A Glimpse Into the Future: Health Care Compliance

Five Years From Now, Domestic and International

 

Presented by

Lewis Morris, Assistant Inspector General for Legal Affairs, Office of the Inspector General (OIG), U.S. Department of Health and Human Services (DHHS), Washington, D.C., and

L. Stephan Vincze, J.D., LL.M., President & C.E.O., Vincze & Frazer, LLC and

Vincze Compliance International, LLC

 

I.                    "Past Is Prologue" -- Where We've Been and How We Arrived Here

a.     HIPPA Funding for Law Enforcement

b.     National Projects

c.    Compliance Programs Adopted by Institutions

d.    New Benefits

e.     Defense Industry Initiative (DII) Model for Healthcare

                                                              i.      Healthcare May Serve as Model for Other Industries

1.      Confidentiality/Privacy Issues

2.      Technology/Internet

3.      Domestic & International

                                                            ii.      Evolution From Pure Compliance/Legal-Based Programs to Combination of Ethics and Compliance-Based Programs

 

II.                  "Clouds on the Horizon" -- Risks to Sustaining Effective Compliance

a.     Perceived Lack of Credibility

                                                              i.      Government Regulation and Enforcement

                                                            ii.      Private Compliance Programs' Effectiveness

b.     Perception of Compliance Programs As Pure Cost Centers

c.    One Dimensional Understanding of Compliance as Legal Defense Mechanism/Insurance Policy

d.    Lack of Empirical Measurement of Compliance Effectiveness That Links Effectiveness to Operational Quality and Financial Performance

e.     Organizational/Management Budget Pressures to "Cut Back" on Compliance Efforts

                                                              i.      Staffing

                                                            ii.      Training

                                                          iii.      Monitoring and Auditing

                                                           iv.      Reporting

f.     Reduced Government Enforcement

g.    Lack of Positive Financial Incentives to Sustain Compliance Investment

 

III.                "Politics of Partnership" -- Public and Private Sector Unity of Purpose

a.     Common Goals: 

                                                              i.      Stop Fraud, Waste and Abuse

                                                            ii.      Increase Accuracy, Efficiency and Quality of Care

b.     Focus on Results/Outcomes

                                                              i.      Attitudes/Awareness

                                                            ii.      Behavior/Conduct

                                                          iii.      Operational Quality/Efficiency

                                                           iv.      Financial Performance/Productivity

c.    Develop Empirical Measurement and National Standard for Effectiveness

                                                              i.      Harness Technology and Current Data Bases

1.      Measure Specific Billing Activity

a.      Coding (DRG, CPT, ICD)

b.      Over/Under Billing

2.      Compare Results To National/Regional Baseline

                                                            ii.      Reduce/Eliminate Regional Regulatory Variations and Interpretations

d.    Enhance Behavior Modification Through Greater Public Disclosure

                                                              i.      Licensure Board Action

                                                            ii.      OIG Exclusion List

                                                          iii.      National and State Level

e.     Build Coalition Between Medical, Business. Legal, Academic and Government Sectors to Establish Compliance As A Sustainable and Supportable Process that Integrates These Sectors To Achieve Mutual and Individual Goals and Objectives

f.     Provide Carrots as Well As Sticks To Organizations To Sustain Compliance

g.    Share Lessons Learned With Other Nations To Enhance Global Efficiency

                                                              i.      Political/Government Lessons

                                                            ii.      Legal/Regulatory Lessons

                                                          iii.      Economic/Financial Lessons

                                                           iv.      Healthcare Lessons

1.      Clinical

2.      Technological

3.      Informational/Administrative