1. Health and Home Cares Compliance Program
Compliance is Everyones Responsibility
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2. What is Compliance?
Compliance means following the rules. It means we understand and comply with all the laws, regulations, policies and procedures that apply to Health and Home Care and Health and Hospitals Corporation.
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3. The Compliance Climate Continues to Change, even Since our Presentation last year!
Congress and National Governors Conference Focus on Medicaid Fraud
Ex-Governor Spitzer appoints JamesSheehan NY Medicaid Inspector General
Governor Patterson appoints NYSMedicaid Inspector General Joseph Fisch
Authorization to hire 75 additional auditorsthis year in NYOIG.
First Annual NY OIG Work Plan issued by James Sheehan on April 19, 2008 with a focus on Fraud and Abuse of the 48 billion dollar Medicaid program.
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4. How does Health and Home Care Structure its Compliance Program?
Developed and expanded our comprehensive internal audit and Compliance Program to:
Monitor and audit areas based on the 2008 OIG Work Plan and internal risk assessment areas of concern.
Track and trend based on perceived and/or audited process issues
Use results to formulate a plan of corrective action
Re-audit to determine performance improvement
Share comparative audit results quarterly with all department heads at the newly created audit committee
Develop education programs to address audit findings and improve process and quality issues.
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5. The Auditing Cycle
(Re)Audit
Findings
Interventions
Plan of Corrective Action
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6. Who Oversees H&HCs Compliance Program?
Compliance Committee Members
Executive Director
Associate Executive Director/Compliance Officer - Committee Chairman
Deputy Executive Director/Chief Nurse Executive
Chief Financial Officer
Director Patient Safety/ PI
Associate Director Nursing/Compliance
Privacy Officer
Ad Hoc Participants
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7.The Buck Stops Here
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8. New York City Health & Hospitals Corporation Compliance Oversight
HHC Pres
Corp Compliance Off
Corp Compliance Committee
Health & Home Care Executive Director
Health & Home CareCompliance Officer
Health & Home Care Compliance Committee
Health & Home Care Employees
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9. Office of the Inspector General (OIG) Major Home Care Risk Areas include:
Billing for falsely credentialed HHA/PCA workers.
Billing for services that could be performed by other willing and able caregivers
Billing for items or services not actually rendered (All Payers)
Billing for medically unnecessary services (All Payers)
Submitting claims for equipment, medical supplies and services that are not reasonable and necessary
Billing for Services provided to patients who are not confined to their residence (homebound)-as defined by the Medicare COPS
Insufficient documentation to evidence that services were performed and/or to support reimbursement (All payers)
Source: 2008 NY Medicaid OIG Work Plan
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10. What Activities Comprise the Health and Home Care Compliance Program?
Summary of Internal Audits

PPS Medicare Audit

11. Outlier Audit 12. Cost Report Audit 13. Rehab Audit 14. OASIS Integrity Audit 15. Start of Care Documentation Audit 16. HHA/PCA Attendance Audit and Training Certificate Review 17. Vendor HIPAA Privacy Audits10
18. What Internal Audit Activities Comprise the Compliance Program?
Quarterly Mock Surveys
HIPAA Privacy and Security Audits
Professional and Paraprofessional Quality Integrity Audits
Intake Audit
Select Data External Coding Audit
Select Data Invoice Review
Post Billing Audits
Managed Care denials followed-up for resolution
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19. Professional and Paraprofessional Quality Integrity Audits
A total of 217 patients (approx. 20% of census)were contacted during Q4 2007 to confirm Clinician Visits
100% of visits were found to have been made.
We expanded this Professional Services audit to include attendance checks of HHA/PCAs beginning April 1st, 2008
Continuous review of HHA training certifications of new aides assigned to our cases and compare with the AG list of fraudulent training schools
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20. What Activities Will Ensure Continued Compliance in the Future?
Enhancing the visibility of the Compliance Program via Compliance Fairs, Compliance topic presentations at monthly borough meeting, posters with the theme that Compliance is Everyone's Responsibility, Compliance Newsletter and Compliance Tips
Continue audits to address the annual NY OIG Work Plan and other risk areas identified by our internal risk assessment
Expanding HIPAA Security audits in coordination with central IS
Expanding clinical review functions
Developing educational initiatives to address significant audit findings or areas where clinical, operational or financial improvements are indicated
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