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Corporate Compliance
Eugenia Smither, RN, BS, CHCCorporate Compliance Officer
Vice President of Compliance and Quality Improvement
Acronyms• (D)HHS- Department of Health and Human Services• OIG- Office of Inspector General • NH- Nursing Homes • GIP- General Inpatient Level of Care • CMS- Centers for Medicare and Medicaid Services • IDG- Interdiciplinary Group/Team • HOB- Hospice of the Bluegrass *Other abbreviations and acronyms should be addressed within
the presentation
Definition of a Compliance Program
“A comprehensive strategy to ensure an organization consistently complies with applicable laws relating
to its business activities.”
- National Health Lawyers Association
Definitions
FRAUD – “Intentional deception
or misrepresentation which an individual or entity makes, knowing it to be false & that the deception could result in some unauthorized benefit.”
ABUSE – “Any incident or
practice inconsistent with accepted & sound medical, business, or fiscal practices which directly or indirectly results in unnecessary costs to the benefit program.”
Why have a
Compliance Program ? Helps identify intentional criminal &
unethical conductHelps identify weaknesses in internal
systems & management structuresEncourages staff to report concerns
internally, rather than externallyAllows for investigation of potential
problems
Rationale for a Compliance Program
Individual members of management can be liable under the “responsible officer doctrine” for illegal acts by employees under their supervision
Board members can be liable for breach of fiduciary duty if they do not ensure that management had proper procedures in place to avoid violations of law
Responsible to report both to the Secretary of HHS & to Congress:
• Program & management problems• Make recommendations to correct them.
•Duties are carried out through:• Audits• Investigations• Inspections• Other mission-related functions performed by
OIG components (divisions).
In October 1999, published the OIG Compliance Program Guidance for Hospices
OIG Risk Areas Uninformed consent to elect the Medicare
Hospice Benefit Admitting patients who are not terminally ill Arrangement with another provider who hospice
knows is submitting claims for services already covered by the Medicare Hospice benefit
Underutilization Falsified medical records or plans of care Untimely &/or forged physician certifications on
plans of care Inadequate or incomplete services rendered by
the IDG
OIG Risk Areas Insufficient oversight of patients, those receiving
more than six consecutive months of hospice care Hospice incentives to actual or potential referral
services (physicians, NH, hospitals, patients) that may violate the anti-kickback statute or other similar regulations, including improper arrangements with NH
Overlap in the services that a NH provides, which results in insufficient care by the hospice
Improper relinquishment of core services & professional management responsibilities to NH homes, volunteers & privately-paid professionals
OIG Risk Areas Providing hospice services in a NH before a contract
has been finalized, if required Billing for a higher level of care than was necessary Knowingly billing for inadequate or substandard care Pressure on patient to revoke the benefit when
patient is eligible for & desires care, but care has become too expensive for hospice to deliver
Billing for hospice care provided by unqualified or unlicensed clinical personnel
False dating of amendments to medical records High pressure marketing to ineligible beneficiaries
OIG Risk Areas Improper patient solicitation activities such as
“patient charting” Allowing the hospice to review records to find their own patients- hospice patients must
be referred not found
Inadequate management & oversight of subcontracted services, which results in improper billing
Sales commission based on length of stay in hospice Deficient coordination of volunteers Improper indication of the location where hospice
services were delivered
Why We’re on the OIG Radar• When the hospice benefit was created in 1982,
Medicare did not cover more than 210 days of hospice care per beneficiary. Congress changed the benefit to eliminate the limit on the number of days covered by Medicare.
• Since then, the number and types of diagnoses associated with hospice utilization have increased, and longer stays have become more common.
• The number of for-profit hospices now exceeds not- for –profit hospices
OIG Workplan• Each year, the OIG develops a work plan
by provider type
• Areas of focus are outlined, and what the OIG intends to do about it
• Addendum to this orientation module will highlight the current areas of focus for the current year
• Focus continues on GIP, NH, eligibility
Laws & RegulationsAdministrative Sanction & ExclusionAnti-Kickback Statute Antitrust LawsBalanced Budget ActDeficit Reduction ActFalse Claims ActFraud and Abuse Statutes/Illegal
Remuneration StatutesMedicare Conditions of Participation
STATE LEVEL
Dept. of Aging
State Medicaid
REGIONAL LEVELUS Congress
Health &Environment
Cahaba GBA(FI)
Cigna(MAC)
Palmetto (MAC)
Hospice
FEDERAL LEVEL
US GovernmentAccountability Office
(GAO)
Medicare PaymentAdvisory Commission
(MedPAC)
Office ofInspector General
(OIG)
US Dept. of Health &Human Services
(DHHS)
Office of Ass’t Secretary for Planning & Evaluation
(ASPE)
Centers for Medicare &Medicaid Services
(CMS)
Conditions of Participation (CoPs)42 CFR Part 418
Medicare AdministrativeContractors
(MACs)
CMS Regional
National Hospice & Palliative CareOrganization
(NHPCO)Hospice & Palliative Care
State Organizations
Environmental Forces Impacting Hospice Agencies
Zone Program Integrity Contractors(ZPICS)
Medicaid Integrity Contractors(MICS)
Payment Error Rate Measurement(PERMS)
Comprehensive Error Rate Testing(CERTS)
Health Care Fraud Prevention & Enforcement Action Team
(HEAT)
Recovery Audit Contractors(RACS)
NGSFI
NHIC (MAC)
Surveyors
©Harry Hynes Memorial Hospice,
2011
Oversight by Compliance & Legal as records are submitted
CERT
QIORoutine Business
FI/Carrier/MAC
MIC
RAC
ZPIC/PSC
OIG
DOJ
Compliance Oversight
Legal Oversight
RISKSource: Strafford Publishing
OVE
RSIG
HT
Regional Home Health Intermediaries (RHHI)Fiscal Intermediaries (FI)
Medicare Administrative Contractors (MACs)
• Medicare Modernization Act of 2003– Transition from FI/carriers to a competitive bid process
– Contracts rebid every 5 years
• Transition period 2005 – 2011• Benefits to CMS:
– Improved beneficiary services (less contractors + consistency)
– Improved provider services• simplified• competition=better service, financial management, more
accurate claims processing, consistency in payment decisions
www.cms.gov/MedicareContractingReform
Comprehensive Error Rate Testing(CERT)
• Paid Medicare claims randomly selected• Requests medical records to determine provider
compliance with Medicare coverage, coding and billing requirements
• Assigns error to claim if denied & instructs FI/MAC to take back money and sends provider a demand letter for that money
• Appeal process for CERT denials is the same as the appeal process for Carrier/FI/MAC denials
• Calculates an error rate for each MAC• CERT does not measure fraud
www.cms.gov/CERT
Payment Error Rate Measurement(PERM)
• Measures improper Medicaid Medicaid payments• Perform statistical calculations, medical
records collections and medical/data processing review
• Three contractors providing a 17-state rotation – Each state reviewed once every 3 years– Allows States to plan in advance
www.cms.gov/PERM
Quality Improvement Organizations (QIO)
53 QIOs: one for each state, territory, and Washington DC. A QIO is a group of practicing doctors and other health care
experts that:– Ensure that payment is made only for medically
necessary services– Review the quality of care provided to Medicare
beneficiaries– Review Medicare beneficiary appeals of certain provider
notices– Investigate Medicare beneficiary complaints about
quality of care – Review potential anti-dumping cases– Implement quality improvement activities as a result of case review activities
Recovery Audit Contractors(RACs)
Tax Relief and Healthcare Act of 2006Detect and correct past improper payments so that
CMS, Carriers, FIs, &/or MACs can implement actions to prevent future improper payments:
• Providers can avoid submitting claims that do not comply with Medicare rules
• CMS can lower its error rate • Taxpayers and future Medicare beneficiaries are
protected • RAC’s are paid on a contingency basis
– Incentivized to take back Medicare funds
www.cms.gov/RAC
Medicaid Integrity Contractors(MICs)
Review Medicaid claims for:• Inappropriate payments• Fraud• Identify areas of riskSimilar to RACS – use data analysis, however:
– No limit on # of claims– Look back period based on State laws – Not paid on contingency, but eligible for
bonuses• Required to provide education
www.cms.gov/ProviderAudits
Healthcare Fraud Prevention and Enforcement Action Team (HEAT)
• Announced May 2009• Joint operation of Dept. of Health & Human Services
( DHHS) and Dept. of Justice (DOJ)• Supported by Obama included in 2011 budget request• Mission of HEAT
– Prevent waste, fraud & abuse in Medicare & Medicaid programs
– Reduce skyrocketing healthcare costs while improving quality of care
– Highlight best practices
– Utilize “Strike Forces” to reduce fraud and recover taxpayer dollars
www.justice.govwww.hhs.gov www.stopmedicarefraud.gov
Zone Program Integrity Contractors(ZPICs)
In 2008, consolidated PSC (Program Safeguard Contractor) with MEDIC (Medicare Drug Integrity Contractor) to form ZPICs– Fraud & abuse through data analysis & audits– Prepay and/or post pay review– Announced/unannounced onsite visits – Determine actual/extrapolated overpayments– All Part of Medicare - A, B, C, D– Provide support to law enforcement– Refer providers from Medicare exclusion– Identify areas of risk
Ky in Zone 4
The Quality Assessment Performance Improvement
Plan
Assists in Compliance by: Monitoring ActivitiesPolicy and ProceduresEmployee Training
and Participation
Code of Conduct
Directs our conduct within ethical & legal standards.
Helps us understand our ethical and legal responsibilities.
Applies/outlines appropriate relationships with our partners:
Patients/Families, MD’s, affiliated providers, third party payers, subcontractors, contractors, vendors, suppliers, consultants, colleagues, volunteers, communities, donors, regulators
Code of Conduct
HOB’s mission and ethical requirementsHOB’s commitment to comply with federal, state,
and private insurer standards & our partnersOutlines leadership responsibilitiesDirects us in response to inappropriate/unlawful
behaviorAddresses disruptive behavior and
organizational responseDefines Environmental CompliancePolitical activitiesMarketing practices
Compliance PlanLists how we address the “Seven Elements” of an
effective compliance program Work plan is developed based on our risksLists the OIG Risk Areas, Applicable Laws and
Regulations Supported by HOB policies
Address regulatory complianceAddress accreditation processFinancial reporting and records (internal controls)Business courtesies (receiving, extending)Outlines handling of business information/systemsAntitrust, Information re: Competitors, Truthful Advertising
Reporting Process Open lines of communication with
Corporate Compliance Officer Hotline Telephone # (859) 275-1126 or
(800) 798-4146 or e-mail [email protected]
Suggestion Box in every office, internet and intranet
HHS-OIG Hotline # (800) 447-8477 or (1-800-HHS-TIPS)
Joint Commission (safety or quality of care) (630) 792-5000 or 1-800-994-6610 or e-mail [email protected]
Confidentiality (effort will be made to ensure staff confidentiality in reporting and during investigations)
No retaliatory disciplinary action against employees who report safety or quality concerns to Joint Commission, or internally
Internal Investigation
May include:Interviews with management personnel,
staff, patient, contractors, and agencies Review of relevant documentsEngagement of legal counsel, auditors or
other health care expertsSubsequent review for similar problems
Reporting to Authorities Have a duty to report when requiredFederal and State authorities promptly notified
Timeframes vary, depending on the issue 5 days to 30 days
Any reporting would be done under the advice of counsel Provide all relevant evidence and any potential cost impactReport disciplinary actions taken and changes to the Compliance Plan
Violations
Includes non-compliance to the Code of Conduct, other HOB policies or violation of any Federal or State Statute or any Federal program regulations
Actions to be fair & equitable Actions to be determined case-by-case Actions may result in termination of
employment or contractual arrangement
Disciplinary Process The Corporate Compliance Officer will bring
the offense/violator before the Committee which will decide the degree of disciplinary action, if any.Verbal warningWritten warningWritten reprimandSuspensionTerminationRestitution
Thank- you!!!• Feel free to contact the Compliance
Officer with any questions
• 859-276-5344 [email protected]– [email protected]
Commit to “Doing the Right Thing”. Obey the regs and policies that apply to your job. Make compliance awareness part of your job. Put your Code of Conduct in an accessible spot. Lead by example. If in doubt, check it out. Attend training sessions. Notify supervisor of possible wrongdoings. Communicate openly & honestly. Ethics is a part of all activities.