Transcript Corporate Compliance Education

Add your presenter name here
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This is a sample overview presentation for
Corporate Compliance requiring agency
individualization.
As a home health agency, you may wish to add
specifics regarding CoPs and clinical
documentation.
Feel free to adjust and modify as needed.
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Please delete this slide.
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Introduction……….
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Compliance efforts should support a corporate
culture that promotes prevention, detection,
and resolution of instances of conduct not
conforming with Federal and State Law or
ethical and business practices.
Federal Register 62:9436
March 1997
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This Corporation is committed to promoting
strong business ethics, monitoring compliance
with applicable rules, regulations, and law.
Having a strong compliance program with
solid internal quality control mechanisms
assists this Corporation to maintain its
commitment as a firm of integrity and assists to
prevent unethical conduct.
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Continually improving the quality of services
and products provided as well as consistent
environmental structure that encourages
employees to report potential problems
Having procedures in place for prompt
investigation of areas of concern.
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Describe the mission of a Corporate
Compliance Program
Identify what is the Office of the Inspector
General (OIG) and its focus
Identify potential areas of vulnerability
Identify how this Corporation looks to
minimize Corporate Compliance risk
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List some of this Corporation’s responsibilities
to its clients
Identify what the employee should do if they
suspect violation of Federal Law or ethical
business conduct.
Identify required elements of a compliance
program and its input on personnel.
The OIG has identified the following seven
critical elements of an effective compliance
plan:
1 Written policies and procedures
2. Designation of a Corporate
Compliance Officer
3. Ongoing education and training
4. Effective lines of communication
5. Enforcement of Standards
6. Auditing and Monitoring
7. Investigation and corrective action
Providing easy to understand explicit guidelines for
Compliance for all employees to follow
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Ensure that employees understand what is
expected of them in the conduct of their job
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Ensure that objective quality standards
are defined for each department.
 Ensure that those quality standards are
measurable and metrics are routinely
deployed
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Ensure employees are using Compliance
Standards in their daily work activity
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Enhance corporate performance in basic business
relationships
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Ensure the business culture at the Corporation
supports ethical, quality oriented and honorable
conduct.
Develop and maintain trust in the healthcare
community of firms using services and products of
this Corporation.
Provide a process for decision making when the
business standards DO NOT provide a clear answer to
an issue or dilemma.
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By providing a written Standard of Conduct for
distribution to all employees upon hiring
By training on Compliance Standards with Policies
and Procedures to employees of the Corporation.
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By providing ease of access to the
Corporate Compliance Officer
By providing a hotline to report areas of
potential non-compliance
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By monitoring and enforcement
through the Compliance Officer
and Compliance Committee
By review and update of the
Corporate Compliance Program
annually and as needed
By participation of all levels of
management in the Compliance
program
To provide efficient, cost effective systems
and support services in accordance with the
highest quality and ethical standards.
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Coding
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Billing
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Accounting
Write a statement about services
provided and adherence to
regulation. Below is a sample :
This Corporation provides Coding
and Billing services to many Clients
nationwide. Compliance guidelines
for Billing companies and Coding
conventions for Coding companies
have been developed by regulatory
bodies and are followed by this firm.
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Upcoding – placing patient in a higher case mix
category than is warranted.
Downcoding – coding patients at a lower level
than is appropriate
Sequencing – arranging Diagnosis in proper
order from Primary reason for Home Health to
lessor conditions that may impact on HH Care
and ADLs.
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Correctly assigning primary and primary
secondary diagnoses
Correctly applying therapy diagnosis
Diagnosis with wound, ulcer, or surgical
detail support
Assuring all diagnoses have adequate
documentation supportive detail
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Charting entries consistent with Dx coding
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Evidence of homebound status in charting
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Following specific state regulation
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Evidence of genuine medical necessity face to
face
Assessment or reassessment of patients
Time points
Charting/Documentation consistent with
original Plan of Treatment or change in
condition
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Failure to return credit balances made by
Federal Government
Billing for services not Medically Necessary
Billing for services for a non-homebound
patient
Routine waiver of co-payments
Billing for services without a Physician’s Order
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Billing for services without proper clinical
documentation
Overcharging for services or supplies
Billing for services before physician orders are
signed
Duplicate billing
Inappropriate Coding
Improper application of CBSA codes
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Which of the following is a reason the
government might investigate a billing
company for potential fraud and abuse?
A. Unfavorable analysis of billing
patterns
B. Billing two different payors for the full
invoice
C. Patient or client complaint
D. All of the above
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Provide Management Reports to insure
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There are physician orders for services rendered
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There are signed Physician Orders
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Adherence to current ICD-9-CM coding convention to
 Prevent upcoding or downcoding
 Monitor for proper sequencing
 Monitor accuracy of OASIS integrated assessment
 Notification of potential non-reimbursable visits
based on 485 (Medical POC) review
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Code to the highest level of specificity with
documentation to support the coding decisions
Provide reliable response to documentation
and coverage questions
Provide a tool that assures validation of visits
made.
Release only “clean” claims
A.
Have a Strong Corporate
Compliance Program
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Policies and Procedures
Code of conduct
Confidential Disclosure Program
Training and Education
Screening
Internal audits Clinical, Coding, Billing
Departments for Compliance
Seeking Data, Data, Data!
Disciplinary guidelines
B.
Have a Corporate Compliance Officer
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Upper level position with direct access to the
CEO
CCO experienced and credentialed to execute
the Corporate Compliance plan
Employees know how to contact the Corporate
Compliance Officer
C.
Legal Review
 Corporate Counsel review of all
Client Contracts
 Corporate Counsel review of Joint
Ventures
 Corporate Counsel availability to
Corporate Compliance Officer
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You have the option to
speak with your Supervisor
or contact the Corporate
Compliance Officer
If you are uncomfortable
with this direct approach
you may complete a
Compliance Concern Form
(located_________) or call
the Compliance Help Line
at________________.
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The identity of all callers is treated as
confidential!
The information provided will not be disclosed
or discussed with anyone other than those who
have legitimate need to know in order to
perform their duties.
If, because of the nature of the complaint or
issue, it becomes necessary to provide your
name, that fact and other options will be
discussed prior to disclosure.
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All information is expected to be truthful and
accurate.
This Corporation does not condone the making
of false or malicious reports.
This Corporation will not tolerate any
retaliatory actions taken against any employee
for providing truthful and accurate
information.
1.
DUTY TO REPORT
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Employees have the duty to report all suspect or questionable
conduct.
HOW TO REPORT
Employees should notify their immediate supervisor of any
suspected impropriety. Once notified, the supervisor must
immediately notify the compliance officer.
Employees may notify the Corporate Compliance
Officer directly in person or by phone or e-mail
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“Bobby doesn’t like me.”
“My Supervisor isn’t fair.”
“My manager overworks me.”
“I’m not happy.”
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Oh my!
Although these are important
concerns, the company has other
problem solving procedures for
employees with issues of this nature.
The Fundamentals of a Compliance Program
may be expressed as the four E’s:
- Educate
- Encourage
- Enable
- Enforce
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Gain competitive advantage through greater
credibility and assurance to employees and
client partners. What does this mean?
Enhance reimbursement and operating
margins by focusing on personnel
improvement and education in documentation,
coding, billing and operational efficiencies
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Decrease the potential of negative audits
through documentation of procedures and
reviews that minimize problems before coding
and claims submission. What does this mean?
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Improve organizational structure to distribute
legal and corporate policy changes throughout
the organization.
Reduce liability exposure by demonstrating
commitment to implementing a comprehensive
and effective compliance program.
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Knowing you are
a part of a team
committed to
quality control
and ethical
conduct in the
business world.
Your comments?