investigation protocols · 1/26/2015 1 1 code of conduct investigations protocols real life case...

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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


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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


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


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


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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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?


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



Vendor Relationships – A Case Study

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Credit Card Usage – A Case Study


Medicare VS. Ethics – A Case Study

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ROUND TABLE:

SUCCESSESIMPROVEMENT OPPORTUNITIES

BEST PRACTICESTIPS


investigation protocols · 1/26/2015 1 1 code of conduct investigations protocols real life case...

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