Annual compliance training for providers

Annual compliance training for providers May 2020

Confidential Notice: This document contains privileged information and is for the sole use of the intended recipient(s). Disclosure or distribution to and review or use by any unauthorized Luxottica EyeMed associate(s) and external parties is prohibited.

Why do I need this training?

The state and federal government programs require providers to complete training on several topics and so do the health plans that participate in those programs. We’ve simplified the process of completing the required training by merging the content into 1 easy-to-digest course. EyeMed is committed to compliance with all applicable regulations including: • Program regulations from the US Department of Health and Human Services and the

Centers for Medicare and Medicaid Services (CMS) • The Affordable Care Act Section 1557 • The California Health Care Language Assistance Act • The Civil Rights Act • The Americans with Disabilities Act • State and local laws


Training modules

The following topics are covered by this training course:

• Compliance programs for providers

• Fraud, waste and abuse

• HIPAA

• Information security

• Disability accommodations and cultural competency

Let’s get started.

• Human trafficking

• Recognizing and reporting abuse, neglect and exploitation

• Member Bill of Rights/grievances and appeals

• Medicaid provider training

1

Compliance Programs for Providers


The what and why of compliance programs

Compliance is the process of making sure your practice follows applicable laws, regulations, standards and ethical practices.

A compliance program helps protect you and your practice against improper payments, fraud and abuse, and other potential liability areas.

Simply put: The purpose is to protect your organization while you provide quality care to patients.


Seven elements of a good compliance program for individual providers and small group practices

1. Conduct internal monitoring/auditing 2. Implement practice standards 3. Designate a Compliance officer or contact 4. Conduct training for staff 5. Respond to detected problems and develop corrective actions 6. Maintain open lines of communication 7. Enforce disciplinary standards with well-publicized guidelines


Compliance programs aid good patient care

• Federal guidelines strongly encourage providers to develop and implement compliance programs that recognizes the financial and staffing resource constraints faced by individual providers and small group practices.

• Patient care is, and should be, the first priority of a provider practice and a practice’s focus on patient care can be enhanced by the adoption of a voluntary compliance program.

• For example, the increased accuracy of documentation that may result from a compliance program will actually assist in enhancing patient care.


Compliance elements to emphasize

Compliance measures do not take away from patient care, but instead augment the ability to provide quality patient care.

A well-designed compliance program can: • Speed and optimize proper payment of

claims;

• Minimize billing mistakes;

• Reduce the chances that an audit will be conducted by a federal enforcement agency; and

• Avoid conflicts with the self-referral and anti-kickback statutes.

A compliance program sends an important message to the practice’s employees that, while the licensed providers recognize that mistakes can occur, their employees have the affirmative, ethical duty to come forward and report erroneous or fraudulent conduct, so that it may be corrected.


Element 1: Conduct internal monitoring

To monitor compliance, the practice needs to periodically review the care and billing standards or procedures to determine if they are current and complete.

If the standards and procedures are found to be ineffective or outdated, they should be updated to reflect changes in government regulations or compendiums generally relied upon by physicians and insurers, i.e., changes in Current Procedural Terminology (CPT) and ICD–9 codes.

Compliance Program for Providers


Element 2: Establish Practice Standards

Written standards and procedures are a central component of any compliance program.

They reduce the prospect of erroneous claims and fraudulent activity by identifying risk areas for the practice and establishing tighter internal controls to counter those risks.

Also, they help the business by identifying aberrant billing practices.


Practice standards: Recordkeeping

Patient charts support both quality care and billing. Medical record checklist: • dated, complete and legible (with legible signature) • each encounter has reason for visit, relevant history, assessment andfindings, test

results, clinical impression or diagnosis and care plan rationale or support for additional diagnostic testing

The medical record validates: • site & appropriateness of services • accuracy of billing • identity of actual caregivers


Coding and billing standards

Billing issues that result in federal audits are:

• Services/materials not provided as claimed

• Claims deemed not reasonable and necessary

• Duplicate claims resulting in duplicate payments

• Billing for non-covered services as if covered

• Knowing misuse of provider identification numbers

• Unbundling (service components billed, not the all-inclusive codes)

• Improper use of coding modifiers

• Upcoding the level of service


Attention to laws against inducements, kickbacks and self-referrals

Fraud, waste and abuse (FWA) laws are detailed in a later section. Generally, providers risk FWA when payments:

• distort medical decision-making

• cause overutilization of services, supplies and tests

• increase costs to Federal healthcare programs

• exclude others who won’t pay for referrals (unfair competition)

Patient inducements can also be illegal, such as waiving all coinsurance, cost-sharing or deductible amounts. If you make individual determinations of financial need, you need to document each inquiry.

Compliance Program for Providers


FWA provider risks

Do not enter a referral-based arrangements without experienced counsel’s review of

anti-kickback and self-referral laws.

FWA investigators look for: • transactions with 3rd parties who make government healthcare program referrals;

• joint ventures that supply goods/services to providers/patients

• contracts for consulting or as clinical director

• Office/equipment leases among referral parties

• gifts/gratuities (above nominal value) in government healthcare program referrals


Audits and audit findings

After checking patient care and billing standards, self-audits determine if standards are being met.

Make appropriate responses if audit identifies a problem and take action as soon as possible after the audit.

Specific action depends on the circumstances.

In some cases, the response can be as straight forward as generating a repayment and explanation to Medicare or the affected payor.


Element 3: Compliance Officer

While often impossible to designate a full-time compliance position, it’s acceptable to spread functions across staff to:

• oversee monitoring, corrective action plans and staff training

• establish periodic audits and investigate reports of wrongdoing

• review HHS–OIG’s list of excluded and debarred individuals (employees or contractors)


Element 4: Education and training

Tailor the program to practice’s needs, specialty and size.

There are three basic steps for setting up educational objectives:

1. Determining who needs training (in coding, billing and FWA)

2. Determining the type of training that best suits the practice’s needs (e.g., seminars, in-service training, self-study or other programs)

3. Determining when and how often education is needed and how much each person should receive.


Element 5: Corrective action

After detection of a possible compliance issue, the next steps are: • make a formal determination of response, including any self-report to the payor • develop the corrective action plan • Monitor to avoid re-occurrence.


Element 6: Open Communication

For small provider practices, encourage ‘‘open door’’ policy among all staff levels and use of staff meetings and bulletin board postings outside patient areas. Address topics like:

• making reports a reasonable person would find erroneous or fraudulent

• user-friendly process for reports & follow-ups

• anonymity for those who report, if possible

• assure no retribution for good faith reporters

• if a billing company is used, engage its compliance officer in monitoring and education


Element 7: Enforce Practice Standards

Assure that practice employees understand job consequences if they behave in a non-compliant manner that can harm the provider’s business or reputation or result in debarment from government programs. Be open about disciplinary guidelines, sanctions and mechanisms you will use consistently with offending individuals.


Additional learning

To learn more, check out this resource: DEPARTMENT OF HEALTH AND HUMAN SERVICES Office of Inspector General OIG Compliance Program for Individual and Small Group Physician Practices

https://www.hhs.gov/

https://www.hhs.gov/

https://oig.hhs.gov/authorities/docs/physician.pdf





Sources

This training was developed from the following expert references:

• Centers for Medicare and Medicaid Services • Modern Medicine Network • Rutgers University, College of Law

2

Fraud, waste or abuse


The what and why of fraud, waste or abuse

Every practice must have policies and procedures in place to detect, correct and prevent fraud, waste and abuse (FWA).

Fraud, waste and abuse cost taxpayers and health care systems staggering amounts of money each year.

Careful monitoring of FWA is essential to maintaining a health care system that is affordable for everyone.

The primary difference between fraud, waste and abuse is intent and knowledge.

Fraud is generally defined as knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain any of the money or property owned by, or under the custody or control of, any health care benefit program. (18 U.S.C. § 1347) Waste is overutilization of services that, directly or indirectly, result in unnecessary costs. It is not generally considered criminally negligent, but rather a misuse of resources. Abuse includes payment for items or services when there is no legal entitlement to that payment and the individual or entity has not knowingly or intentionally misrepresented facts to obtain payment.


Indicators of potential fraud, waste or abuse

• Cash incentives offered to beneficiaries to join a particular vision care plan

• Patients being led to believe that the cost of care is one price, but billed costs are higher

• Making inappropriate risk adjustments on insurance claim submissions

• Providing samples that are later billed to a federal health care program


Reporting

• Everyone is required to report suspected instances of fraud, waste and abuse.

• All employees should report any concerns to your compliance department or compliance officer.

• Employees should not be concerned about whether it is fraud, waste or abuse.

• The compliance officer will investigate and make the proper determination.


Good faith protection

Everyone is protected from intimidation and retaliation for good faith participation in the compliance program.

Intimidation and retaliation includes, but is not limited to, reporting potential issues, investigating issues, conducting self-evaluations, audits and remedial actions, and reporting to appropriate official.


External reporting

There are also many external sites provided by federal and state regulators where you can report FWA.

• State Attorney General: (phone numbers vary by state)

• Agency for Health Care Administration (AHCA), Medicaid Program Integrity: 888.419.3456

• Dept. of Financial Services, Div. of Insurance Fraud: 800.378.0445

• Office of Inspector General (OIG): http://oig.hhs.gov

• Department of Health and Human Services (DHHS): www.hhs.gov/ocr/hipaa

• Centers for Medicare and Medicaid Services (CMS): www.cms.gov


Correcting fraud, waste or abuse

• You must correct fraud, waste or abuse once it is detected.

• Your compliance officer should develop a corrective action plan and document the actions taken.

• Correcting fraud, waste or abuse shows compliance with federal and state regulations.

• It does not necessarily protect individuals or your practice from potential consequences.


Consequences of committing fraud, waste or abuse

The following are potential penalties. The actual consequence depends on the violation.

• Civil financial penalties or prosecution

• Criminal prosecution, fines or imprisonment

• Loss of provider license

• Exclusion from federal health care programs


Fraud, waste or abuse review

• Fraud, waste and abuse involves inappropriate payments to providers

• The primary difference between the 3 is intent and knowledge

• Correction must be prompt and is mandatory

• Consequences could be severe


Additional learning

To learn more, check out these resources:

• False Claims Act primer

• Medicare Learning Network booklet

https://www.justice.gov/sites/default/files/civil/legacy/2011/04/22/C-FRAUDS_FCA_Primer.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/fraud_and_abuse.pdf


Sources

This training was developed from the following expert references: • Centers for Medicare and Medicaid Services • Health Care Fraud Prevention and Enforcement Action Team • Humana

https://www.cms.gov/Medicare/Compliance-and-Audits/Part-C-and-Part-D-Compliance-and-Audits/ComplianceProgramPolicyandGuidance.html

https://www.oig.hhs.gov/newsroom/video/2011/heat_modules.asp

https://www.humana.com/about/legal/disclaimer-and-licensure/fraud-waste-and-abuse

HIPAA

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The what and why of HIPAA

Health Insurance Portability and Accountability Act of 1996, known commonly as HIPAA, establishes national standards to protect individuals' medical records, and other personal health information (PHI), for providers who conduct certain health care transactions electronically.

This government policy helps you deliver the best service possible while safeguarding patient information.


The 4 main areas of HIPAA

• Privacy Rule: Sets national standards for when protected health information (PHI) may be used and disclosed

• Security Rule: Specifies safeguards that covered entities and their business

associates must implement to protect the confidentiality, integrity and availability of electronic PHI (ePHI)

• Enforcement Rule: Outlines penalties in the event of a breach, audit or

complaint. Violations may result in civil monetary penalties. In some cases, criminal penalties enforced by the U.S. Department of Justice may apply

• Breach Notification Rule: Requires covered entities to notify affected

individuals, HHS and, in some cases, the media of a breach of unsecured PHI


Everything is PHI

What information is protected by HIPAA’s privacy, security, enforcement and breach rules? All information regarding your patients is protected health information and must be protected against unauthorized use or disclosure. That includes: • Any conversation you and your staff have with patients, whether in person or

over the phone • Any information you collect for computer input or information you use for

documentation or identification • All information that you keep in your charts and systems


How to communicate PHI

Conversations with your patients • Always be aware of who may be able to

overhear your conversations and take steps to keep the conversations private.

• That could be as simple as lowering your voice, or it may mean moving to another part of the office.

Email or fax communication • Never send PHI by unencrypted email or

unencrypted fax.

• If you are unsure if an unencrypted email or unencrypted fax contains PHI, do not send it until safeguards are in place, such as:

• Ensuring that you enter the correct email or fax number accurately

• Letting the receiver know when to expect your fax

• If you are receiving a fax with PHI, pick it up immediately.



Social media • Social media and personal conversations

• Don’t post personal or private information about patients on social media (e.g., Facebook, Twitter, Instagram) without their written consent, under any circumstance.

• Don’t share information about patients to your friends or anyone.

Hard copy records

• Control physical access by storing PHI in locked cabinets or drawers.

• When you have finished with any documents, return them to their appropriate folder or place them face down so no one can view them.

• Ensure that patient files or information are never left out where anyone can see them.



Electronic files • Practice smart IT security, such as password

protection on all computers and controlling access to electronic files (refer to the next training module for more on IT security).

• Clear your computer screen of any customer-specific information once you’re finished using it.

• Set your screen saver to start after a few minutes of inactivity.

HIPAA and other providers or insurers • When talking with other vision or health care

providers, insurers or other authorized entity, use the Minimum Necessary Rule.

• Provide only the information required to complete a specific task. Never exchange any other information regarding the customer.

• During treatment, share only the PHI detail needed for the specific discussion.


Patients and their PHI

According to HIPAA, patients have the right to review and request changes to the information you have collected about them.

However, you must be sure the person you share PHI with is either:

• The patient

OR

• Someone with the legal right to access and update the records

When someone asks for access to PHI, you must verify his/her identity and relationship to the patient.

Some accepted approaches to verifying a customer’s right to access PHI:

• In person you can ask for a photo ID and confirm against your records

• On the phone, ask open-ended questions. For example, to verify an address, ask, “What’s your address?” rather than asking, “Is your address 123 Street in Springfield?” Have the individual verify at least 2 elements currently on file


When PHI is shared or obtained inappropriately

The HIPAA Breach Notification Rule requires you to notify affected individuals, HHS and, in some cases, the media of a breach of unsecured PHI.

Most notifications must be provided without unreasonable delay and no later than 60 days following the discovery of a breach to both the individuals affected and HHS. Notifications of breaches affecting fewer than 500 individuals may be submitted to HHS annually.

The Breach Notification Rule also requires your business associates (e.g., claims processing, billing, etc.) to notify you of breaches at or by the business associate.


HIPAA review

• Everything about a patient is protected information

• All communication and files must be protected

• Use the Minimum Necessary Rule when sharing information with other providers

• Verify identify before sharing PHI with patients or their caregivers/guardians

• Notify individuals and HHS if PHI is shared or obtained inappropriately


Additional learning


• Health IT Privacy and Security Resources for Providers

• CMS HIPPA Training for Providers

https://www.healthit.gov/topic/privacy-security-and-hipaa/health-it-privacy-and-security-resources-providers

https://www.healthit.gov/topic/privacy-security-and-hipaa/health-it-privacy-and-security-resources-providers

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/HIPAAPrivacyandSecurity.pdf


Sources


• Centers for Medicare and Medicare Services

• US Department of Health and Human Services

• HealthIT.gov

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/HIPAAPrivacyandSecurityTextOnly.pdf

https://www.hhs.gov/hipaa/for-professionals/index.html

https://www.healthit.gov/sites/default/files/basic-security-for-the-small-healthcare-practice-checklists.pdf

4

Information (IT) Security


The what and why of IT security

IT security refers to the steps you take to keep electronic information safe from misuse.

It’s important for building trust with your patients.

When patients trust you and your IT systems enough to share their health information, you will have a more complete picture of patients’ vision care needs and overall health.

That means you and your patient can make more informed decisions about his/her care.


The risk when IT isn’t secure

Poor privacy and security practices heighten the vulnerability of patient information in your health information system, increasing the risk of successful cyberattack. When breaches of health information occur, they can have serious consequences for you, your practice or your patients, such as: • Damaged reputation • Financial losses • Identify theft


Basics of IT security

IT security rests on confidentiality, integrity and availability. • Confidentiality is the concealment of information or resources • Integrity refers to the trustworthiness of data or resources • Availability refers to the ability to use the information or resource desired That means when your IT is secure, data can’t be found or seen, and comes from/is shared with only trusted sources.


Simple but secure practices

Here are a few easy tips for keeping your data secure: • Keep software and operating systems updated (new protections are added often) • Think before you click (don’t trust attachments or links from unknown senders) • Don’t plug unknown media (i.e. jump drives) into your computer • Secure your computer (i.e. with a locked screen saver) • Use strong and unique passwords • Protect sensitive data with encryption • Do not use public Wi-Fi or any public networks Let’s dig deeper into a few of these.


More on strong passwords

A strong password includes a random combination of 8 or more numbers, symbols, capital and lowercase letters.

Using a variety of character types increases the time it takes to crack the password.

One good way to create a strong password it to use an easily remembered phrase and substitute letters and numbers for words. For example:

“I Like to Sing and Take Long Walks” = 1L2$&Tlw


More on encryption

Encryption is the process of encoding messages or information in such a way that only authorized parties can read it.

Basically, encryption can’t stop the email from getting into the wrong hands, but it does make it hard for them to read it.


More on the dangers of free Wi-Fi

It’s important to remember that free Wi-Fi networks may actually be quite costly. You may be accustomed to hopping on the Wi-Fi at your local coffee shop, but so are hackers. Do not expose your practice to unnecessary security risks by connecting your work laptop, or personal laptop with work files, to free unsecure Wi-Fi networks. Only use secured Wi-Fi networks such as your home Wi-Fi or hotspot devices (i.e. mobile phone/tablet).


IT security review

• Secure data can’t be found or seen

• Secure data only comes from/is shared with trusted sources

• Simple tips for protecting data include: • Using strong and unique passwords

• Protecting sensitive data with encryption

• Not using public Wi-Fi or any public networks


Additional learning

To learn more, check out these resources: • 5 Basic (And Cheap!) Tasks That Will Dramatically Improve IT Security

• Introduction to Computer Security, by Matt Bishop, PhD

https://businessarticleshub.com/five-basic-and-cheap-tasks-that-will-dramatically-improve-it-security-for-small-businesses/

https://www.amazon.com/Introduction-Computer-Security-Matt-Bishop/dp/0321247442


Sources

This training was developed from the following expert references: • Basic security guide for small medical offices

• HealthIT.gov

• U.S. Department of Health and Human Services





https://www.hhs.gov/about/agencies/asa/ocio/cybersecurity/security-awareness-training/index.html

https://www.hhs.gov/about/agencies/asa/ocio/cybersecurity/security-awareness-training/index.html

Disability accommodations and cultural competence

5 57


Americans with Disabilities Act of 1990 (“ADA”)

Provider offices need to comply with ADA requirements: • Appropriate waiting room and exam room furniture • Parking and building accessibility for disabled individuals to include designated parking,

ramps, doorway/hallway widths and restroom availability • Clear signage throughout office identifying accessible areas • Interpretive services for patients, parents and guardians who have limited English

proficiency and available aids for those with visual and hearing impairments

Disability accommodations


The what and why of cultural competence

Cultural competence is the ability to interact with people who represent different cultures or belief systems. It’s an attitude and an ongoing process. It is important to recognize the value in cultural diversity and to provide culturally competent care to all of your patients. Commit to providing culturally and linguistically appropriate services that are respectful of and responsive to the health beliefs, practices and needs of diverse patients.


Culture impacts service

Culture impacts your patients…

• Different attitudes toward healthcare providers

• Different views on illness and disease

• Expectations and beliefs about health

• Different ways to express concerns and fears

Culture impacts you… • How you provide explanations and

solutions • What you assume about your

patients • Your ability to communicate

effectively with patients • Accessibility to your facility and care


Limited English Proficiency (LEP)

Limited English Proficiency refers to an inability or a limited ability to speak, read, write or understand the English language on a level that permits that individual to interact effectively with healthcare providers or healthcare employees.

• One in 2 adult healthcare patients has a hard time understanding basic health information due to lower level English proficiency.

• The average physician interrupts a patient within the first 20 seconds.


Helping patients with LEP

You can help improve communication with LEP patients by:

• Using a variety of instruction methods

• Taking advantage of EyeMed’s translation services

• Encouraging questions

• Using clear, specific and plain language

• Offering printed materials in multiple languages

Note: Providers are responsible for abiding by federal and state regulations, including meeting accessibility and effective communication requirements. Most notably, this includes, but is not limited to, a language assistance requirement to make interpretive services available in their offices to LEP members.


Health literacy

Health literacy is the ability to obtain, process and understand basic health information and services needed to make appropriate decisions. More than 1/3 of patients have limited health literacy, which results in their not understanding what they need to do to take care of their health. Improved communication leads to better care for your patients and a better experience with your practice.


Seniors and people with disabilities

Be aware that accommodations may be needed to fully care for the mental and physical need of seniors and people with disabilities. The Americans with Disabilities Act (ADA) requires you to consult with people with disabilities before an accommodation is offered or created on their behalf. Seniors deserve the same courtesy. Regardless if a formal accommodation is made, remember there are simple things you can do to slow down, speak clearly, use plain language and obtain a thorough health history.


Things to consider

Different people require different approaches to achieve positive outcomes due to their unique health and home challenges. Some patients may not be comfortable discussing personal information with or being treated by someone of a different gender. You may need to ask another care provider or staff to step in.

Some cultures are tolerant of verbal interruptions, while other cultures see this as disrespectful. Be patient and take the time to invite and answer questions.

In some cultures, decisions may be made with the inclusion of family members. Ask patients who else may need to be included in the conversation.


Practice tips

• Speak in plain language

• Confirm that patients or caregivers understand your explanation

• Use a translation service

• Encourage the patient to ask questions

• Explain terms that may be unfamiliar or confusing

• Make a note of the patient’s language preference for future communication

• Arrange an accommodation for patients with physical, vision or hearing difficulties


Cultural competence review

• Cultural competence is being able to interact with people from cultures or belief systems

• It requires both awareness and action, such as arranging for special accommodations

• Communication is a key component to overcoming many potential pitfalls


Additional learning


• The National Standards for Culturally and Linguistically Appropriate Services

• Americans with Disabilities Act

https://www.thinkculturalhealth.hhs.gov/

https://www.thinkculturalhealth.hhs.gov/

http://www.ada.gov/


Sources


• US Department of Health and Human Services

• HRET and the Institute for Diversity

https://minorityhealth.hhs.gov/

http://www.diversityconnection.org/diversityconnection/membership/Resource%20Center%20Docs/Equity%20of%20Care%20Report%20FINAL.pdf

Human trafficking

6 70


The what and why of human trafficking

Human trafficking is a modern form of slavery. It occurs when a trafficker exploits an individual with force, fraud or coercion to make them perform commercial sex or work.

Healthcare providers have a crucial role in victim identification. They are in a unique position to recognize problems that may not be obvious at first glance.

The interaction with a healthcare worker may be the only private setting they have to ask for help.

Human trafficking is the second largest criminal enterprise in the world. Traffickers can range from small-time solo operators, to loose networks of criminals, to highly sophisticated criminal organizations that operate internationally.


Who gets trafficked

Victims of human trafficking are frequently lured by false promises of a lucrative job, stability, education or a loving relationship. Victims can be men or women, adults or children, foreign nationals or U.S. citizens. They often share the trait of vulnerability (i.e., young, experienced abuse/violence, drug use, etc.). But victims have diverse ethnic and socio-economic backgrounds, varied levels of education and may be documented or undocumented.


How to identify trafficking victims

• Is not allowed or able to speak for themselves (a third party may insist on being present and/or translating)

• Is not in control of his/her own money, has no financial records or bank account

• Is not in control of his/her own identification documents (ID or passport)

• Is unable to provide his/her address

• Has tattoos or other forms of branding, such as tattoos that say, “Daddy,” “Property of...,” “For sale,” etc.

• Is unwilling or hesitant to answer questions about an injury or illness

• Demonstrates fearful or nervous behavior or avoids eye contact

• Is resistant to assistance or demonstrates hostile behavior

Refer to this PDF from the trafficking resource center for other signs of general, labor and sex trafficking.

Here are few red flags. Your patient:

https://traffickingresourcecenter.org/sites/default/files/What%20to%20Look%20for%20during%20a%20Medical%20Exam%20-%20FINAL%20-%202-16-16.docx.pdf


How to you can help

To request help or report suspected human trafficking: • call 888.373.7888

• text HELP to: BeFree (233733)

• visit National Human Trafficking Hotline website

http://www.humantraffickinghotline.org/


Human trafficking review

• Trafficking is more common than you might think

• Health care providers play a key role in identifying and supporting victims

• Know the signs someone might be a victim

• Report any and all suspected human trafficking


Additional learning

To learn more, check out these resources: • Covenant House

• Identifying a victim

• Polaris Project

https://www.covenanthouse.org/homeless-issues/human-trafficking

https://www.covenanthouse.org/homeless-issues/human-trafficking

https://www.dhs.gov/blue-campaign/identify-victim?utm_source=google.com&utm_medium=cpc&utm_campaign=rg.search-fy18.exact-allcit&utm_content=About&utm_term=human%20trafficking%20information

https://polarisproject.org/blog/2016/11/03/healthcare-providers-play-crucial-role-victim-identification


Sources

This training was developed from the following expert references: • US Department of Homeland Security

• Human Trafficking: The Role of the Health Care Provider

• Training US health care professionals on human trafficking: where do we go from

here?



https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3125713/




7

Recognizing and reporting abuse, neglect or exploitation


The what and why of abuse, neglect or exploitation

You may sometimes have a reason to suspect that a patient is the victim of abuse, neglect or exploitation.

It is your responsibility to report reasonable suspicions of abuse, neglect or exploitation to the appropriate agency or resource. Just as with human trafficking victims, providers have a crucial role identifying abuse victims.

You are in a unique position to recognize problems, and your practice may be the only private setting they have to ask for help.


Understanding abuse, neglect or exploitation

Abuse is willful infliction of physical or emotional harm, pain or anguish. This includes sexual abuse, as well as encouraging anyone to commit an act of abuse. Neglect is the failure to provide or arrange for the necessities of life. Neglect can be willful or passive, and it could be 1 instance or an ongoing situation. It also includes self-neglect. Exploitation is the unlawful or improper act of using a person or a person’s resources for monetary or personal benefit, profit or gain.


How to identify abuse, neglect or exploitation

Some signs your patient may be a victim of abuse, neglect or exploitation: • Inconsistent information from patient and caregivers about the patient’s health or

treatment, particularly in the event of injury • Patient does not recall seeing or signing documents • Patient does not seem to understand or recall financial agreements that have

been made on his or her behalf • Caregivers or family patients do not allow the patient to speak for himself or

herself • The patient is a victim of threats, intimidation or verbal abuse from a family

patient or caregiver


How you can help

It is your responsibility to report reasonable suspicions of abuse, neglect or exploitation to the appropriate agency or resource. State laws and Medicaid contracts include reporting requirements. If you suspect abuse, neglect or exploitation, you must take steps to report your suspicion. In general, people who report in good faith are protected from civil and criminal liability.


How you can help

You can make a report to your local police department or local abuse hotline. You can also call: • National Domestic Violence Hotline at 800.799.7233 • National Child Abuse Hotline at 800.422.4453 Call 911 immediately if you suspect someone is in immediate danger!

http://www.thehotline.org/

https://www.childhelp.org/

https://www.childhelp.org/


Additional learning

To learn more, check out these resources: • NCADV Signs of Abuse

• Know the signs

https://ncadv.org/signs-of-abuse

https://ncadv.org/signs-of-abuse

http://www.joyfulheartfoundation.org/learn/child-abuse-neglect/about-issue/know-signs




Additional learning

This training was developed from the following expert reference: Centers for Disease Control and Prevention

https://www.cdc.gov/violenceprevention/index.html

8

Member Bill of Rights

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Member Bill of Rights

EyeMed has a publicly available Member Bill of Rights which outlines members’ rights and responsibilities. For example, members have the right to: • Respect, consideration and dignity without discrimination of any kind • Clear information about their vision plan and in-network providers • Participate in their eye care decisions • Relay a concern or report potential fraud, waste or abuse practices by providers or

your plan • Accessible and useable equipment at their provider’s location


Member Bill of Rights, cont.

For example, members have the responsibility to:

• Understand plan benefits, exclusions of coverage and costs of their eye care

• Share complete and accurate health history

• Seek immediate care for eye emergencies

• Offer respect and consideration to their vision

• Express opinions, concerns or complaints constructively

• Let their eye doctor know if they are running late or need to cancel an appointment

You can review the full set of rights and responsibilities on eyemed.com

https://eyemed.com/en-us/member-bill-of-rights


Grievances and appeals

Members also have the right to appeal their vision plan’s decisions, file a complaint or request an independent review.

Neither the vision care plan nor you as a provider can penalize and/or discriminate against patients or their dependents for expressing dissatisfaction or filing an appeal.

You can review the full grievance and appeal process on eyemed.com.

Medicaid provider training

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The what and why of Medicaid provider training

The Centers for Medicare and Medicaid Services (CMS) requires providers to meet additional training content requirements.

The following section covers CMS’s requirements that have not yet been covered elsewhere in this training.


CMS model of care

The Centers for Medicare and Medicaid (CMS) model of care is designed to help improve access to medical, mental health and social services. It allows members access to affordable care and preventive health services.

The model of care promotes:

- Coordination of care through an identified point of contact

- Transitioning each member’s care between health care settings and health care providers


CMS model of care, cont.

The model of care allows a focus on health outcomes and each member’s satisfaction with their health status and health services.

In addition to focusing on the member’s experience, CMS’s model of care provides appropriate utilization of services and facilitates cost-effective health services delivery.

Members are faced daily with a variety of life challenges. CMS aims to eliminate the challenges and frustration of navigating a complex health care system by integrating a variety of administrative processes for members and providers.


Coordination of Medicare and Medicaid benefits

It is important that all Medicare and Medicaid benefits are member-center and coordinated.

Member-centered, coordinated care is defined as ”person-centered and collaboratively planned care by a care team with knowledge about the specific needs of the member and the array of medical, nonmedical, behavioral services and benefits available to meet those needs are critical to helping the member achieve his/her optimum level of wellness.”


Long-term support services

Some members who have been assessed by the state require a broad range of long-term services and supports (LTSS) and community support in order to meet their functional needs. LTSS defined as the services and supports used by individuals of all ages with functional limitations and chronic illnesses who need assistance to perform routine daily activities such as bathing, dressing, preparing meals and administering medications. Effective coordination and administration of LTSS benefits, and easy access to these services, help ensure that these needs are adequately met and reduce the reliance on less appropriate and more costly emergency- or hospital-based care.


Provider’s role and responsibility

You may be asked to provide the vision care or share health records in response to an interdisciplinary care team (ICT) or as part of an individual care plan (ICP).

The ICT is a team of caregivers from different professional disciplines who work together to deliver care services focused on care planning to optimize quality of life and to support the individual and/or family.

ICP is a plan developed by the ICT meet the care needs of a specific patient.


Person-centered planning and self-determination

Recognizing the significant needs of its many members, CMS incorporates all of the principles of multidisciplinary integration, as well as person-centered care planning, coordination and treatment in its care coordination program.

The member is encouraged to participate in all aspects of care management and coordination, including in the development of an individualized care plan.



Members should receive clear information about:

• His or her health conditions and functional limitations

• How family members and social supports can be involved in the care planning as the member chooses

• Self-directed care options and assistance available to self-manage care

• Opportunities for educational and vocational activities

• Available treatment options, support and/or alternative courses of care



Each CMS member and/or his/her authorized caregiver are maintained at the core of the model of care, ensuring person-centered care and supported self-care.

Each member is assigned a care coordinator who leads the member’s ICT and links closely to the member’s care plan to support him/her in ensuring the member gets the care needed across the full spectrum of medical, behavioral health and long-term care services.


Quality enhancements

Quality enhancements are defined as certain health-related, community-based services that CMS-contracted providers (affiliated and subcontractors) must offer for, and coordinate access to, members. These include children’s programs, domestic violence classes, pregnancy prevention, smoking cessation, substance abuse programs and abuse recognition and reporting. Your patients may have access to these enhancements through their CMS benefits.

CMS benefit providers may offer such quality enhancements as: • Domestic violence prevention

programs • Prenatal and postpartum programs • Smoking cessation • Substance abuse screening and

referrals • Pregnancy screening and referrals


Affordable Care Act: Nondiscrimination requirements

Providers that operate a health program or activity and receive federal financial assistance from the Department of Health and Human Services (HHS) for any part of that program or activity are required to comply with Section 1557 of the Affordable Care Act.

Requirements include:

• Posting of a nondiscrimination statement in their offices

• Posting of a notice about nondiscrimination and accessibility requirements


Additional learning

To learn more, check out these resources: • Model Notice of Nondiscrimination

https://www.hhs.gov/civil-rights/for-individuals/section-1557/translated-resources/index.html


Sources

This training was developed from the following expert references: • Humana Illinois Medicaid provider training (Jan 2020)

• CMS

https://www.cms.gov/


Congratulations

You’ve completed required annual training for EyeMed network providers.

Visit eyemedinfocus.com for any questions and to attest that you’ve completed it.

http://eyemedinfocus.com/

Documents

Annual compliance training for providers