Case Study:

Hospital Compliance Program with External Support at a Rural Referral Center

The Circumstances and Challenges

A medium-sized hospital that served as a referral center for other small rural hospitals had just “lost” its Compliance Officer.  As is so often the case in medium-sized and small hospitals, the Compliance Officer function is an add-on to the duties of the Risk Manager.  When the Risk Manager resigned, the Hospital suddenly found itself with two essential functions vacant.

The Hospital had also reviewed its compliance activities by an accounting firm, which identified 62 areas for improvement.  Implementing these recommendations had already been lagging.

The Hospital is located in a relatively remote area, with a population of fewer than 25,000 persons in the metropolitan area around the institution.

The combination of the loss of the Risk Manager and the deficiencies identified by the accounting firm led the Hospital to consider using a consulting firm to assist their compliance efforts.


The Change and Selection of a Consulting Firm

The CEO had heard of The Fox Group, LLC from another area hospital CEO, a client of The Fox Group, LLC, and contacted us to discuss a long-term consulting engagement to cover both the Hospital’s Compliance Officer and Privacy Officer functions.

The Fox Group proposed a fixed monthly fee as a part of our concept to partner with the Hospital and their compliance program. This approach appealed to the CEO as it allowed him to accurately and confidently budget his expense. In addition, it freed his organization from the burden of monitoring and managing the consulting hours related to this endeavor. As a part of the engagement, The Fox Group agreed to provide Privacy Officer services, thus relieving the Health Information Manager of those burdensome duties, which had become overwhelming for them.

The hospital compliance program had significant deficiencies, and it struggled to meet even the basic requirements as outlined by the Office of the Inspector General. For example:

  • Compliance committee meetings were sporadic,
  • Auditing and monitoring activities were not happening,
  • Their annual compliance workplan was nonexistent.

The Fox Group immediately assumed the role of oversight of both the compliance office and privacy officer functions. This freed the Risk Manager and Health Information Manager of those duties and allowed them to concentrate their time and efforts on their assigned functions. Initially, The Fox Group implemented several initiatives to strengthen its compliance program. Among these initiatives were:

  • Immediately instituted monthly compliance meetings involving management staff to maintain proper focus on compliance issues,
  • Immediately drafted an Annual Compliance Workplan,
  • Integrate the recommendations of the accounting firm into the Hospital’s compliance activities (ultimately, 54 of the 62 recommendations were adopted and implemented into the Hospital’s operations).


The Solution, Outcome, and Sustainability

In the first year of the partnership with The Fox Group, the compliance and privacy functions were well-established and smoothly running within the organization.

In addition to the routine activities such as committee meetings, audits, and privacy investigations, the Compliance Department is contacted several times a week for review or advice. These requests included:

  • New contracts and business associate agreements,
  • Financial transactions with referring physicians, and
  • Questions about activities that involve interpreting the code of conduct.

As a part of the engagement with the Hospital, The Fox Group has assigned a team of experienced healthcare professionals to assist the Hospital. This team approach has the advantage of bringing a wider set of eyes, knowledge, and experience to every situation rather than relying upon one individual.

The compliance and privacy professionals furnished by The Fox Group have helped the Hospital deal with thorny issues that many hospitals face, including:

  • The policies on access to employees own electronic medical records were reviewed and revised. This is an area where managers sometimes want to excuse their employees’ accessing medical records of themselves, their family members or even friends or other relatives. This is a good example of advocating for compliance with laws and regulations, even in the face of opposition from some members of management.
  • Proper billing and medical record documentation are an area of constant inquiry. The compliance officer functions as a resource to the revenue cycle department on a host of billing questions. These include Medicare coverage and billing requirements and financial assistance policies required for non-for-profit hospitals.  The Fox Group always provides documented references for hospital staff when responding to these requests.
  • Occasionally a new staff member is hired who is on the OIG exclusion list. The compliance officer is called upon to analyze the situation and help the Hospital take steps to report the occurrence to the OIG and manage the follow-up if a self-report and financial penalty is indicated.

Utilizing consultants for the Compliance Officer and Privacy Officer functions has worked well for the Hospital.

The Hospital has enjoyed the benefits of a fixed budget for services and highly professional staff assigned to their account.  The arrangement has stood the test of time through turnover in hospital staff, even at the CEO level.  As would be true of any arrangement, both parties see the value and benefit!

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