Your first reaction

How do you react? Are you calm, cool, and collected? Do you freak out and run for the hills? It’s probably somewhere in between. You know that you’re going to be super busy over the next several months managing both your day job and the audit. If you have a vacation planned to start in the next few weeks, you might be wondering if you should reschedule it—and you probably should.

Although none of us relish the thought of an audit, you might also be thinking that this will be an excellent opportunity for you to showcase your program and all the good work you do day in and day out. I’ve been through several of these audits and have felt all of those emotions. What has played a significant role in my approach to regulatory audits of all kinds is the confidence I have in the compliance investigations team we’ve assembled at Kaiser Permanente, and in the procedures and processes we’ve embedded in the work that we do to safeguard our organization from fraud, waste, and abuse (FWA).

Building a high-performing team isn’t as intimidating as it sounds, if you understand your objective and the work streams involved in fulfilling it, and if you have a set of guiding principles to help you organize and coordinate your team’s work.

Your guiding principles

Aligning with the Office of Inspector General’s seven elements of an effective compliance program^[1] is job one. The OIG’s Health Care Fraud Prevention and Enforcement Action Team^[2] advises:

• Implementing written policies and procedures

• Designating a compliance officer and compliance committee

• Conducting effective training and education

• Developing effective lines of communication

• Conducting internal monitoring and auditing

• Enforcing standards through well-publicized disciplinary guidelines

• Responding promptly to detected problems and undertaking corrective action

You’ll want to build a team able to prevent, detect, investigate, correct, and monitor the organization and its employees, all in support of these elements of an effective compliance program.^[3] You will want to have written policies and procedures that support your work. You’ll need to conduct effective training and education as it relates to your team’s objective. You’ll want to standardize systems as much as possible (e.g., use one case management system to track all reported instances of noncompliance across the entire organization).

Focusing more specifically on the respond, correct, and monitor elements, we developed the structure of the compliance investigations team at Kaiser Permanente. The team is composed of four units: the case management and reporting unit, the national special investigations unit, the national fraud control unit, and the strategy and program management unit. To facilitate consistency and align the work that we do across the program, we developed an overarching document called the investigations working agreement (IWA), and more detailed procedure manuals for the national special investigations unit and the national fraud control unit.

The IWA is a high-level document that outlines Kaiser Permanente’s approach to coordinating investigative activities within the organization, from timely entry of issues into our case management system to investigating and taking corrective action. The procedures manuals are more detailed documents for internal use by investigators. We also have national policies for FWA control and for reporting compliance and ethics concerns. We maintain an up-to-date reference library with all our policies, procedures, and related documents, and we store all audits and associated responses in a secure location for ready reference. These documents and materials are foundational to the work that we do and to ensuring our responses to regulators are consistent and aligned.