Podcast: Bridging the Gap Between Compliance and Auditing Departments

Hello, folks!

I’ve got a new Compliance Conversations podcast episode for you, hosted by yours truly, to use in your continuous education efforts–or to rock out to during your commute.

I’m pretty excited about this episode, Bridging the Gap Between Compliance and Auditing Departments, because the subject is really important for a solid compliance program.

In this episode, I sat down with none other than our own superstar auditor, Charla Prillaman, to discuss the importance of good communication lines between your auditing and compliance departments.

Charla started out in data entry for billing service for a radiology practice. Being the motivated person that she is, she eventually moved through all facets of billing services, including serving as a compliance officer for a moderate sized service. Then, she worked for a consulting firm for a couple years, moved onto PriceWaterhouseCoopers for a short while, and decided to move into the non-traveling mode, and worked almost seven years for a large healthcare system in North Carolina, where she was the Director for Physician Compliance where she mostly oversaw the audit staff. She loved it but eventually retired from there in 2010 and joined Audit Services in 2011 and have been a part of our Audit Services family ever since.

Tune in to our conversation about potential ways compliance professionals can make auditors’ jobs easier, how both departments can leverage each other's expertise, and much, much more. And, be sure to subscribe to my Compliance Conversations Podcast for your regular dose of compliance education. Give this episode a listen and be sure to let me know what you think.

Podcast Episode Details >> 

Episode Transcript:

CJ: Welcome everybody to another episode of Compliance Conversations, this is CJ Wolf Healthicity’s Senior Compliance Executive, and today we have Charla Prillaman who is regional vice president of Healthicity’s audit services. We’re really grateful that she’s taken some time to join us today. Welcome Charla.

Charla: Thank you! Glad to be here!

CJ: And as usually, we like to have our guests just introduce themselves a little bit. Just give us a little information on your background, what kind of things you’ve done in healthcare and audit.

Charla: Sure, well I started years and years, oh so many years ago, basically doing data entry for billing service for a radiology practice. Through the years, somewhat being in the right time and at the right place, but also rather un-afraid to take on a new challenge I moved through all facets of billing services, including serving as a compliance officer for a moderate sized service. I worked in a small consulting firm for a couple years, moved onto Price Waterhouse Coopers for a short while, and decided to move into the non-traveling mode, and worked almost seven years for a large healthcare system here in North Carolina, where I was the Director for Physician Compliance. My duties there mostly were really overseeing an audit staff, we had, in the neighborhood, it varied over time, ten to twelve, maybe even as many as fifteen auditors, and another group of coding experts who assisted our processes and physicians, roughly 2,000 physicians in that organizations.

CJ: Wow!

Charla: Yeah, I loved it. Retired from there in 2010 and joined Audit Services in 2011 and have been a part of our Audit Services pretty much from the beginning.

CJ: That’s Great! And we’re grateful to have you on the team and your expertise and obviously vast amount of experience. As you mention Radiology is your start, I was thinking back when I first started in coding and compliance. One of my first assignments with Intermountain Healthcare was to work with their radiology service line. So I have found memories of some my first detailed knowledge that I tried to gain in coding and compliance was from intervention radiology. Did you do much in interventional or conventional?

Charla: No, this was back in the day, and back in the day there wasn’t such a thing as interventional radiology.

CJ: Ah-Ha!

Charla: I am not a young spring chicken, we were doing diagnostic stuff. We didn’t even use ICD codes to submit our claims, we used regular English words to describe our claims.

CJ: Now that’s really interesting! You’ve got a great perspective of how this has all evolved, and maybe before we get to some of the questions, what is your overall perspective of how this has all evolved over the years. Has it gotten better, worse, the same?

Charla: It has been a fascinating, exciting ride. There are aspects that maybe are a little more difficult, some that are better, it’s just really depending on what glass you’re looking through I suppose.

CJ: Well, thank you again. When Charla agreed to speak with us I wanted to maybe pick her brain a little bit on the relationships between auditing departments, compliance departments. In some organizations, you might have compliance officers, a lot of organizations I’ve worked with there’s been separate departments that do that kind of thing, and they work with compliance departments. I thought we would try to mine the knowledge of Charla, and Charla the first question I wanted to ask you; What do you think the some of the biggest hurdles are that need to be overcome between compliance and auditing departments, or sections, if they are separated?

Charla: Well, when those two functions are separated, I think the biggest hurdle is communications. Very often I’ve seen kind of the worker bee, where the feet on the ground soldiers don’t necessarily aren’t tuned into the vision of the overall compliance program, and without that communication bringing both parties to the same vision there are lots of stumbling blocks in just execution and delivery of information.

CJ: Yeah, I think that’s true as well that I’ve observed from my experience in healthcare that communication is a big, big piece of it. Do you think, in your experience, are a lot of these departments separated, or have you found it kind of half and half where a lot of them work within the compliance department? What’s your experience been?

Charla: Most of the larger organizations that have an identified auditing team in house either roll up through compliance or the revenue side, which of course creates a whole different side of hurdles. I’d say it’s probably mostly in the compliance department, if you have small organizations sometimes it’s one hat doing all the jobs, one head wearing all the hats I should say.

CJ: Right! You mentioned there could be some issues if the auditing team is housed in the revenue cycle or the financial arm of the organization. What are some of the things you’ve seen there that might be of concern?

Charla: Well I think it’s a perception even more than a conflict of reality, where the leadership of a revenue cycle department on obtaining adequate reimbursement of their services, viability of their organization, and sometimes a compliance officer will discover areas where there’s some gaps, and potentially some money has to be paid back, or potentially a process or a coding process needs to be changed that will have, at least a short-term effect, on the revenue stream. Sometimes people feel a little conflicted when I tell the revenue VP we’re going to lose X dollars for the next short term.

CJ: Yeah, that’s a hard message to send sometimes when you’re talking about communication. How would you communicate that?

Charla: Well, straightforwardly. You have to call it what it is, it doesn’t mean, in my experience, most the time when we find a gap in documentation and reimbursement, the gap is not so much between the actual work and the codes that are submitted on a claim, but rather between the work and the documentation. So usually you can kind of guide somebody. Nobody who hires a consultant to help them do the right thing wants to do the wrong thing, so you have to kind of just make sure that your customer, or your department head if you’re working internally, has a good understand that you’re all on the same team working towards correctness and avoid those hostile kinds of words that set the stage for misunderstanding.

CJ: Yeah, I think that’s a good point. I recall just working with a client recently where we had to give them some bad news. We had to say the supervision requirements were not met, I’m just paraphrasing here, but no one had any malintent, it wasn’t that somebody was trying to cheat or anything like that, but unfortunately it was apparent that the supervision requirements were not met and so it meant a great deal of money because it happened for many, many years and it was really hard to swallow that. But I think you’re right, just say it straightforward, you just say what it is. The other thing I’ve found, I don’t know if you agree with this or not, is just try to avoid the blame game. Try to speak very matter-of-factly like a reporter might, where I say “Look we did this investigation, or we found this audit, it lead to trying to find the root cause, the root cause was this” and kind of avoid the judgmental kind of things, unfortunately the leadership their first thing is “well how did this happen” is sometimes the first response, and you can go down that road without naming names, sometimes you do have to name names, but you can do it in a way that is much more methodical, and reporter like or investigator like as opposed to quickly pointing the finger or laying blame.

Charla: I agree, and I always like to approach those situations with at least one potential solution for the go forward basis. If there’s light at the end of the tunnel, even bad news can go a little easier.

CJ: You know, that’s a great point, don’t just bring the bad news but say “Look these are the four options...” You can do nothing, at least you’re saying that’s probably not a good choice, but that is a choice. And you’re leaving up to the leadership to make those decisions and you’re giving them all the possible solutions.

Charla: Right.

CJ: Let me ask you this, how do you think that compliance and auditing departments could leverage each other’s expertise. Let’s assume the communication is good, or you at least get it to the point that it is good. How could you then build on that and leverage the expertise that each of those departments might have?

Charla: Well I think that many of us, those of us who are older, who worked in healthcare before there was such a thing as a former compliance plan, have kind of grown up and watched how this way of structuring our compliance department has grown. I think we naturally see that synergy, I consider audit services, whether your talking about profession audits or DRG audits, even HIPAA compliance audits, wherever you are, an audit is simply a measurement.

CJ: Right

Charla: that’s on of the things I use sometimes with clients sometimes who fear the government audit. An audit isn’t an accusation, and audit is a measurement, and what business other than healthcare would have ever gone forward without measuring their successes, AND their failures. If there are gaps we need to know what’s caused my widget to explode, so that I can make widgets that don’t explode and my customers will be delighted to buy them. I consider the whole thing a quality measure, with the auditor providing the micro measurements that compliance leaders can implement and you move from not only claims submission, which is not the largest chunk if you will of an auditor’s day, claims submission reviews, into some of the more global processes that are so critical to successful operations.

CJ: When you were talking, it made me think about billing compliance committees that I’ve been a part of in the past. In larger organizations, typically, we might have an executive compliance committee, and then we may have a subcommittee of that group that focuses just on billing compliance. Part of the reason we did that, as we all know, billing compliance is probably one of the larger buckets in the compliance program in healthcare at least. One of the things we found really effective, and I’d be interested in your thoughts and observations if you’ve seen this. In our billing compliance committee, there was really only one compliance representative, and the rest it was operations. We had somebody from revenue cycle, from business office, and patient account services, the CFO actually attended, but we had around the table a group of people that, we’re all on the same team I think you had mentioned earlier, and I found that to be really effective because it was the committee to find missing revenue as well as to correct errors that might exist, and it was much more collegial and less accusatory, and that was one way we tried to leverage the use of others. Have you seen that in committee?

Charla: I have, I’ve seen it in a variety in committee and executive structures that include operational folks. One of the tenants, I guess, of doing things right, we can think up all the correct rules and kind of in an ivory tower decide how one should go forward, but if it isn’t practical, usable, and to a degree user friendly in the clinic, where the patient receives their patient care, without patient care we don’t need any of this, so I kind of circle back to where we are. We can’t impose unrealistic procedural steps that get in the way of patient care. Anything we propose to make better is going to take input from operations, from clinical operations, as well as from the suits as they say.

CJ: Yeah, you know that is such a great point, and I’ve said that so many times before when I’ve had compliance employees that have worked for me that maybe get a little overzealous in their compliance fervor, is what you just said. Look without patient care and without revenue none of us are here. So, you take step back and say look, what’s the mission of the organization? One of the best organizations I worked for had a wonderful mission statement, and our compliance office purposefully developed our own mission statement that tied right into that. Because it really drove home that point you just made that without those patients, without the doctors, without this environment there would be no need for this compliance department. In other words, the compliance department is there to contribute to that overall organizational mission, and I found that the most enjoyable compliance department to work in.

Charla: I worked in a department that similarly developed their departmental mission to just dovetail right into the clinical mission of the organization, and I think that’s really a recipe for success.

CJ: I agree. Let me ask you maybe some practical questions, and I’m going to ask you one and kind of revers that question as the second question. How do you think a compliance professional, or a compliance department personnel could make the auditors job easier?

Charla: Well. I wish we were face to face so that everybody could see my face, I’m not a poker player. I think one of the biggest areas where things go amiss is people who audit, typically, and I’m painting with a very broad brush, are very detailed oriented, prefer their world to be ordered, like yes or no answers, find maybe in sometimes to be out of a comfortable place, and when people of that personality need to communicate and collaborate with someone who is less detailed, more broad pictures, more fifty thousand foot view, I think that the breakdown can be where auditors seem to be very ridged and unyielding and the people with whom that specific individual is having an interaction might be seen as not understanding the details of what I’m trying to tell you because they are looking to broadly. And we need both. An auditor has to be detailed to do their job, but they also need to understand where that detail sits in the bigger picture, to really be effective and helpful, and I think the broader viewing leadership, again typical personality, broad brush, understanding that your best auditors might be your most difficult communicators, just that understand of how you’re working there I think opens the door for a better communication, a better sharing of information, and a better program.

CJ: As you were talking about the detailed oriented nature of auditors it made me think of a phrase, a quote I’ll kind of paraphrase “You rarely have success when you deal generalities, but if you can deal in specifics you’ll rarely have a failure.” And as you were talking about the nature of an auditor vs the nature of somebody that is interested at a higher level, I think recognizing that detailed nature as you pointed out is a really good reminder that that’s how a lot of auditors are, and that can really help. So, if that’s true, what could an auditor do, to make a compliance officers job a little easier.

Charla: That’s a little easier for me, I think that every auditor needs to make it a business to make their program succeed. If that’s their focus, the steps they take are going to provide information, they’re going to be naturally a little more open than their detailed nature might suggest. They will be the eyes and ears as they go around doing their job, they may trip over other items that may need attention. People will trust them, people in the trenches, sometimes I have found, are more willing to say to the audit team “Gosh, I’m not sure this is just right...” than they are to make a formal complaint, for example, to the compliance officer that kind of has that connotation of policing.

CJ: Yeah, right.

Charla: So I think in those ways, of kind of being open, and aware, and approachable, will inherently make them a better support for their team.

CJ: Yeah, if I could maybe throw out an idea too, I started my career more in the auditing and coding side of things, trying to education physicians and auditing physicians, and then late, more recently I’ve been more on the compliance officer track. And I think about those two roles, and I think that the auditors know so much about what is actually happening, in my experience some auditors may be assigned to a certain department or service, and they become really acquainted with those physicians, and they can often have a really good insight when something might be wrong. One of my bosses in the past use to tell me “Look, if their doing in billing compliance, they might be doing poorly in their research compliance or other areas of compliance that a compliance program oversees.” And we were always telling our auditors be a part of the overall compliance program, do your job, yes, but also keep your eyes open, there may be other issues you may not be the auditor over, but such you have such good relationship and you’re often on the front line with those physicians and those departments you have the best view into some of the things that are going on. Do you think that’s true?

Charla: Exactly, I think that’s very well said. I used a slide presentation once with an audit team, and had a graphic that said “Eves dropping is allowed.”

CJ: There you go!

Charla: Pay attention to your surroundings, the people who are doing the work may just very casually let you know that things are in order and don’t need further attention, or perhaps they do.

CJ: Yeah, I’ve found ta lot of the auditors do have better relationships that let’s say some of the compliance personnel, because a lot of times the compliance department and the compliance folks might not get involved or be introduced into a department or a physician until something untoward has arisen. Whereas a lot of the auditors it is a routine part of their work, let’s say they’re going to audit somebody every quarter, they or an educator is probably going to meet with a physician on the results of those audits every quarter so they develop a relationship, and what I’ve seen, sometimes the auditors can be a really valuable part of bridging the relationship if compliance has to come in and take some sort of action and they don’t normally interact with that physician.

Charla: I agree.

CJ: Well, let me give you a moment and see if there are any thoughts of concepts that you’ve thought about since we’ve been talking that you’d like to bring up, I know I’ve been asking all the questions but what other things come to your mind on this topic.

Charla: Well, it’s kind of one of my pet peeves and I’d like to share it with you. So many times, we see auditors who are interacting with physicians who tend to accuse in their language. And if their auditors listening to us talk to today, if there is anything that I can share that has been helpful in my auditing life, and many people who say it has helped them, take the world “You” out of your vocabulary. When you’re describing an error or flaw in the medical record, if you say the medical record is not showing me X, the message is so different than telling that physician You failed to write down X.

CJ: Yes!

Charla: So just that little preposition “You”, kill it, it’s not valuable.

CJ: That’s so true. I think I learned that the hard way when I first started working, you obviously know it to be true. That is great advice. Because Docs, you know, they are busy, typically in my experience, they want to do the right thing, but that’s not their life, to document things in a way that a reimbursement payer is going to look at it. I think that’s great advice, to take “You” out of it, and say the documentation lacks this. Because maybe, as we know, some documentation is allowed to be put in by staff. So maybe it was not the doctor that failed, maybe it somehow didn’t get in the medical record.

Charla: Right.

CJ: Well this has been wonderful, any other last minute thoughts before we kind of close up for today?

Charla: No, thank you for the opportunity to share with the world my driving force in my auditing life, it’s been fun!

CJ: Well thank you so much Charla for your expertise and your passion and your experience. I’d love to talk some more with you as I’m sure some of our listeners would love too. Thank you, I appreciate your time.

Charla: Thank you.

CJ: And to all of our listeners, Thanks for listening to another episode, and please join us again for our next episode of Compliance Conversations.


Questions or Comments?