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
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
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
For more information on Emory's compliance program or training, call
to December 8, 1997 Contents Page