Emory Report

 December 8, 1997

 Volume 50, No. 15

Emory mounts proactive
health care compliance effort

Karen Guarino, a lawyer and nurse, has been director of Compliance Programs at Emory Healthcare and the School of Medicine since May. She'll eventually head a staff of seven, located at the 1525 Building, who will proactively train, monitor and guard against noncompliance of the many federal and state regulations that govern health care programs, including Medicare and Medicaid.

Required medical staff training on documentation, coding and billing is already underway and should be completed by the end of the month. A letter from Michael Johns, executive vice president for health affairs, said physicians who fail to complete training will lose their billing privileges.

Emory has undertaken this initiative proactively and takes it very seriously-with good reason. Major health care institutions such as Columbia/HCA Healthcare and the University of Pennsylvania Medical Center have been in the news recently with investigations and accusations of fraud and wrongdoing. The University of Pennsylvania had to pay damages of some $30 million for failure to comply with federal billing guidelines for physicians and medical residents at teaching hospitals. As part of its settlement, Penn had to set up a compliance program. "The programs the government imposes as part of a settlement or sentence-called 'integrity programs'-are very onerous," Guarino said.

To get credit with the government for an effective compliance program, institutions must include in their initiatives oversight responsibilities, delegation of authority, compliance standards and procedures, employee training, monitoring and auditing; response and prevention, and enforcement and discipline. For Emory employees responsible for billing and coding patient accounts, that simply means they must know the applicable laws and regulations, agree to abide by them, agree to detect and report noncompliance, and help design and implement internal mechanisms to correct problems.

Organizations that are investigated, but already have compliance programs in place, are given "credit" by the government if violations are found, said Guarino. "An organization can save as much as 95 percent of a criminal fine or civil settlement if they have an effective compliance program."

But those fines can still be steep. In a letter sent to Georgia hospitals in August, including Emory and Crawford Long, the U.S. attorney stated that institutions participating in a voluntary self-audit of outpatient laboratory billings would pay double the amount of any error found. Those that didn't volunteer could pay substantially more, including penalties of thousands of dollars per error found by the government.

"The health care industry has had more than ample warning that health care fraud has been elevated by the attorney general to the nation's top enforcement priority, second only to violent crime," said D. McCarty Thornton, associate general counsel in the Office of the Inspector General.

Guarino shows a slide with Thorton's warning during training sessions. Other statistics she gives: since 1992 the FBI has tripled its number of health care fraud investigations from 657 to 2,200; civil health care fraud investigations by the Justice Department have increased ninefold from 270 in 1992 to 2,488 last year. The government no longer accepts "ignorance of the law" as an excuse to avoid prosecuation, said Guarino. "The standard has changed. It has evolved from you had to intend to cheat the government, then it was you knew or should have known you were submitting a false claim. And now under the new Health Insurance Portability and Accountability Act, the standard has been broadened to include recklessness, disregard or intentional ignorance of the rules. Our compliance training and monitoring demonstrates Emory's intent to comply."

The primary goal of a compliance program is preventing violations. However, the good news is that institutions that find billing errors themselves and repay the government the disputed sum will incur no penalty-hopefully. "I think there's always concern that if you go and make a disclosure, it might trigger a broader review, but I don't find that to be the case," said Guarino. "If the government sees that you're willing to come forward when there's a problem, they're grateful and view the entity as a good corporate citizen."

For more information on Emory's compliance program or training, call 778-2757.

-Stacey Jones

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