Flipping the Script with CJ Wolf and Nick Merkin – The Host Becomes the Guest!

We're switching things up in our latest episode of Compliance Conversations! This time CJ Wolf is in the hot seat, with Nick Merkin conducting the interview. Nick is a healthcare attorney and the CEO of Compliagent, a nationwide consulting firm specializing in compliance infrastructure.

Check out this episode, “Turning the Tables: Our Guest Interviews Our Host CJ Wolf,” as they discuss:

• The winding road to careers in compliance
• Real-life scenarios and questions that blend medical knowledge with compliance expertise
• How to build strong relationships with doctors and medical officers
• Why compliance officers to need think holistically about big picture issues and granular challenges
 

As a longtime healthcare compliance expert, Nick brings a unique perspective to the conversation, asking CJ about considerations for medical necessity, proper documentation, and how cultivating stronger relationships can ultimately lead to a more robust compliance program.

Episode Transcript

CJ Wolf: Welcome everybody to another episode of Compliance Conversations. I'm CJ Wolf with Healthicity and we are glad that you're listening to these episodes. We want to just remind you that it's important to subscribe and hit the like button, so that others can find this content and that you also don't miss future episodes, so just a quick reminder there. 

Today we're going to switch things up a little bit. We've had Nick Merkin on prior podcasts as a guest. But today I'm going to be on the hot seat. Nick, maybe we'll just first give you a quick 30 seconds or so to reintroduce yourself. We know you've done it on other podcasts, but you know, I know some may have not listened to those other podcasts, so maybe just tell us quickly about yourself and then we'll let you ask me questions.  

Nick Merkin: That sounds good. Thank you, CJ. Just a little bit of background. My name is Nick Merkin and I'm actually a healthcare attorney by background, but I run a consulting firm called Compligent, we're a national firm and we specialize in building out compliance infrastructure for different kinds of healthcare provider organizations.  

CJ: Yeah, and I'll just put in there, besides Nick being an expert in healthcare compliance, he's just good people. I've known Nick for a while and I just appreciate his attitude and his approach. He's just so great to work with. So, thanks Nick for being who you are.  

Nick: Thank you, my pleasure and thank you for having me. I don't know how many interviews you've done, but how does it feel to be on the other side of the mic, so to speak? 

CJ: Well, I'm a little scared now. What have I done to past guests, that now karma is going to come back and get me?  

Nick: I'll be easy on you, I promise. Well, let's start with this because I'm always interested in people's backgrounds. And compliance, and particularly healthcare compliance is kind of a unique field. In some sense, it’s not the kind of thing that you thought about, "Hey, in 6th grade, I want to grow up and become a fireman or an astronaut or something like that." Not that many people say, "Well, I'd like to be a Chief compliance officer at a major Medical Center or something along those lines." And I know your background is in clinical medicine originally. Tell us a little bit about that and how you got into the world of compliance. 

CJ: Yeah, it's a good question because my kids still ask me, "What is it you do again dad, you know?" "Oh, I teach people about rules." They're like, "that sounds like the worst job in the world." But you're right, I started in the clinical route, and I loved it. And in undergrad, I took an anatomy class and just fell in love with anatomy, my anatomy teacher was just one of those people who inspired me. And I was in the cadaver lab looking at cadavers and just thought, "Wow, this is it."  
So that was my initial desire to kind of be in life sciences. I ended up going to medical school and loved medical school. I loved the learning but kind of towards the end of medical school. I thought, "I don't love this direct patient care as much as I thought I would." Even though I love the science and so I was just, "what do I do now?" It's like, "whoa, I just spent all this time and money." So, long story short, I finished medical school, and started a residency program in psychiatry of all things and early in that residency I thought, "I need to do something different" and jump ship and started working for a large healthcare organization called Intermountain Healthcare, that was looking for somebody dumb enough to try to teach doctors about Medicare compliance. I guess I was dumb enough, I love teaching and so I loved the healthcare side and they were looking for somebody with a little bit of experience to kind of play that angle with the docs and then from there it progressed. So, I started with coding and billing, certified coder, medical coder and then I got into compliance overall. Worked at MD Anderson Cancer Center as their director of billing compliance and then went to the University of Texas system; for the academic and medical institutions, and then I went international; worked as a Chief Compliance Officer for an international medical device company, and then I've been doing teaching and consulting. So, kind of been doing it for a while.  
But you're right, it's weird, it's funny how we all end up where we are, but we all do come from different paths, right? We meet people from law, people from finance who do auditing, nurses, and all sorts of great people.  

Nick: Yeah, that's actually one of the things I most enjoy about working in a compliance field, as I mentioned, I have a legal background and I come across people and interact with people all the time that have a clinical medicine background, maybe a research background, a lot of people come to compliance on the finance side, they've been CFOs of hospitals or other kinds of healthcare organizations, and I think the multidisciplinary nature of it, if that's a good way of saying it, is kind of one of the things that makes it a really interesting career path.  
Like you were saying, "Life sometimes only makes sense in reverse," right? Like if you would talk about how you got here it might not make a lot of sense, but it does. 
So, on that, I want to know a little bit about what you're passionate about within the field. Maybe a way to ask this is– if you had to write a book on a compliance-related subject, I know you've done some university-level teaching on compliance, what would be the subject of that? What would you write about?  

CJ: I think what gets me excited in the field of compliance is the whole issue of medical necessity. I've spent time doing all sorts of compliance, HIPAA, and coding, all that sort of stuff, but the medical necessity piece for me is exciting because it really is the foundation of healthcare compliance.  
What I mean by that is, I know doctors, and we've trained doctors well enough in the documentation rules and in the coding rules, that I could get them to write a perfect note for a procedure, so that from a coding or a paper review, somebody would read the note, "Yep, that's the right code," but if it wasn't medically necessary or appropriate to perform the service in the first place, it shouldn't have been done and billed.  
So, in the Medicare world, right? Medical necessity is this foundation, and it's a space that I think combines a little bit of my background, right? I like the medical piece and understanding, "why would somebody do a heart Cath? Why would somebody do a surgery?" and there are tons of settlements, with DOJ and OIG, where doctors and hospitals have had false Claims Act settlements because the services weren't medically necessary. So, I would love to pontificate on that in a book.  

Nick: What's interesting, I think about the way you framed the question surrounding medical necessity is there's a legal aspect of it, right? So, there are standards and criteria that have to be met in order to have a procedure or maybe it's a medication or something be deemed medically necessary, but making that determination requires some medical knowledge because you have to know how to make that argument.  
Tell us a little more about, how does that work? when you see a sort of real-life example, what kind of questions do you get asked? How does this come up and what kind of analysis do you do? 

CJ: I think that's a good question. So, an example, we see these all the time. One that just kind of came up a few months ago for me, was in one of the districts in New York, either the Eastern District or the Southern District of New York, and it had to do with dialysis patients.  
Dialysis patients need a vascular access to perform dialysis and you have to have a large enough diameter tube to withdraw blood, send it through a machine and put it back in.  
Well, dialysis patients are getting hemodialysis three times a week, so their veins and their arteries start to lose patency, and typically you have to surgically create a fistula, which is a connection between the artery and vein so that you have a safe place that maintains patency to insert these needles to do dialysis because over time you start to lose access ports, in other words, so surgeons do that and then these fistulas often can get clots in them, or they can become obstructed, which obviously affects how well you're able to do dialysis.  
Well, in this case in New York, a nephrologist was the Qui Tam whistleblower said, "these doctors are doing, what are called fistulograms and angioplasties, those are diagnostic tests of the fistula, you inject contrast and look at it to see if it's blocked and then angioplasties; you take a balloon and you open up that space,” but the allegation was, “these doctors were doing them as a routine that it wasn't medically necessary for them to put the patients through that.” In other words, doctors can do it. They have the skills, but just because they do, doesn't mean every dialysis patient should have that done. There should be some criteria, and typically those criteria relate to how well is dialysis going, and there are some medical tests that say, “uh, there may be something wrong with this fistula. Let's go in and look at it.” You shouldn't automatically just do these things. There should be a medical necessity.  
So that was just one recent example that affects dialysis patients.  

But you get this in so many different specialties, so that's why I find it interesting, I'm not a nephrologist, but I know enough of the science to go ask nephrologists what and to read guidelines and clinical studies and those sorts of things to find out, "Was that medically necessary or not?"  
Now, I know on the legal side Nick and maybe you have some thoughts. I talked to attorneys and they're like, "yeah, this is the argument of experts, right? You get nephrologists who say it was medically necessary and nephrologists who say it wasn't." So, that can muddy the waters too.  

Nick:  Probably should be mentioned, these analyses might not be implied one case at a time, you may have millions of dollars’ worth of reimbursements that are at issue, that a particular practice or a particular physician has done over the course of years, that are being challenged in a medical necessity question. It can be very high stakes.  

CJ: And another example of that, there was a cardiologist in Tennessee, you know, cardiologists are looking at the blood vessels that feed the heart, and if there's a blockage then that's when you can get angina and potential heart attacks. In order to fix that blockage, they can put in stents and they can open up those arteries. That should only be done when the blockage is to a point where it's starting to affect things. This cardiologist in Tennessee was allegedly overestimating the amount of blockage and saying the blockage was 50 and 60%, when looking at the images, it was maybe only 10% or 20%, which doesn't necessarily rise to the need to perform these cardiac procedures. Well, that was the allegation. Again, in this case, it was a medical director who alleged against another doctor and they ended up settling for millions of dollars because like you said, it was over and over and over again he was doing these cardiac caths that weren't necessarily appropriate.  

Nick: So, taking kind of a step back, those are some particularly specific examples of cases, but putting on our compliance officer hat. So, I'm a compliance officer maybe it's for a very large medical practice, maybe it's in a hospital-based setting where the types of procedures that you described are going on, and I'm designing my compliance work plan for the year or my compliance plan for the year. And I know this is a risk issue, right? I read the OIG reports. I see what enforcement actions are going on. You know, we've done all the things you're supposed to do doing a risk analysis and detecting this as a risk.  
Tell me about what would be your recommendations, maybe it's from a policy perspective, maybe it's from a training perspective, maybe it's from an auditing and monitoring perspective, What are the kinds of things– especially if I'm a compliance officer, like we mentioned, not all of us come from a clinical background and we may not have as much sensitivity about this issue or really even enough expertise to make some of these determinations. What kind of infrastructure should I be thinking about putting into place, like practically speaking?  

CJ: Yeah, I think that's a good point and I'm glad you prefaced it with kind of this risk assessment because, for example, one of the issues that came up in the prior medical necessity audit was hyperbaric oxygen therapy. Those hyperbaric oxygen chambers that people enter to get their wounds treated with this high-pressure oxygen. If you don't do HBO therapy, hyperbaric oxygen therapy, that should not be on your risk, even though there have been all sorts of settlements there. So, the premise that you started with I think is the right one– Do your risk assessment, know what's going on out there and then find out which of those things are you doing.  
So, some of this is data analytics, like urine drug screening is a big medical necessity issue right now. So, do you do urine drug screening and you do a certain volume? So, I think part of it is knowing what your business does and what it doesn't do.  

Nick: To your point, and I think it's a good one, I often talk to clients about doing those kinds of risk assessments and you know what I tell compliance officers is, know your organizations’ revenue streams, right?  

CJ: That's right.  

Nick: Like you should know where money is coming from, because the risk is generally going to follow the money, right? Financial risks are not the only risks, but they're probably one of the major, if not the major compliance risk in any healthcare organization. And if you're a compliance officer, you may not come from a finance background, you should learn that. Sit down with your CFO. Sit down with the people on the finance side and understand, where are we making our money from. And pick up on things like, "wow, there are certain providers that are doing a disproportionate amount of billing for a particular procedure, is that standard? what's happening at a comparable organization across town? like, is that something that's going to get picked up on?"  
So, I think your point is well taken. I didn't mean to stop you in your discussion of how I stop it, and how I mitigate my risk.  

CJ: I think that comment is spot on. Let me kind of continue with that, but I'm going to bait all of you and I'm going to say I'm going to continue with that in a few minutes. We're going to take a short break and then I'll come back and give you my answer to the rest of the next question.  

CJ: Okay, welcome back!  

Nick: Welcome back! 

CJ: So, Nick let me respond to that a little bit more, because I think you were asking a little bit about how do you put practicality into your plan and address these issues. I think we talked about identifying those risks and once you can identify what is risky about those activities, one thing to make sure you add is Medicare has LCDs and NCDs, local coverage determinations and national coverage determinations.  
So, now when we're talking about medical necessity in this space, a doctor might clinically think, "this is medically appropriate." But Medicare says, "we're not going to pay for it for these conditions, and so we don't consider it medically necessary for payment."  
So, there could be a difference between performing something within the scope of a physician's license, which may be appropriate for them to discern, but they can't automatically demand that Medicare pay for it. If Medicare has a policy that says they're not going to, I'll give you an example.  
Some services, like you probably heard of facet injections and joint injections, are for people who have chronic pain in the back and certain areas. Some LCDs state, "you have to do a certain number of months of conservative therapy before you're allowed to proceed to this higher level of service." Meaning you have to demonstrate that they fail these lower levels of service before you can do this other one.  

So, one way to deal with that, in a practical sense is, you find the codes that relate to those procedures, you run some sort of revenue report that says, "these are our top producers of these codes," and then you go in and you look at the records and say, for that one particular issue, "Oh, did they do three months of conservative therapy? Did they document that it failed before they did the injection?" and that to me is an example of how you can kind of take a practical approach. You take this step-by-step approach and you kind of go back to see, "Did they do what they needed to do before they before they build for it?"  

Nick: It sounds like a lot of what you're mentioning touches on the issue of having the providers within your own organization, having them develop a sensitivity to these kinds of questions, right? and you mentioned that a payment determination might actually be different from a standard of care determination. If you're in a situation where kind of science, so to speak, has progressed faster than the willingness to cover, especially if it's a particularly expensive procedure or a pharmaceutical product or a medical device or something like that.  
I think kind of like you were saying about your experience in medical school and how distinct that was from some of the things you do as a compliance officer. My sense is physicians don't know a lot about this, right? And maybe for a really good reason, a physician is trained to treat a patient to the best of his ability, and that's probably as it should be. But then, of course, there are financial realities and legal realities that can temper that at times.  
So, how do you teach physicians about that? when you talk to them about that, without worrying about them compromising their ability to really treat a patient properly.  

CJ: That is such a good question. First of all, I think comes down to relationships and I think most people in compliance know that we need to get out of our offices and meet with people. Meet with the folks who are on the front lines and so, number one–You better be developing relationships with your docs and with your medical officers, right? most of these organizations will have a chief medical officer to kind of deal with some of these quality issues, but you're spot on.  
I usually approach docs with deferring to their judgment and saying, "my discussion today is not to tell you how to practice medicine, that is up to you and the leadership of our organization of what we're going to do. I'd like to talk to you about what you might and might not get paid for, and that might dictate what you're willing to do in a practical sense," and so, I don't want to judge their clinical decision making, but I want them to face the reality, that you can't just do services for free, even if you think it's the best thing, "Doctor, Do you work for free? Would you be willing to do all of this for the next year without getting paid? Do you believe in the service that much that you're willing to do this without getting paid?" Sometimes the answer is yes. Sometimes the organization says, "this is so important that we are going to put our money where our mouth is and we're going to do that," but typically when I drill down to that level, most of them are like, "well, I'm not sure I'm going to do this if Medicare is not going to pay me for it," that changes the dynamic a little bit, and so I try to keep those two issues separate. I try to say, “you're the doctor, you're the expert in the clinical decision making and no one wants to take that away from you, even Medicare.” But what we start to get into now is payment. And just like you mentioned Nick, the financial reality is sometimes reality, and you just need to explain to them, now we're talking about what you can get paid for, "Oh, but let me just use this code because I know the guy down the street gets paid for it." Yeah, well, that's when you start to worry about the False Claims Act because if you're using a code that doesn't accurately describe what you did, now you're potentially falsifying what you're reporting to the government.  
So, I try to divide things by, "here's the clinical decision-making. Here's the financial reality." 

Nick: I mean you touch on something that I think is really crucial and that's credibility as a compliance officer and the way you put it is, "Don't sit in your office. You need to get out there and walk the halls and make friends and solve people's problems," right?  

CJ: Right.  

Nick: I think a lot of the ways that I like to talk about being a compliance officer is much less as a policeman, which is probably when many people outside of the field and who work in healthcare, think of the term compliance officer, they think about this as the person who's there to get me in trouble if I do something that's a policy violation or something like that.  
But it's really crucial if you're going to have to have those tough conversations. And they are truly tough. You're telling someone who may have decades of experience in training that there may be some coverage determination that says, "that it's not so simple. how you treat your patient," and that's a difficult conversation, and I can tell from experience, and I'm sure you can too, that's a really difficult conversation to have with somebody for really understandable reasons.  

CJ: One thing that I sometimes do for the doctors who are very passionate, I say, "Look, you're an expert here, do you know that the local Medicare administrative contractor has meetings when they talk about these LCDs? Do you know that you can write letters to say this policy should be accepted, because the most recent clinical study, XY&Z, shows AB&C?" and so some doctors are like, "I don't want to bother with that," and other docs are like, "Yeah, I want to get involved, right? that's something that I should get involved in," so they can get engaged in the process of getting local coverage determinations approved and getting changes made with clinical evidence.  

Nick: One of the terms that I always hear in conversations about medical necessity is documentation, proper documentation, because you at some point may have to defend if you're a physician or you're a healthcare organization, why you made a particular decision, a particular treatment decision? and trying to do that by recreating things that aren't found in the medical record, that aren't found in the file, gets a lot harder, so I was wondering if you could say a few words on proper documentation and really practically, how do we, as compliance officers, try to encourage that and ensure that that gets done well? 

CJ: Whenever I talk to people who make entries into the medical record, I use the analogy of you're the artist, right? And I'm not an artist, but some people are artists and they can paint a picture. And I say, "with your words, you get to paint the picture" and so be thinking about that this service, these medical records, may need to be requested to demonstrate that the service was medically necessary, so please paint the picture, I'm not telling you to falsify, but paint the picture in an accurate way.  

So, in other words, I'll use the example that I used with the facet injections. I would make sure you put in the medical record, "Mrs. Smith is on her 4th month of conservative therapy XY&Z. She has seen no improvement in this therapy. The next appropriate option is to do the injection." So, you've painted the picture in the medical record for somebody who's going to read that, potentially, to demonstrate that you met that requirement of medical necessity, which is the failure of less invasive and more conservative therapy first before you went on to this next procedure.  

Including that, I'd like to use the term– paint the picture, paint it in a way, and sometimes docs are like, "well, that should be obvious," right? Because they're in a hurry, they're just documenting stuff, so it is a balancing act. I don't expect them to teach an auditor, in a medical record, everything they learned in medical school, but you could lead people in an appropriate way to say, "Look, I met XY&Z the requirements say I need to do these things," and you put that in the documentation. And maybe you even get the ancillary providers to do some of that work, meaning; nurses, PAs, nurse practitioners, so that's not necessarily the doc, but you could review the records and say, "Based off of these last three months, this is what the next step is".  

Nick: To build on what you're saying. I think one of the things that's important to teach people is, you may say, "Well, I don't need to be so detailed about this today, because if somebody were to ask me tomorrow, I'm familiar enough with the case and I could talk about it." But you may have to have this conversation, two years and thousands of patients after you've made that treatment decision and not only are you not going to remember that colleague who is in the room with you, well, that person may be long gone.  

CJ: That's right.  

Nick: The nurse you were working with, even the patient themselves or the patient’s family whom you discussed it with, may not be there. So, what I like to tell people is– pretend that there is going to be nobody around that's going to remember this, including you, are you putting enough information in there that you're going to be able to look at that and say, "Oh, okay, this was the situation and this is what the discussion was and this was why this was a proper determination." 

CJ: Exactly! And the other thing I like to tell them is, "How close to the edge of the cliff do you want to be?" Because some docs will be like, "Well, I'll argue that in court if I have to,” well, wouldn't it be better to have it so clear in the documentation that it doesn't get denied in the first place, right?  
Some doctors are like, "Well, no. I'll just skimp through it and then I'll prove to them later." That is an approach, but it's usually a very time-intensive, usually expensive approach to say, "I'll defend it when I have to," as opposed to saying, "let me be proactive and put everything in there up front that I can," in a reasonable manner, we don't want to overburden them, but these are the three or four things that you could do today, that might help prevent this claim from being denied.  

Nick:  Let's talk a little bit about the future and the evolution of the field of medicine and in healthcare compliance, in particular, I think it's almost a platitude that we're standing at a time in medical history, where there're advances; telemedicine, digital health, within the field of pharmaceuticals, within the field of medical devices, that things are advancing really, really quickly in terms of available treatments and standards of care. How do you see that?  
And we mentioned a little bit about situations where the medicine can progress faster than the treatment decision.  
How do you address that challenge? if you're you are a healthcare organization; whether you're a physician, or a compliance officer working with that organization. It seems to me something that is a challenge that's going to become more and more acute as the years go by.  

CJ: I think you're right. One example is– personalized medicine.  
Years ago, if a woman had breast cancer, all breast cancers were treated the same way. Not today, they do molecular diagnostics to look for receptors on that cancer tumor. And now you have under breast cancer all of these different subtypes, molecularly, because you want to find out that type of receptor will respond to this kind of medication, that one won't, and so that's personalized medicine.  
It means you're going down to the genetic level to identify it, and it's really, and we're already in it, but it's the next major phase of medicine.  

Why is that important from a compliance standpoint? Well, if you follow DOJ in settlements, you'll see how many fraud settlements have happened because of genetic testing, right?  

Nick: It's really interesting.  

CJ: So the layperson here is like, "Genetic testing, It's the newest thing" and they hear it on the news and that's exciting and it is, the science is really cool. But as you mentioned and we've talked about already, the payment methodologies and the coverage decisions, haven't caught up with that. So, people often get ahead of themselves and in some cases appropriately so. You want to take care of people's health, but you need to be engaged.  
So, what I would recommend to large systems– Be engaged with your professional society.  
So, if you're an oncologist, make sure your oncology professional society is leading the charge with Medicare, for example, and coverage decisions and saying, "Look, this is so important, this science is so important. We need to make sure Medicare covers it," and that's really the only way is you have to plead your case.  
And so for large health systems, personalized medicine is an example of what you just asked, but in the broader sense, other technologies, other devices that can really benefit people, you just need to be pushing your, and I don't mean this in a bad way, but you have to kind of push your agenda. You have to say, "This is really important and the science is here." If you wait for Medicare to discover it, it's going to be 5 and 10 years later, right? But if you're bringing it to the forefront, when those studies are being released, I think you can get these things. You can get codes, so CPT codes; for example, are approved when those services become more of a standard and so get into the game early to get a recognized code and then to get payers to cover it for recognized reasons.  

Nick: We've talked a lot about, Medicaid, Medicare, and federal programs. Are there differences if you're dealing with or working for an organization that is primarily commercial payers, like insurance companies and health plans, and how you, and maybe in the challenges that exist?  

CJ: I think the risks, because of the laws that are out there, are generally federally focused, like the federal False Claims Act, is for federal payers, Medicare, Medicaid, CHAMPUS, all these government payers.  
But there are some states, and I believe California is one of them, that they have state false, most states have state false claims acts as well, but I think in California and some others, they even go to the point of commercial insurance.  
So, some of these state laws address false claims under commercial insurance. Without those types of things, I think you're dealing with, and I'm not the lawyer here, but I think you're dealing with things like; contract disputes and maybe other types of broad fraud types of things that you'd have to prove like; fraud versus like a stake type of thing.  

Nick: It's true that the standards can be different from state to state, and there are overlapping jurisdictions, right? There's sort of the federal program level of things and, as you mentioned, many states have analogs to some of these fraud, waste and abuse requirements and false claims restrictions, and there's also most states have insurance codes, and there's you know some parallel regulations, and even in some cases, stricter regulations that have to do with what you need to do to substantiate a claim on that a commercial carrier, or that an insurance company is going to compensate for.  
I know we're getting closer to the end of our time.  

CJ: Yeah. We can talk forever!  

Nick: Well, let me, maybe this is a good closing question. What should I have asked you that I didn't? What do you wish that I had asked, that you think is important that you want to say a few words on that maybe I didn't ask? 

CJ:  Maybe we took a pretty deep dive into one topic of medical necessity. Let me maybe just take a step back and just look at a very high level, just compliance program effectiveness. We can get very granular on certain issues like we did, but it's I think it's good, as compliance professionals, every now and then take a step back and take a step out of your organization, maybe bring in a colleague. Maybe bring in a third-party vendor to do a review, a fresh set of eyes to say, "Okay, how does this compliance program function now? Maybe not at the granular level, but are they meeting all the elements, right? Do they have good leadership? Is the board actively engaged in their oversight duties? Is the compliance officer running the show, or is there a committee, right?"  
Different little things that you can look at it. "How are policies functioning? how is your proactive auditing?" A lot of us in compliance do a lot of good reactive auditing, when an issue arises, but are we being proactive? I think that demonstrating how proactive you are, to me is a sign of a little bit more mature compliance program, you're not just being reactive.  

One thing that kind of answers your question is I would say, "Take a step back and look at a high level of the overall effectiveness of your entire compliance program." I know you do some of this work as well, so I mean, do you have thoughts on that point?  

Nick: I think medical necessity, part of it, is a piece to integrate into your overall compliance program, and there are many, many components, ranging from financial pieces and medical necessity, certainly fit in there, but there are questions of quality, there are questions of privacy and security of data. There are so many complex issues. This is maybe a good question to end on because I think it touches on one of the earliest things that you were mentioning, getting into the field of healthcare compliance, and some of the challenges.  
But really, what makes it very interesting, is there are a lot of overlapping pieces and I think to be an effective compliance officer– you need to be good at the specifics, in something as detailed and granular as medical necessity and maybe the medicine or science behind a specific claim, but also be able to see the really big picture and what your organizational risks are generally.  
And by definition, you're going to have finite resources and the hardest thing is to be able to say, "Well, this is going to be my focus this year or this quarter or this month or this week, because I know if I focus on this or I spend resources on that, I may not be able to apply those resources or focus on something else." 
So, I think it's important that you know your organization well and know you're able to think in broad terms.  

CJ: I think what you just described is kind of the work plan approach, right? It's limited resources. I have these 300 risks. I can focus on the top 20% because those are our probably biggest bucket and then I usually get that work plan approved by a committee or a board, so that it's an intentional decision to say, "With our limited resources, this is where we need to focus." Consciously recognizing that we might not get to these other things and DOJ in their evaluation of compliance program documents, talk about that. They're saying, "Even if you miss a lower-risk issue because you've been focusing on higher risks, that does not necessarily mean your compliance program is ineffective. It just means you applied things in the right way." So, I like what you said there.  

Nick: Well, thank you very much. Well, thank you for this opportunity I had. It was very interesting sitting in this seat as the interviewer, as you mentioned, I've been your guest a couple of times and I like the pressure of being on someone else.  

CJ: Yeah, well I was nervous, but then I'm like, "Okay, Nick's a good guy. He's a good friend" and you gave me some good questions but the nervousness went away and so I appreciate you asking some great questions and really appreciate your presence here today, and maybe we'll do it again, Nick.  

Nick: Sounds good.  

CJ: Go ahead Nick anything else you wanted to add?  

Nick: No, just say be well and it's almost Thanksgiving at the point of taping. I think this will probably come out after that, but happy Thanksgiving.  

CJ: You too. And everybody, thank you all for joining us for another episode of Compliance Conversations. Again, just a quick reminder, make sure you subscribe and hit the like button, and all that stuff to raise awareness of these types of communications. Take care, everyone.