Internal Investigations: Common Conundrums, Conflicting Agendas, and How to Deal With Them Al Josephs and Frank Sheeder
A. • • • • • •
Chief Executive Officer Set proper tone consistent with corporate values. Communicate with Board of Directors. Physician relations. Financial impact of process and underlying issue. Protect reputation. Competent management of compliance process.
B. • • • • • • • • •
Physician Leader Protect interest of physicians. Understand and validate audit process. Financial impact. Expectation that physician is not primarily accountable for non-compliance. Timely communication to physicians about process and developments. Impatience and frustration. Desire to control process. End-runs around the process. Individual vs. group problem and responsibility.
C. • • • • • • • • • •
Business Manager Defensive. No buy-in on process. Failure to identify compliance issues. Denial that there is a problem. Personnel issues. Physician relations. Implement recommended changes. Ensure consistency of operations. Live daily with results of compliance process. Ensure staff competency.
Internal Investigations: Common Conundrums, Conflicting Agendas, and How to Deal With Them
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D. • • • • • • • •
Board of Directors Corporate Responsibility and Corporate Compliance: Care Boards of Directors. Duty of care. Hold management accountable. High level knowledge of compliance matters. Routine progress reports. Protect reputation. Financial impact. Plan for future prevention of compliance issues. A Resource for Health
E. • • • • • • • • • • • • • •
Compliance Officer Get issue to CEO promptly. Validate issue. Stop any potentially non-compliant activities. Integrity, independence, consistency, and fairness in process. Well-designed workplan. Communication. Confidentiality. Non-retaliation. Select and manage external lawyers and consultants. Manage the varying interests of all stakeholders and accommodate them. Critique and critical analysis at end of process. Remove stakeholders from the process. Recommendations for resolution. Internal action plans.
F. • • • • • •
Consultants Quality, defensive work product. Comfortable with accuracy of information. Understand players and agendas. Duty to client contact vs. duty to entity. Define scope of engagement. Develop workplan.
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G. • • • • • • • •
Physicians Too busy. Does not impact quality of patient care. Never happen to me. Complex and vague rules. Why didn’t management catch this sooner? Financial impact. Allocate responsibility to management and staff. I want a second opinion.
H. • • • • • • •
Internal Coding Auditor Ability to identify and document issues. Establish credibility with physicians, billing staff, management. Clear lines of communication and reporting. Know when to call “time out.” Keep up with regulatory changes. Education of physicians and staff. Provide useful feedback from audits.
I. • • • • • •
Billing Office Quality of information and documentation needed to bill properly. Prevent “us vs. them” mentality. Allocate responsibility to clinics and physicians. Accountability and reporting to clinics and physicians. Dealing with payor inquiries and patient complaints. Detecting and preventing inappropriate billing.
J. • • • • • • • • •
Counsel Development of facts. Application of law to facts. Deal with conflicting information. Anticipate defenses. Credibility. Understand and deal with contractual relationships, historical practices, and entity’s past compliance issues. Defend and advocate for the entity. Recommend, engage, and manage consultants. Maintain privilege and work product protection.
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Communicate and deal with authorities, regulators, payors, opposing counsel, witnesses. Evaluate and recommend means of resolution.
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