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* Can we integrate our compliance and patient grievance reporting systems?
* ABN-Gs and Ls
* Pay-per-view article: Payroll audits: Look for holes in your salary process

Compliance Monitor, May 4, 2003

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Q: What are the pros and cons of integrating our compliance reporting system with our patient grievance reporting system? If integrated, we would handle the compliance reports in a manner that meets the functional requirements for a sound compliance reporting system.

A:Integrating a compliance program with another committee or organizational function is doable, but only if careful attention is given to maintaining the integrity and goals of each group. For example, many organizations have recently integrated HIPAA oversight into their compliance programs, since the two share many common links and integration issues. With proper oversight, the two groups achieve a synergy that would not be accomplished in separate settings.

The major challenge, though, is to effectively combine the programs and avoid unnecessary duplication, bureaucracy, communication problems, and ineffective resolution processes. If the scope of the new committee becomes too big, someone must determine its focus-whether it's strategic, policy, or operations-and then lead its members in that new direction. Some organizationsuse a large oversight committee and separate sub-committees. Sometimes committees become ineffective, though, trying to do too many things at once without the appropriate support or direction. Be careful to avoid this.

Let's review the purpose of each committee and program before we consider the challenges of integrating them:

1. A compliance program should prevent and detect any violations of federal, state, or local laws with a focus on billing and coding issues. A procedure and process is in place to investigate and correct any violations. Compliance workers also monitor and audit, educate and train, develop and implement new procedures and evaluate compliance effectiveness.

2. A patient grievance committee usually has an ombudsman function to triage patient complaints to a point person. The ombudsman then tracks all complaints and works with departments to seek resolution. The risk management department and the legal department sometimes get involved. Issues are usually presented to a grievance committee to track patterns, trends, and address policies and procedures that may need to be changed. From this committee, subgroups and task forces may address a particular problem or concern. If the issue has a quality assurance component, your quality department may become involved.

Integrating these functions could

• save time for employees who participate in both groups.
• create synergy in problem solving and timely solution finding.
• help the organization to address broader organizational compliance issues.
• strengthen decision-making processes.

If you're going to try it, also consider the following:

• It could be difficult cleanly separating the tasks of each group. One group could dominate while another takes a lesser role.
• One large committee could be less effective than two smaller ones.
• Increased volume of work could cause the training and education functions of both committees to diminish.
• "Grievances" may include patient, physician, and employee grievances and, as a result, may slow down existing processes.
• Centralized functions are not always better. The organization could become dependent on the committee to resolve problems that need to be resolved at the local or department level.

If your organization is interested in combining the two committees, form a work group with representatives from both committees to explore the feasibility of integration. With enough time, effort, and careful consideration of the issues, they can decide whether your organization can support an integrated approach to compliance and grievance issues.

This question was answered by Michael O'Connell, MHA, CMPE, CHE, senior director of the Cleveland Health Network MSO, LLC, in Independence, OH.

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Q: Is it appropriate to use the advance beneficiary notice G form (ABN-G) when performing lab tests in a hospital setting? Our case management department says we should use only the advance beneficiary notice L form (ABN-L) for lab tests, and ABN-G for everything else ("G" is for general). Our computer system automatically generates an ABN-G when someone enters an order in our system that does not meet medical necessity requirements. ABN-L forms are manually generated for patients, and I would like to save our lab personnel time by letting the system generate the ABN-G.

A: The Centers for Medicare and Medicaid Services (CMS) says that either form is acceptable and will meet the requirements under the advanced beneficiary notice (ABN) guidelines. However, CMS indicated that the "Lab" form, CMS-R-131-L, was specifically designed for laboratories to make it easier to obtain the necessary patient information to ensure compliance.

The general ABN form, CMS-R-131-G, does not provide the three extra spaces for listing the lab test, as the L-form does. One would list the lab test based on the expected reason for denial. The test in this case would do one of the following:

1. Lack medical necessity
2. Exceed frequency limitations
3. Be considered xperimental

Most laboratories use the lab form because it is more user-friendly and it clearly indicates to the patient that laboratory tests are scheduled.

This question was answered by Rick Oliver, JD, CHCO, CPC, MT (ASCP), director of compliance at AmeriPath, Inc.

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