developing an effective compliance...

30
12/4/2014 1 Developing an Effective Compliance Program Presented By: Sean M. Weiss, Partner Vice President & Chief Compliance Officer 12/4/2014 Partner/Vice President and Chief Compliance Officer; DoctorsManagement, LLC Representing more than 150 medical groups, hospitals and health systems annually in appeal Serving as the Corporate Director of Coding for Adventist Health System Recognized expert by The United States Federal Court System Former Compliance Officer for Southeastern Region; Tenet Health System Former Senior Physician Coding Consultant for Columbia/HCA Steering Committee Government Affairs Assist the Office of Inspector General: development of studies to determine appropriateness of physician coding and deciphering complex guidelines and statutes NAMAS Approved Instructor: DOJ, RAC, ZPIC, Medicare Carriers, BCBS Published Author Hold numerous coding and compliance certifications: (CPMA, CCP-P, CPC, CPC-P, CMC, CMOM, CMIS, ACMPE, (CMCO- Pending) About Your Speaker 2 12/4/2014 Having the OIG and DoJ show up to your office and not having an effective compliance program will make you… 12/4/2014 3

Upload: others

Post on 02-Aug-2020

3 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: Developing an Effective Compliance Programnamas.co/wp-content/...an-Effective-Compliance-Program-38859DPL … · Developing an Effective Compliance Program Presented By: Sean M. Weiss,

12/4/2014

1

Developing an Effective Compliance Program

Presented By:

Sean M. Weiss, Partner Vice President & Chief Compliance Officer

12/4/2014

• Partner/Vice President and Chief Compliance Officer; DoctorsManagement, LLC – Representing more than 150 medical groups, hospitals and health systems

annually in appeal – Serving as the Corporate Director of Coding for Adventist Health System – Recognized expert by The United States Federal Court System

• Former Compliance Officer for Southeastern Region; Tenet Health System • Former Senior Physician Coding Consultant for Columbia/HCA

– Steering Committee – Government Affairs

• Assist the Office of Inspector General:

– development of studies to determine appropriateness of physician coding and deciphering complex guidelines and statutes

• NAMAS Approved Instructor: – DOJ, RAC, ZPIC, Medicare Carriers, BCBS

• Published Author • Hold numerous coding and compliance certifications:

– (CPMA, CCP-P, CPC, CPC-P, CMC, CMOM, CMIS, ACMPE, (CMCO- Pending)

About Your Speaker

2 12/4/2014

Having the OIG and DoJ show up to your office

and not having an effective compliance

program will make you…

12/4/2014 3

Page 2: Developing an Effective Compliance Programnamas.co/wp-content/...an-Effective-Compliance-Program-38859DPL … · Developing an Effective Compliance Program Presented By: Sean M. Weiss,

12/4/2014

2

“There can be no doubt but that the statutes and provisions in question,

involving the financing of Medicare and Medicaid, are among the most

completely impenetrable texts within human experience. Indeed, one

approaches them at the level of specificity herein demanded with dread,

for not only are they dense reading of the most tortuous kind, but

Congress also revisits the area frequently, generously cutting and pruning

in the process and making any solid grasp of matters addressed merely a

passing phase.”

— Chief Judge Ervin

United States Court of Appeals for the

fourth Circuit in Rehabilitation Association

of Virginia v. Kozlowski, 42 F. 3d 1444,

1450 (4th Circuit 1994)

4 12/4/2014

Effective Compliance Programs Lead to Accurate Coding, Which is Essential

“It is the physician’s duty to present an accurate claim. This is more binding than the desire to act as a financial advocate for the patient or the practice. Complete and accurate coding ensures Accurate claims are submitted, which stems from a comprehensive compliance program that forces both staff and providers to take notice in what they are selecting for levels of service, procedure or service codes, and diagnosis codes. Without an effective compliance program practices fail to demonstrate a “Good Faith” effort to comply with the standards established by the payers.” -- Sean M. Weiss

5 12/4/2014

CMS and Their Bounty Hunters

6 12/4/2014

Page 3: Developing an Effective Compliance Programnamas.co/wp-content/...an-Effective-Compliance-Program-38859DPL … · Developing an Effective Compliance Program Presented By: Sean M. Weiss,

12/4/2014

3

Who’s Looking At Your Practice

7 12/4/2014

Laws To Be Familiar With

Federal Health Care Fraud and Abuse Laws

The False Claims Act

– Statute: 31 U.S.C. §§ 3729–3733

The Anti-Kickback Statute

– Statute: 42 U.S.C. § 1320a–7b(b)

– Safe Harbor Regulations: 42 C.F.R. § 1001.952

The Physician Self-Referral Law

– Statute: 42 U.S.C. § 1395nn

– Regulations: 42 C.F.R. §§ 411.350–.389

The Exclusion Authorities

– Statutes: 42 U.S.C. §§ 1320a–7, 1320c–5

– Regulations: 42 C.F.R. pts. 1001 (OIG) and 1002 (State agencies)

The Civil Monetary Penalties Law

– Statute: 42 U.S.C. § 1320a–7a

– Regulations: 42 C.F.R. pt. 1003

Criminal Health Care Fraud Statute

– Statute: 18 U.S.C. §§ 1347, 1349

8 12/4/2014

Waiving copayments routinely

Waiving copayments on a case by

case basis for financially needy

Providing free or discounted services

to uninsured patients

9 12/4/2014

Page 4: Developing an Effective Compliance Programnamas.co/wp-content/...an-Effective-Compliance-Program-38859DPL … · Developing an Effective Compliance Program Presented By: Sean M. Weiss,

12/4/2014

4

10 12/4/2014

Why Develop a Compliance Plan?

• Federal Sentencing Guidelines

– Must be an effective program to prevent and detect violations of the law.

• OIG Compliance Guidance

– Individual and Small Group Physician Practices, 65 Fed. Reg. 59,434 (Oct. 5, 2000)

11 12/4/2014

Why Develop a Compliance Plan?

• Health Care Reform

– Compliance plans to become mandatory as a condition of participation in Medicare and Medicaid

– . . . but only after CMS promulgates implementing regulations to establish the core elements for mandatory compliance programs

12 12/4/2014

Page 5: Developing an Effective Compliance Programnamas.co/wp-content/...an-Effective-Compliance-Program-38859DPL … · Developing an Effective Compliance Program Presented By: Sean M. Weiss,

12/4/2014

5

Understanding Your Risks

• Fraud includes obtaining a benefit

through intentional misrepresentation

or concealment of material facts

• Waste includes incurring unnecessary

costs as a result of deficient

management, practices, or controls

• Abuse includes excessively or

improperly using government resources

13 12/4/2014

Have You Seen the OIG’s Website Lately?

14 12/4/2014

Aggressive Enforcement

• From new joint DOJ/OIG website www.stopmedicarefraud.gov

15 12/4/2014

Page 6: Developing an Effective Compliance Programnamas.co/wp-content/...an-Effective-Compliance-Program-38859DPL … · Developing an Effective Compliance Program Presented By: Sean M. Weiss,

12/4/2014

6

Risk Areas for Physician Practices

• OIG Compliance Guidance for Physicians

– Accurate Coding & Billing • Billing for non-covered services, unbundling, failure to properly

use coding modifiers, upcoding

– Reasonable & Necessary Services • Medical record & orders should support appropriateness of

service

– Physician Documentation

– Improper Inducements, Kickback and Self-Referrals • Financial arrangements with referrals sources, joint ventures,

leases, gifts/gratuities

16 12/4/2014

Risk Areas for Physician Practices

• OIG Work Plan

– Compliance with Medicare Assignment Rules

– “Incident-To” Services

– Evaluation & Management Service Coding

17 12/4/2014

New Compliance Obligations

18 12/4/2014

Page 7: Developing an Effective Compliance Programnamas.co/wp-content/...an-Effective-Compliance-Program-38859DPL … · Developing an Effective Compliance Program Presented By: Sean M. Weiss,

12/4/2014

7

60-Day Repayment Requirement

• §6402 of PPACA requires reporting and repayment of overpayments within 60 days of identification (or due date of next cost report, if applicable)

– Applies to Medicare and other federal health care programs

– What’s “identification”?

• Failure to repay within 60-days may be a false claim

19 12/4/2014

60-Day Repayment Requirement

• Regulatory guidance will be forthcoming... (or so we’ve heard)

• Absent guidance, providers must struggle to come up with practical approaches to complying with the 60-day requirement

20 12/4/2014

Monthly Exclusion Checking

• What is exclusion checking?

• Growing number of State Medicaid Programs are requiring monthly screening of current employees and contractors.

• State Medicaid Director Letter instructed states to “require providers to search the HHS-OIG website monthly to capture exclusions and reinstatements that have occurred since the last search.”

• HHS-OIG CIAs still only require annual screening

21 12/4/2014

Page 8: Developing an Effective Compliance Programnamas.co/wp-content/...an-Effective-Compliance-Program-38859DPL … · Developing an Effective Compliance Program Presented By: Sean M. Weiss,

12/4/2014

8

Monthly Exclusion Checking

• Need to have a policy

– Before hiring and at least annually

• Need to check the websites

– http://exclusions.oig.hhs.gov/search.html

– http://epls.arnet.gov

• Check everyone, including physicians

– www.healthcarecertified.com

22 12/4/2014

The Road Ahead!

• Increasingly aggressive federal/state enforcement

– Alphabet soup of government contractors looking for fraud, waste and abuse

• Whistleblowers driving government priorities

• Increasing importance of comprehensive and aggressive compliance efforts

23 12/4/2014

What is a Compliance Program?

24 12/4/2014

Page 9: Developing an Effective Compliance Programnamas.co/wp-content/...an-Effective-Compliance-Program-38859DPL … · Developing an Effective Compliance Program Presented By: Sean M. Weiss,

12/4/2014

9

WHY HAVE A COMPLIANCE PROGRAM?

• Risk Minimization • Financial Risks & Operational Risks • Health & Safety Risks • Reputational Risks

• Better Image, Improved Relationships, Greater Trust • Community • Regulators

• External Pressures • CMS (ZPIC, RAC, UPIC, PSC, Private Payors, etc.) • Governmental Expectations (e.g. DHHS OIG)

• (Possibly) Reduced Fines and Penalties • Greater Efficiency and Improved Outcomes

• Better trained workforce, better morale • Elimination of uncertainty and confusion about roles and responsibilities • Better quality operations • Identifying and addressing problems early • Reducing likelihood of government audits & investigations

25 12/4/2014

WHY HAVE A COMPLIANCE PROGRAM?

Consequences of Noncompliance • Fines, penalties, and legal fees

• Imposed compliance “settlements”

• More regulatory and audit agency scrutiny

• Management time and effort required to perform damage control

• Management turnover

• Lower faculty and staff morale

• Increased bureaucracy and lower efficiency

• Lingering effects ……….

• Guilt by association: when one of us is tarred, we all wear the feathers

Source: Steve Jung

26 12/4/2014

WHAT ARE THE PURPOSES OF A COMPREHENSIVE COMPLIANCE PROGRAM?

Example:

Mission Statement: To serve, safeguard, and promote ethical practices at the Medical Practice by:

• Identifying compliance risks and effective methods to mitigate those risks;

• Improving delivery of compliance resources;

• Educating and promoting awareness of ethical and legal standards of conduct through effective programs; and

• Partnering with responsible representatives to monitor compliance and to ensure that appropriate and effective corrective actions are taken where non-compliance is detected

27 12/4/2014

Page 10: Developing an Effective Compliance Programnamas.co/wp-content/...an-Effective-Compliance-Program-38859DPL … · Developing an Effective Compliance Program Presented By: Sean M. Weiss,

12/4/2014

10

UNITED STATES SENTENCING GUIDELINES (USSG) – ELEMENTS OF COMPLIANCE

Organization must promote culture “that encourages commitment to compliance with the law” by minimally:

1. Establishing compliance standards and procedures to prevent and detect violations

2. Governing authority oversight: “shall”

• Be knowledgeable about content and operation of program

• Exercise reasonable oversight regarding implementation and effectiveness

• Assign specific high-level person(s) direct, overall responsibility – Give adequate resources

– Give adequate authority

– Have person report directly to governing authority or subgroup on implementation and effectiveness

28 12/4/2014

Assessing specific compliance risks

29 12/4/2014

RISK INVENTORY AND ASSESSMENT IN 2 STAGES

• Stage 1 Risk Identification – “Cradle to Grave” of whatever can “go wrong” in the risk area

– NOT an inventory of legal rules. Event driven and plain language

– Steps

1. Identify Risk areas

2. Identify specific risks within these areas

• Stage 2 Risk Evaluation

30 12/4/2014

Page 11: Developing an Effective Compliance Programnamas.co/wp-content/...an-Effective-Compliance-Program-38859DPL … · Developing an Effective Compliance Program Presented By: Sean M. Weiss,

12/4/2014

11

Compliance Plan Fundamentals

Seven Fundamental Elements

1. Written policies and procedures

2. Compliance professionals

3. Effective training

4. Effective communication

5. Internal monitoring

6. Enforcement of standards

7. Prompt response

31 12/4/2014

32 12/4/2014

LEADING VS. LAGGING INDICATORS

• Leading – predictive of future outcomes

– Assessment of training effectiveness

– Culture – willingness to report concerns

– Hotline trend reports

– Well-understood Standard Operating Policies (SOP)

– Clear and understood delegations

• Lagging–where compliance breakdowns have occurred

– Individual hotline reports

– Audits findings, etc.

– Fines, lawsuits, sanctions, etc.

33 12/4/2014

Page 12: Developing an Effective Compliance Programnamas.co/wp-content/...an-Effective-Compliance-Program-38859DPL … · Developing an Effective Compliance Program Presented By: Sean M. Weiss,

12/4/2014

12

COMPLIANCE SELF-ASSESSMENT APPROACHES

“soft” “hard”

Culture Programmatic Audits Risk Area Specific

34 12/4/2014

ASSESSMENT: SAMPLE KEY INDICATORS

• Awareness of ethical/legal issues at work

• Perception of fair treatment among employees

• Willingness to report legal violations

• Knowledge of where to go with ethics/compliance questions

• Perception that leadership cares about ethical conduct

• Perception that ethical behavior is rewarded and unethical behavior is punished at all levels

35 12/4/2014

Kick The Tires

• Once a compliance

program has been

established, develop a

process to evaluate it and

measure its effectiveness

36 12/4/2014

Page 13: Developing an Effective Compliance Programnamas.co/wp-content/...an-Effective-Compliance-Program-38859DPL … · Developing an Effective Compliance Program Presented By: Sean M. Weiss,

12/4/2014

13

What is Compliance?

• A voluntary program, but strongly recommended by the OIG

• A complete set of policies and procedures as they pertain to a practice and its operations

• It is designed to identify potentially abusive, deficient, or fraudulent activities and create methods and controls to assure that they are identified and corrected

• Auditors have indicated practices that have an effective compliance plan in place are less likely to be prosecuted for fraud due to their inability to convince a jury beyond a reasonable doubt of intentional deception even if there are mistakes detected.

37 12/4/2014

Who Is Liable?

• Any entity who is found to be fraudulently submitting claims (not only the provider)

• Potential civil/criminal penalties

– Up to $10,000 per claim for each fraudulent claim submitted

– Possibly held liable for up to three times the amount unlawfully claimed

– Criminal penalties range from 5 years in prison, $250,000 per claim, and exclusion from federally funded programs

38 12/4/2014

Benefits of a Compliance Program

• The OIG believes the following benefits can be awarded to practices that have effective compliance programs:

– Internal controls

– Better documentation

– Highly educated employees

– Reduced denial percentage

– Significantly reduced risk of penalties/fines

– Reduced exposure to audits

39 12/4/2014

Page 14: Developing an Effective Compliance Programnamas.co/wp-content/...an-Effective-Compliance-Program-38859DPL … · Developing an Effective Compliance Program Presented By: Sean M. Weiss,

12/4/2014

14

Categories of Policies Needed

• Anti-Kickback Statutes

• Stark I and II self-referral legislation

• Waiver of co-pay and deductibles

• Patient termination

• Self-disclosure protocol

• Job descriptions, background and employment checks

• Employee training

• Non-retaliation

• Code of Conduct

• Compliance attestation

• Duties of compliance personnel

• Infrastructure of compliance plan

• Auditing and monitoring process

• Procedures for handling search warrants, subpoenas and investigations

• Reporting of wrongdoing

• Response and prevention

40 12/4/2014

Compliance Policies Needed

• Disciplinary process

• Fire safety

• OSHA

• Hospital

• Home health

• Nursing home care

• Hospice care

• Medical equipment and supplies

• Lab services

• Drug reimbursement

• Medicare managed care

• Legal council

• Auditing the compliance program

• Compliance record retention

• Billing and reimbursement guidelines

• Patient accounting

• Medicare as a secondary payer

• Waiver of liability

• Billing services agreements

• Business relationships

• Gratuities and gifts

• Credit balances, bad debt and collections

• Incident to billing

41 12/4/2014

What Your Compliance Program Should Contain

42 12/4/2014

Page 15: Developing an Effective Compliance Programnamas.co/wp-content/...an-Effective-Compliance-Program-38859DPL … · Developing an Effective Compliance Program Presented By: Sean M. Weiss,

12/4/2014

15

Develop Effective Policies and Procedures

• Policies and procedures are up to-date and user-friendly

43 12/4/2014

Compliance Standards and Procedures

• Establish compliance standards and procedures that are reasonably capable of reducing the prospect of erroneous claims and fraudulent activity, while identifying any aberrant billing practices.

• Effective compliance standards will identify the organization’s risk areas and establish internal controls to contain those risks.

44 12/4/2014

Standards of Conduct

• Indicate what is appropriate conduct with regard to all office operations.

• Provide standards to prevent criminal conduct

• Must be in writing. If it is not in writing, you do not have P&P’s.

• Corporate commitment - if the top brass in the company don’t buy in, then the program is destined to fail.

• Applies to all employees. This means everyone!

• Everyone must understand his/her role (sign it). A Compliance Pledge is a MUST!

45 12/4/2014

Page 16: Developing an Effective Compliance Programnamas.co/wp-content/...an-Effective-Compliance-Program-38859DPL … · Developing an Effective Compliance Program Presented By: Sean M. Weiss,

12/4/2014

16

POLICY NUMBER: 1.0

APPLICABLE RULE: OIG DOCUMENTATION COMPLIANCE

POLICY ON: Cloning of Medical Records

Applicable Rule: OIG Documentation Compliance

Implementation Date: 05.08.2013

Purpose:

The word 'cloning' refers to documentation that is worded exactly like previous entries. This may

also be referred to as 'cut and paste' or 'carried forward.' Cloned documentation may be

handwritten, but generally occurs when using a preprinted template or an Electronic Health

Record (EHR). While these methods of documenting are acceptable, it would not be expected the

same patient had the same exact problem, symptoms, and required the exact same treatment or

the same patient had the same problem/situation on every encounter.

Cloned documentation does not meet medical necessity requirements for coverage of services.

Identification of this type of documentation will lead to denial of services for lack of medical

necessity and recoupment of all overpayments made when a payor or carrier determines the

services to be cloned.

Items that could be linked to Cloning:

Op Reports that were obviously pre-populated templates and were identical in content

even down to the Estimated Blood Loss.

Gender errors resulting from a cut and paste function. A patient is "he" in one paragraph

and a "she" in another paragraph.

Documentation in the H&P indicating body system findings are Within Normal Limits

(WNL), yet the same body system is the reason for the admission and in fact, not within

normal limits.

Protocols that are being used as standard orders and in most cases have not been adapted

to the patient but results in many pages of orders.

The use of pre populated templates for H&Ps, Discharge Summaries and orders creates a

huge medical record but it is often repetitive and reimbursement is not based on the

quantity of documentation but upon the quality of the documentation.

The "cut and paste" option used when templates are not pre-populated creates less

credible information because errors go unnoticed within the volume of the records.

Providers will strive to ensure each encounter is unique to the current patient encounter and will

only carry forward information from previous dates of service that are relevant and applicable.

This information will be re-confirmed or a note will specifically state how the carried forward

information is being utilized for the current encounter.

46 12/4/2014

Measuring the Effectiveness of Your Plan

• Develop benchmarks and goals in team with Compliance Committee, Board, and department managers What do you want to measure?

47 12/4/2014

OVERSIGHT, GOVERNANCE & LEADERSHIP EXPECTATIONS

U.S. Sentencing Guidelines Now Provide …..

• The organization’s governing authority shall be knowledgeable about the content and operation of the compliance and ethics program and shall exercise reasonable oversight with respect to (its) implementation and effectiveness.

• High level personnel … shall ensure that the organization has an effective compliance and ethics program … [for which] specific individuals within high level personnel shall be assigned responsibility.

• Specific individuals within the organization shall be delegated day-to-day operational responsibility for the compliance and ethics program. [These individuals] shall report periodically to high-level personnel and appropriate , to the governing authority, or an appropriate subgroup of the governing authority, on the effectiveness of the … program. To carry out such operational responsibility, such individual (s) shall be given adequate resources, appropriate authority, and direct access to the governing authority or an appropriate sub-group of the governing authority.

48 12/4/2014

Page 17: Developing an Effective Compliance Programnamas.co/wp-content/...an-Effective-Compliance-Program-38859DPL … · Developing an Effective Compliance Program Presented By: Sean M. Weiss,

12/4/2014

17

Oversight and Governance

Issues:

– How do you provide compliance information to leadership to enable them to meet their duty (“knowledge” element)

– How do you provide compliance assurance to leadership—e.g. that you have programs in place for your highly regulated areas that meet compliance “good” practices that are effective to prevent, detect, and in fact do respond to breakdowns. This is “due diligence.”

• How do you do this without micro-managing?

– How do you institutionalize the above in the most effective least burdensome way?

49 12/4/2014

Oversight Responsibilities

• The organization must designate one or more high-level individuals to oversee compliance activities. Responsibilities may include oversight of all compliance activities or be limited to implementation of specific compliance functions.

• The organization must not put individuals who have demonstrated a propensity for violating the law into positions of substantial discretionary authority.

50 12/4/2014

The Compliance Officer

• Loyal, responsible, and trustworthy.

• This person(s) must have the authority to maintain the compliance plan. A Compliance Officer is usually one of the most powerful and influential people in an organization.

• Should report regularly to the board or chief officer(s) to assure that the plan is effective

• Must be able to delegate compliance responsibilities to appropriate individuals. They are, in most cases, considered to be a separate unbiased part of the organization.

51 12/4/2014

Page 18: Developing an Effective Compliance Programnamas.co/wp-content/...an-Effective-Compliance-Program-38859DPL … · Developing an Effective Compliance Program Presented By: Sean M. Weiss,

12/4/2014

18

Some Roles of the Compliance Officer

• To know and administer all aspects of the plan

• To ensure proper delegation of responsibilities to members of the staff is done so in writing and to whom it is believed are the most honest, loyal and capable of making the judgments called for in the delegation

• To consult with outside counsel to obtain interpretations of “gray areas”

• To bring to the attention of the compliance committee/board all changes in circumstances that could reasonably suggest that the plan should be modified or changed to current standards

• To promptly carry out all duties assigned to the compliance officer by the plan and established through the steering committee

• To report to the compliance committee/board on a quarterly basis as determined by the compliance committee or established policies

52 12/4/2014

Pay Attention to What Employees are Saying

• Investigate concerns employees raise to see if there's any validity.

• Show employees that you are following up and showing due diligence, even if your first impression is that the employee is raising an HR issue.

• Pushing employees away may make them angry that their complaint fell on deaf ears with management and could lead them to file a whistleblower claim.

53 12/4/2014

Training and Education

• Test knowledge

• Make training part of the job

• Compliance staff/officer education & networking

54 12/4/2014

Page 19: Developing an Effective Compliance Programnamas.co/wp-content/...an-Effective-Compliance-Program-38859DPL … · Developing an Effective Compliance Program Presented By: Sean M. Weiss,

12/4/2014

19

Education and Training

• The organization must communicate its standards and procedures to all employees, professional staff, and physicians in a meaningful and effective manner by implementing an effective training program that explains the requirements of the compliance program and applicable laws.

• Compliance training may involve in-person training sessions, newsletters, other written materials, and/or bulletin boards.

55 12/4/2014

Effective Training and Education

• Three steps for setting up educational objectives:

1. Decide who needs training (coding, billing and compliance staff).

2. Decide what type of training is best for the practice.

3. Decide when and how much training is needed.

56 12/4/2014

Types of Education

• The importance of compliance and provisions of the plan

– Overview as it relates to providers

– Outline of the education and review process

– Specific risk areas to providers

• Provider billing guidelines

– General principles of coding and documentation of CPT & ICD9

– Importance of proper CPT coding

– Importance of proper ICD coding

Regulations by type of CPT coding: • Evaluation and Management Codes

•Admits •Daily in-patient visits •New vs Established patient visits •Consults •Emergency Room •Preventative Medicine •Incident-To billing

57 12/4/2014

Page 20: Developing an Effective Compliance Programnamas.co/wp-content/...an-Effective-Compliance-Program-38859DPL … · Developing an Effective Compliance Program Presented By: Sean M. Weiss,

12/4/2014

20

Types of Education

• Procedure Codes

• Major surgery

• Immediate availability

• Endoscopy

• Minor surgery

• Time-based billing

• Psychotherapy

• Critical Care

• Counseling and Coordination of Care

• Interpreting diagnostic tests

• Supervision of tests, teaching physician requirements and modifiers

58 12/4/2014

Sample Attestation

I have received a copy of Anywhere USA Company’s compliance plan including all policies and procedures. As it has been explained to me by the compliance officer and as I have read it, the manual contains descriptions of appropriate and inappropriate company behavior.

I have read, understand and agree to abide by all policies and procedures included in the manual.

This attestation, as I understand it, does not constitute an employment contract between Anywhere USA Company and its employees.

_________________ ___________________

Employee Date

_________________ ___________________

Compliance Manager Date

59 12/4/2014

Medical Documentation & Coding

Compliance Pledge

As a physician, Phychologist, Social Worker, Professional Counselor, nurse,

coder , support staff team member, or administrator ( associate ) employed, or

contracted by Anywhere USA Company , Mental Health Service here after

referred to as the (Departmentc); I understand that I am expected to adhere to the

standards of documentation, medical coding, and conduct described in this

pledge so that the Department’’ may fulfill its obligations to observe federal,

state, and local laws affecting patients, colleagues, and institutional partners.

I understand that failure to comply with this pledge will result in serious

consequences including disciplinary action, possible termination of employment,

monetary fines, and prosecution by the proper authorities when intentional

violations are reported and substantiated. I will read and review this Pledge

carefully and will only sign it when I have no further questions concerning its

intent or specific performance criteria.

Compliance Officer . I also understand that I must advise the Department’s compliance officer,

Mike Harrington, who has countersigned this pledge, when I have knowledge of any other

associates actions which appear to rely upon questionable interpretation, or in disregard of these

standards, deliberate or not, or else I will not be in compliance. The compliance officer is

responsible for overseeing and implementing this compliance Pledge which has been adopted by

the governing Board of the Department. The compliance officer is responsible for making

recommendations to the Board for possible changes to this pledge. The compliance officer has

the authority and is expected to take corrective actions and is required to forward all reports of

possible non-compliance and the corrective actions taken to the Departments’ compliance

attorney. The attorney will review all incidents reported which may violate one or more of the

acts or laws cited in this Pledge. These reviews will be presented by the attorney to the Board.

The content of these reports are intended to be protected under the attorney-client privilege. The

compliance officer must provide written confirmation of receipt of information pertaining to

possible non compliance from an associate. Reports not confirmed within 10 working days

should be resubmitted directly to the Department’s compliance attorney. The Department will

ensure that no one is subjected to reprisal, discipline, or discrimination based on having made a

report in accordance with this Pledge. The compliance officers must protect the anonymity of

associates who report apparent non complainant associates whenever possible.

1

The HIPAA proscribes that knowing and willful execution of, or attempt to execute a claim

which contains false or fraudulent representations to any health care benefit program can result

60 12/4/2014

Page 21: Developing an Effective Compliance Programnamas.co/wp-content/...an-Effective-Compliance-Program-38859DPL … · Developing an Effective Compliance Program Presented By: Sean M. Weiss,

12/4/2014

21

Crate an Audit Committee

Proactively audit:

– Coding

– Contracts

– Care

61 12/4/2014

Auditing and Monitoring: A Critical Process

62 12/4/2014

Monitoring and Auditing

• The organization must evaluate the effectiveness of its compliance program on an ongoing basis by monitoring compliance with its standards and procedures and by reviewing its standards and procedures to ensure they are current and complete.

• A review of pending claims not yet submitted can establish a benchmark that will be used in ongoing reviews to chart the success of the organization’s compliance efforts. (Counsel often recommend this be conducted under attorney-client privilege).

63 12/4/2014

Page 22: Developing an Effective Compliance Programnamas.co/wp-content/...an-Effective-Compliance-Program-38859DPL … · Developing an Effective Compliance Program Presented By: Sean M. Weiss,

12/4/2014

22

AUDITING, MONITORING & TRENDING

• Sentencing Guidelines & USSC Advisory Committee Recommendations

• Two components: (1) Traditional Auditing and Monitoring to review/assess adherence to applicable laws, regulations and policies, and (2) Periodic evaluation of the effectiveness of the compliance program itself.

• Auditing and Monitoring efforts should be tied to (driven by) results of the risk assessment process. Activities with greatest risk should normally be highest audit priority.

64 12/4/2014

Auditing and Monitoring

• Internal and external auditing and monitoring of the claims submission process.

• Baseline audits serve as a basis for future audits. Minimum of 20 charts should provide a strong statistical sample for a baseline audit!

• After baseline audits, periodic audits should be conducted to ensure the effectiveness of the program. Every quarter you should pull 5-10 charts per physician. Large facilities should do it at a higher frequency.

65 12/4/2014

Baseline (Snapshot) Audits

• Identifies over time the practice’s progress in reducing or eliminating potential areas of vulnerability

• This process known as benchmarking allows the practice to chart its compliance efforts by showing a reduction or increase in the number of claims paid and denied

• The process is used to examine the claim development and submission process from patient intake through claim submission and payment

• This process provides identification of elements within this process which may contribute to non-compliance or that may need to be the focus for improving execution

66 12/4/2014

Page 23: Developing an Effective Compliance Programnamas.co/wp-content/...an-Effective-Compliance-Program-38859DPL … · Developing an Effective Compliance Program Presented By: Sean M. Weiss,

12/4/2014

23

Erroneous vs. Fraudulent

• Erroneous - claims submitted to the carriers with inadvertence or negligence. Refunds should be made once a detection is made. Providers are not subject to civil penalties, interest or jail

• Fraudulent - claims submitted intentionally or with reckless disregard for the intent of inappropriate monetary gain. Providers are subject to civil penalties and jail

67 12/4/2014

Compliance Monitoring

• The OIG acknowledges that full implementation of all components may not be feasible for all practices

• Practices should adopt those components which are likely to provide an identifiable benefit based on previous history of specific billing problems or compliance issues

– Auditing and monitoring of the plan must be one of the seven steps adopted

• It is advised that providers participate in other compliance programs, such as the hospitals or other settings in which the physician practices

68 12/4/2014

Auditing and Monitoring Implementation

• This step is crucial to the success of a compliance program

• This process not only ensures the practice’s standards and procedures are current, but also whether they are accurate and if the compliance program is working -- ensuring individuals are carrying out their responsibilities

69 12/4/2014

Page 24: Developing an Effective Compliance Programnamas.co/wp-content/...an-Effective-Compliance-Program-38859DPL … · Developing an Effective Compliance Program Presented By: Sean M. Weiss,

12/4/2014

24

Standards & Procedures Review

• An individual (Compliance Contact) in the practice should be given the responsibility to ensure the standards and procedures are current and complete

• Policies should reflect Federal Payer changes relied upon by physicians

(CPT, ICD, HCPCS II, refer to previously discussed policies)

70 12/4/2014

Claims Submission Audit

• The primary purpose for this type of audit is for compliance with coding, billing, and documentation requirements.

• Reviews can be done either retrospectively or prospectively

– What are the differences and the risks for performing each?

• Audits can be used to determine whether:

• Bills are accurately coded and accurately reflect the services provided

• Documentation is being completed correctly

• Services or items provided are reasonable and necessary; and

• Any incentives for unnecessary services exist

71 12/4/2014

Periodic Audits

• The OIG recommends that these are performed at a minimum of one per year

• There is no set formula for the number of records that should be reviewed

• A basic guide is five or more medical records per federal payer or five to ten records per physician

72 12/4/2014

Page 25: Developing an Effective Compliance Programnamas.co/wp-content/...an-Effective-Compliance-Program-38859DPL … · Developing an Effective Compliance Program Presented By: Sean M. Weiss,

12/4/2014

25

REPORTING & CORRECTIVE ACTION

• Encouraging reporting of noncompliance (Code of Conduct, Hotline, Whistleblower & Non-Retaliation Policies, Training)

• Have clear policies and procedures regarding required reporting to regulatory agencies and other third parties (accreditors, contract partners)

• Establish and follow (escalating) sanction policies

• Establish and follow procedures for communications with managers/supervisors and appropriate institutional officials (Department Chairs) about noncompliance events.

73 12/4/2014

Keep Open Lines of Communication

• Solicit feedback

• Maintain visibility with employees

74 12/4/2014

Lines of Communication • Comfort in reporting potential problems without

fear of being pointed out or terminated is important. Trust is a factor!

• Staff must be made to understand that reporting a non-compliant activity is imperative to protect the practice

• Failure to report potential fraudulent activity is a violation of the program! Could lead to immediate termination!

• If you think it’s a problem, it probably is!

75 12/4/2014

Page 26: Developing an Effective Compliance Programnamas.co/wp-content/...an-Effective-Compliance-Program-38859DPL … · Developing an Effective Compliance Program Presented By: Sean M. Weiss,

12/4/2014

26

Open Lines of Communication

• The organization must put in place an accessible system for reporting inappropriate activities and for communicating compliance questions and concerns.

• Standards and procedures must emphasize that failure to report erroneous or fraudulent conduct is a violation of the compliance program.

• Standards and procedures also must stress that no retaliation may be taken against individuals who in good faith report what reasonably appears to be misconduct or a violation of the compliance program.

76 12/4/2014

Lines of Communication

• One important strategy for nipping whistle-blowers in the bud is to manage employees' complaints more effectively.

• Many employee complaints that come into a compliance office — either directly to the compliance officer or through other channels, such as the hotline — appear to be human resource problems, and are typically referred to the HR department.

• It's time for compliance officers to slow down and reconsider referrals to HR.

77 12/4/2014

Listen Carefully

• Employees may gripe about their supervisors and how badly they treat employees, which seems like an HR issue.

• Before you refer them to HR, listen closely to what they are saying about the supervisor and inefficiencies and whether they could result in a compliance issue.

• If an employee is calling from the billing department and talking about management in a way that indicates the employee is pressured to get bills out the door, that may potentially mean there is the same pressure on all employees, and that may be creating mistakes on the bills.

78 12/4/2014

Page 27: Developing an Effective Compliance Programnamas.co/wp-content/...an-Effective-Compliance-Program-38859DPL … · Developing an Effective Compliance Program Presented By: Sean M. Weiss,

12/4/2014

27

Response and Prevention

• If an compliance violation is detected, the organization should take all reasonable steps to respond appropriately to the violation

– Take corrective action to rectify any harm resulting from the current offense

– Prevent similar offenses from occurring in the future.

79 12/4/2014

Investigation and Disciplinary Action

• Do not discriminate! Disciplinary action should apply to every member of the practice, regardless of position (written policy).

• The compliance officer has the obligation to follow-up on any information with regard to non-compliant activities.

80 12/4/2014

Corrective Action

• What steps will be taken to assure that the same offenses do not occur again?

• How many times do we allow a problem to reappear until we do something about it?

81 12/4/2014

Page 28: Developing an Effective Compliance Programnamas.co/wp-content/...an-Effective-Compliance-Program-38859DPL … · Developing an Effective Compliance Program Presented By: Sean M. Weiss,

12/4/2014

28

ROLE OF LEGAL COUNSEL

• Perhaps some or all of the above?

• Provide legal advice and “final word” on all legal questions

• Serve as “Subject Matter Experts” in various areas.

• Interpret/Assess external enforcement and liability environment

• Lead/Assist with investigations

• Assist with risk assessments, gaps analyses, possibly under attorney –client privilege

• Policy drafting and implementation

• Assist with training

• General problem-solving

82 12/4/2014

Enforce Policies and Procedures

• Act promptly when issues arise

• Take and document corrective action

83 12/4/2014

Understanding Program Exclusions

• The OIG has the authority to exclude individuals and entities from participation in Medicare, Medicaid, and other Federal health care programs.

84 12/4/2014

Page 29: Developing an Effective Compliance Programnamas.co/wp-content/...an-Effective-Compliance-Program-38859DPL … · Developing an Effective Compliance Program Presented By: Sean M. Weiss,

12/4/2014

29

Monetary Effects of Exclusion

Excluded individual or entity cannot be paid. Directly or indirectly, by the Federal health care programs

for any items or services they provide.

85 12/4/2014

Exclusions

• Types:

– Mandatory and Permissive.

– Who: Any individual or entity.

– Time: Generally defined period, but certain may be indefinite in length.

86 12/4/2014

12/4/2014 87

You’re Responsible to Know!

• Screen against the OIG’s List of Excluding Individuals/Entities. www.oig.hhs.gov/fraud/exclusions.asp.

• Self-disclose if you discover you have employed an excluded individual

• Maintain documentation of searches

Page 30: Developing an Effective Compliance Programnamas.co/wp-content/...an-Effective-Compliance-Program-38859DPL … · Developing an Effective Compliance Program Presented By: Sean M. Weiss,

12/4/2014

30

CEU Index #38859DPL

12/4/2014 88