Nursing

Why comply?

Staff Development Weekly: Insight on Evidence-Based Practice in Education, November 14, 2005

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Warren is a compliance officer for a small community hospital. Susan, a billing clerk, approaches him, and Warren notices Susan looks concerned. "Hi, Susan," he says. "What's wrong?"

"I was looking over some recent lab bills, and I think we've been billing for additional panels," Susan says.

"Are you saying that we didn't provide the services?" asks Warren.

"We provided the services, but they were never ordered by the attending physicians. I'm concerned because I've noticed them on a number of recently submitted claims, and this practice might go back years," she says.

"Well, I'm glad that you brought this to my attention," Warren says. "I'll have to look into it in greater detail, but for now, make sure that you correct the current bills before they go out. And please don't mention this problem to anyone else."

After several weeks, Susan visits Warren in his office: "Hi, Warren. I've done what you asked about lab claims, but I wanted to check back with you about your review of past claims."

"We've been very busy here, and I haven't had a chance to fit it into our work plan yet. Don't worry about it," he says.

Several more weeks go by, and Susan hasn't heard anything from Warren. She's becoming concerned because she knows that false billing is a major exposure for hospitals. She's worried about the stability of her job and whether she could be found at fault by government enforcers. She's thinking about seeing an attorney.

What would you do?

First let's look at what Warren did right: He was receptive to Susan's initial concern. Also, he acknowledged that there could be a problem and seemed grateful that it was brought to his attention.

However, he never investigated the problem, and he didn't follow up with Susan. Warren is gambling that the potential problem is not a major exposure and that Susan won't take her findings to an outside source. Furthermore, by not doing what's right, Warren is undermining the compliance program's intent. If an employee comes forward with a compliance concern, you or another member of the compliance team must investigate the concern and, if possible, follow up with the employee.

Editor's note: The above excerpt is from the online course, "Key Issues in Compliance Planning." For more information on this and other courses in our library, go to www.hcprofessor.com.



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