Live from Managed Care – When the Whistle Blows! Responding to a Potential Relator



by Kortney Nordrum, CHC

We’re live blogging from HCCA’s Managed Care Compliance Conference. This session was presented by:

Steven Baruch, Compliance Officer, Sutter Health
Brian Callihan, Director of Special Projects, Sutter Health

An employee contacts a leader in your organization with a concern that if provided or shared to a regulatory agency, would be of interest, and possibly result in an investigation.

How do you proceed?

Basic Information Gathering

  • Make contact with the individual and introduce yourself if they don’t know who you are. Do an initial assessment and triage the claim.
  • It’s probably not comfortable for employees to come forward, so work to put your everyone at ease and start building trust.
  • Assure the employee that you’re concerned about the issue and want to resolve the matter appropriately and professionally. Let them know you and your organization are trying to do the right thing.
  • Assess – who is this person? What do they do in the organization? What kind of information do they have access to in their role?
    • Is it reasonable to believe the info the have is within the scope of their work? How did they come by this knowledge?
    • Do they sound coached? Even if they haven’t mentioned anything aboutwhistleblowing or qui tam do you have any reason to believe they would pursue such a case?
      • An example is an unsophisticated worker using legal terms. Is a lawyer coaching them about a qui tam case?
    • Do they have documents/data? Are they willing to provide copies?
      • Get as much information as possible about what they have documented.
    • Ask what they feel would be an appropriate resolution? What would do they want to accomplish by bringing this issue forward?

Initial Goal for 1st Meeting

  • Get a basic overview of their concerns and whether it is necessary to move forward

Decision Point

  • Based on the information you have, do you want to contact counsel? Do you want the investigation to be protected by privilege?

Pre-Investigation Self-Assessment

  • What are areas in this investigation might you be lacking in knowledge or experience?
  • Is it wise to investigate alone? Should you bring others with more expertise into the investigation?
    • Who else can help? What experience do you need to succeed?
  • What relationships and expertise do you have in your organization that can support you? Who is in your village?

Investigations – Just find the facts

  • Who, what, where, when, why – focus on these questions
    • Who are you investigating?
    • Who are you interviewing?
    • What are you investigating?
      • You need to fully understand what it is you’re actually investigating.
    • Is there a timing issue? Reporting to government agencies?
  • Objective
    • Remain neutral at all times.
    • As a compliance professional, your role is to gather the facts.
    • Don’t form an opinion before you start gathering facts.
    • Act if you have never encountered the parties before and be completely neutral.
      • Don’t ignore “frequent flyers”—they may have a serious allegation this time.
    • Treat all allegations seriously, until you can determine the facts.
  • Plan your investigation
    • Map out what you are trying to prove or disprove.
    • What are you trying to achieve with the investigation?
    • Identify who will be involved (even if it eventually changes).
      • Bring in subject matter experts if needed.
    • Evaluate whether additional resources may be needed.
  • Interviews
  • Let the individual tell you their complete story, don’t cut them off.
  • Ask open-ended questions.
  • Listen patiently without judging.
    • You are likely going to listen to more than you want to hear.
    • Many times, individuals just want to “get things off their chest.”
  • Who do you interview?
    • Reporter/complainant/person making the allegation
    • Others who may have facts about the situation.
      • Can someone corroborate? Disprove the claims?
    • Document the interview
      • Accurately report what the interviewee told you.
      • Make your conversation clear to the reader of your report.
      • If you’re confused by what the interviewee tells you, seek clarification. It is very difficult to summarize information for a report, if you don’t have a clear idea what is happening.
  • Social Media
    • Check sources on social media, but be careful not to go too far. Check your local rules about what you can/can’t do when looking at employee’s social media.
  • Learn and educate yourself
  • Document
    • Report results of the investigation
    • Reporting mechanism varies with type of investigation you are performing.
    • Compliance matters generally reported and documented into vendor-based system.
    • Reporting of investigation may vary if subject to direction by attorneys
  • Final Report
    • May be included as part of investigation documentation.
    • Could include credibility determinations or conclusions.
      • Separate this from the factual analysis.
    • Could include recommendations for reporting to government agencies.

Next Steps

  • Consideration of a root cause analysis as the final step of the investigation.
  • Consideration of corrective or remedial action to prevent the issue from occurring again.
  • Do you need additional review by management/counsel of the investigative activities?
  • Possible reporting to regulatory agency.
    • Always be forthcoming and honest with government agencies.