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Recent Compliance Updates & Tips

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Tips From Experts

Careless handling of hotline complaints can result in serious problems for an organization and the Compliance Officer, who is expected to address information received from complainants. The right decisions have to be made on the proper way to deal with the information. All allegations or complaints that appear to have merit need to be promptly analyzed.

Tom Herrmann, JD, served for more than thirty years in the Office of Counsel to the Inspector General and as an Appellate Judge of the Medicare Appeals Board. He states, “Proper front-end analysis of complaints is similar to the ‘triaging’ process of a hospital assessing a patient being admitted. The objectives are the same: to determine the seriousness of the issues, what action is needed, and who is best equipped to address the problem.”

Steve Forman, whose career spans from having been the Director of Management Operations for the OIG to ten years as Vice President of Audit and Compliance for one of the largest hospital systems in the country, believes, “The first problem is who is in the best position to evaluate and take any needed action on the information provided. Many of the common complaints do not fall within the scope of responsibility of the Compliance Officer and the issues are often best resolved by human resource management, the HIPAA Privacy or Security Officer, or some other program official.”

Suzanne Castaldo, JD, a senior compliance consultant, makes it a point to note: “Some matters may require direct involvement of legal counsel, and sometimes the matter may require reporting to the local police or other law enforcement agency. Also, it is important to remember that many allegations and complaints may be quickly resolved. The information may be so vague as to not offer any leads to follow, or the information is such that there may not be corroborating evidence to support the allegations. As such, without additional information, there is either little that can be done, or what can be done may not warrant expenditure of resources and the matter should be closed.”

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Encourage Anonymity

Al Bassett, a former Deputy Inspector General and FBI executive who has been providing compliance advices to many providers, states: “There are many who don’t like having anonymous reporting and believe forcing identification would reduce the number of frivolous or bad-faith complaints, but they are wrong. It is a mistake to assume that just because the person is anonymous, the information they provide should be discounted and failing to act upon information thus provided can create a potential liability, especially where a violation of law or regulation is involved. The reality is that the best practice is to encourage anonymous reporting.  It is strongly encouraged by the HHS OIG, DOJ, and US Sentencing Commission to permit anonymous reporting for those fearful of reprisals; failing to provide this avenue would cut off the reporting of potentially serious violations of laws or regulations.”

Carrie Kusserow, a former owner of one of the largest hotline service vendors, has seen thousands of complaints. She notes, “Some of the most serious allegations received anonymously may involve a senior person in the organization, which heightens the whistleblower’s fear of potential reprisal; failing to properly act upon that kind of information could result in serious intervention and penalties by outside authorities. Furthermore, as long as the person remains anonymous, there is no burden to protect that person from any adverse actions by management. The alternative to anonymity is confidential reporting, where the person making the report is guaranteed protection against reprisals and retaliation. Depending upon the value of the information received, an organization may want to negotiate with an anonymous person to identify themselves under assurance of protection, in order to more fully debrief the person and to assist in determining the level of credibility.”

Jillian Bower, Vice President of the Compliance Resource Center, advises: “Before any complaint is received, it would be best to have policies in place that address the duty to report; anonymity and confidentiality; compliance office operating protocols with legal counsel, human resources and others who might become involved in an investigation; and the process by which internal investigations should be conducted.”

Steps in Resolving Substantive Complaints

  1. Establish who is responsible for resolving the issues raised in the complaint
  2. Determine any law, regulation, policy, standard, or Code of Conduct provision implicated
  3. Assign an individual who is best qualified to investigate issues
  4. Determine the urgency and timeframes needed to resolve questions
  5. Discuss the issue with the deciding officials to determine what they would need to resolve a matter
  6. Establish a timeline to complete the investigation or inquiry
  7. Determine if legal counsel involvement is needed
  8. Gather relevant information on-hand related to the issue (Code, work logs, videos, policy documents, names of employees/supervisors related to the issue area, etc.)
  9. List those who need to be interviewed, and in what order
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