Suffering from Rule Overload?

Welcome back to Compliance University — Class is now is session! This month I will begin a “maxi-series” of articles to address a major problem home care providers face: Rule Overload.

Let’s listen to the home care providers’ lament: “Help! We must track hundreds of reimbursement rules, OSHA rules, CLIA rules, anti-fraud rules, privacy rules, security rules, government rules and private payer rules! It’s too much to monitor, let alone conquer. We’re at the end of our rope!”

Clearly, these providers suffer from that new malady “Rule Overload.” Perhaps HIPAA has elevated the rule-overload problem to epidemic proportions by imposing specific and detailed regulatory obligations with firm deadlines for compliance.

While it is true that new reimbursement rules also have firm deadlines for enforcement, the reimbursement rules tend to be communicated only one or two at a time, so the accumulated stress from Rule Overload may go unnoticed.

And, while it is also true that anti-fraud rules tend to hit in bigger clumps, these rules frequently are colored in shades of gray, with subtle dangers that, ironically, make it easier to push them to the back of our heads to be dealt with later. In addition, anti-fraud compliance programs have been optional, not mandatory, and have not had deadlines by which mandatory compliance programs were required. This has led many providers to put off focused compliance efforts.

HIPAA, with its firm rules and deadlines, has hit providers differently. As a result, a majority of providers who have approached HIPAA compliance from the perspective of “learning the rules” now suffer from Rule Overload.

Some HIPAA rules conflict with existing operations. Some rules are resisted or misunderstood by personnel. Different advisors offer different advice about how to apply the rules. Rules interfere with making money. Efforts to focus on the HIPAA rules take precedence over efforts to comply with reimbursement rules (which then leads to reimbursement problems) or the anti-fraud rules (which then leads to OIG problems). Rules, rules, rules.

The ROPE Ladder

However, there is a solution: If you are at “the end of your rope,” then it is time to climb a ROPE ladder.

What is ROPE? Rule Overload Prevention and Elimination. A ROPE ladder, quite simply, is a way to eliminate your existing Rule Overload and prevent it from recurring. We may summarize the secret to climbing a ROPE ladder like this: It’s all about the system.

To elaborate, climbing a ROPE ladder requires us to customize the teachings of systems management and quality-improvement initiatives for the goal of rules compliance. The ISO Series of Standards, Six Sigma Process Improvement tools and the Baldridge Healthcare Criteria for Performance Excellence can all be used to climb our ROPE ladder by creating systems that will comply with the rules and monitor ongoing rules compliance — without requiring you to keep track of all the many rules.

It really works. It is worth the effort. Starting now and continuing through future sessions of Compliance University, we will discuss how to use these tools to climb your ROPE ladder. Let’s begin by exploring the basic premise.

The Premise

Compliance is not just a set of rules to be learned and followed. When run correctly, compliance is a process. Compliance programs should run and monitor themselves. The key to conquering Rule Overload is to incorporate the rules into your existing systems of operation. Then, all you need to do is run your own systems. When set up properly, your own systems will be practical and effective — because they are your own.

Remember, smart providers make sure their operating systems comply with compliance rules. Then they run the systems; they don’t run the rules.

Compliance programs can, and should, handle all of your compliance needs. You do not need multiple compliance systems for HIPAA, reimbursement, fraud and abuse, OSHA and accreditation. Compliance should fit together into an integrated system. At this point, benefits can become synergistic, with circumstantial overlaps among the compliance efforts. These overlaps yield substantial efficiencies and economies of scale.

Simple? Yes. Easy? Not really. But climbing a ROPE ladder is not particularly difficult, as long as you devote creative energy and quality time to the initial set-up process. Worth it? Absolutely.

Five Rungs On Your ROPE Ladder

In upcoming sessions of Compliance University, we will discuss how to apply systems management tools to compliance activities. These tools ultimately teach us that there are five rungs — made up of a total of 12 strands — on an effective ROPE ladder.

ROPE Ladder Rung I: Determine How You Intend Things to Run

• Strand 1: Acknowledge your reality. Acknowledge your Utopia.
• Strand 2: Apply “rules” as needed.
• Strand 3: Write it down.

At this point, you will have determined the “best practices” for each particular operating system you have analyzed. It is a combination of present-day reality, improvements you would like to make and refinements required by law.

ROPE Ladder Rung II: Teach the Systems

• Strand 4: Train employees to follow your systems.
• Strand 5: Teach refreshers and updates.

You should also develop an orientation program for new personnel. This should address the concept of compliance, but focus on the importance of following your internal systems.

ROPE Ladder Rung III: Install Reporting, Investigating and Monitoring Systems

• Strand 6: Report errors.
• Strand 7: Investigate problems.
• Strand 8: Monitor ongoing compliance.

ROPE Ladder Rung IV: Solve the Problem

• Strand 9: Fix the system.
• Strand 10: Fix the people.

Sometimes, the government will get involved in these issues, at which point you must understand your rights and your tactical options.

Again, the best approach is to craft a specified policy for dealing with government inquiries and investigations. This policy is especially important because it is so easy to get flustered when confronted by the government’s machinery. A written blueprint for dealing effectively with government requests or demands can save much grief from mistakes caused by careless comments or unwise responses.

ROPE Ladder Rung V: Conduct Ongoing Education

• Strand 11: Refresh and update.
• Strand 12: Educate your compliance team.

Remember, the only people who need to learn “the rules” are the people who incorporate the rules into your existing policies. Everyone else simply needs to learn the internal policies that apply. Even your compliance team only needs to learn or monitor the rules in order to integrate internal policies. Then the rules disappear, while your systems persist.

As an aside, one benefit to this approach is that many changes in the law will not require any modification to your existing policies, because you will frequently run your activities in a manner that complies with the new legal rules. When this happens, your compliance team learns that the rules have changed, but the rest of your organization will continue with business as usual.

It Really Works

The ROPE ladder analogy works. It builds on the same management foundations you may already use for running other components of your company, and customizes the same tools to police itself and improve its effectiveness. So, if you are at the end of your rope, climb a ROPE ladder for successful — and sane — compliance: Rule Overload Prevention and Elimination!

Class dismissed!

Neil Caesar is president of the Health Law Center (Neil B. Caesar Law Associates, PA), a national health law practice in Greenville, S.C. (www.healthlawcenter.com). He also is a principal with Caesar Cohen Ltd., which offers compliance training, outsourcing and consulting. A frequent author and speaker, Caesar is the author and editor-in-chief of the Home Care Compliance Answer Book. He can be reached via e-mail at [email protected] or by telephone at 864/676-9075.