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1/26/2015
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Code of Conduct Investigations
Protocols
Real Life Case Studies
Round Table Discussion
Timshel Tarbet and Candice Kramer, CHPCFebruary 15, 2015
© 2014 Cambia Health Solutions, Inc.
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INVESTIGATION
PROTOCOLS
© 2014 Cambia Health Solutions, Inc.
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Unpack & Examine the allegation
� Define criteria: What’s the rule, or rules,
alleged to have been broken?
Identify Stakeholders
� Who will be the investigation team?
Test & Synthesize
� Audit: emails, reimbursement statements, access reports, etc.
� Interview affected parties
� Put it in order
Evaluate
Recommend
© 2014 Cambia Health Solutions, Inc.
Standard Structure
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Introductions
Define: Purpose–Process–Guidelines
� Duty to cooperate & be truthful
� Confidentiality
� Non-Retaliation
Share the allegation
Ask specific questions
� The interviewee needs to tell his/her story
Wrap up
� Answer questions & assign point of contact
© 2014 Cambia Health Solutions, Inc.
The Interview
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Get a baseline - Beware traditional “tells”
� Eye contact & movements
� Hand gestures & other body language
Critical Tools
� Open-ended questions
� Silence
� Observation
Gaps
� Not answering a question is a RED flag
� If the statement is not logical, get clarity from the interviewee
© 2014 Cambia Health Solutions, Inc.
The Interview: Spotting Lies
66 © 2014 Cambia Health Solutions, Inc.
Evaluation
Reasonableness Test:
After interviewing & gathering the facts, is it reasonable to determine that the allegation is substantiated?
Vetting with leadership &/or investigation team
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77 © 2014 Cambia Health Solutions, Inc.
Recommendation
Corrective Action
� Process improvement
� Sanction
Consistency is essential
� What do the policies outline?
� How has the organization responded to others who acted the same way?
Fairness
� Systemic or “tone at the top” issue?
Mitigating factors?
88 © 2014 Cambia Health Solutions, Inc.
Documenting the Case
Early & frequently
Tell the story
� Use a succinct, neutral voice
� NO: Interviewee was nervous.
� YES: Interviewee was sweating,
refrained from eye contact, and
stammered when she was speaking.
� Spell out the decision-making rationale
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REAL LIFE CASE
STUDIES
© 2014 Cambia Health Solutions, Inc.
1010 © 2014 Cambia Health Solutions, Inc.
Vendor Relationships – A Case Study
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1111 © 2014 Cambia Health Solutions, Inc.
Credit Card Usage – A Case Study
1212 © 2014 Cambia Health Solutions, Inc.
Medicare VS. Ethics – A Case Study
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ROUND TABLE:
SUCCESSESIMPROVEMENT OPPORTUNITIES
BEST PRACTICESTIPS
© 2014 Cambia Health Solutions, Inc.