Transcript Corporate Compliance: - Heaven's Hands Community Services

Corporate Compliance
What Is it?
What Does It Mean To Me?
Purpose Of This Session
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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
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Employment and discrimination
Governance, licensing & certification
Protection from abuse
Health and safety
Physical environment
Service provision
Billing and reimbursement
Laws and Regulations
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To comply with the laws and
regulations, the Agency develops:
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Policies,
Procedures
Practices
What is Corporate Compliance?
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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)
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Increased resources for detecting fraud
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Expanded power and authority of enforcement
agencies
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Creation of Health Integrity and Protection Data bank
Balanced Budget Act of 1997 (BBA)
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Agencies work together/share information
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Enhanced authority for exclusions
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Beneficiary Incentives
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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
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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
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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
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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?
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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)
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Created in 2005, is the first OMIG in
nation at the state level
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“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:
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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 ...
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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:
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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
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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
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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
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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
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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
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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
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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
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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
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3/27/03
MSC arrested and charged with
$50.000 Medicaid fraud for billing for
services documented but not provided.
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3/19/04
Westchester Nurse Pads work Hours
in Health Care Fraud, receives
$12,000 in funds.
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Any questions
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Thank You
Corporate Compliance
Program
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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
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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
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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
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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
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Compliance Officer and Compliance
Committee
Board and Management Staff
Effective methods to report
compliance-related issues
Compliance Officer Duties
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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
Training and Education
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Is Mandatory and Regular
Includes
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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
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“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
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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
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Assure authorization for service (NOD. MD order, signed,
effective service/treatment plans)
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Process to assure documentation to support claims
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Staff meet qualifications
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Develop system that promotes adherence and reports
shortcomings back to programs
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Identify systemic and process problems
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Internalize findings
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Train
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Re-evaluate
Follow-up and Corrective
Actions
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Investigate reports of actual or
suspected non-compliance
Report findings
Develop corrective action plans
Review for effectiveness