Podcast: Tools That Make Compliance Easier

In our latest Compliance Conversations episode, I sat down with product development expert, Jeff Young, to discuss tools that can simplify compliance and make you more effective as a compliance officer.

Young explained how tools are changing healthcare organizations, “with the tools that are out there today you can gather data consistently in one location, identify risks based on data trends and decide what to do. Maybe you need to put a new policy in place, or you need to introduce training to your organization. The idea is that it gives you the power to get away from some of this manual work by utilizing technology to help automate and optimize what you’re doing as a compliance officer.”

Tune in to this episode of Compliance Conversations, Tools That Make Compliance Easier, to learn how to utilize technology to decrease manual labor, improve training, easily identify risks, and much, much more!

Episode Transcript

CJ: Welcome everybody to another episode of Compliance Conversations, I’m CJ Wolf Healthicities Sr. Compliance Executive and today we have Jeff Young, Healthicity’s Vice President of Product Development. Welcome Jeff.

Jeff: Thank you CJ.

CJ: Glad that you’re here.

Jeff: Glad to be here.

CJ: You know, what we traditionally do with some of our guests is we just have them introduce themselves a little bit and tell us a little bit professionally of your career and what’s gotten you into what you do for a living.

Jeff: Absolutely. And just to give you a little background I’ve been with Healthicity just about four years now. Before that I was with a company where I focused on fraud protection and prevention, spent about twelve years doing that. Maybe just to back up a little bit, I’ve been in the healthcare industry about twenty years. My start in that was in managed care, went on to go onto graduate school in public health where I focused on analytics, and that’s what brought me into the area of analyzing and looking at data for questionable behavior. I did that again for about twelve years, and along with that developed products that focused on detection of aberrant patterns or of fraud waste and abuse, and then had the opportunity to come to ABC and Healthicity, and that’s where I had a nice shift in my career where I wasn’t so much looking at things from a managed care perspective but also look at products and services from a physician and provider perspective, and so here at Healthicity we focus on products that are looking at how we can help in the business of healthcare for physician practices, health systems, and hospitals.

CJ: Exactly. And Jeff oversees a team that helps our products become better, so you and your team are constantly interacting with folks like our listeners who are in the compliance field or are in the auditing field, you’re trying to find out what they need in their day to day jobs to make their jobs easier.

Jeff: Absolutely, Absolutely. And then we reach out to our users, potential users, all the time on how we can make their lives easier from a compliance / auditing and any type of aspect of their job.

CJ: And for those of you listening, Jeff is all yours as well as I am on how to make products better. I’d love to hear ideas from our listeners on “I wish my auditing software would do this” or “I wish the compliance program that we have set up, the tools that we have, we really need something for this”, so if you have those kinds of ideas feel free to email them to us or comment on our blog and we’ll get Jeff’s team right on that.

Jeff: Absolutely.

CJ: And they do great work so we’re really fortunate to have him here today. As you can tell from his brief introduction he has a lot of experience with data mining and with technology. I wanted to talk to Jeff mainly about some of those ideas and concepts and to have him kind of expound on those areas. Jeff, maybe to kind of get the ball rolling, how can technology assist compliance officers today, to help them run their compliance more effectively.

Jeff: So, I think just to start off with that CJ, the nice thing with technology is it’s designed to make our lives easier. In the past compliance officers have really had not a lot of tools back in the early days. They would keep a binder up on a shelf that would include some policies and procedures. But compliance historically has been fragmented. So, there are a lot of different sources on where you’re managing that program. So, with the tools that are out there today, from a technology perspective, you can start to work with data, you can start to gather data consistently in one location. You can start to look at trends whether you need to put a new policy in place, or you need to introduce training to your organization, or you need to, where you can identify a risk based on some of the trends that you’re seeing in the data that you’re collecting. The idea is that you get away from some of this manual work, and you utilize technology to help automate and optimize what you’re doing as a compliance officer. So, getting away from the manual.

CJ: Yeah, that it’s really a tool, not the program in and of itself. I talk to a lot of people that go “If I buy that compliance software I’ve got a compliance program.” And you and I know that’s not true, it’s a tool, and so you need to have an educated compliance officer, or compliance professional, but these are tools that can help you do certain aspects of a compliance program like you mentioned, and maybe it’s training and it’s tracking the training. Wouldn’t it be great if you had a tool or technology that helped you track the training so you could spend your time as a compliance officer building relationships, or doing more of the thought or thinking work in compliance as opposed to the tasks that we all know need to get done, and need to be recorded and some sort of audit train or paper train. But are not necessarily the best use of an expert’s time.

Jeff: yeah, so, I know that if I were acting as a compliance officer in an organization my time is finite, I’m only able to get so much done, I’m not going to recall everything that I need to do. And so if I have a tool, or tools, that help me, that prompt me, when I need to do either some type of risk assessment or an audit, or something that prompts me on looking at an incident that was reported. That will help me do my job and be more efficient.

CJ: Absolutely. You know, I thought I was using technology when I was a compliance officer I was using spreadsheets or email. So, I guess that is technology and maybe introductory technology, it’s been than, you know I was doing compliance work a lot of businesses used a lot of those tools on a regular day to day basis. I think when those first came out it was a way, but wouldn’t you say those are kind of old school tools, and we’re now getting into a much more sophisticated and thoughtful use of technology?

Jeff: Yeah, so, I think if you’re using spreadsheets and other electronic methods for collecting information, that’s good. And it’s a step beyond just paperwork, getting beyond just a paper trail, but there’s an opportunity to take that to the next step, to your point. And I think that the challenge is that, in some cases, there’s multiple individuals that are involved in a compliance program across an organization. If you’re collecting certain files that are not sharable or not accessible by others, that prevents the ability for you to run your program effectively. And how do you know where all those other files are located? So let me give you another user case. So we talked about how bringing that all into a particular tool or solution will help you manage it more effectively to collect that data. Another example is that there are those situations where we may be audited, and from an auditing standpoint you’re going to get asked questions “Can you show me these certain documents, can you show me how you’re tracking your incidents” and if it’s in discrete locations or if there are other people that are tracking it makes in a lot more difficult to be able to identify or find those documents and that evidence.

CJ: That’s a great point you bring up. We were doing a webinar recently and we were talking about kind of what an end goal of a compliance program is. Which is, you want the government to say “Wow, you guys have your program together so well, that you’ve demonstrated to us that if there was some sort of non-compliance, it may have been a one off, or bad apple, it’s not your culture.” The example we were using is what we call a declamation, where the government says we’re not going to intervene and prosecute you as n organization, we’re going to go after that individual, but your program is in place, and the example that the government used to decline to intervene was they were talking about the training program or the compliance program, and you know a lot of these enforcement actions happen many years after the events occur, and the government declined and they said “from 2002 to 2008 your compliance program trained this individual 54 times with 16 reminders and they sent these other documents” they had all of that there, and you talked about kind of having that in different systems, and in the paper days we had them in folders and we thought we were doing good if we could get all of those into a paper folder, which actually isn’t bad, but how many of us and how many of you listening, if you were called by an enforcement agency tomorrow and they said “Demonstrate to us how many times you did training for this one employee on this topic” with technology if you’re tracking things in real time as you’re going along there’s a lot less work to reproduce that information after the fact.

Jeff: Correct. And then you start to pick up on some of the trends and some of the patterns if you’re tracking it. And you may have these things, these anomaly’s, that come up that then influence where you’re going to spend your time and focus on your blind spot.

CJ: You’re right. One thing that we use to track, for example, would be hotline calls or incidence. And you could maybe once a quarter or maybe twice a year you could analyze that data and see if you could find trends for example.

Jeff: Exactly, exactly.

CJ: So, let’s talk more about auditing. So, in my opinion, what I’m going to call compliance 1.0, kind of the beginning of compliance. We focused on let’s say random audits, so let’s take a physician practice, or a physician group for example. We may have audited every doctor we may have done ten claims or ten encounters randomly for each doctor. Now that’s better than doing nothing, right? We know that. But today you know, compliance has been around long enough, and auditing has been around long enough that there’s a more sophisticated way to approach this. So, if we’re going to call today's environment compliance 2.0 how could using data and data analytics help you be smarter than just kind of doing random shotgun audits.

Jeff: So, to your point. Random audits are not bad, and it’s better than not doing anything. But there are a couple of opportunities to expand that and strengthen your program from an auditing perspective. So, one example is, if you’re looking at just ten random records, how do you know those are representative of what the physicians doing, and how does it really help you to understand where you need to focus for that physician. So, for example. When you look at a physician, if you can benchmark that physicians billing data against his peers, then you can start to see, okay does he bill like his peers? Or does he very or does he differ in the way that he’s billing.

CJ: yeah, kind of stick out.

Jeff: Yeah, is he an anomaly. And really what that helps, and this is something that’s interesting, and I wanted to cite an article on that, this is an article titled “Why physicians performance benefit from healthcare analytics” this is an article that was written by Joseph Kim. In this article, he starts off by saying that physicians, they are motivated by seeing how they are doing and how they are performing, and how can they improve if they are not given the information. And on a random audit like that, you could give some good feedback on what they are doing gin those records. But if I’m a physician, I want to know, out of a 6 month or 12-month time period, how am I doing, or should I be doing something different, should I be documenting things differently, how does my treatment pattern compare to other physicians of my same specialty. By taking some of the benchmarking data that’s out there, either comparing my own organization, or comparing against peers outside my organization, how do I fall within those patterns. And then from a compliance side, you can target training specifically directly to what’s identified and what’s found.

CJ: And we know the OIG is doing that, I was at a conference last fall where and OIG representative spoke to us and highlighted the data analytics team they had in place. So, they were speaking specifically “Yes, we’re still going to respond to hotline calls and tips and fraud tips and those sorts of things” of course they are going to respond to those, but they also want to be proactive with their resources, and they highlighted how they were going to use data. And just because somebody’s an outlier doesn’t mean there is fraud or inappropriate behavior, it just means there is an outlier and you want to investigate further, and it may be an appropriate outlier. But how, I know your team uses data, what kind of resources is it, is it Medicare data, Medicaid, managed care, how do you get the data for the products you develop compared what might be out there for me to go download publicly.

Jeff: Sure, there are some public data sources that you can go out and get. And physician offices, practices, providers have a little bit easier time than even organization like ours to even obtain data. So, some of the resources out there, the most readily available of course, that’s available publicly is the Medicare data. There is Medicare data out there you can download and start to do some comparisons against. The challenge with that is that you may have patients in your practice, or within your organization that are Medicaid or commercial patients. So, if you’re only focusing on the Medicare side you may have some skewed results. For example, pediatrics, OBGYN data is not going to be as prevalent, if at all, in the Medicare data. So, you need to look at other sources. Another source will be MGMA, and so if you’re part of that organization, I know that they have data sets available. For us, we went out and found an organization that we’re able to get commercial Medicare/Medicaid data that we could be able to do some benchmarking with.

CJ: And that’s really useful, you know, because, as you just said, you know, the Medicare data might be available and it might be free, but there’s very few practices out there that are 100% Medicare. Now, maybe if you’re in geriatrics that might be a decent source, but still you may need to massage it or tweak it a little bit, but most doctors will see a varied pair mix, so getting that in your data. And once you have that data, what would a compliance officer do with it. When you say benchmarking, talk to me about that, let’s say I’m not a data person. I get the law, and I understand regulations, but break that down a little bit for me.

Jeff: Yeah, so one of the areas that is one of the common types of analysis to do is look at your evaluation of management services, how are the physicians in my practice or organization billing evaluation and management services compared to providers of the same specialty. So, one thing you could do, is you could go through with that data and you could basically aggregate it, right? For all the family practicing physicians, and I recommend doing it by specialty, but for all the family practice physicians for example, counting up the number of times they are using a certain level. With the levels of E/Ms you want to break it out, right? So, you’ve got your new patient your established patient.

CJ: Inpatient, outpatient, all that stuff…

Jeff: So you look at your range, and then you’ll come up with, what is the distribution, or in that range what % are 99211, 99212 through 99215, and you come up with that with your control data or with that benchmark data. Now you’ve got a norm. Usually with the evaluation management services you can see a normal distribution. Most of those are going to fall within the 99213 or the middle range for those visits. I can then take my organization's data, my family practice providers, do the same thing, I recommend doing no more than 12 months, and looking to see what their distribution is, and then to overlay those two together to compare against it. If I have a family practice provider that’s always billing 99215 in my organization, to your point earlier it doesn’t mean they are necessarily trying to purposefully get paid for a higher visit, but it raises some question, and it allows me now to focus in on a particular area. You brought it up before the OIG has a specific team that is focused on where do they put their time and attention because they only have so much time. It’s the same thing in an organization that is doing audits, and from a compliance perspective I only have so many people that I can be able to focus on these physician audits, so where do I spend my time. If I’m looking to see where some of these anomaly’s come out, physicians, the family practice Dr. that is always billing 99215, that’s an area I can focus on.

CJ: Right, so then you get a human to actually audit the records, so rather than doing 10 random cards, you go that guy or that gal is kind of an anomaly in the distribution curve, doesn’t mean they’ve done anything wrong, but because they are sticking out let’s look at those, and let’s take 10 99215’s because that person has so many of them.

Jeff: Right, and to be fairer on the distribution on the randomness of that, you could take from an established evaluation management set of data services, find out, okay, let’s look at 10 ENM service established patients, and that way you’re at least narrowing it down to a particular area of concern and making sure that you’re using your time effectively.

CJ: Yeah, and you’ve told me before, some of your clients, and actually everybody out there, you may, and this is kind of the benefit of a compliance program, we’re trying to prevent non-compliance and over charging and that sort of thing, but when you do these sorts of activities you’re really trying to help providers do it right, and sometimes not only do you find things that are over coded but you find examples of under coding and you can then capture some revenue that’s actually legitimate. Are you finding that when your clients are using these data tools?

Jeff: Absolutely, so, I’m glad you brought that up. It’s not just the red flags that jump out that can help you, but also identifying those areas where it’s documented that there has not been an opportunity to bill for them, or they haven’t been billed for, absolutely it’s both ways.

CJ: Okay. Well Good. Let me kind of shift gears a little bit, well we kind of touched on this, but, you know, I have a lot of colleagues that they are really great compliance officers, they have a lot of experience in interpreting regulations and those sorts of things. What would you tell them, they might not be technology savvy so to speak, they might not be good in running queries or doing this or doing that, or maybe if they are in a big enough organization they might actually have somebody on staff, I know that as I was a compliance officer, I actually had people with those skills, so they would then mine data internally and that sort of thing and that was really helpful. But let’s say you’re in a smaller organization and you’re not that tech geek so to speak, what advice would you give them when they are looking for tools so that they can still kind of be smart in their approach, but they don’t have to be a technology wiz.

Jeff: Well the biggest thing is to find a tool or solution you’re comfortable with. So when you’re searching or doing the vetting process look to find something that you’re comfortable with, try it out. Most of these solutions have an opportunity to do a trial.

CJ: A trial. Yeah, that’s a good point.

Jeff: And look for something that, you know all of us are different in how we learn, some of us learn visually and pick up on things visually, some of us like to look at the actual data, an effectually solution will give you both, right? Either a dashboard of a very quick view of here’s how I’m performing and here’s how my compliance program is performing and where I need to focus my attention visually, but also what is the data that is driving it. I think the other thing is to look for something that again helps you to be, helps you to focus all of my different areas of compliance into an application that can keep it all together. So I’m not having to buy 5 separate tools or solutions that help me manage my compliance program. So, hopefully that gives you a…

CJ: Yeah, it does. And I like what you said about a dashboard concept you know. I’m not an auto mechanic, but I use my dashboard in my car for a few basics, and when certain things go off I go get an expert. So when that little light, check engine light comes on, I might not be an auto mechanic, but that’s a dashboard that tells me I either need to get that expertise or, you know, if my temperature gauge is over a certain level I know I might need to stop my car it’s overheating. So, I have certain dashboards that I look at constantly. That might be a smart way to use technology in a compliance program to monitor things from a semi high level, and then as needed, you seek out that additional expertise either internally or externally.

Jeff: Absolutely, you shouldn’t be afraid of the technology. And know that a good tool out there is not going to require you to be a statistician or a data analyst, and so the good tools out there or the good solutions are going to provide you the information that you need for you to make a decision, for you to build a monitor, and for you to be effective.

CJ: Yeah, and it can help you monitor the overall health and effectiveness of your compliance program, and I’ve been involved in scenarios where did need a statistician, we didn’t need that person full time, and we didn’t need them all of the time, so what I guess I’m trying to get at for our listeners is that you can use technology to kind of monitor the overall health and effectiveness of your compliance program, and then there other uses of technology that get much more granular and much more detailed.

Jeff: Exactly, and leave that to the experts.

CJ: Yeah, you don’t necessarily have to know all that, you should understand that they are available. But I think a really good way to demonstrate to either the OIG or to even your board who’s invested money and resources into your compliance program is to show them kind of the standard metrics quarter to quarter. So I use to meet with the board every quarter, and one of the things we were reporting on is how many incidents were started this quarter, how many have you closed from last quarter, you know, what are the hurdles to get one nagging incident closed, it’s been open these last 3 quarters, what are the issues around that. And the board doesn’t want that drilled down detailed either.

Jeff: They want the high level.

CJ: They kind of want that high level, and I think that’s a smart way to keep that general fitness in your compliance program.

Jeff: Absolutely. And that’s the thing. Whatever solution you use, should be able that quickview, that high level perspective of what’s happening, the trends that are happening. I love that your example. How do you control that, how do you focus in on that? And then, yeah, if you need to dig down deeper, and get a statistician in to understand things deeper.

CJ: And if you’re compliance program, if it’s good, is going to eventually uncover mistakes, we all make mistakes. So let’s say you found a billing error that goes back 4 years, and you know you are going to have a significant overpayment. At that point, you can kind of get the right resources to do the statistics and what you need to do for that. But you don’t necessarily need them every day when I’m turning on my computer in the morning and running my compliance program.

Jeff: Correct.

CJ: Jeff, you know, it’s been wonderful to talk to you, do you have any last-minute thoughts or comments, something that I might not have asked you that you think “Now why did this dummy not ask me this question?”

Jeff: No, I think we covered things well. And I think that the biggest thing is that there is technology out there, and there is an opportunity to make your life as a compliance officer easier, so take advantage of that and find something that works best for you.

CJ: Thank you Jeff, and thank you everybody for listening to another episode of Compliance Conversations, until next time.