Transcript Compliance and Ethics Program

Compliance and Ethics Program
NASVH – CFO Forum
July 11, 2012
Presented By: Donna R. Burn
Medicare Compliance
Louisiana Department of Veterans Affairs
[email protected]
Compliance Programs for Nursing Facilities required by March 2013
The requirement is in the Affordable Care Act – Health Care Reform Act.
Affordable Care Act (ACA)
_ Nursing Home (NH) Transparency Requirements {Section 6101}
_ Accountability - Compliance Programs for NF {Section 6102}
_ Changes to Federal Sentencing Guidelines and the OIG’s seven
elements of an Effective Compliance Program {Section 6102}
The OIG issued:
• LTC Compliance Program Guidance in Federal Register / Vol. 65, No.
52 / Thursday, March 16, 2000
• Supplemental Compliance Program Guidance for Nursing Facilities in
Federal Register / Vol. 73, No. 190 / Tuesday, September 30, 2008
ACCOUNTABILTY REQUIREMENTS FOR FACILITIES
Thirty six months from March 23, 2010, the operating
organization (i.e., the entity that operates the facility)
of each Medicare and/or Medicaid certified nursing
facility must have in operation a compliance and
ethics program that is effective in preventing and
detecting criminal, civil, and administrative violations
and in promoting quality of care.
ACA Section 6102
MAY
2000
SHOULD
2008
MUST
2013
Per OIG Guidelines a Compliance and Ethics Programs
should at a minimum include the following seven
elements:
(1) The development and distribution of written
standards of conduct, as well as written policies,
procedures and protocols that promote the nursing
facility’s commitment to compliance, including
adherence to the compliance program as an element in
evaluating managers and employees, and address
specific areas of potential fraud and abuse, such as
claims development and submission processes, quality
of care issues, and financial arrangements with
physicians and outside contractors;
(2) The designation of a compliance officer and other
appropriate bodies (e.g., a corporate compliance
committee) charged with the responsibility for
developing, operating and monitoring the compliance
program, and who reports directly to the owner(s),
governing body and/or CEO;
(3) The development and implementation of regular,
effective education and training programs for all affected
employees;
Training and educational programs for nursing facilities
should be
detailed, comprehensive and at the same
time targeted to address the
needs
of
specific
employees based on their responsibilities within the
facility. Existing in-service training programs can be
expanded to address general compliance issues, as well as
the risk areas identified in that part of nursing home
operations.
(4) The creation and maintenance of an effective line of
communication between the compliance officer and all
employees, including a process, such as a hotline or other
reporting system, to receive complaints, and the adoption of
procedures to protect the anonymity of complainants and to
protect whistle blowers from retaliation;
(5) The use of audits and/or other risk evaluation
techniques to monitor compliance, identify problem areas,
and assist in the reduction of identified problems;
For example, periodically spot-checking the work of coding
and billing personnel should be part of a compliance
program. In addition, procedures to regularly monitor the
care provided to nursing facility residents and to ensure
that deficiencies identified by surveyors are corrected
should be incorporated into the compliance program’s
evaluation and monitoring functions.
(6) The development of policies and procedures
addressing the non-employment or retention of
excluded individuals or entities and the enforcement of
appropriate disciplinary action against employees or
contractors who have violated corporate or compliance
policies and procedures, applicable statutes,
regulations, or Federal, State, or private payor health
care program requirements; and
(7) The development of policies and procedures with respect to
the investigation of identified systemic problems, which include
direction regarding the prompt and proper response to detected
offenses, such as the initiation of appropriate corrective action,
repayments, and preventive measures.
While those are the OIG Guidelines –
PPACA adds another one –
The organization must periodically undertake
reassessment of its compliance program to identify
changes necessary to reflect changes within the
organization and its facilities.
So how do we do this and what
does all this mean?
Policies and Procedures:
•
Regularly review and update with department
managers and Compliance Committee.
•
Assess whether they are tailored to the intended
audience and their job functions.
•
Ensure they are written clearly.
•
Include “real-life” examples.
Measuring Effectiveness:
•
Develop compliance
measurable goals.
program
with
benchmarks
and
•
Set up a system to measure how well you are meeting
those goals.
•
Involve the Board in creating the program and regularly
update the Board regarding compliance risks, audits, and
investigations.
•
If one or more goals are not met, investigate why and
how to improve in the future.
•
Assess whether the compliance program has sufficient
funding and support.
Training:


Regularly review and update training programs. Try different
approaches. Use “real-life” examples.
Make training completion a job requirement.

Test employees’ understanding of training topics.
Maintain documentation to show which employees received
training.

Train the Board.


Train yourself and your compliance staff. Attend conferences and
webinars, subscribe to publications and OIG’s email list, monitor
OIG’s website, and network with peers to stay up-to-date and get
ideas.
Lines of Communication:







Have open lines of communication between you and
employees.
Maintain an anonymous “hotline” to report issues to
you.
Enforce a non-retaliation policy for employees who
report potential problems.
Establish a direct line of communication between you
and the Board.
Use surveys or other tools to get feedback on training
and on the compliance program.
Use newsletters or internal websites to maintain
visibility with employees.
Regularly meet with the Board and brief them on the
compliance program.
Internal Auditing:






Perform proactive reviews in coding, contracts, and
quality of care.
Create an audit plan and re-evaluate it regularly.
Identify your organization’s risk areas. Use your
networking and compliance resources to get ideas and
see what others are doing.
Don’t only focus on the money – also evaluate what
caused the problem.
Create corrective action plans to fix the problem.
Refer to sampling techniques in OIG’s Self Disclosure
Protocol and in the Corporate Integrity Agreements
(CIAs) to get ideas.
Enforcement and Response:




Delegate and empower teams closest to the issues to
perform reviews, but be careful of possible conflicts or
personal relationships that may interfere with getting
an objective review.
Act promptly, and take appropriate corrective action.
Create a system or process to track resolution of
complaints.
Enforce your policies consistently through appropriate
disciplinary action.
So how do we develop a Compliance
and Ethics Plan for our specific home?
Perform
• Perform billing and operational audits to
determine areas of deficiencies in your facility.
• Your open windows to investigation are
your claim submission and your annual
survey.
• By reviewing timeliness and correctness of
billing as well as how staff performs patient
care, you can determine potential problem areas
and develop action plans to resolve issues
Prioritize
• Prioritize deficiencies based on how they
affect your facilities ability to meet state and
federal guidelines.
• As a VA home, we must also incorporate
additional VA regulations in our plan
development.
• It may also be necessary to includes plans to
meet city ordinances as well.
Develop
• Develop an action plan that addresses the
findings of your audits
• If it is determined that accurate diagnosis codes
are not being used on the claim submitted,
develop a prebilling mechanism to coordinate
between clinical and fiscal departments.
• If it is determined that residents are not
receiving baths on a regular basis, implement a
plan where aides sign in on daily baths and
explanations for when baths are not provided.
Follow
• Follow the OIG guidelines for LTC facilities
• THE OIG has several recommendations for
compliance for several areas of health care
• Following their guide for compliance will
guarantee any plan that meets the
appropriate standards for a compliance plan
Combine
• Combine the recommendations from OIG
with the action plan from the on-site audits
to create a list of policies and procedures for
your LTC facility.
• This step ensures that the plan you develop
meets the global standards for the LTC
facilities as well as particular problems that
exist at your particular home.
Find
• Find an existing compliance plan and use it as a
template for formatting the compliance plan.
• No need to reinvent the wheel, customization
has already occurred with the findings from your
audits.
• Using a template ensures your plan will have the
look and feel of a compliance plan.
• Remember if it is copyrighted material do not
use it word for word, only as a guide
Write
• Write your individual compliance plan using
your action plan, OIG guidelines and
recommendations and the compliance
template you have created.
• Perfection is not the object of this step, this is
a first draft.
• Make sure the main focus, compliance, is
communicated throughout the plan.
Review
• Ask other respected individuals in the LTC industries to
review and edit your plan.
• Ask if your plan is clear and concise on it’s purpose,
compliance.
• Have them give you specifics of plan shortfalls,
inconsistences and areas open to various interpretations.
• Review their comments and suggestions and then
incorporate in new draft.
• Repeat process.
• Follow the same process with a healthcare attorney
OIG WANTS YOU TO ASK:
1. What are the goals of the program and benchmarks used?
How is management accountable?
2. How is quality measured and by whom?
3. How is quality integrated into policies and operations, and
how are they enforced? What controls are in place?
4. Is there an education program on quality for Board
members, and do any members have quality expertise?
5. What is the essential information on quality, and how
frequently is it received?
6. How do quality and compliance coordinate, and how are
they addressed in the risk assessment and action
plans?
7. What are the processes for reporting quality issues and
preventing retaliation? What are the guidelines for
Board reporting?
8. Are human and other resources adequate to support
quality? Are systems in place to account for different
patient needs?
9. Do competencies, training, credentialing and peer review
adequately focus on quality?
10. How are adverse events identified, analyzed and reported
and incorporated into performance improvement?
These questions are all selfregulating questions. Ask these
questions to protect your facility
because these are the questions
OIG will ask when/if you have a
problem.
Without ComplianceProviders Face Enforcement Risks
• Fraud and abuse enforcement authorities:
– False Claims Act, 31 U.S.C. §§ 3729-3733
– Exclusion, 42 U.S.C. § 1320a-7
– Civil Monetary Penalties Law, 42 U.S.C. §1320a-7a
– Criminal, 18 U.S.C. §§ 287, 1001, 1035, 1347
QUESTIONS?