corporate compliance what is it? what does it mean to me?
TRANSCRIPT
Corporate Compliance
What Is it?
What Does It Mean To Me?
Purpose Of This Session
To provide attendees with an understanding of the regulatory environment in which the Agency operates
To provide an overview of Corporate Compliance and the components of a Corporate Compliance Plan
To provide attendees with an understanding of documentation requirements
Laws and Regulations
Employment and discrimination Governance, licensing & certification Protection from abuse Health and safety Physical environment Service provision Billing and reimbursement
Laws and Regulations
To comply with the laws and regulations, the Agency develops: Policies, Procedures Practices
What is Corporate Compliance?
A long term commitment by an organization to conduct business in a manner that promotes compliance, continually monitor for compliance, and create systems that allow it to be responsive to changes in the regulatory environment.
Regulatory History
Health Insurance Portability and Accountability Act of 1996 (HIPAA) Increased resources for detecting fraud Expanded power and authority of enforcement
agencies Creation of Health Integrity and Protection Data bank
Balanced Budget Act of 1997 (BBA) Agencies work together/share information Enhanced authority for exclusions Beneficiary Incentives 1-800 hotline for reporting fraud
Regulatory History
False Claims Act Enacted during Civil War, revised in
1986 Prohibits the submission of a false
claim or making a false statement in order to secure payment of a false or fraudulent claim from the Government
Fines of $5,500 - $11,000/claim
Medicaid
New York State by far spend the most in Medicaid dollars.
50 Billion Dollars. An average of $2000.00 per person in
Medicaid spending.
Qui Tam Actions
Under the False Claims Act, private persons file on behalf of the government. The qui tam relator (whistleblower) is entitled to 15%-25% of the amount if the government proceeds with the action, or 25%-30% of proceeds if the government does not proceed.
Deficit Reduction Act of 2006
Policies and Procedures are now a requirement for all applicable Medicaid Service providers
Emphasis is on fraud detection and prevention Training and Education of Staff regarding
False Claims Act Requirement for Protection of Whistleblowers Encourages State level “qui tam” actions under
False Claims Act provisions Enforcement of State Medicaid laws and
regulations is expected/required
Who’s Who?
Office of Inspector General (OIG) Health and Human Services (HHS) Center for Medicaid Services (CMS) Department of Justice (DOJ) Federal Bureau of Investigation (FBI) NYS Office of the Attorney General - Medicaid Fraud
Control Unit (MFCU) NYS Office of Medicaid Inspector General (OMIG) OMH/OPWDD/DOH/OASAS/SED
Office of the NY State Medicaid Inspector General (OMIG)
Created in 2005, is the first OMIG in nation at the state level
“To coordinate the Medicaid fraud, waste and abuse control activities of…DOH, OMH, OMR/DD, OASAS, OCFS, SED”
The False Claims Act
This statute prohibits, among other things:
knowingly presenting or causing to be presented a false or fraudulent claim for payment to the United States;
knowingly making or using, or causing to be made or used, a false record or statement to obtain payment on a false or fraudulent claim;
conspiring to defraud the United States by getting a false or fraudulent claim to be allowed or paid; and
knowingly making or using, or causing to be made or used, a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money or property to the government.
In Other Words ...
presenting a claim that the person knows or should know is false;
presenting a claim for services not provided as claimed;
upcoding; presenting claims for physician services not
provided by a physician; violation of anti-kickback legislation; contracting with someone excluded from a
federal health care program; and inducements to referrals or recipients of
service
Common Examples
Billing for a service that was not provided Billed for days the person was in hospital Documentation is false or inaccurate Billed for more service than provided Service is provided by unqualified staff Billed for service that is not authorized or
medically necessary Billed twice for the same service
The False Claims Act Penalties
This statute has teeth; it provides for treble (triple damages) damages and civil penalties of $5,500–$11,000 for each false or fraudulent claim presented for payment
Provider entities or individuals can face criminal or civil prosecution
Fraud
misrepresentation, omission, or concealment calculated to deceive.”
Abuse“...performing acts that are inconsistent with acceptable
business practices.”
Innocent Errors
No civil or criminal penalties. Provider must return the funds
erroneously claimed. Prosecution would require criminal
intent to defraud (criminal) or actual knowledge of the claim being false; reckless disregard or deliberate ignorance of the false claim (civil).
No One is Perfect!!!
Honest Mistakes and Innocent Errors Happen
You must be able to demonstrate how your internal controls are designed to assure compliance
Policies and Procedures relative to returning funds once errors are found
Demonstrate that $$$ has been returned in the past
Protections and Safeguards
Agency policies, procedures and practices
Educated, qualified and trained staff, Communication between
management, billing and program staff Internal controls Auditing and monitoring activities
Common Mistakes
Not documenting allowable services Not proving medical necessity Not supporting provision of planned services Allowing ineligible/inappropriate providers to
provide billed services Implementing unauthorized or expired
service/treatment plans Service/treatment plans lack specific
interventions/ activities Billing without service documentation
Service Documentation
Services must be documented “contemporaneously” with service delivery (at the same time or in close proximity)
Documentation must include required elements
Documentation must be permanent and legible (able to be read by a reviewer)
Documentation Do’s and Don’ts
DO Use full date (mm/dd/yy) Use signature and title on all entries Include date with your signature Use ink not pencil in records No use of “white out,” black markers, or
scribbling over….Draw a line, note error, sign and date!
Assure documentation is accurate
Documentation Do’s and Don’ts
DO Document service delivery promptly Document only for services you provided Only submit claims (billing) for services
provided Obtain proper authorization for services
Documentation Do’s and Don’ts
Don’t: Document in colored ink or pencil Document anything you have not actually
done or observed Leave labeled fields blank Use initials without corresponding signature
key Attempt to obliterate errors Alter previous documentation
Service Planning and Delivery
Services must be medically necessary Services must be authorized
ISP, IEP, Treatment Plan, Habilitation Plan, Service Plan, Prescription, MD order
Services must be reviewed as required
Service Planning and Delivery
Services must be delivered by trained and qualified staff and as specified in the service/treatment plan
The effectiveness of the service/treatment plan must be reviewed on a frequent and regular basis
The plan must be revised as necessary
Medical Necessity
Medicaid only pays for medically necessary services
Allowable services Based on diagnosis or disability Staff actions Goal driven Measurable Meaningful
Medical necessity must be clearly documented in every plan, note and summary in your program records to someone outside your program.
Keep in Mind…
Provider agrees to:(a) Prepare and maintain contemporaneous records demonstrating their right to receive payment…and keep, for 6 years from date care/service furnished, all records necessary to disclose the nature & extent of the service furnished and all information regarding claims for payment by, or on behalf of, the provider…
NYCRR Title 18, Section 504.3
Keep in Mind…
Provider agrees:(e) To submit claims for payment only for
services actually furnished and which were medically necessary…
(h) That the information provided in relation to any claim for payment shall be true, accurate and complete; and
(i) To comply with the rules, regulations and official directives of the department.
NYCRR Title 18, Section 504.3
Code of Conduct
Distributed to all employees with signed acknowledgment of receipt
Written in plain, understandable language Reviewed and revised with changes in
laws and regulations Written policies and procedures that
address key points in the Code of Conduct
Code of Conduct
Written code - applies to all employees and independent contractors
Clearly expresses commitment to compliance by board, management and all employees
Communicates commitment to comply with all federal and state laws, standards and regulations and the prevention of fraud and abuse
Clear expectations for board, management, employees, contractors and agents
Your Responsibilities
Attend required training(s) Read Agency’s Corporate Compliance Plan Read and follow Code of Conduct Comply with laws, regulations, and Agency’s
policies, procedures and practices Provide and document services according to
Service/Treatment Plans Report any issues, concerns or possible violations Keep in mind this training needs to be conducted on
an annual basis. Any Questions
Recent Events
NYS Attorney General Press Releases
AG Recovers $3.4 Million in Settlement from Buffalo-Area Mental Health Provider for Medicaid Over billing
7/14/00
Recent Events
AG Recovers $670,000 In settlement with Ulster County Alcoholism Treatment Center.
3/14/01
State Told to Pay Medicaid 436 Million Dollars
6/23/05 NY improperly billed Medicaid for Speech Therapy for services billed by NYC Dept of Education. Could not verify that services were
provided by qualified staff. 42 of 100 claims (42%) lacked adequate
documentation to determine if services were actually provided.
Recent Events
AG recovers $2.3 Million in settlement with Long Island
Substance Abuse Treatment Center
3/15/01
Recent Events
3/27/03 MSC arrested and charged with
$50.000 Medicaid fraud for billing for services documented but not provided.
3/19/04 Westchester Nurse Pads work Hours
in Health Care Fraud, receives $12,000 in funds.
Any questions
Thank You
Corporate Compliance Program
Definition
…is a set of formal organizational systems intended to prevent, detect and respond to misconduct committed by employees and other agents.
Benefits of a Compliance Plan
You find your ‘weaknesses’ before Medicaid does
(Early detection) Promotes ethical conduct Communicates agency’s commitment to
regulatory compliance Educated staff (Whistleblower lawsuit protection) Drives more efficient and effective operations Improves financial health of agency Defends the organization; may mitigate
paybacks/fines
7 Elements of a Compliance Plan
1. Written Policies and Procedures
2. Compliance Program Oversight
3. Training and Education
4. Effective, Confidential Communications
5. Enforcement of Compliance Standards
6. Auditing and Monitoring
7. Responding to Offenses & Developing a Corrective Action Plan
Written Policies and Procedures
Based on Laws, Regulations and Practices
Provides direction and guidance to staff Must adhere to them Need to be updated as laws and
regulations change Revise as necessary based results of
internal or external reviews
Corporate Compliance Policies and Procedures
Code of Conduct Conflict of Interest Billing and Reimbursement Education and Training Expense Reimbursement Exclusion or Sanction Screening Auditing and Monitoring Internal Reporting Mechanisms Responding to Governmental Investigations Document Retention and Destruction Enforcement of Compliance Standards/Discipline
Compliance Oversight
Compliance Officer and Compliance Committee
Board and Management Staff Effective methods to report
compliance-related issues
Compliance Officer Duties
Developing and implementing policies and procedures (P&P).
Overseeing and monitoring the implementation of the compliance plan on a regular basis.
Directing agency internal audits established to monitor effectiveness of compliance standards.
Providing guidance to management, medical/clinical personnel and individual departments regarding P&P and governmental laws, rules and regulations
Investigating compliance-related issues
Training and Education
Is Mandatory and Regular Includes
Content of Agency’s compliance plan Overview and importance of compliance Department specific risk areas Summary of fraud and abuse laws How to report non-compliance Confidentiality and non-retaliation for reporting
Effective, Confidential Communications
“Open Door” Policy to raise issues with Management
Methods to report actual or suspected non-compliance confidentially or anonymously
Non-retaliation for reporting actual or suspected non-compliance
Enforcement of Compliance Standards
Clear guidance for staff Supervision and monitoring Disciplinary action for non-compliance
with laws, regulations, policies, procedures and practices
Disciplinary action for failing to report actual or suspected non-compliance
Internal Auditing and Monitoring
Objective: Close gap between service delivery and billing Assure authorization for service (NOD. MD order, signed,
effective service/treatment plans) Process to assure documentation to support claims Staff meet qualifications Develop system that promotes adherence and reports
shortcomings back to programs Identify systemic and process problems Internalize findings Train Re-evaluate
Follow-up and Corrective Actions
Investigate reports of actual or suspected non-compliance
Report findings Develop corrective action plans Review for effectiveness