One of the biggest challenges compliance professionals face is how to get the attention of their audience (board members, physicians, nurses, administrators, staff) when making others aware of the importance of the compliance programs within their institutions.
As any good teacher would do, it is important to be creative in achieving your goal of having your audience remain attentive and retain the message you are delivering. Today, with the threat of RACs coupled with healthcare reform, the pressure on all healthcare providers to ensure that payments are proper (being compliant) is more significant than ever. Still, it is important that we not lose sight of opportunities to be creative in delivering the message about why these issues are important and why everyone should be concerned and aware.
Real Life Lessons
When I was a compliance officer, I always tried to find "real-life" healthcare compliance or fraud and abuse stories to draw the attention of the audience. Today, due to all of the compliance settlements and investigations occurring in numerous industries, it is becoming easier and easier to find stories to which people can relate.
This became apparent to me recently while watching an episode of HBO's Real Sports. After a long day of helping healthcare providers across the country with regulatory issues, the last thing on my mind while sitting down to watch a sports show was compliance. However, it soon became clear to me that the chronicle being presented could represent a real opportunity for compliance professionals to "tell an interesting story" about why compliance and ethical behavior is important, and how it can work or not work. In this case, the story involved a very different subject than coding, documentation, RACs, etc...
The story was about the University of Southern California (USC) Trojans athletic program. Mostly, the story focused on the school's storied and successful football program and the recent investigation of illegal behavior that led to draconian penalties being levied. The Reggie Bush scandal was the basis of the story, and for me it was fascinating to compare it to issues we are seeing today in healthcare fraud and abuse settlements.
The thrust of the USC story is as follows (understanding that amateur college athletes are not permitted by NCAA regulations to accept any money or benefit from playing sports beyond earning approved scholarships): Bush was a star tailback at USC who won the 2005 Heisman trophy (honoring college football's best player) after starting on USC's national championship team in 2004. However, during his time at USC there was substantial evidence that Bush and his family accepted more than $100,000 in improper benefits while playing there. Documents and on-record interviews showed that Bush and his family received benefits from individuals hoping to become his sports agent when he turned pro.
The story as HBO presented it is very interesting for a couple of compliance reasons that caught my attention. The first is that Mr. Bush during his sophomore year allegedly began to drive a car that he apparently could not afford. When paperwork was presented to Bush to disclose the source of funding for his vehicle (apparently a compliance requirement at USC), he failed to complete a substantial portion of the form. According to the school's head football coach at the time, Pete Carroll, when this form was returned to the compliance department, even though it had not been completed, the compliance officer never followed up or investigated the matter further. In fact, Carroll went on to say that compliance basically had not done its job. The other evident problem was that apparently no one else (the head coach, athletic director, teammates, alumni, school administrators) questioned how Mr. Bush could afford this vehicle.
The second interesting point was that this matter probably would not have been uncovered by investigators if an informant, a disgruntled former associate of Bush (we call them "whistleblowers" in healthcare), had not come forward to disclose it. The informant allegedly provided some of the funding for Bush and his family, including a new home and a monthly living stipend.
The conclusion of the four-year investigation into the matter included the following: USC ended up being placed on four years of probation, including a two-year bowl ban, and scholarship reductions were enacted for the football program. The basketball program, which already had been under self-imposed probation, also was penalized.
Culture of Compliance
Going forward, USC now is committed to making sure that it prevents athletes from receiving illegal benefits when they play for the school. It also was reported that the school has expanded its compliance staff from one officer to eight. A new athletic director, former Rhodes scholar and star football player Pat Haden, was hired, and he apparently understands the challenge in front of him. According to websites he was quoted as follows: "we want to compete ferociously and win in every sport, but we want to do it ethically and within the rules. We're going to have a culture of compliance around here. Every meeting is going to start with the No. 1 item as compliance. ... We're going to try to be perfect. When we make mistakes, we're going to fess up, and we're going to try to do better next time."
In adhering to the NCAA's rulings, every connection with Bush has been removed from USC's storied Heritage Hall, including a replica of his Heisman Trophy and his No. 5 jersey.
Given the pressures on healthcare providers today, it is important that everyone understand the compliance threat. Even though the Reggie Bush story is different from what we deal with in making sure documentation and coding are compliant, there are striking similarities in behavior to those providers that don't take proactive compliance measures.
Lessons to be Learned
In comparison to our challenges within the healthcare compliance industry, here are a couple of thoughts to consider in regard to the applicability of the USC story: USC's compliance efforts were increased after the fact; o all providers have enough resources and the right leadership in place today? USC didn't respond to the incomplete disclosure form that Bush was to file; are there documentation lapses that providers have identified which haven't been fixed, with no payments refunded or corrective actions taken?
The investigation of USC occurred because of an informant; do providers have measures in place, including policies and procedures, education programs, hotlines, etc. to protect against this threat? Everyone saw Mr. Bush driving his car around the USC campus his sophomore year, so why didn't anyone question it? And have providers properly educated their employees to be observant for noncompliant behaviors and reminded them of their obligation to report them?
It is obvious by watching the HBO story that USC didn't really embrace compliance as an organizational culture within its football team.
About the Author
Bret S. Bissey, MBA, FACHE, CHC, is a nationally recognized expert in healthcare compliance. He is the author of the Compliance Officer's Handbook, published in 2006, and has presented at more than 40 regional and national industry conferences/meetings on numerous compliance topics. He has more than 25 years of diversified healthcare management, operations and compliance experience.
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