such as an anonymous hotline, to receive complaints
    – Adoption of policies and procedures to protect the anonymity of complainants and to protect complainants from retaliation
  6. Investigate and remediate all detected deficiencies that include:
    – Routine monitoring efforts and process controls that will reasonably prevent reoccurrence
  7. Enforce standards and procedures by:
    – Routinely verifying that healthcare providers, vendors, etc., have not been sanctioned or excluded from participation in government funded programs such as Medicare and Medicaid
    – Employing effective disciplinary action, including possible termination, for violations

 

The QHR Health Approach to Compliance Program Effectiveness Evaluation

In short, our approach complements the OIG guidance and focuses on:

  • Interviews,
  • A detailed review of hospital policies,
  • A comparison of findings to OIG and DOJ guidance and industry best practices,
  • Risk identification, and
  • Risk scoring.

Stay tuned for a future blog that details how we evaluate compliance program effectiveness.

Through our work on independent compliance and risk assessments, we collaborate with the leaders of hospitals like the small Midwestern one for which QHR Health identified a false claims issue due to incorrect coding and billing and worked with the hospital to return the excess funds. In the words of one of the hospital’s leaders,

“Without our partnership with QHR Health’s compliance solutions, I fear our hospital would not have had a timely resolution of our false claims issue and would have risked paying treble fines.”

I am especially proud of the work we did with a 150-bed hospital in the Southeast. Their leaders sought an independent assessment of the organization’s compliance program and a management action plan to remedy identified high-risk areas.

At a high-level, the holistic assessment included three components over a three-month period:

  • Assessment of meeting minutes from the Board of Directors and Compliance Committee as well as policies and procedures,
  • A series of onsite and virtual meetings with senior leadership and stakeholders, and
  • A final report with recommendations and a detailed management action plan.

The previous assessment of this hospital’s compliance program was not well-received due to regulatory approach and tone of the review. In contrast, my team brought a collaborative and educational approach to the assessment, leading to more buy-in of the findings and a stronger commitment to remedying the identified gaps.

As the CEO of the hospital shared,

“The entire team appreciated QHR Health’s approach to compliance. Making an audit as much educational as investigative takes unique skill and experience.”