Health and Home Care’s Compliance Program

“Compliance is Everyone’s Responsibility”

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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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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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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. 4

The Auditing Cycle

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(Re)Audit

Findings

Plan of Corrective Action

Interventions

Who Oversees H&HC’s 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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The Buck Stops Here…

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New York City Health & Hospitals Corporation Compliance Oversight

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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 caregiversBilling 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 necessaryBilling for Services provided to patients who are not confined to their residence (“homebound”)-as defined by the Medicare COPSInsufficient 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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What Activities Comprise the Health and Home Care Compliance Program?

Summary of Internal Audits

• PPS Medicare Audit• Outlier Audit• Cost Report Audit• Rehab Audit • OASIS Integrity Audit • Start of Care Documentation Audit• HHA/PCA Attendance Audit and Training Certificate

Review• Vendor HIPAA Privacy Audits

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What Internal Audit Activities Comprise the Compliance Program?

Quarterly Mock SurveysHIPAA Privacy and Security AuditsProfessional and Paraprofessional Quality Integrity AuditsIntake AuditSelect Data External Coding AuditSelect Data Invoice ReviewPost Billing AuditsManaged Care denials followed-up for resolution

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Professional and Paraprofessional Quality Integrity Audits

A total of 217 patients (approx. 20% of census) were contacted during Q4 2007 to confirm Clinician Visits100% of visits were found to have been made.We expanded this Professional Services audit to include attendance checks of HHA/PCAs beginning April 1st, 2008Continuous 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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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 TipsContinue audits to address the annual NY OIG Work Plan and other risk areas identified by our internal risk assessmentExpanding HIPAA Security audits in coordination with central ISExpanding clinical review functionsDeveloping educational initiatives to address significant audit findings or areas where clinical, operational or financial improvements are indicated

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