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AGENDA

BAY ARENAC BEHAVIORAL HEALTH BOARD OF DIRECTORS

HEALTH CARE IMPROVEMENT & COMPLIANCE COMMITTEE MEETING Tuesday, March 5, 2019 at 5:00 pm

Behavioral Health Center, Room 225, 201 Mulholland, Bay City, MI 48708

Committee Members: Present Excused Absent Committee Members: Present Excused Absent Others Present: BABH: Janis Pinter and Sara McRae

Legend: M-Motion; S-Support; MA-Motion Adopted; AB-Abstained

Robert Pawlak, Ch Robert Luce

Colleen Maillette, V Ch Patrick McFarland

John Andrus Justin Peters

Richard Gromaski James Anderson, Ex Off

Richard Byrne, Ex Off

Agenda Item Discussion Motion/Action

1. Call to Order & Roll Call

2. Public Input (Maximum of 3 Minutes)

3.

Corporate Compliance Report 3.1) Corporate Compliance Report

3.2) Corporate Compliance Meeting Notes from January 15, 2019

3.1) M - S - MA

Receive the report

3.2) M - S - MA

Receive the notes

4.

Other Reports 4.1) Primary Network Operations & Quality

Improvement Committee Meeting Notes from January 10, 2019

4.2) Meaningful Use/ Merit-Based Incentive Payment System Incentives Preliminary Report for 2018

4.1) M - S - MA

Receive the notes

4.2) M - S - MA

Receive the report

AGENDA

BAY ARENAC BEHAVIORAL HEALTH BOARD OF DIRECTORS

HEALTH CARE IMPROVEMENT & COMPLIANCE COMMITTEE MEETING Tuesday, March 5, 2019 at 5:00 pm

Behavioral Health Center, Room 225, 201 Mulholland, Bay City, MI 48708

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5. Unfinished Business 5.1) None

6.

New Business 6.1) Leadership Dashboard Review

6.2) 2019 Corporate Compliance Plan

6.1) M - S - MA

Receive the report

6.2) M - S - MA

Refer to full Board for approval of the 2019 Corporate Compliance Plan

7. Adjournment M - S - pm MA

BAY-ARENAC BEHAVIORAL HEALTH

BABH CORPORATE COMPLIANCE COMMITTEE MEETING Tuesday, January 15, 2019 (2:30 - 4:00)

BABH - Room 225

MEMBERS Present MEMBERS Present MEMBERS Present Janis Pinter, Compliance & Privacy Officer, Chair X Brett Kish, Security Officer X Joelle Sporman, Records X

Ellen Lesniak, Finance Manager, Vice Chair X Chris Tomczak, Quality & Comp. Coord. X Karen Amon, Director of IHC X

Amy Folsom, Clinic Practice Manager Erin Lewis, Contract Admin. X Melissa Prusi, RR/CS Manager X

Becky Smith, Director of HR X Joelin Hahn, Director of IHC X Sarah Holsinger, Quality Manager X

Brenda Beck, Medical Records X GUESTS:

# Topic Key Discussion Points Action Steps

1 Agenda: Review/Additions Meeting Notes: Approval of 12/18/18

There were no additions to the agenda. Meeting notes were approved as is.

2 Data/Monitoring: Monthly: a) Phoenix and Gallery Breach

Monitoringb) Meaningful Use/MIPS Prescriber

Compliancec) Exclusion/Debarmentd) Monitoring of Group Drives for

Unsecured PHI Filese) Officer Updates (Corporate

Compliance, Privacy, Security,Ethics, Recipient Rights/CustomerService)

Carried Forward from November: f) Provider Network Site Review

Summary

January: g) Report of HIPAA Breach Log to HHSh) Review of OIG Work Plan

a) No findings to report this month.b) There’s an appointment with the consultants next week to do the

filings. We registered with MiHIN for the quality measure upload,we just need to do a test. Some prescribers cannot be attested for.

c) No findings to report this month.d) No findings to report this month.e) There is a possible privacy issue with people looking at records

outside of their need to know but within their permissions. Stillhave the one issue out to the OIG they continue to investigate.

f) The 2018 site reviews overall score was between 90-100%. Theoverall score is usually in compliance, it’s the section scores thattend to be low, mainly the compliance plan and trainings sections.The site review scoring summary shows the score for all sectionsreviewed.

g) There were no HIPAA breaches to report to HHS this year.h) The fed created a site with a rolling list of projects, and when

finished, the reports are published. We have to improve managedcare identification referral of suspected cases of fraud or abuse, sowe need to report more than when we think fraud is at stake.

i) Defer

i) Report on next month.

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i) Corporate Compliance Report

3 Open/Outstanding Items: a) Home/Community Based Rules

Compliance Statusb) Ability to Pay Compliance Ratec) State Electronic Event Verification

System for Non-Per Diem PersonalCare and CLS

d) Implementation of VendorAttestation

e) Autism Tech Credentialingi.) Inclusion of Plan of Service In-

services (Sedlock Email) ii.) Process for Annual Update of

ABA Provider Staff Credentials f) Review of Site Review Templatesg) Guidance for Users/Reviewers re:

where to locate docs in Phoenix

a) MSHN is indicating they may need more staffing or help fromCMH’s. Karen received an email from Chris and will report back tothe committee at the next meeting.

b) Nothing to report this month.c) Nothing to report this month.d) The Dykema attorneys made recommendations for additional

checks that we do not have to ask vendors to sign attestations.Janis asked for that to be put in writing.

e) i.) Joelin sent an email back to MSHN for clarification and has notyet received a response. In the email, they make it specific to theBCBA, and Joelin’s question was shouldn’t it be the behavioral techbecause the BCBA is the one creating the treatment plan. One ofthe 7 things checked is that all staff that touched the consumerhave evidence that they signed off on the IPOS. Sarah to emailJanis what she stated describing the circumstance, when it tookplace, and who the reviewer was. ii.) This was added based onconversation at the last meeting. This is an outstanding item.

f) Work has been done on the site review templates, but it is on holdfor Janis to work on before handing back to Sarah and Chris.

g) Staff have questioned where to find documents in Phoenix, so Janisasked Brenda to give staff an update as to what tools are availablenow. Brenda has a spreadsheet of all the documents in Phoenix.All scanned/uploaded documents include everything that has beenscanned or uploaded, it does not include anything that was doneelectronically. Most of the documents listed are electronicdocuments. If there are other documents that need to be listed, itcan be added to the Help tab.

a) Karen to report back next monthabout the email from Chris.

d) Janis to follow-up with Dykema.e) i.) Sarah to email Janis what she

stated about the IPOS evidence, so itcan be relayed to Chris. ii.)Outstanding item

f) Defer

4 Plans, Policies, Procedures and Assessments a) Bi-Annual Fraud/Abuse Risk

Assessmentb) Review of Corporate Compliance

Planc) Review of Data Monitoring

Schedule for 2019

a) Nothing to report this month.b) Janis went over the changes and made more changes to the

Corporate Compliance plan. The hotline posters have been postedat all sites/waiting rooms. The hotline posters can be provided atthe group homes as well. Vocational services should be added tothe additional monitoring on claims since it was added in this year.It’s not one of the highest risks but there were problems. Janisgoes over the general education every year but Joelin would like to

b) Janis to add something in about thevendor attestations. Janis to add in anotation around education for theproviders per Joelin’s request.

Becky to look at page 4.

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take time at the Provider Network meeting to address it, so they are aware of what they are responsible for.

c) Janis went over the data monitoring plan for 2019. Janis separatedVerification of Medicaid services so there’s one for contractedservice providers and one for direct operated programs. Becauseof the separation, a timeframe is needed for the direct operatedprograms.

c) Sarah and Chris to give a timeframe ofwhen direct operated programs needto be reported on.

5 Other/New Business: a) Background Checks – B.Hawks

Email; 2016 Wieferich Memob) New Compliance Reporting to

MSHN/MDHHS OIGc) EDIT III Meetingsd) Changes to State-Federal Laws and

Regulations

a) According to the Wieferich memo, background checks need to bedone every 2 years.

b) BABH needs to report disenrollments, data mining and complaintsand referrals quarterly, and the reporting is due January 29th. Erinwould normally remove the providers from the provider directorybut will leave them on and mark them as disenrolled. Erin couldkeep a copy of the OIGs PIHP Quarterly Submission Document andupdate the disenrollment’s tab.

c) Nothing new to report this month.d) Janis went over the changes to what regs were signed in to law.

Those reported on today will be reported out on at the Februarymeeting.

a) Janis will make sure backgroundchecks is addressed in the contract.

b) Erin to keep a current copy of thedisenrollment’s tab and will send toJanis when requested.

6 Adjournment/Next Meeting The next meeting is scheduled for Tuesday, February 19, 2019 from 2:30 - 4:00 in Room 225.

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BAY-ARENAC BEHAVIORAL HEALTH PRIMARY NETWORK OPERATIONS & QUALITY MANAGEMENT COMMITTEE MEETING

Thursday, January 10, 2019 1:30 p.m. - 3:00 p.m.

Mulholland – Conference Room 225

Page 1 of 7

MEMBERS Present MEMBERS Present MEMBERS Present BABH Primary Care Director: Joelin Hahn (Chair) X BABH Clinical Services: Heather Friebe X MBPA CSM/SC Supervisor: Kathy Coleman X

BABH Quality Manager: Sarah Holsinger (Chair) X BABH Nursing: Heather Seegraves MPA Adult OPT Program Supervisor: Katy Dean X

BABH - Integrated Care Director: Karen Amon BABH Vocational Services: Brenda Rutkowski MPA Adult CSM/SC Supervisor: Matt Lance X

BABH Children Services: Noreen Kulhanek X BABH Medical Records: Brenda Beck MPA Children’s OP Supervisor: Michelle Richards X

BABH Children Services: Emily Young BABH Quality & Compliance: Chris Tomczak X Saginaw Psych. Therapist: Barb Goss X

BABH IMH/HB: Kelli Maciag BABH SIS Assessor: Mary Gilbert Saginaw Psych. Clinical Director: Nathalie Menendes

BABH Clinic Manager: Amy Folsom X BABH Customer Services: Kim Cereske X BABH BI Secretary: Joelle Sporman (Recorder) BABH ES/Access: Kristy Moore BABH RR/Customer Services: Janelle Steckley Consumer Representative: Kathy Johnson - Parent X

BABH ES/Access: Margaret Dixon BABH RR/Customer Services: Jeff Wells BABH AD-HOC MEMBERS: Present BABH Access: Stacy Krasinski X BABH North Bay: Lynn Blohm X BABH Finance Department: Ellen Lesniak

BABH Adult ID/DD Manager: Melanie Corrion X LPS COO: Jacquelyn List BABH Contracts Admin.: Erin Lewis

BABH ACT/Adult MI Manager: Kathy Palmer X LPS Site Supervisor: Rachel Keyes X BABH RR & CS Manager: Melissa Prusi

BABH BI/Corporate Compliance: Janis Pinter X MBPA Clinical Director: Cindy Soto X BABH Nursing Team Leader: Sarah Van Paris

Topic Key Discussion Points Action Steps/Responsibility

1. Review of and Additions to Agenda

Approval of 12/13/18 Meeting Notes

Agenda was reviewed with additions. - 2d. Use of H0002- 2e. Care Alerts- 5d. MDHHS Director Update- 6e. LOCUS to MIFAST Review

The December 13th meeting notes were approved as is.

2. Summary/Data Analysis – Follow-Up to Data Analysis a. Dashboard Review

• Utilization Measuresb. Quality of Care Record Review Discussionc. Review of MSHN Priority Measure

Performance Reportd. Use of H0002e. Care Alerts

a. The group incorporated UM discussion with review of thedashboard. The following indicators on the dashboard werereviewed by the group. The indicators are childrendemonstrating improvement, Inpatient days per month, # ofpeople served by quarter by disability designation, # ofchildren and adult consumers served, and children and adultconsumers served FYTD. The group discussed barriers toState Facilities (hospital) admission due to lengthy wait listsfor this state level service. The issue may be impacting our

a. Janis will look at the graphs fordiscrepancies.

b. BABH staff will reach out tothe provider if anything comesup during the reviews.

c. Sarah will be updatingeveryone on the DiabetesMonitoring project. Sarah isavailable to attend staff

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Page 2 of 7

local inpatient admission length of stay data. Data for the dashboard is based on encounter data. There was consensus to add dashboard review and UM discussions to the committee.

b. The group reviewed the BABH Quality of Care Reviewelectronic form that is used for chart reviews. Sarah H.provided education on BABH’s process for chart reviews thatincludes random selection of charts, which may include chartsfrom a Primary Care provider as the assigned Primary Caseholder. Chart review results are provided to each BABHsupervisor for follow up/corrective action for any issuesidentified during the chart review. The group discussedsystem efficiencies regarding Primary Care providernotification of identified issues. Group consensus is to notifyprimary care provider agencies via email.

c. The PIHP’s and Medicaid Health Plans are required by thestate to work together for purposes of integrating health careand coordination of care. Janis went over the PriorityMeasure Performance Report submitted by MSHN for FY18.Diabetes Monitoring is a Performance Project we will beworking on. This is the next lab that needs to be received ifyou are diagnosed with diabetes. This project will be donemonthly, and follow-up emails will be coming out from Sarahor Mary regarding the specifics of it. Materials need to bedeveloped around this project. If anyone wants Sarah tocome to their site to discuss the project let her know.

d. The group discussed the current use of the H0002 code byprimary care provider sites. Discussion included the purposeof different measures used for an assessment code, howproviders are using the assessment code, and if performanceindicators are being included in data pulls for reports. Sarah

meetings to provide information and education about the Care Alert communications.

e. Adjust timeframe in Phoenixfor alerts to pop up in 60 days,not 45.

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Page 3 of 7

H. gathered the provider specific information during thediscussion. There was additional discussion regarding thepotential use of the H0002 code for inpatient follow-upservices provided by Case Management/SupportsCoordination and Home-Based Services. The HEDIS measureused for MDHHS Priority Measure Performance Report datadoes not include the T1017/T1016 codes by CSM/SC, whichresults in decreased evidence of Inpatient follow-up servicesprovided by BABH via CSM/SC services. There was discussionabout reviewing the BABH data available in Zenith. BABH willcontinue to investigate this issue.

e. There was discussion regarding the Phoenix Alert system(EHR) for documentation due dates. Stated concerns includethat the alerts come on too early and end too soon after thedocumentations due date. There was group consensus toadjust the alert system notification timeframe from 45 dayspost document due date to 60 days.

3. Project Descriptions/Development/ Improvements

Nothing to report this month.

4. Consumer/Stakeholder Feedback/Activity a. Standing Committees, Councils, Program and

Contract Provider Reporting

• Consumer Councils - Consumer Log

• Child and Family Committee

• Recovery Committee

• Quality of Life Committeeb. Consumer Council Representation

a. Nothing to report this month.b. Kathy Johnson, parent of a consumer, has joined the

PNOQMC as a representative of the Consumer Council andshe will be attending quarterly or as needed.

5. MSHN/MDHHS Updates a. DHHS Benefit Requirements - Work/

Volunteer Hoursb. Annual Submission Update

a. The group reviewed a draft letter to the local DHHS to be usedfor consumers who are adversely affected by the DHHSbenefit requirements. The goal is to have the letterembedded in the PCE system. The purpose of the letter is for

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Page 4 of 7

c. MSHN MEV Updated. MDHHS Director Update

consumers who receive notification from the state about their food assistance program being cut off because they are not meeting the regulation of working/volunteering at least 20 hours a week. The state created a process where consumers of specialty mental health services should be deemed exempt from this requirement. Some consumers that should be exempt have received a letter from DHHS that their benefits are being cut off and on the second page it explains how to appeal that decision and request an exemption. There’s a check box that states they have a physical/mental disability that excludes that person from working and it requires a statement from a physician, psychiatrist, etc. The letter is intended to accompany the DHHS form that the consumer must submit to appeal the termination of food assistance benefit. The BABH letter includes a section to identify the treating health care professional (the prescriber of psychiatric medications).

b. BABH is in the process of gathering information fromstakeholders in areas of expertise and are looking forfeedback on community needs. Sarah H. and Mary G. will begoing around to talk to the stakeholders on their feedback.

c. MSHN will be here in February to do the MEV audit. Ifanything is needed from anyone, Sarah or Chris will be intouch.

d. The new State DHHS Director is Robert Gordon and hereplaces Nick Lyon. Gordon currently served as Senior VP ofFinance and Global Strategy for The College Board. He wasappointed by Obama to serve as acting deputy director at theU.S. Office of Management and Budget and served as actingassistant secretary for Planning, Evaluation and PolicyDevelopment at the U.S. Department of Education.

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Page 5 of 7

6. Clinical Processes - Issues/Discussion a. Plan of Service and Related Document

Changes for Phoenixb. Proposed Change to Crisis Planc. Coordination of Care Consentsd. Narcan Remindere. LOCUS to MIFAST Review

a. Still in development with PCE.b. Still in development with PCE.c. Carry over from previous meeting.d. Carry over from previous meeting.e. Mi-Fast reviews of LOCUS are being required by the state.

The LOCUS was mandated by the state a few years ago. Thenext step is complete a Mi-Fast fidelity review. BABHprovided the group with the Mi-Fast standards and hasrequested each provider program (internal and external) whouses the LOCUS tool to complete a self-assessment.

c. Remove from agenda.d. Remove from agenda.e. By next meeting all provider

programs using the LOCUStool should complete a self-assessment of the Mi-Faststandards. Determine howmany staff need the trainingand/or an updated training forthose that haven’t had trainingsince 2013. Determine if thereare any times to avoidscheduling the Mi-Fast review.Joelin will schedule a meetingin the next month to go overthe review.

7. Corporate Compliance Updates/Discussion a. BABH Personal Representative P/P revisionsb. Encryption of Email

a. There were changes in the law regarding who can act assomeone’s personal representative. Janis will send to thecommittee for review, and if there are any questions we willaddress them at the next meeting.

b. Just a reminder to encrypt any emails that contain PHI. Thisincludes any identification numbers, initials, etc. If BABHreceives any PHI in a non-encrypted email, we will follow-upwith the agency.

a. Janis will send to thecommittee for discussion atthe next meeting.

8. Phoenix System Updates/Discussion Nothing to report this month.

9. Prescriber Update a. Patient Portalb. Prescriber Updates

a. Nothing to report this month.b. Dr. Dumlao retired in November, so we are looking at

replacing him. Jill LeBourdais has covered most of his time onTuesdays and Thursdays but that may change. Mona Habib,NP, covers for Dr. Ibrahim at Ausable Valley so BABHcredentialed and provided orientation for her as a backup.

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Page 6 of 7

Walgreens is now McLaren Pharmacies. The Indigent Pharmacy program has been switched to the McLaren Walgreens. Acute individuals being discharged from acute care program get 45 days, so their first prescription and follow-up script are free. The prescriptions will then be at a discounted rate, but the consumer has to pay for that rate. Walgreens will also be doing the injections. Jail services have branched off to Maplewood. When getting out of jail, and if still indigent, the scripts will be transferred to Walgreens.

10. Standing Committees, Councils, Programs and Provider Updates a. LPSb. MBPAc. MPAd. Saginaw Psychologicale. ACT/Adult MI CSMf. Arenac Centerg. Children’s Servicesh. ES/Accessi. IDD Adult/Specialty Care Servicesj. Psychiatric Services Madison Clinic

a. Rebecca Hawkins, Therapist, is no longer with LPS. A newperson started on January 7th and a male therapist, LMSW,will be starting on January 14th.

b. A LMSW is on extended medical leave. Open to referrals forthose with Medicaid only.

c. Quite a few referrals have been coming in.d. Two LMSW’s have started with Saginaw Psych. They are open

for referrals.e. ACT just made an offer for another peer. Kristen Bordeau has

resigned and her last day will be on Friday, January 18th.Looking to hire a Team Leader for the Adult MI Team.

f. The Arenac Center met with Peer 360 and are hoping to getthem to come in and do group work and recovery coaching.

g. There is one position opened for a Family Support Worker inthe Children’s Department.

h. A new ES worker has been hired. The Juvenile Detention isback up and running.

i. Nothing to report this month.j. Sharon Manszewski, Secretary, will be leaving on Friday,

January 11th.

11. BABH/MSHN Announcements Nothing to report this month.

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Page 7 of 7

12. Other/Additional:

• Peer Connect 360-SUD/Co-occurringRecovery Coaching, Support Groups

• Families Against Narcotics (FAN)

• Hope Not Handcuffs (a Program of FAN)

• Peer Connect 360 is open for referrals and have groups 2 daysa week in Bay County.

• The Great Lakes Bay Families Against Narcotics (FAN) Groupmeets at Delta College the 2nd Thursday of every month at7:00 PM. This is a very powerful meeting with valuableresources and excellent networking. You can also watch onFacebook.

• Hope Not Handcuffs is up and running in Bay County. 125people have signed up and been trained as Hope NotHandcuffs Angels in Bay, Midland and Saginaw Counties.

13. Adjournment

Next Meeting

The meeting adjourned at 3:00 pm. The next meeting is scheduled for Thursday, February 14, 2019 from 1:30 - 4:00 pm in Room 225. If there are any additional items that need to be covered at the next meeting, please contact Joelin Hahn or Sarah Holsinger.

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Meaningful Use - Medicaid Meaningful Use - Medicaid Program Year 2011 Program Year 2012 Program Year 2013 Program Year 2014 Program Year 2015 Program Year 2016 Program Year 2017 Program Year 2018

MD/DO

Dr. Ralph -started BABH Oct

2010

-BABH unable to

attest; using ECHO

record

-BABH unable to

attest; using ECHO

record

-Filed for Adopt-

Implement-Upgrade

(AIU)

$21,250

-Left BABH Jul 2015

-Attested to

meaningful use

$8,500

Dr. Lenhart -Filed for Adopt-

Implement-Upgrade

(AIU)

$21,250

'-BABH unable to

attest; using ECHO

record

-BABH unable to

attest; using ECHO

record

-Left Aug 2014

Dr. Smith -Filed for Adopt-

Implement-Upgrade

(AIU)

$21,250

'-BABH unable to

attest; using ECHO

record

-BABH unable to

attest; using ECHO

record

-Attested to

meaningful use (multi-

site)

$8,500

-Attested to


site)

$8,500

-Attested to


site)

$8,500

-Attested to


site)

$8,500

-Attested to


site)

$8,500

Dr. Conciatori -Started BABH Sep

2012

-prescriber declined

-Prescriber declined -Prescriber declined -Prescriber declined -Left Oct 2016

Dr.

Chamberlain

-Started BABH Oct

2012

-BABH unable to

attest; using ECHO

record

-BABH unable to

attest; using ECHO

record

-Filed for Adopt-

Implement-Upgrade

(AIU)

$21,250

-Attested to

meaningful use

$8,500

-Attested to

meaningful use

$8,500

-Attested to

meaningful use

$8,500

-Attested to

meaningful use

$8,500

Dr. Jeffries -Started BABH Jul 2013

- Prescriber declined

-Prescriber declined -Prescriber declined -Left Apr 2016

Dr. Movva -Started BABH Apr

2014

-Prescriber declined

to participate

-Prescriber declined

to participate

-Filed for Adopt-

Implement-Upgrade

(AIU)

$21,250

-Provider eligible but

did not meet criteria

for participation



for participation

Dr. Ibrahim -Started BABH Aug

2015

-Filed for Adopt-

Implement-Upgrade

(AIU)

$21,250



for participation



for participation



for participation

Dr. Dumlao -Started at BABH Jun

2015

- BABH unable to file;

he reports elsewhere

-BABH unable to file;




-Left BABH Nov 2018



Dr. Tao -Started at BABH May

2016

-BABH unable to file

AIU as he did so thru

another practice

-Left BABH March

2018

-BABH unable to

attest - did not meet

criteria for

participation

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Dr. Attia -Started at BABH Apr

2018

-Not eligible -

Prescriber never

registered; 2016 last

year to start

Dr. Mahesh

Nurse Practitioners

J. Kreiner -Filed for Adopt-

Implement-Upgrade

(AIU)

$21,250

-BABH unable to

attest; using ECHO

record

-Eligible but did not

meet criteria

-Attested to

meaningful use

$8,500

-Attested to

meaningful use

$8,500

-Attested to

meaningful use

$8,500

-Attested to

meaningful use

$8,500

M. Holbrook -Started at BABH Aug

2015

-Filed for AIU

elsewhere

-Attested to MU

(multi-site)

$8,500

-Attested to


site)

$8,500

-Attested to


site)

$8,500

-Attested to


site)

$8,500

H. Vossos -Started at BABH Aug

2015

-Filed for Adopt-

Implement-Upgrade

(AIU)

$21,250

-Left BABH Apr 2016



for participation

W. Rose -Started at BABH May

2016



for participation

-Left BABH Jan 2017



for participation

K. McLaren -Filed for Adopt-

Implement-Upgrade

(AIU)

$21,250

-Left BABH 2013

-BABH could not file;

using ECHO record

Physician Assistant s $21,250

J. LeBourdais -Started BABH May

2015

-Not eligible when

working in a CMH

-Not eligible -Not eligible -Not eligible

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Physician Quality Reporting System (PQRS)Physician Quality Reporting System (PQRS) Merit-based Incentive Payment System (MIPS) Program Year 2011 Program Year 2012 Program Year 2013 Program Year 2014 Program Year 2015 Program Year 2016 Program Year 2017 Program Year 2018

MD/DO

BABH Group

Practice

PQRS submission

completed; not all

prescribers

participating

$-5,363 penalty for

2017 Medicare

Payments

PQRS submission

completed; not all

prescribers

participating

$-3,288 penalty for

2017 Medicare

payments

Group MIPS

submission

completed for all

prescribers

1.22% bonus for 2019

Medicare Payments

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Leadership Dashboard

Updated 2/11/2019 Through FY19Q1 Updated 3/4/2019 Through FY19Q1 Updated 2/5/2019 Through FY19Q1

Nature of Closed Compliance Issues By Quarter% Audited Services w/ Proper Doc for Encounters Billed

(BABH Direct, Contracted Secondary & Tertiary) Per Quarter

The percentage of consumers diagnosed with

schizophrenia or Bipolar Disorder and taking an

antipsychotic who have received a screen for diabetes.

02/11/19: Revised graph to add detail

Notes: Notes:

Indicators for Health Care Improvement and Compliance Committee

Notes:

02/11/19: New graph01/08/19: Spike in errors in late FY17 primarily due to individual

staff errors at List, MBPA, Sag Psy; possibly due to staff turnover in

a tight LMSW hiring market

0

2

4

6

8

10

Potential Fraud-AbuseCredentialing IssuesDocumentation Issues (only; may inc under/over pay)Fed-State Gov't Involved

50%

60%

70%

80%

90%

100%

BABH Direct

BABH Contracted-Secondary

BABH Contracted-Tertiary

50%

60%

70%

80%

90%

100%

NEW GRAPH

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Updated 1/9/2019 Through FY19Q1 Updated 3/4/2019 Through FY19Q1 Updated 1/9/2019 Through FY19Q1

Reported Medication Related Occurrences for BABH per

quarter

Reportable Adverse Events (Risk, Critical, Sentinel) per

1000 persons served by BABH# of Reported Infections (Specialized Residential & Day

Program Staff) per quarter

Notes: Notes:

01/08/19: Infestations in a home are not included in infection

reporting, as the reporting is by person; lice infections are included

Notes:

01/08/19: One individual accounted for 3/14 EMT Due to

Injury/Med Error in FY18Q2

0

2

4

6

8

10

Reportable Suicide Deaths

Reportable Non-Suicide Deaths

Reportable Emerg Med Treat due to Injury or Med Error

Reportable Hospitalizations due to Injury or Med Error

Reportable Rate of Arrests

Linear (Reportable Emerg Med Treat due to Injury or Med Error)

0102030405060708090

100

Numerator: # of medications errors

Numerator: # of omissions (Not LOA)

Numerator: # of LOA Omissions

0102030405060708090

100

# of Reported Infections (Specialized Residential &Day Program Staff) per quarter

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Updated 3/4/2019 Through FY17 Updated 3/4/2019 Through FY17

% Adults w/MI served by BABH indicating "General

Satisfaction" w/services on survey

% Children w/SED served by BABH indicating

"Appropriate/Quality" services, i.e., General Satisfaction on

survey

Notes: Notes:

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

FY11 FY12 FY13 FY14 FY15 FY16 FY17

80% satisfied Threshold Percentage - MHSIP

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

FY11 FY12 FY13 FY14 FY15 FY16 FY17

80% satisfied threshold Percentage - YSS

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Corporate Compliance

Plan 20182019

APPROVALS Strategic Leadership Team: March 5, 2019

Full Board Approval Date: __________________

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BABH CORPORATE COMPLIANCE PLAN 20198

Contents Statement of Purpose .................................................................................................................................................................. 1 Definitions .................................................................................................................................................................................... 1 Policies, Procedures, Standards of Conduct ................................................................................................................................ 2

Regulatory Compliance ...........................................................................................................................................2 Medical Records .....................................................................................................................................................2 Prohibited Affiliations .............................................................................................................................................2 Privacy and Security ................................................................................................................................................3 Standards of Conduct/ Operating Philosophy and Ethical Guidelines ...................................................................3

Ethics Committee ...............................................................................................................................................4

Program Integrity Requirements for Clinical Contracted Service Providers ..........................................................5 Compliance Officer and Compliance Committees ....................................................................................................................... 5

Corporate Compliance Officer ................................................................................................................................5 Corporate Compliance Committees .......................................................................................................................7

Training and Education ................................................................................................................................................................ 8 Board of Directors ..................................................................................................................................................8 Employees ..............................................................................................................................................................8 Contracted Service Providers .................................................................................................................................9 Corporate Compliance Officer, Security Officer, Privacy Officer, CC Committee ..................................................9

Lines of Communication ............................................................................................................................................................ 10 Disciplinary Guidelines ............................................................................................................................................................... 11

Employees ........................................................................................................................................................... 11 Contracted Service Providers .............................................................................................................................. 12

Monitoring and Auditing............................................................................................................................................................ 13 Environmental and Risk Assessments ................................................................................................................. 14

Response and Corrective Action ................................................................................................................................................ 15 Investigations ....................................................................................................................................................... 15 Corrective Action ................................................................................................................................................. 16

Claims/Over-Payment Recoupment and Voiding of Encounters .................................................................... 16

Other Corrective Action and Enforcement ...................................................................................................... 16

Compliance Reporting ............................................................................................................................................................... 17 Employee/ Contracted Service Provider Guidance and Reporting ..................................................................... 17 External Reporting ............................................................................................................................................... 18

Reporting of Overpayments ............................................................................................................................ 18

Medicaid Eligibility ........................................................................................................................................... 18

Provider Disenrollment ................................................................................................................................... 19

Evaluation of Program Effectiveness and Program Priorities .................................................................................................... 19 Plan Attachments....................................................................................................................................................................... 22

Corporate Compliance Education Plan (2019) .................................................................................................... 23 Compliance Committee Data Monitoring Plan (2019) ........................................................................................ 24 Data Monitoring Plan: Supplemental Compliance Reports ................................................................................. 25 Compliance Education Log .................................................................................................................................. 26 Corporate Compliance Log .................................................................................................................................. 27 BABHA Fraud and Abuse Risk Assessment (With Action Plan) ............................................................................ 28 Corporate Compliance Fraud/Abuse Report ....................................................................................................... 30 Hotline Poster ...................................................................................................................................................... 31

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BABH CORPORATE COMPLIANCE PLAN 20182019 PAGE 1

Statement of Purpose

It is the policy of the BABHA Board of Directors to have a Corporate Compliance (CC) Plan in effect, as stated in

BABHA policy and procedure C13-S02-T18 Corporate Compliance Plan. The CC Plan is in place to guard against

fraud and abuse, and to ensure that appropriate ethical and legal business standards and practices are

maintained and enforced throughout BABHA1.

Furthermore, the BABHA Corporate Compliance Plan ensures the integrity of the system in which BABHA

operates and the culture in which it is served is maintained at the highest standards of excellence, with a focus

on business and professional standards of conduct compliant with federal, state and local laws, including

confidentiality, compliance with reporting obligations to the federal and state government, and promotion of

good corporate citizenship, prevention and early detection of misconduct.2

The BABHA Corporate Compliance Plan is reviewed and updated each year.

Definitions

BABHA means Bay-Arenac Behavioral Health Authority and all divisions and departments.

Contracted Service Provider means an individual who has an independent contract agreement with BABHA to provide goods or services to BABHA or its consumers, or an organization with such a contract.

CEO means Chief Executive Officer of Bay-Arenac Behavioral Health.

CC is an abbreviation for Corporate Compliance.

CC Officer means Corporate Compliance Officer.

Licensed Independent Practitioner (LIP) means a licensed professional engaged with BABHA through either an employment contract or as a Contracted Service Provider, providing health care services for consumers consistent with their licensure.

Participant means an individual subject to the CC Program. Participants shall include all: Employees, Directors and Officers of BABHA; and all Contractors and Licensed Independent Professionals

Privacy Officer means the individual assigned the responsibility for overseeing the ongoing development of privacy related operations.

PHI is an abbreviation for Protected Health Information, which is comprised of several types of confidential consumer treatment information which is defined as protected under the Healthcare Improvement Portability and Accountability Act.

Security Officer means the individual assigned the responsibility for overseeing the ongoing development and management of security related technological operations.

1 Managed Care Rules: 438.608 Program Integrity Requirements (a)(1) 2 CARF Standards: Section 1 Aspire to Excellence: E Legal Requirements: Standard 1

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Policies, Procedures, Standards of Conduct

BABHA has established written policies, procedures, and standards of conduct that articulate the organization’s

commitment to comply with applicable Federal and State standards, including but not limited to the False Claims

Act (31 USC 3729-3733, the elimination of fraud and abuse in Medicaid provisions of the Deficit Reduction Act of

2005; and the Michigan Medicaid False Claims Act (PA 72 of 1977, as amended by PA 337 of 2005) and the

Michigan Whistleblowers Protection Act (PA 469 of 1980).3

The policies have been approved by the BABHA Board of Directors in accord with Federal Program Integrity

requirements.

Regulatory Compliance

BABHA maintains a list of Federal and State laws and rules with which the organization must comply. The list is

available from the CC Officer. The BABHA Corporate Compliance Committee has also introduced a new

regulatory monitoring process for review and disposition of regulatory requirements and maintains a log of

regulations and BABHA’s assessment of their applicability.

Medical Records

BABHA maintains an electronic record keeping system to ensure documentation of services delivered is

maintained in a manner that is consistent with the provisions of the Michigan Medical Services Administration

Policy Bulletins and the Michigan Medicaid Manual, and appropriate state and federal statutes. BABHA requires

clinical service delivery records to document the quantity, quality, appropriateness and timeliness of services

provided. Clinical contracted service providers (including Licensed Independent Practitioners) are required to

either utilize the BABHA electronic medical record keeping system or establish and maintain a separate

comprehensive individual service record system. At a minimum clinical contracted service providers are

required to scan (or provide for scanning by the BABHA) Records Specialist) key documents into the BABHA

electronic health record (EHR)or in the case of LIP’s, work with the BABHA Records Specialist to ensure their

documentation is scanned into the BABHA EHR. See BABHA policy and procedure C04:S10: T01 Clinical

Documentation and C13:S02: T19 Date of Signature for more information regarding BABHA record keeping

standards.

BABHA policy and procedure C13-S02-T03: Document Retention and Disposal outlines BABHA’s strategies to

comply with retention schedules in place by the State of Michigan.

Prohibited Affiliations

BABHA has an active program to protect the organization from knowingly having a relationship with individuals

debarred, suspended or otherwise excluded from participation in Federal procurement activities and healthcare

programs such as Medicare.4 The program also ensures BABHA does not knowingly have relationships with

individuals excluded from participation in Medicaid, or any other state healthcare program.

BABHA policy and procedure C13-S02-T11 Prohibited Affiliations and/or Exclusions or Convictions outlines

BABHA’s monitoring and response program. The program covers BABHA’s Board of Directors, CEO and

3 Managed Care Rules: 438.608 Program Integrity Requirements (a)(1)(i) 4 Managed Care Rules: 438.610 Prohibited Affiliations

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employees, as well as contracted service providers (including Licensed Independent Practitioners), vendors and

suppliers.

Federal exclusion/ debarment registries are checked monthly for BABHA Board of Directors, Officers (i.e., senior

managers), employees, licensed independent professionals and clinical contracted service provider

organizations, CEO’s and key prescribers. BABH also checks non-clinical vendors with significant transactions

with BABH and declared co-owners of contracted entities as appropriate.

In 2015 BABHA entered into a contract with a vendor to facilitate reviews of the registries monthly. BABHA

requires providers to declare ownership and control interests, and monitors these individuals concurrently with

the aforementioned providers and BABHA personnel. Members of the BABHA Board of Directors, the BABHA

CEO and new employees sign attestations of their compliance with these requirements and commit to notifying

BABHA of any changes in status including criminal convictions.

As described in the Requirements for Clinical Contracted Service Providers section of this Plan, cClinical

contracted service provider organizations (including Licensed Independent Practitioners) are likewise required to

perform initial and monthly checks for exclusion/debarment and criminal convictions for their employees and

relevant subcontractors, if any.

Criminal background checks are completed for BABHA employees upon hire and every two years thereafter.

Abuse registry checks are completed for persons working with children. Contracted service providers are

required to comply with the criminal background checks. The abuse registry checks are being added to contract

requirements for providers service children.

Privacy and Security

BABHA has policies and procedures in place to ensure compliance with the Health Insurance Portability and

Accountability Act (HIPAA) for confidentiality of health care records, 42 CFR PART 2 for confidentiality of

substance abuse treatment records and state laws governing the confidentiality of mental health and substance

use disorder (SUD) treatment records and HIV/AIDS information. The policies and procedures cover protected

health information (PHI) and substance use disorder treatment information generated, received, maintained,

used, disclosed or transmitted by BABHA and its contracted service providers (including Licensed Independent

Practitioners).

BABHA’s Agency Manual Chapter 9, Information Management, contains the organization’s HIPAA Security,

Transaction and Code Set Rule compliance strategies. Privacy and confidentiality strategies are addressed in

Chapter 13, Corporate Compliance, Section 1.

Contracted service provider organizations which are not covered entities for purposes of HIPAA compliance are required by BABHA to follow privacy and security provisions as defined in the MDHHS Medicaid Managed Specialty Supports and Services Contract or and sign a HIPAA Business Associate and Qualified Service Organization Agreement.

Standards of Conduct5/ Operating Philosophy and Ethical Guidelines

BABHA has written Standards of Conduct and an Operating Philosophy and Ethical Guidelines for employees and

contracted service providers (including Licensed Independent Practitioners) to clearly delineate BABHA’s

5 Managed Care Rules: 438.608 (a)(1)(i) Program Integrity Requirements

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institutional philosophy and values concerning compliance with the law, government guidelines and ethical

standards applicable to the delivery of behavioral health care. BABHA operates an Ethics Committee to provide

guidance to staff regarding ethical dilemmas.

The BABHA Director of Human Resources prepares and reviews/ revises the Standards of Conduct/ Operating

Philosophy and Ethical Guidelines, as appropriate. The Standards of Conduct/Operating Philosophy and Ethical

Guidelines are submitted to the Strategic Leadership Team, CEO and BABHA Board for consideration and

approval.

A copy of the Standards of Conduct/Operating Philosophy and Ethical Guidelines is distributed to all employees

as part of the new employee orientation process and is also available to staff on the BABH intranet site. It is

posted for (and contracted service providers through the provider section of the BABH website. as

appropriate). Changes to the Standards are communicated to all staff via the policy/ procedure/ plan

educational system.

Policy topics in the BABHA Agency Manual related to Standard of Conduct reside in Chapter 7: Human Resources

and include (but are not limited to): Licensure and Certification Renewal, Employee Discipline, , Employee

Handbook, including sections addressing Non-Discrimination, Recruitment, Selection and Appointment, Driving

Record, Termination of Service, Standards of Conduct, Standard Practices, Grievance and Drug-free Workplace.

Ethics Committee

BABHA operates an Ethics Committee chaired by the Director of Human Resources, which is a sub-committee of

the BABHA Corporate Compliance Committee. The Ethics Committee is responsible for serving as a forum for

the review and analysis of ethical dilemmas. The Committee also oversees BABHA standards for ethical conduct,

including establishing policies and procedures to enhance the organization’s responsiveness to internal and

external customers with respect to the ethical dimensions of managing, coordinating, and providing community-

based behavioral health services. The Ethics Committee is responsible for promoting staff understanding of

ethical concerns in contemporary behavioral health care, including ongoing education.

The Ethics Committee is comprised of representatives from the major departments and programs of BABHA, as

well as subject matter experts, internal and external to the organization. The Ethics Committee reports through

the Corporate Compliance Committee as well as through the BABHA senior Leadership Team. The Director of

Human Resources has direct access to the CEO to address issues that overlap with personnel management and

the Corporate Compliance Officer in the event of ethics issues that coincide with corporate compliance

concerns.

The Ethics Committee meets twice per year, with additional meetings called on an ad hoc basis as needed for

case review. Employees can submit an ethical question for consideration by the Committee. An Ethicist is on

contract for consultation with the Committee as needed.

Duties of the Committee include but are not limited to:

o Assisting with annual updates of the BABHA Standards of Conduct/Operation Philosophy and Ethical

Guidelines as appropriate.

o Concerns raised by staff and leadership of BABHA that are not determined to involve regulatory

compliance will typically involve a conflict of interest or ethical dilemma. The Ethics Committee is

responsible for serving as a forum for review and analysis of ethical dilemmas. The Committee analyzes

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ethical dilemmas, consults with an Ethicist as necessary, and provides feedback/ recommendations to

the individual who submitted the issue for consideration.

o Assisting the Director of Human resources with overseeing BABHA standards for ethical conduct,

including establishing policies and procedures to enhance the organization’s responsiveness to internal

and external customers with respect to the ethical dimensions of managing, coordinating, and providing

community-based behavioral health services.

o The Ethics Committee is responsible for promoting staff understanding of ethical concerns in

contemporary behavioral health care, including ongoing education.

Program Integrity Requirements for Clinical Contracted Service Providers

BABHA requires clinical contracted service providers (including Licensed Independent Practitioners) to adhere to

Federal and State requirements regarding guarding against fraud and abuse, and complying with applicable

regulatory requirements and standards, as outlined in BABHA policy and procedure C13-S02-T16 False Claims.

Organizational (clinical) contracted service providers are further required to implement and maintain written

policies, procedures and standards of conduct, appropriate to the type and scale of the Provider agency, that

articulate the organization’s commitment to comply with federal and state program integrity requirements,

including provisions for monitoring for exclusion and debarment from participation in state and federal health

care programs.6

The required program integrity elements are communicated to the providers through contractual requirements.

Compliance by contracted service providers is monitored by BABHA during site reviews.

Compliance Officer and Compliance Committees

The BABHA CEO has designated a Compliance Officer7. The BABHA Board of Directors has established a

regulatory Compliance Committee and the CEO has a regulatory Compliance Committee at the senior

management level.8

Corporate Compliance Officer

The CEO appoints the Corporate Compliance Officer. The CC Officer reports to the CEO for purposes of the CC

program. The CC Officer also has the authority to address compliance concerns with the Chair of the BABHA

Board of Directors and the Health Care Improvement and Compliance Committee of the Board of Directors. The

CC Officer has direct access to the BABHA Chief Financial Officer for consultation, as well as to specialized legal

counsel of BABHA.

The CC Officer is responsible for the following:

o Developing and operating the CC Program; reviewing/ revising the CC Plan annually as necessary to

meet changes in the regulatory and business environment;

6 Managed Care Rules: 438.608(a)(6) 7 Managed Care Rules: 438.608(a)(1)(ii) 8 Managed Care Rules: 438.608(a)(1)(iii)

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o Reviewing and revising as necessary BABHA policies, procedures and practices governing corporate

compliance, privacy and confidentiality; and ensuring the Security Officer reviews and revises as

necessary BABHA policies and procedures governing security;

o Chairing the CC Committee or appoint a designee; and maintaining meeting records;

o In consultation with the CC Committees as needed, preparing and implementing an education plan, to

include Board members, senior management, all other employees and contracted service providers

(including Licensed Independent Practitioners), as appropriate; including performance of new employee

orientation;

o Identifying new Federal and State Acts, Regulations or Advisories relative to corporate compliance, fraud

and abuse prevention, privacy, security and identity theft for which BABHA must comply; assisting with

identifying other regulatory requirements; reviewing, analyzing and assisting with the development of

strategies to comply.

o Maintaining effective lines of communication, including monitoring and responding to calls received on

the Corporate Compliance Hot-Line or via other methods of communication;

o In conjunction with the CC Committee, establishing a system and schedule of routine monitoring

activities (see Attachments for Monitoring Plan template) and ensuring follow-up activities are

completed;

o In conjunction with the CC Committee, ensuring HIPAA Security and Fraud/ Abuse compliance risk

assessments are conducted in accord with the monitoring plan and findings are addressed;

o Promptly investigating potential compliance and privacy issues discovered through monitoring/ auditing

activities and disclosures by employees and contracted service providers (including Licensed

Independent Practitioners); includes mitigation and remediation; maintaining investigative files;

ensuring the Security Officer promptly investigates, mitigates, remediates and reports as required any

security incidents;

o Working with the CFO to ensure prompt repayment of any overpayments identified through the

corporate compliance program, including suspension of payments;

o Communicating reportable fraud/ abuse issues to payers and state authorities prior to investigation if

required;

o Maintaining a log of compliance issues, whether substantiated and remedial actions;

o Maintaining breach logs and reporting to HHS and regional/state payers as required on an annual basis;

o Working with legal advisers to develop and issue HIPAA Privacy Notices for use by BABHA Clinical

programs and contractors;

o Working with legal advisers and BABHA contract managers to develop and issue Business Associate

Agreements;

o Ensuring disclosures of protected health information are logged by Medical Records staff as required by

HIPAA; and

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o Prepare and complete reports to the CEO and BABHA Board of Directors on the activities of the CC

Program.

Corporate Compliance Committees

The BABHA Board of Directors Health Care Improvement and Compliance Committee (HCICC) is the compliance

committee of the Board. The HCICC Committee’s duties include overseeing the BABHA Corporate Compliance

Program by reviewing and approving the BABHA Corporate Compliance Plan and receiving regular reports of

organizational activities to guard against fraud and abuse. The Corporate Compliance Officer formally reports

on Corporate Compliance Program activities to the BABHA Board of Directors at least once per year with

monthly updates provided at each meeting.

The BABHA Board of Directors also has an Audit Committee, which helps ensure the fiscal integrity of the

organization through internal controls and practice up to and including inspection of disbursements, paid health

care claims and financial statements. The Committee also arranges for an independent audit, review the

Financial Statement Audit and Compliance Audit and recommend appropriate actions.

In addition to the Board Committees and the Ethics Committee, BABHA operates a Corporate Compliance

Committee comprised of members of senior management and key subject matter experts. The Committee is

chaired by the Corporate Compliance Officer. The Corporate Compliance Committee is responsible for all

matters related to the legal and regulatory requirements of BABHA operations as it relates to contractual

compliance, HIPAA privacy and security, and guarding against fraud and abuse of state and federal healthcare

funds.

Duties of the Committee include but are not limited to the following:

o Assist the CC Officer in the ongoing development and operation of the CC Program,

o Perform fraud and abuse risk assessments, identify focus areas, conduct any necessary audits and self-

review and develop compliance program improvement priorities,

o Assess existing policies and procedures in the identified risk areas for incorporation into the CC Program

and develop new policies and procedures as needed,

o Assist the Director of Human Resources with development of the Standards of Conduct/ Operating

Philosophy and Ethical Guidelines,

o Assist the CC Officer with systems level remediation and mitigation of substantiated compliance issues,

where appropriate,

o Assist in the monitoring of new laws and, regulations and trends regarding CC activities, and the

development of strategies to comply,

o Assist with the review of internal and external monitoring and auditing activities to ensure that efforts

are appropriate to provide assurance of compliance,

o Ensure routine monitoring occurs as scheduled and findings are responded to, as assigned to the

Committee via the Corporate Compliance Plan.

Committee membership is comprised of the following staff roles within the organization:

o HIPAA: Security and Privacy Officers

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o Finance (including Claims) Management: Finance Manager

o Regulatory Compliance and Accreditation: Corporate Compliance Officer, Quality Manager, Records

Specialist, Quality/Compliance Coordinator and Secretary (Committee Recorder)

o Contracting: Contract Administrator

o Clinical Practices: Directors of Integrated Care, Clinical Practice Manager

o Ethics and Personnel: Director of Human Resources

o Recipient Rights: Customer Service/ Recipient Rights Manager

The Committee reports through the BABHA Corporate Compliance Officer to the CEO. The Committee

membership includes several members of the BABHA senior management, who likewise have access to the CEO

and can speak to compliance concerns of the agency. The CC Committee meets 8-109-12 times per year. , on a

day and time selected by the members. Meeting records are maintained by the Secretary member of the

Committee.

Training and Education

BABHA has established an effective training and education program for its Board of Directors, senior managers,

Compliance and HIPAA officers, employees and clinical contracted service providers (including Licensed

Independent Practitioners)9. All training is documented via employee training records, various meeting records

and Corporate Compliance Activity Reports. The current BABHA Corporate Compliance Education Plan is

attached to this document. The Corporate Compliance Officer maintains a Corporate Compliance Education Log,

which is also attached.

Board of Directors

Members of the BABHA Board of Directors are oriented to the corporate compliance program at the start of

their first term. The Board of Directors also receives an annual training on corporate compliance requirements,

including information regarding how to report compliance concerns. The Board of Directors does review and

approve the Corporate Compliance Plan each year and receives reports on the status of the program.

Contemporary compliance issues, such as new Medicaid and Medicare regulations, Office of Inspector General

enforcement actions and federal/state compliance program standards are included on the Board of Directors

Health Care Improvement and Compliance Committee agendas as warranted to keep the members abreast of

changes in the compliance environment.

Employees10

New employees are oriented to the compliance program and privacy/ confidentiality requirements within 30

days of hire. All employees receive an annual corporate compliance and privacy/ confidentiality training update.

Training content includes but is not limited to the Standards of Conduct/Operating Philosophy and Ethical

Guidelines and appropriate reporting mechanisms (e.g., the Corporate Compliance “Hot-line”, etc.). Employee

orientation and training updates also cover the False Claims Act (31 USC 3729-3733), the elimination of fraud

9 Managed Care Rules: 438.608 Program Integrity Requirements (a)(1)(iv) 10 CARF Standards: Section 1 Aspire to Excellence: A Leadership: Standard 7

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and abuse in Medicaid provisions of the Deficit Reduction Act of 2005; and the Michigan Medicaid False Claims

Act (PA 72 of 1977, as amended by PA 337 of 2005), the federal False Claims Act (31 U.S.C. §§ 3729–3733) and

the Michigan Whistleblowers Protection Act (PA 469 of 1980). Training content is updated regularly to reflect

relevant content from the BABHA Corporate Compliance Plan.11

As compliance or privacy/ confidentiality concerns arise throughout the year or as they are identified as through

priorities defined in the BABHA CC Plan, educational communications are issued to employees. This includes

intranet site announcements, and discussion of topics at Strategic Leadership Team meetings, Prescriber

Meetings, or Agency Supervisors’ Meetings.

Contracted Service Providers12

Contracted clinical service provider agencies are required to follow program integrity requirements as applicable

(see the policy section of this document). Adherence is monitored via on-site compliance reviews by the BABHA

Quality and Compliance Coordinator. Site review templates are updated regularly as needed and are reviewed

with the CC Committee to ensure all regulatory requirements and standards are included.

Individuals (including Licensed Independent Practitioners) who are contracted with BABHA to provide clinical

services receive an orientation to the BABHA Compliance Program and the Operating Philosophy and Ethical

Guidelines. They sign an attestation to the completion of the orientation.

Clinical contracted service provider organizations are kept abreast of relevant current risk areas and trends as

necessary via email communications and discussion during periodic primary, residential and vocational provider

meetings, as well as Prescriber Planning Meetings and/or Medical Staff Meetings. An annual training is

completed by the BABHA Corporate Compliance Officer for primary clinical contractors, vocational and

residential service providers. In 2019 a new Autism Provider meeting series will be started. The BABHA

Compliance Officer will begin providing training and topical information regarding current risk areas and trends

for this new provider group.

A provider orientation checklist includes education regarding the BABHA Corporate Compliance Program.

Training materials on Corporate Compliance, Privacy/Security and other topics, as well relevant BABHA policies

and procedures are posted to the BABHA website in a Provider section for access by contracted service

providers.

Corporate Compliance Officer, Security Officer, Privacy Officer, CC Committee

The Corporate Compliance Officer, HIPAA Officers and various other senior managers and key staff of BABHA

subscribe to Federal and State list-serves which provide alerts regarding emerging regulatory requirements.

BABHA also takes advantage of available governmental guidance and technical websites for the operation of

Medicaid and Medicare program integrity programs and maintenance of HIPAA regulatory compliance.

BABHA contracts with legal counsel with extensive healthcare experience and regularly seeks opinions and other

educational guidance regarding general compliance and privacy issues. The Officers also attend conferences

and webinars on compliance, security and privacy concerns as available and if cost effective. Changes to state

11 CARF Section1: Aspire to Excellence; Section A Leadership; Standard 7 (requires training of personnel on the corporate compliance plan) 12 CARF Standards: Section 1 Aspire to Excellence: A Leadership: Standard 7

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contractual program integrity requirements for 2019 will no longer permit Compliance Officers to be just ‘self-

trained’. Many compliance related trainings in the marketplace are cost prohibitive. BABHA will seek to identify

additional cost-effective training opportunities.

Occasionally CMHSP and PIHP CC Officers will gather to share expertise, which BABHA representatives attend as

feasible. A new Regional Compliance Officers meeting for MSHN has been initiated which will offer a forum for

communication of MI Office of Health Services Inspector General guidance regarding preventing and detecting

fraud and abuse.

The Corporate Compliance Committee stays informed by reviewing changes to program integrity regulations for

Medicaid, Medicare and other state health care programs, federal Office of Inspector General’s Compliance

Work Plans and federal program integrity guidance materials. The Committee reviews new laws and regulations

from the federal and state government, and attorney general opinions, on an ongoing basis.

Lines of Communication

Effective lines of communication are in place between the compliance officer and the organization's

employees13. BABHA operates a hot-line for consumer, employee, provider and contracted service provider

reporting of compliance and privacy/ security concerns. BABHA’s policy and procedure C13-S02-T01 Internal

Reporting (Hot-LINE) and Response for Suspected Fraud, Waste and Abuse describes the purpose and procedure

for the hot-line and other reporting provisions. The current BABHA Corporate Compliance Hot-Line Poster is

attached to this plan.

Revisions to the state contract for Medicaid services for FY19 require the dissemination of addresses and toll-

free numbers for reporting fraud, waste and abuse to all BABH sub-contractors. The information will be added

to training materials. The BABHA hotline poster has been updated to include Mid-State Health Network and

state MDHHS Office of Inspector General (MIOHSIG) contact information. The revised poster will be posted to

all BABHA waiting, conference and break rooms, and given to all contracted service providers for posting.

Employees and contracted service providers (including Licensed Independent Practitioners) have direct access to

the BABHA Corporate Compliance Officer via phone, email and in person, both for consultation regarding

compliance strategies and for reporting of suspected fraud and abuse, or privacy and security concerns.

Compliance activity is reported to the BABHA Board of Directors, as well as the Corporate Compliance

Committee, which includes representatives from senior management. The BABHA Corporate Compliance

Officer attends Agency Leadership and contracted service provider meetings (vocational, residential/CLS and

primary provider, to include Autism providers in 2019) to receive and respond to compliance related issues.

Information regarding the Corporate Compliance Hot-Line and how to contact the BABHA Privacy Officer are

included in the handbook provided to individuals receiving BABHA services. An interpreter would be made

available to individuals with limited English proficiency if needed.

BABHA policy and procedure C13-S02-T02 Non-Retaliation/ Non-Retribution reflects BABHA’s commitment to

ensuring individuals reporting fraud/abuse or privacy/ security concerns are not subject to retaliation or

retribution.

13 Managed Care Rules: 438.608 Program Integrity Requirements (a)(1)(v)

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Disciplinary Guidelines

BABHA’s corporate compliance related standards are communicated to staff and clinical contracted service

providers (including Licensed Independent Practitioners) through the Corporate Compliance education program

outlined in this plan, including disciplinary guidelines and provisions for adverse contract action14.

Employees

In addition to the corporate compliance and privacy/ confidentiality education afforded new and existing employees, employees are informed of expectations for their compliance with regulatory requirements and standards via document-specific education on new and revised BABHA plans, policies and procedures. This includes education on the Corporate Compliance Plan, corporate compliance policies and procedures, and privacy and security policies and procedures.

Employees are educated at least annually regarding BABHA compliance, privacy and security related policies and

procedures, which include the obligation to report suspected fraud, waste, abuse and privacy/security

violations, to report criminal convictions, as well as the protections available to individuals who are

whistleblowers.

Employees directly responsible for fraud, abuse and privacy/security violations, as well as those who assisted,

facilitated or ignored a violation, are subject to disciplinary action. Disciplinary action is commensurate with the

severity of the offense and occurs at the discretion of the CEO in consultation with the Director of Human

Resources and the involved supervisor. All disciplinary action is applied in accordance w/ BABHA human

resources policies/ procedures.

The following disciplinary guidelines are communicated to staff:

o Employees may be suspended with or without pay during an investigation

o For minor violations employees may be subject to verbal/written warnings

o For more severe violations employees may be subject to significant disciplinary action including

suspension and/or termination of employment

o Considerations may include:

o Inaccurate or incomplete documentation

o Unsigned or missing documentation

o Deliberately fraudulent service documentation

o Failure to maintain continuous licensure, registration or certification

o Falsification of licensure or certification

o Discipline may also be applied to employees who assisted, facilitated or ignored a fraud and abuse,

including supervisory and senior management staff

14 Managed Care Rules: 438.608 Program Integrity Requirements (a)(1)(vi)

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Provisions for disciplinary action are outlined in the BABHA Agency Manual and the BABHA Employee Handbook.

Each employee receives a copy of the Employee Handbook at the time of hire. The handbook and all agency

policies, procedures and plans are posted on the agency intranet site, accessible by all employees. Records of

disciplinary actions are maintained in human resources records.

See the section on External Reporting for discussion of potential additional adverse action against licensed and

registered professionals.

Contracted Service Providers

The contract boilerplate language outlines contract remedies for failure to comply with the terms of the

contract, such as substantiated privacy/confidentiality or security violations, and fraud or abuse involving state

or federal healthcare funds, as follows:

• Require a plan of correction together with status reports and/or additional oversight by BABHA;

• Suspension of payments;15 or

• Termination of the contractual agreement.

For purposes of example only, the following is a non-exhaustive list of compliance or performance issues for

which BABHA may take remedial action to address repeated or substantial breaches, or patterns of non-

compliance or substantial poor performance:

• Reporting timeliness, quality and accuracy;

• Performance Indicator Standards;

• Repeated Site Review non-compliance (repeated failure on same item);

• Failure to complete or achieve contractual performance objectives;

• Substantial inappropriate denial of Services required under this Agreement or substantial Services not

corresponding to condition. Substantial can be a pattern, large volume or small volume, but severe

impact;

• Repeated failure to honor appeals/grievance assurances;

• Substantial or repeated health and/or safety violations;

• Failure to adhere to training requirements and timelines for completion;

• Failure to complete required documentation for each service provided; and/or

• Failure to comply with prohibitions regarding exclusion, suspension or debarment from state and/or

federal health care programs.

Adverse contract action is documented in contract files for each provider by the Finance Department. See the

section on External Reporting for discussion of potential additional adverse action against contracted licensed

and registered professionals and organizations.

15 Managed Care Rules: 438.608(a)(8)

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Monitoring and Auditing16

BABHA has an active internal prevention, monitoring and auditing program17. The Attachments to this Plan

include the current BABHA Compliance Committee Data Monitoring Plan. The Monitoring Plan is used by the CC

Officer and Committee to define monitoring activities. The Monitoring Plan changes frequently based upon

reporting timelines, results of ongoing environmental assessment activity and periodic risk assessments, and the

availability of information. Copies of current and previous monitoring schedules are maintained by the CC

Officer and are available for review.

BABHA’s monitoring program includes methods to verify, by sampling or other methods, whether services that

have been represented to have been delivered were received by the individuals whom BABHA intends to

serve.18 BABHA applies the verification process on a regular basis (see BABHA policy and procedure C13:A02:T20

Service Event Verification and Restitution) and participates in twice yearly verification activities by its regional

payer. Monitoring activities include but are not limited to:

1. Privacy and Security

a. Electronic Health Record monitoring for use of “break the glass” feature in the role-based security

system

b. Security risk assessment (annual)

c. Scan of shared/ group network drives for exposure of PHI

d. Monitoring the network for security breaches

e. Completion of Business Associate (or Qualified Service Organization Agreements, if applicable) for

non-covered entities (relative to HIPAA) or non-licensed service providers (relative to substance use

disorder services)

2. Fraud and Abuse

a. Fraud and abuse risk assessment (bi-annual)

b. Annual financial compliance audits

c. Record reviews to verify Medicaid service claims and data mining priorities for service claims which

do not meet coding and billing criteria

d. Checks for sanctioned, excluded or debarred employees, directors/ officers, contracted service

provider CEO’s or their owners

e. Human Resource checks for maintenance of professional licensure or registration by clinical staff

and prescribers

f. Verification of specialized residential provider Adult Foster Care Licensure

g. Maintenance of Medicaid waiver enrollment certifications and minimum service requirements

(Habilitation and Support Waiver program, Autism benefit, etc.)

h. Service claim audits for potential recall recoupment of Medicaid funds

3. General Compliance

a. On-site reviews of organizational contracted service providers against contract requirements per a

defined annual schedule, including record reviews (see BABHA policy and procedure C04-S12-T35

Site Reviews.)

16 CARF Standards: Section 1 Aspire to Excellence: A Leadership: Standard 7 17 Managed Care Rules: 438.608 Program Integrity Requirements (a)(1)(vii) 18 Managed Care Rules: 438.608(a)(5)

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b. Quality Record reviews for direct operated programs, including verification of:

i. documentation of medical necessity including diagnostics and clinical assessments;

ii. completion of annual ability to pay assessments;

iii. Proper qualification of clinical staff for services rendered;

iv. the presence of physician orders for Medicaid services for which orders are required;

v. presence of a properly completed and signed plan of service, including signature by clinician,

consumer or parent/ guardian as required; and

vi. Coordination of care with primary care physician.

BABHA compliance staff run routine compliance monitoring reports for clinical supervisors and team leader self-review. (See the attached Data Monitoring Plan and Supplemental Compliance Reports). Record reviews and corrections to documentation are completed as needed.

System barriers to compliance identified are addressed by quality and compliance staff in conjunction with clinical leadership. If compliance errors (not due to system errors) are not resolved within a reasonable timeframe, the Supervisor develops a corrective action plan.

Fraud/abuse risk areas for routine monitoring are identified by the Corporate Compliance Officer in

collaboration with the BABHA Corporate Compliance Committee based on previous compliance concerns, state

and federal priorities and identified risk areas. Monitoring reports are received by the CC Committee and

corrective action taken as necessary.

BABHA electronic health record has various quality and compliance reports available to line staff users and their

supervisors. BABHA has developed additional monitoring reports which will be published on a monthly and

quarterly basis beginning in 2017 to assist line staff and leadership with ensuring regulatory compliance. This is

in addition to signing of clinical documents by supervisory staff and the data quality checks that are performed

monthly and quarterly by primary case holders, supervisors, quality and state reporting staff to ensure data is

complete and meets logic tests prior to submission to either regional or state entities.

BABHA also emphasizes prevention of fraud and abuse by limiting the service codes which can be used by

employees and contracted service providers (including Licensed Independent Practitioners) to those which are

relevant to their scope of work and credentials, as applicable. The electronic health record and its billing engine

include extensive business rules which work to preclude as many billing errors as possible. Service authorization

parameters and packages or bundles are employed to minimize the risk of abuse as much as feasible without

adversely impacting person-centered planning by consumers served. Further information regarding BABHA

claims management controls are outlined in the C08 Fiscal Management, Section 7 – Claims, of the BABHA policy

and procedure manual.

Environmental and Risk Assessments19

BABHA CC Officer and CC Committee members monitor the environment on an ongoing basis to identify new or emerging compliance requirements. The Officer and members participate in various list-serves and attend statewide and regional meetings, conferences and webinars.

The CC Officer, with assistance of the CC Committee, reviews the risk or focus areas identified in the Office of

Inspector General (OIG) for the United States Department of Health and Human Services Work Plan, the

19 CARF Standards: Section 1 Aspire to Excellence: A Leadership: Standard 7

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Michigan Office of Health Services Inspector General (MIOHSIG) Recovery Audit Contractor Approved Scenarios,

if any, as well as any other priority compliance or risk areas communicated by the Michigan Office of Health

Services Inspector General or the Mid-State Health Network.

In addition, BABHA identifies themes in the results of its data/monitoring activities for reimbursement trends,

prior audit findings, and internal record reviews to identify other areas of potential risk. The BABHA CC

Committee members, as well as the BABHA PI Council, complete compliance related self-reviews (i.e., desk

reviews) as required and participate in on-site audits and reviews.

A security risk assessment is completed which reviews existing BABHA technological, administrative and other

safeguards to ensure compliance with HIPAA requirements.

A bi-annual BABHA fraud and abuse Risk Assessment is completed by the Corporate Compliance Committee. The

assessment involves tracing BABHA’s workflows for generation of service claims from contact with the person

served to the submission of claims file to payers to assess and mitigate weaknesses in fraud/abuse protections.

The Risk Assessment evaluates the likelihood of fraud and abuse occurring and potential impact on the

organization should it occur. Workflows for both direct operated and contracted services are evaluated.

These activities result in corrective action planning to reduce risk and response to changing expectations in the

external compliance environment. The BABHA Fraud and Abuse Risk Assessment template is attached to this

plan.

The results of such reviews, on-site audits and CC data/monitoring activities are incorporated into BABHA

policies, procedures and practices as necessary, and/or added to the CC data/ monitoring schedule for further

oversight by the CC Committee. Findings from the risk assessments are also included in the Corporate

Compliance Plan evaluation of plan effectiveness and priorities.

Response and Corrective Action

BABHA has policies and procedures which provide for prompt response to compliance issues as they are raised,

investigation of potential compliance problems as identified in the course of self-evaluation and audits,

correction of such problems promptly and thoroughly (including any required coordination of suspected criminal

acts with law enforcement agencies) to reduce the potential for recurrence and ongoing compliance with

requirements.20

Investigations

BABHA policy and procedure C13-S02-T22 Complaint Investigations provides detail regarding BABHA

investigation strategies. The BABHA Corporate Compliance Fraud/Abuse Report template is attached to this

plan.

In general terms, the CC Officer oversees the prompt and thorough investigation of any report, in coordination

with the HR Department and/or management structure as appropriate, as made through the CC Program.

Suspected fraud and abuse of Medicaid funds is reported prior to investigation to the Mid-State Health Network,

Michigan Department of Community Health and the Michigan Office of Health Services Inspector General per

20 Managed Care Rules: 438.608(b)(7) Program Integrity Requirements

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contract requirements. The MIOHSIG now has a reporting form which must be used. The CC Officer may

delegate specific investigative tasks to the appropriate department, supervisor or legal counsel, if necessary.

This delegation may be done generally or on a case-by-case basis, at the CC Officer’s discretion, in consultation

with the CEO, if appropriate.

Each investigation includes the gathering and preservation of relevant documents and identification and

interviewing of employees, recipients of services and/or contracted service providers (including Licensed

Independent Practitioners) who may be able to provide pertinent information, as warranted. However, any

investigation which overlaps with potential Recipient Rights violations or Customer Service appeals, grievances,

local dispute resolutions or complaints are coordinated with the relevant officials within BABHA. The BABHA CC

Officer may use reports and interviews from those functions as a basis for determination of whether fraud/

abuse or a privacy/ security concern will be substantiated, to minimize the impact of investigations on the

involved parties.

The BABHA CC Officer maintains a compliance log (and documentation files where warranted) of CC related

issues and their disposition, including privacy, security, fraud and abuse concerns.

Corrective Action

Each investigation is documented, including information about the issue or incident, conclusions reached and

the recommended corrective action, where such action is necessary. The CC Officer, or appropriate

management personnel responds to the reporting party, as appropriate and to the extent reasonably possible,

regarding the status of the investigation and any corrective action taken.

Corrective actions are geared to mitigate the impact of the issue or incident, remediate the error(s), and prevent

future occurrence if possible. Steps taken range from employee education or training, consultation with

contracted service providers, revision of policies, procedures, or contract boilerplate, revision of electronic

health record functionality, service claim recall, reporting and reporting recoupment of over-payments,

disciplinary action against employees and adverse contract action against contracted service providers (including

Licensed Independent Practitioners), as previously described in this Plan.

Claims/Over-Payment Recoupment and Voiding of Encounters

Recoupment of Medicaid, Medicare and other state/federal healthcare related over-payments for fraudulent or

erroneous service claims from contracted service providers (including Licensed Independent Practitioners) are

handled by the Chief Financial Officer and addressed in BABHA financial policies. The CFO or designee also

manages the voiding of encounters and any cost write-off or repayment that may be required for substantiated

fraud or abuse by BABHA employees which may have resulted in an excessive or erroneous service claim.

Recoupments are tracked on the BABHA Corporate Compliance Log by the CC Officer.

Providers are required to agree to a repayment strategy, to the satisfaction of the CFO. The CFO, in consultation

with the CEO as necessary, determines whether contracted service providers (including Licensed Independent

Practitioners) will be subject to additional action, such as being turned over to collection agencies, if they fail to

meet repayment obligations.

Other Corrective Action and Enforcement

BABHA works with the Michigan Office of Health Services Inspector General, and other governmental entities at

the state and federal level which hold civil and criminal enforcement authority under Medicaid, Medicare and

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other state/federal healthcare program integrity related statutes. Corrective action plans are also coordinated

with the Michigan Department of Health and Human Services and Mid-State Health Network in accord with

contract requirements.

Compliance Reporting

BABHA requires employees and providers to report to the CC Program and the CC Program must submit

required information to its payers. The CC Program endeavors to be accessible and consultative to stakeholders.

Employee/ Contracted Service Provider Guidance and Reporting21

BABHA employees are required to report to the CC Officer and their Supervisor any suspected fraud/ abuse or

privacy/security violation. BABHA policy and procedure C13-S02-T01 Internal Reporting (Hot-LINE) and

Response for Suspected Fraud, Waste and Abuse provides more information about such provisions. New

employees are advised of this requirement during their orientation and other employees are reminded during

annual training updates. Reporting obligations are cited in the contract boilerplate for contracted service

providers (including Licensed Independent Practitioners).

Board members sign an attestation indicating they agree to report any criminal charge or conviction related to

Medicaid, Medicare and any other Federal/State Healthcare Program, as well any other crime involving the

delivery of a healthcare item or service.

Through the contractual agreement, provider agencies and licensed independent practitioners agree to report

to BABHA any suspicion or knowledge of fraud or abuse and to fully cooperate with investigations. Providers are

required to immediately report to BABHA any invalid claims and/or overpayments for correction. Also,

providers agree to immediately notify BABHA with respect to any inquiry, investigation, sanction or otherwise

from the Office of Inspector General (OIG).

Employees and contracted service providers (including Licensed Independent Practitioners) are encouraged to

utilize the CC Program as a source of consultation and guidance regarding compliance related questions.

Technical assistance is offered by the CC, Privacy and Security Officers to the maximum extent possible as

questions arise and when investigations occur. The CC Officer meets face-to-face with each new employee

during new employee orientation and participates in face-to-face meetings with key contracted service

providers.

CC and other agency policies, procedures and documents are designed to encourage and facilitate regulatory

compliance. As an example, the business rules embedded in the electronic health record are narrow, limiting an

employee’s ability to make wrong choices. BABHA has dedicated staff to verify service claims and

communicates regularly with contracted service providers (including Licensed Independent Practitioners)

regarding questionable or erroneous claims.

(See Lines of Communication for additional information).

21 CARF Standards: Section 1 Aspire to Excellence: A Leadership: Standard 7

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External Reporting

As noted earlier, BABHA is required to report potential fraud and abuse occurrences which warrant investigation

to Mid-State Health Network, and ultimately to the Michigan Department of Community Health and the

Michigan Office of Health Services Inspector General.22

BABHA is also required under state law to report licensed or registered professionals and organizations to the

Michigan Department of Licensing and Regulatory Affairs (LARA) for potential investigation and possible adverse

action.

On In the past, on a semi- annual basis BABHA providesd a summary report to MSHN of the number of

complaints of fraud and abuse that warranted preliminary investigation throughout the year. For each incident,

BABHA supplies the name(s) of the party(ies) involved, the Medicaid ID number of the consumer(s) involved, the

source of the complaint, the type of provider(s) involved, the nature of the complaint, the approximate dollars

involved, the legal and administrative disposition of the case and the funding source involved. BABHA and

MSHN coordinate the required reporting to the Michigan Department of Community Health and the Michigan

Office of Health Services Inspector General.

The program integrity provisions in the MDHHS Medicaid specialty services contract were significantly revised by

the MDHHS OIG for FY19 to require expanded quarterly reporting, including virtually all compliance related

activity by CMHSP’s. BABHA has revised it’s compliance log and reports to capture the required information.

As a covered entity under HIPAA, BABHA must also report security breaches to the Federal government on an annual basis. BABHA also has mandatory State reporting obligations as an employer.

Reporting of Overpayments23

BABHA’s policy and procedure C08:S03:T13 Third Party Revenue Collection and Repayments outlines steps for

prompt reporting and recoupment of all Medicaid and Medicare overpayments identified or recovered. BABHA

reports to regional and state payers, and federal and state offices of inspector generals as required by law and

contractual obligations. In accord with regulatory requirements, BABHA specifies the reason for overpayments,

including if due to potential fraud.24

Medicaid Eligibility

If BABHA becomes aware of changes in a Medicaid enrollee’s circumstances that, to the best of its knowledge,

may affect the enrollee’s eligibility for Medicaid, BABHA notifies a representative of the local office of the

Michigan Department of Human Services, which is responsible for managing Medicaid eligibility determinations.

As a Community Mental Health Services Program, BABHA is also responsible for reporting to the State of

Michigan the death of an individual receiving services. 25

22 Managed Care Rules: 438.608(a)(7) 23 42 CFR 401Reporting and Returning of Overpayments (for Medicare) and Section 1128J(d) of the Affordable Care Act for

Medicaid overpayments 24 Managed Care Rules: 438.608(a)(2) 25 Managed Care Rules: 438.608(a)(3)

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Provider Disenrollment

BABHA also notifies regional and state payers when information is received about changes in a contracted

service provider’s circumstances that, to the best of BABHA’s knowledge, may affect the provider’s eligibility to

participate in a managed care program as a Medicaid provider. 26

Contracted service providers who leave or who are removed from the BABHA provider network must also be

reported to BABHA’s Medicaid payers, MDHHS and MSHN for purposes of MDHHS monitoring of Medicaid

provider enrollment.

Evaluation of Program Effectiveness and Program Priorities

The BABHA Corporate Compliance Program remains largely effective, however certain areas were identified for

improvement in the 20187 plan which have beenwere addressed over the course of the year as follows:

o Procedures for review of clinical records was modified to increase the consistency and volume of

records reviewed per year. The process was transitioned to a peer review model and documentation of

corrective action improved.

o Non-healthcare service providers such as office suppliers, software vendors, etc. were added to BABHA’s

process for monitoring for exclusion and debarment.

o Additional service documentation training and guides were provided to residential and vocational

contracted service providers to improve documentation compliance with Medicaid requirements.

o Additional attention and streamlining of processes has been applied to the corporate compliance

program to improve responsiveness to issues and requests despite reduced personnel capacity.

o There continue to be some gaps inTraining was provided for staffresidential and vocational clinical

contracted service providers understandingregarding of documentation requirements; continued

education and deployment of electronic health record solutions for compliant documentation are

needed.

o Guidance was provided for Sstaff and contracted service providers who are case holders need writtenguidance regarding handling of privacy and confidentiality in situations where divorced parents sharecustody of a child in treatment through BABHA.

o Additional legal guidance was obtained regarding aAgreements with non-clinical vendors need toinclude language addressing and exclusion and debarment prohibitions.; legal consultation has beenobtained and is ready for implementation.

o BABHA staff and contracted service providers were provided additional privacy guidance and securesolutions for the communication of consumer information for purposes of coordination of care.

o The most recent Fraud and Abuse Risk Assessment identified continuing concerns aboutAdditionalmonitoring was added for claims for services where the consumer of the service is the employer (i.e.,

26 Managed Care Rules: 438.608(a)(4)

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self-determined service arrangements); which will be a focus of Corporate Compliance Committee action. and also for vocational claims to ensure services were received as billed.

o

o Corporate compliance policies were revised to reference BABHA’s commitment to prompt notification to regional and state payers when information is received about changes in:

o A Medicaid enrollee’s circumstances that may affect their eligibility, such as changes inresidence or their death.

o A contracted service provider’s circumstances that may affect their eligibility to participate in amanaged care program.

Areas of the program warranting additional attention (and program priorities) for 2019 are:

o The identification of additional cost-effective training opportunities for the Corporate ComplianceOfficer.

o Policy, contract, training material and site review template changes as necessary to comply with recentclarifications of requirements for background checks, including the abuse registry, ongoing criminal checks every two years and other requirements.

o The Privacy Notice needs to be finalized and published; revisions need to address any changes inorganizational access to Medicaid claims data for coordinating care

o Once the BABH will be finalizing its implementation of the MDHHS finalizes the current set ofmodifications to its uniform behavioral health consent., BABHA will finish the process of adopting theconsent for full use in accord with MDHHS requirements.

o Attend the new Autism Provider meetings to address compliance topics and provide annual training.

o The capacity of the compliance program to resolve compliance complaints in a timely manner needscontinued resources and attention.

o Ensure BABHA Standards of Conduct and Ethical Guidelines are posted to the provider portion of theBABH website and reference in training materials.

o The most recent Fraud and Abuse Risk Assessment identified continuing concerns about claims forservices where the consumer of the service is the employer (i.e., self-determined service arrangements); which will be a focus of Corporate Compliance Committee action.

o Agreements with non-clinical vendors need to include language addressing exclusion and debarmentprohibitions; legal consultation has been obtained and is ready for implementation.

o BABHA staff and contracted service providers need more privacy guidance and secure solutions for thecommunication of consumer information for purposes of coordination of care.

o Informal record review activity by Program Coordinators across clinical programs needs info capture andstructuring consistent with established event verification processes to increase the reach of thecorporate compliance program. More frequent, targeted event verification by the Quality andCompliance Coordinator is needed to reduce look-back periods when issues with documentationsupporting claims are identified.

o Additional checks for exclusion and debarment for selected non-clinical vendors will be added basedupon recent legal consultation.

o Corporate compliance policies should be revised to reference BABHA’s commitment to promptnotification to regional and state payers when information is received about changes in:

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o A Medicaid enrollee’s circumstances that may affect their eligibility, such as changes inresidence or their death.

o A contracted service provider’s circumstances that may affect their eligibility to participate in amanaged care program.

o Maintain and implement data/ monitoring schedule as indicated in this plan

o Implement the education plan as indicated in this plan.

o Ensure continued completion of annual security risk assessments per HIPAA requirements.

o Continue to publish compliance monitoring reports to leadership to assist with monitoring of potentialcompliance gaps in EHR documentation.

o Ensure the revised BABHA hotline poster is disseminated to all BABHA waiting, break and conferencerooms, as well as to all BABH sub-contractors.

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Plan Attachments

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Corporate Compliance Plan Attachment


Corporate Compliance Education Plan (20198)

The purpose of the Corporate Compliance Education Plan is to ensure appropriate communication and understanding of

the Corporate Compliance Plan and the standards and procedures to be followed.

Board of Directors

1. Orient new Board Members to the BABHA Corporate Compliance Program upon start of their first term, including

review of the Corporate Compliance Plan and Code of Ethics/Conduct.

2. Provide annual update training to Board of Directors.

3. Board members to sign attestation annually.

Employees

4. Educate new employees regarding corporate compliance, privacy and confidentiality during new employee

orientation process (monthly).

5. Educate employees regarding corporate compliance, privacy and confidentiality during annual Staff Development

Days (annually).

6. Provide general education to employees via periodic intranet announcements.

7. Ensure “Hot-line” number is posted at BABHA locations.

8.7. Address key compliance and privacy concerns as needed during All Leadership meetings.

Contracted Service Providers

9.8. Orient new organizational providers and Licensed Independent Practitioners to BABHA compliance program upon

initiation of contract.

10.9. Provide general education to key contracted service providers via provider meeting agendas (annually) –

focusing on their particular compliance concerns.

11.10. Address compliance and privacy concerns as needed during Primary Provider, Residential Provider, Autism and

Vocational Provider meetings as needed.

12.11. Post BABHA corporate compliance and privacy/confidentiality training materials on the BABHA web-based

training site for ease of access by contracted service providers to help guide their own training programs.

Corporate Compliance Officer, Security Officer, Privacy Officer, CC Committee

13.12. Include educational information for members on Corporate Compliance Committee meeting agendas (per

meeting).

14.13. Provide Corporate Compliance, Security and Privacy Officers with access to ongoing education via professional

newsletters and email list-serves commensurate with job duties and responsibilities (ongoing).

15.14. Officers to attend compliance related conferences/seminars as available and funds permit.

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Compliance Committee Data Monitoring Plan (20182019)

ACTIVITY RESPONSIBILITY J F M A M J J A S O N D

EHR (Phoenix) Breach Monitoring Records Specialist X X X X X X X X X X X X

Gallery Breach Monitoring IS Manager X X X X X X X X X X X X

Meaningful Use Measures Status Prescriber

Compliance

Clinic Manager X X X X X X X X X X X X

Sanctioned provider list (OIG and GSA) checks

• employees and officers

• contracted service providers

HR Director

Contract Admin.

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

Monitoring of Shared Drives for Exposure of PHI Security Officer X X X X X X X X X X X X

Corporate Compliance Report CCO X X

Report of HIPAA Breach Log to HHS (cc MDCH,

MSHN) (w/in 60 days of end of calendar year)

CCO X

Review of OIG Work Plan CCO X

Quarterly Report of Fraud-Abuse to MSHN/ MDCH CCO X X X X

Compliance review of medical records, including:

• Ability to pay completed in the last 12 months

• Spend-down information present, if applicable

• Physician order for services as required byMedicaid (i.e., OT, and PT)

• Documentation of medical necessity

Quality Manager X X X X

Verification of Medicaid services - Contracted service providers

Q&C Coordinator X X X X

Verification of Medicaid services - Direct operated

programs

Q&C Coordinator X X X X

HSW

• Timeliness of HSW Re-Certification

• Delivery of service other than Supp. Coord.

• Potential Recoupments

Finance Manager X X X X

Organizational Credentialing Risk Assessments Contract Admin (year?)X

Provider Network Site Review Summary Q&C Coordinator X X

Review of Compliance Audit Findings Finance Manager X

Security Risk Assessment Security Officer X

Fraud/Abuse Risk Assessment (Bi-Annual) CCO 2018

Review of Licensure for AFC Homes Contract Admin X

Review of Site Review Templates Quality Manager X

PQRS/ Meaningful Use Incentives and Penalties Finance Manager prn prn prn prn

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Data Monitoring Plan: Supplemental Compliance Reports

Purpose ID# Compliance Metric

Compliance (contract) 7 Missing BH-TEDS Admission Records

Compliance (contract) 8 Missing BH-TEDS Admission Record for HSW Enrollee (at time of enrollment)

Compliance (contract) 9 Concurrent BH-TEDS Admission Records w/o active admission to a state center

Compliance (contract) 10 Missing or overdue BH-TEDS Update Records

Compliance (contract) 11 Closed or deceased consumers w/ a BH-TEDS Admission Record but w/o a BH-TEDS Discharge Record

Compliance (contract) 12 Missing or expired certification and consent for HSW Enrollee

Compliance 13 Missing or expired consents, including Acknowledgement of Receipt (for Privacy Notice, etc.)

Compliance (contract) 14 Missing or expired Consent for Behavioral Treatment [100% of cases are monitored at BTPRC]

Compliance 15 Missing or expired Medication Consent

Compliance (CARF) 16 Missing or expired tele-health consent [work group adding to Interim plan and IPOS]

Compliance (contract) 17 Missing or expired LOCUS

Compliance (contract) 18 Missing or expired CAFAS/PECFAS

Compliance (contract) 19 Missing or expired DECA

Compliance (contract) 20 Assessments, plans, progress notes and periodic reviews not linked to the calendar (i.e., for PI indicator data capture)

Fraud-Abuse 21 Assessment with dates less than 305 days apart (timeframe allows for early annual assessments)

Fraud-Abuse 22 Missing Clinical Assessment, including Respite Only

Fraud-Abuse 23 Missing Assessment (Psychiatric Evaluation or clinical assessment) for Meds Only Consumers

Fraud-Abuse 24 Missing Diagnosis

Fraud-Abuse 25 Missing or incomplete service eligibility criteria and disposition in clinical assessment (or Assessment for External Providers)

Fraud-Abuse; 26 Adequate medical necessity not documented/ Service eligibility criteria not met

Compliance (MU) 27 Missing PHQ-9 for individuals receiving medication reviews or psychiatric evaluations

Compliance (Medicaid) 28 Missing or expired Assessment of Personal Care Needs (3803)

Compliance (Contract) 29 Annual Health Care Screening (Presence of primary care physician)

Fraud-Abuse 30 Injection (i.e., RN Medication Administration) is not occurring on the same day as a physician contact

Fraud-Abuse 31 Injection (i.e., RN Medication Administration) medication is not marked as billable if the pharmacy would have already billed the drug

Fraud-Abuse 32 Injections (i.e., RN Medication Administration) are incident to a physician's presence

Fraud-Abuse 33 Missing or expired Physician's Orders for OT and PT services

Fraud-Abuse 34 Missing or expired Physician's Orders for Private Duty Nursing

Fraud-Abuse 35 Missing or expired PCP for open consumer

Fraud-Abuse 36 Plans of Service with dates less than 365 days apart

Fraud-Abuse 37 Use of Interim Plans of Services for consumers in service over 305 days

Fraud-Abuse 38 Consecutive Interim Plans of Services

Fraud-Abuse 39 Interim Plan of Service older than 30 days for residential and 45 days for all other services

Fraud-Abuse 40 Missing (i.e., no) insurance information

Fraud-Abuse 41 Missing or expired Ability to Pay Assessment

Fraud-Abuse 42 MDHHS shows Medicare without a policy in Phoenix

Fraud-Abuse 43 MDHHS has a Medicaid Spend-Down without a policy in Phoenix

Fraud-Abuse 44 Student intern services billed without supervisor counter signature because Intern radio button in Staff Profile not checked

Fraud-Abuse 45 Unsigned documents older than 30 days - including assessments, PCP's, periodic reviews and progress notes

Fraud-Abuse 46 Services provided are named in the IPOS; Service documentation matches service claim (i.e., event verification)

Fraud-Abuse 48 Overlapping service activity for consumer

Fraud-Abuse 49 Overlapping service activity for staff

Fraud-Abuse 50 Users who have changed signed documents have acted appropriately

Fraud-Abuse 51 Freestanding service authorizations (i.e., without an accompanying plan of service) are only used when appropriate

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Compliance Education Log

Date Audience Topic

Intr

an

et

Em

ail

Sp

rin

g S

taff

Dev D

ays

Po

licy

Ed

uc

ati

on

New

Em

p

Ori

en

t

Ins

erv

ice a

t

Mtg

Notes

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Corporate Compliance Log

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BABHA Fraud and Abuse Risk Assessment (With Action Plan)

Direct Operated Programs and Contracted

LIP’s CSM/SC Outpatient

Therapy Psychiatric Med

Admin Psychological

Services ABA

OT/ PT/ SLP (inc.

LIP’s)

CLS - Spec. Resid.

CLS - Voc.

CLS - SIP/ SIAP ES

Jail Services

HSW Services

ES Only

Meds Only

Respite Only

Medical Necessity - Intake

Medical Necessity - Annual

Insurance/Funding

Qualifications

Service Documentation/SAL

Level 2

Level 3

3rd Party Payor Billing Level 2

Level 3

Contracted Service Programs CSM/SC

Outpatient Therapy Psychiatric

Psychological Services ABA

OT/ PT/ SLP (via

agencies)

CLS - Spec. Resid. CLS-Voc

CLS - SIP/SIAP

CLS - Self

Determination

Inpatient Psychiatric

Hospital

Medical Necessity - Use Phoenix (Y)

- Don’t Use Phoenix (N)

Insurance/Funding - Use Phoenix (Y)

- Don’t Use Phoenix (N)

Qualifications

Service Documentation - Use Phoenix (Y) - Don’t Use Phoenix (N)

Claims

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Action Plan The following workflow areas received the highest risk scores during the BABHA Fraud and Abuse Risk Assessment

and were given priority for auctioning at this time. Action plans follow each prioritized workflow area.

Priority #1:

Provider Network Area:

Provider Type(s):

Workflow Area:

Risk Analysis:

Action Steps:

Person(s) Responsible:

Target Date(s):

Priority # 2:


Provider Type(s):

Workflow Area:

Risk Analysis:

Action Steps:


Target Date(s):

Priority # 3:


Provider Type(s):

Workflow Area:

Risk Analysis:

Action Steps:


Target Date(s):

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Corporate Compliance Fraud/Abuse Report

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Hotline Poster

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