A Post-Acute Long-Term Care Fraud Investigation
By:
David Barmak JD, CEO
A post-acute long-term care Compliance and Ethics Program investigation is only as good as the diversity of the investigators’ perspectives. A client is best served by an eclectic team offering a variety of healthcare disciplines to ideally prevent problems and, as needed, to solve problems post-facto. Talent should include, among others, administrators, nurses, social workers, rehabilitation therapists, and attorneys.
Prioritize Prevention
Prevention is the most important concept in fraud investigations; however, this is not easily attained because of budgetary constraints and a generalized attitude of waiting until a problem develops before conducting an investigation. When the latter occurs, the questions asked include, but are not limited to, “Who did what?” “How do I prove what happened?” “What do I do to rectify the problem?” “How do I mitigate damages?”
Some basic investigation tenets:
- Listen rather than talk. There’s a need to understand what the parties involved in the problem have to say and why these parties are involved with the problem. Sometimes initial explanations and reasons are superficial, and sustained listening will lead to the underlying real issues.
- Active listening. Listen carefully to the parties and reiterate what you’ve heard. Also, put in writing the information you receive from the parties. This helps to ensure the goals of the investigation are clear and the parties involved understand how the investigation is going to move forward.
- Usage. It is very important to understand from the start how the parties want/need to use the information obtained through investigation. Is the information to be used to mitigate risk of a resident/family’s lawsuit? To provide information to the Office of Inspector General’s fraud investigation or for the state department of health? Depending upon usage, the investigation may need to stop while an attorney is assigned to oversee the investigation under the attorney client privilege.
- Candor. For an investigation to succeed, it is essential that the involved parties are perfectly candid. Providing truthful information up front enables an investigation to move forward effectively and efficiently. Anything less than truthful will likely lead to a faulty investigation with minimal ability to mitigate potential damages.
- Expectations. It is very important, from the start of an investigation, to set realistic expectations and to be transparent with the parties involved when sharing these expectations.
- Diversification. The most important part of an investigation is to arrange for an interdisciplinary team to conduct and evaluate investigations. Each profession has a different perspective and, therefore, an investigation can be viewed from many angles in an effort to serve the needs of all parties involved.
A Compliance and Ethics Program investigation depends upon a diversity of investigators’ perspectives. A healthcare provider’s creative, eclectic team, proactively and preventatively focused, is best situated to uncover exposures and propose solutions.
