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DevelopmentandImplementationofCorporateComplianceforFQHC’s Ap
ril 27, 2016
Peak Perform
ance Physic
ians, LLC
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Louisiana Primary Care AssociationTHE COMPLIANCE INSTITUTE
April 27, 2016
Compliance
•Compliance does not get you into trouble; • It keeps you out of trouble.
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LPCAComplianceSyllabus1. Introduction to Compliance ‐‐ Power Point ‐‐MARCH 30
a. OIGb. OCR
2. Getting Started – APRIL 27a. Compliance Officer – Role and Definitionsb. Code of Conduct – Board Adoptionc. Risk Assessment – “top five areas”d. Compliance Hotline
3. Conditions for Coverage – MAY 25a. FQHCb. RHC
4. 340 b Plan – JUNE 295. Human Resources – JULY 27
a. Exclusionsb. Licensure/Certificationsc. Education
6. Financial Relationships ‐‐ AUG 31a. Fraud and Abuseb. False Claims Actc. Stark Laws
7. Data Integrity – HIPAA ‐‐ SEPT 28a. HIPAA Ib. HIPAA HiTech
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PresentationGoals
Compliance Officer – Role and Definitions
Code of Conduct – Board Adoption
Risk Assessment – “top areas” Compliance Hotline
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ComplianceInstitute• A cooperative between Peak Performance Physicians and Louisiana Primary Care Association
•Our main goal:•To assist you in establishing an effective Compliance Plan at your facilities
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WhyComplianceProgram?• Most all of the Compliance Books, Seminars, and other presentations always start with all the punishments….
• We think that compliance is doing what is right.
• We further think that most all employees and employers want to a good job, and to do their jobs effectively and legally.
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WhatisaComplianceProgram?
• A Compliance Program is an effective, practical and integrated management tool that establishes clear and defined goals and procedures designed to create a culture of compliance, reduce the occurrence of mistakes and prevent intentional violations of the applicable health care statutes and regulations.
• An effective Compliance Program provides you and youremployees with tools for acting ethically and for maintainingcompliance with applicable laws and regulations.
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ComplianceGoals
• Goal: to create a “Culture of Compliance” throughout the FQHC by showing a commitment from the top and enforcing compliance standards throughout the entity.
• Benefit: by focusing attention on processes and reinforcing clinical standards through audits and training, Attendees can maintain and improve its high quality of care.
• Benefit: by minimizing potential compliance errors; detecting and correcting any errors that do occur, Attendees will help keep such errors from becoming significant and crippling civil fines and penalties.
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February 2016
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KeyElementsfortheCompliancePlan• Conducting internal monitoring and auditing; • Implementing compliance and practice standards;• Designating a compliance officer or contact;• Conducting appropriate training and education;• Responding appropriately to detected offenses and developing corrective action;
• Developing open lines of communication; and • Enforcing disciplinary standards through well‐publicized guidelines.
http://oig.hhs.gov/authorities/docs/physician.pdf
ToolsforCompliance
• Utilizing the Compliance Officer and Compliance Committee as mechanisms for clarifying requirements and reporting potential misconduct;
• Reviewing and understanding your written policies and procedures;
• Maintaining effective lines of communication with management and other staff members; and
• Participating in training and education opportunities.
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ComplianceOfficerDuties/Responsibilities• The OIG recommends that every healthcare organization designate a Compliance Officer to carry out and enforce compliance activities.
• The Compliance Officer should function as an independentand objective person that reviews and evaluates organizational compliance and privacy/confidentiality issues and concerns. (The OIG prefers that the Compliance Officer answer to the Board and not to the CEO.)
• The Compliance Officer’s main duties include coordination and communication of compliance plan; this involves planning, implementing, and monitoring the program.
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ComplianceOfficerDuties• Overseeing and monitoring the implementation of the compliance plan
• Developing, coordinating, and participating in a multifaceted educational and training program
• Regular reporting to the organization’s Governing Body, CEO and compliance committee on the progress of implementation; helping establish methods to improve the organization’s efficiency and quality of services; and reducing the organization’s vulnerability to fraud, abuse and waste
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ComplianceOfficerDuties(cont’d)
• Periodically revising the program in light of legal and organizational changes, as well as changes in the polices and procedures of government and private payor health plans
• Developing, coordinating, and participating in a multifaceted educational and training program
• Ensuring that independent contractors and agents who furnish medical services to the organization are aware of the requirements of the organization’s compliance program with respect to coding, billing and marketing.
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ComplianceOfficerDuties(cont’d)• Coordinating personnel issues with the organization’s HR Department
• Coordinating the organization’s financial management in organizing internal compliance review and monitoring activities, including annual or periodic reviews of departments or specific risk areas
• Independently investigation and action on matters related to compliance, including the flexible design and coordination of internal investigations (e.g. responding to reports of problems or suspected violations) and any resulting corrective action with all providers, agents, and independent contractors if appropriate
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ComplianceOfficerDuties(cont’d)
• Developing policies and programs that encourage managers and employees to report suspected fraud and other improprieties without fear of retaliation
• Developing a process to screen all employees, physicians, independent contractors and suppliers to ensure that they have not been debarred or excluded from participation in the federal or state healthcare programs.
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ComplianceOfficer• The Compliance Officer must have the authority to review all documents and other information relevant to compliance activities.
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SampleJobDescription• Forwarded to each of you before the presentation….
• This sample is very detailed, and smaller organizations may not have the resources to hire an officer with all of the qualifications and knowledge outlined in the job description.
• Organizations can “bridge” these qualifications, by using the corporate attorney, or outside agents to help with establishing the Compliance Program
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CodeofConduct
• The central element of an effective Compliance Plan is the formal commitment to compliance embodied in the Code of Conduct, which should: • Include a statement of your ethical and compliance principles;• Include a summary of the broad ethical and legal standards under which the you and your administration, personnel and Medical Staff (“Personnel”) should operate; and
• Reflect the your Mission, Vision and Values.
• The Code of Conduct should be:• Reviewed thoroughly with each new employee upon hire during the orientation process and annually thereafter;
• Followed by and reviewed by all Personnel; and • Updated periodically by the Compliance Department and your Board of Directors.
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SampleofCodeofConduct
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RiskAssessment
• A Risk Assessment is find compliance areas that may concern the organization the most. The initial Risk Assessment is based on the type of services provided by Attendees and the applicable Federal and State compliance statutes, regulations, rules and agency guidance (“the Regulatory Issues”)
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KeyElementsfortheCompliancePlan• Conducting internal monitoring and auditing; • Implementing compliance and practice standards;• Designating a compliance officer or contact;• Conducting appropriate training and education;• Responding appropriately to detected offenses and developing corrective action;
• Developing open lines of communication; and • Enforcing disciplinary standards through well‐publicized guidelines.
http://oig.hhs.gov/authorities/docs/physician.pdf
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RiskAssessment
• Our Team has considered the following areas as the Highest Risk Areas for an Organization. – CfC – Compliance with Conditions for Coverage to Qualify as an
FQHC– 340b ‐‐ Compliance with the requirements to participate in the
340b program– Human Resources ‐‐ Compliance with requirements for FQHC
personnel– Financial Relationships – Compliance with Federal and State
healthcare fraud and abuse statutes– Data integrity – compliance with Federal and State requirements
to maintain the confidentiality of patient medical records and financial information
– Medical Record Chart Data Integrity – insuring that the Medical Record fully documents the care given, and supports both the Diagnoses and Level of Service Billing.
RiskAssessment:Questionnaires
• Develop questionnaires relative to each of the Risk Areas that have been defined by the Compliance Officer/Committee.
• The questionnaires are intended to gain a better understanding of Organization’s current compliance efforts and operations and how each address the Regulatory Issues.
• The questionnaires will become the Framework for the GAP analysis, and will allow the Compliance Officer/Committee to establish an Implementation Plan.
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RiskAssessment(cont.)
• What will you need to do to complete the risk assessment?– Select who will answer the questionnaires and how they will be answered;• Identify the individual(s) who will answer the questionnaires (Note: the answering of the questionnaires may be outsourced to another individual or entity)
• The individual(s) or entity should coordinate with the individual(s) and/or departments having information relevant to the questions.
– Coordinate the completion of the Questionnaires with Compliance Officer
ComplianceHotline• Establish Compliance Hotline
• It is confidential• Check it frequently• Keep a log of calls (report to Compliance Committee)• Investigate all calls • Frequently the hotline is used to report personnel problems; discuss issues with Human Resources
• Do Not Discourage the use of the Compliance Hotline
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ComplianceHotline
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Regulatory/Guidance/Enforcement
• Office of the Inspector General – OIG• http://oig.hhs.gov/
• Health Resources and Services Administration – HRSA • http://www.hrsa.gov/index.html
• Office of Civil Rights ‐‐ OCR • http://www.hhs.gov/ocr/index.html
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NextSteps
• Appoint Compliance Officer• Establish a Coding Hotline• Review Compliance Guidance• Review Compliance Plan• Review Areas of Greatest Risk • Perform GAP Analysis• Establish a “Code of Conduct”
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