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5/8/2012
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Ciarra R. MilesJohns Hopkins Health System
SCCE Higher Education ConferenceJune 2012 – Austin, TX
Ciarra R. Miles, RAC Paralegal for the Johns Hopkins Health System (“JHHS”)
Joined JHHS this year in February. Responsibilities include working closely with the recovery audit contractor (RAC) attorney in tracking, reporting, and filing appeals for denials across the health system.
Prior to joining JHHS, I held the following positions:
Corporate Responsibility Regulatory Coordinator
CaroMont Health, Gastonia, NC
Research & Regulatory Analyst
MedStar Health, Columbia, MD
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Overview….
Promoting and marketing different avenues of reporting
Building a rapport between compliance and the reporter
Creating and maintaining a culture of compliance
Establishing the
Foundation
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Establish Core Functions…It is very important when building a program that you establish core function that align with the U.S. Federal Sentencing Guidelines, which describe what an EFFECTIVE compliance program should encompass:
Policies & procedures
Oversight
Education & Training
Reporting
Enforcement & Discipline
Response & Prevention
Key to Compliance: If they knew better;
they would do better!
Education & Training…In order to successfully promote and market the different
avenues, you need to educate & train your employees on:
What constitutes a compliance concern?
Who should be contacted for those matters?
The Severity of each of those issues
The Standards of Conduct for employees
Enforcement & Discipline
Response & Prevention
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Processes & Protocols… Build solid processes and protocols around:
Reporting and case management, which refers to effectively intake, manage, and resolve issues that come to the attention of compliance.
Maintaining confidentiality
Conducting investigations
Identify Key Terms & Team Players…
“Issue” refers to an allegation that a law, regulation, policy, procedure, or the Standards of Conduct has been violated, or that misconduct has occurred. Issues may be received in any form including, but not limited to, calls made to the Hotline, letters, e‐mails, fax communications, web submissions, in‐person visits, and telephone calls.
An Issue does not include requests for information or advice, routine compliance assistance, copies of complaints under investigation by other departments, and in‐person conversations or telephone calls that are not documented because they do not involve an allegation or are minor violations that have been resolved and do not require further action. “
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Identify Key Terms & Team Players… “Reporter” refers to the person who brings forward an issue.
A Reporter may be named or anonymous.
“Subject” refers to the person alleged to have committed the violation, not the person who reported the issue.
“Case Manager” refers to the compliance staff member who is responsible for providing oversight to investigators and ensuring the issue is addressed timely and appropriately.
“Lead Investigator” refers to the person responsible for managing the issue from receipt through case closure.
“Investigator” refers to the person or persons assigned to investigate an issue.
How Do Issues Get Reported
“In‐person” visits
E‐mail
Telephone call
Web submission
Suspicions
Observations
Overhear
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“Let everyone be your
eyes and ears!”
Ways to Promote Reporting… Posters
Intranet sites
FAQs
Code of Conduct
External website
Compliance Week
Newsletters
Trainings– In person and computer based
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Building a Rapport…When assigning an investigator, you should ask yourself the following:
Does the person have the subject matter expertise to investigate the issue?
Does the person understand what is required for an effective investigation?
Does the person understand the obligation to maintain the confidentiality of the Reporter and witnesses to the extent provided by law?
Is the person free of conflicts of interest or other biases that might influence their judgment and the investigation?
Can the person complete the investigation in a timely manner?
Investigating Issues…The purpose of an investigation is to establish the facts as to what occurred and to develop recommendations to assist the decision‐maker in determining what type of corrective or disciplinary action is required to remedy the violation or act of misconduct and prevent reoccurrence.
Understand the Scope of the Reported Issue(s)Prior to assigning an Investigator, the Lead Investigator should contact the Reporter, if contact information is provided, and review the allegation(s) with the Reporter to ensure that the allegation(s) has been fully documented and understood.
Reporting of Significant IssuesIf the Lead Investigator determines that the reported issue contains allegations that are significant either because of who is alleged to have been involved in the misconduct or the nature of the allegations themselves, the Lead Investigator will ensure that appropriate notifications are made. Such notifications shall be on a need to know basis. Only truly significant allegations, which include sufficient facts that appear credible, should be reported to leadership prior to establishing their validity.
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Investigating Issues… If an issue involves a compliance, risk or regulatory matter that could have
significant potential financial, legal, operational or reputation impact, such issue shall be coordinated with the Compliance Department, who will notify the appropriate entity leadership.
Significant Issues require appropriate investigation and notification. The Lead Investigator for significant Issues will use the Investigation Scope and Process Brief document in Appendix A as a tool for briefing client representatives or leadership.
Attorney‐Client Privilege
If the Lead Investigator believes, based on the scope and significance of the allegations, that an issue should be investigated under attorney‐client privilege, the Lead Investigator will contact the Compliance Officer for consultation. If it is determined that an issue should be investigated under attorney‐client privilege, the issue will not be further documented by compliance. Instead, the issue will be documented and reported to the Chief Legal Officer or designated attorney, directly by the Compliance Officer and the involved attorney, who will retain all the files.
Letting Everyone
Know It!
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Building a Culture of Compliance Branding your department
Making the presence of your Compliance Officer &
Department known
Getting Senior Leadership Buy‐in
Communicating daily
Developing both internal & external websites
Key Benefits to Branding
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What Branding Does for Your Department…. A brand is a kind of promise.
It is a set of fundamental principles as understood by anyone who comes into contact with your department.
A brand is an department's reason for being and how that reason is expressed through its various communications media to its key audiences, including customers, shareholders, and employees.
It let’s people both internally and externally know who you are and what they should contact you
for!
Non‐Retaliation
A policy should be developed and it should be:
Implemented and communicated at all levels
Highly enforced
Should be apart of education and training
Should tie into reporting compliance/ethics concerns
Should be cross referenced in all policies where suspected retaliation can occur
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Non‐RetaliationNon‐retaliation means that an employee cannot be treated differently, unfairly, or unkind if they report
a concern to:Manager/Supervisor
Human Resources
The Compliance/Ethics Department
The Compliance/Ethics Officer
The Compliance/Ethics Hotline
Investigating a Concern:
Strictly an internal policy
Lays out how concerns are investigated
Discusses conflict of interest in terms of if a senior leader is involved in an investigation
Lays out the chain of command to report a concern
Explains what reporting a concern means:
Allegations v. Substantiated issues
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How to Maintain the Rapport….
Everyone makes a difference
Conduct purposeful investigations
Ensure non‐retaliation
Maintain confidentiality
Promote, Promote, Promote!
Hotline:
Anonymous
Highly confidential
24/7, 365 Availability
Accessibility‐ telephone, web submissions, email, etc.
Case Management Protocols
Educate & Training
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Key Benefits of Hotline Data Displays risk areas system‐wide Identify potential fraud/waste/abuse Identify vulnerabilities Education/training needed Tells Senior Leadership bout their Directors/Managers
Do employees feel comfortable identifying themselves? Are you receiving multiple complaints about the same the issue?
How many concerns are reported in a designated department/business unit?
What’s the timeframe in which investigations are conducted and resolved?
Key Takeaways
Start with Leadership
Everyone is a key player in Compliance
Welcome everyone in reporting compliance concerns
Establish multiple avenues for reporting compliance concerns
Creating and maintaining a culture of compliance reduces risks
Branding your organization’s Compliance Department is a useful tool
Education/training is a critical component to Compliance
Make processes and protocols for compliance matters easily accessible
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Questions….
Thank you….
Ciarra R. Miles, CHCRAC Paralegal
Johns Hopkins Health System(410) 614‐2281 (tel)[email protected]