Transcript VHA and VISN 21 Compliance & Business Integrity (CBI) Program Contractors

VHA and VISN 21 Compliance &
Business Integrity (CBI) Program
Mandatory Training for
Contractors
Prepared: March 2007, Updated February 2012
VISN 21Compliance Officers List
• Jane Dutton Morris, MHA, CHC
Compliance Specialist, Sierra Pacific Network
•
Patricia Moran, RHIT, CPC
Compliance Officer
VA Northern California Health Care System
(707)437-1905
[email protected]
•
Jon Sedran
Compliance Officer
VA Sierra Nevada Health Care System
(775)788-5512
[email protected]
•
Paul Chung
Compliance Officer
VA Pacific Islands Health Care System
(808)433-7545
[email protected]
(707) 562-8377
[email protected]
• Yvonne Brooks
Compliance Officer
San Francisco VA Medical Center
(415) 221-4810 Ext. 4398
[email protected]
•
Jeffrey Petro, JD
Compliance Officer
VA Palo Alto Health Care System
(650) 493-5000 Ext. 67012
[email protected]
• Syndi Day
Compliance Officer
VA Central California Health Care System
(559) 225-6100 Ext. 6691
[email protected]
Background and Program Structure
Background & Program Structure
(cont’d)
United States Sentencing Commission (USSC) Federal
Sentencing Guidelineshttp://www.ussc.gov/Guidelines/2011_Guidelines/index.cfm
Department of Health and Human Service (HHS)
Office of Inspector General (OIG) Compliance
Guidance for Hospitals (1998)http://oig.hhs.gov/authorities/docs/cpghosp.pdf
HHS Supplemental OIG Compliance Guidance for
Hospitals (2005)http://oig.hhs.gov/fraud/docs/complianceguidance/012705HospSup
plementalGuidance.pdf
VHA CBI Program established in 1999 to reduce fraud,
waste and abuse and to promote high standards of
business integrity and quality- http://vaww.cbi.va.gov/
VHA Definition of Compliance
Compliance is an oversight process which requires
employees and contractors to conduct administrative
and clinical duties in an honest, ethical and professional
manner.
Behavior that is not consistent with ethical business
practices places Veterans Health Administration (VHA)
facilities at risk for penalties, negative publicity and loss
of public trust.
VHA’s Compliance Program
The VHA’s Compliance & Business
Integrity (CBI) program focuses primarily on the
Revenue Cycle and Purchased Care to include the
following business operations:
•
•
•
•
•
•
Patient registration & intake
Medical documentation
Coding for medical procedures & visits
Billing for services provided
Collections from insurance companies
Fee Basis (Purchased care) services
Revenue Cycle Oversight
• Veterans may get charged a co-pay for medical visits and
medications based upon their eligibility status (first
party billing).
• The facility can also bill a patient’s insurance carrier for
eligible visits and medications, and any collections first
go to off-set the related co-pay charge that the Veteran
may owe, and then the rest goes straight back to the
facility for patient care (third party billing).
• This whole process- from enrollment and eligibility to
billing and collections, is known as the revenue cycle.
CBI is tasked with oversight of the entire revenue cycle.
Revenue Cycle
CBI Focus Areas
• Patient registration & intake: the enrollment and insurance
identification process that Veterans go through when initially seeking care
at a VA medical center. Types of information entered are demographics,
disability rating, income status, and insurance information. Inaccurate data
entry may lead to a Veteran being billed inappropriately for VA health care
benefits received, or loss of revenue may result if the Veteran’s insurance
data is not properly entered or identified.
• Medical Documentation: Medical documentation is the provider’s
written description of what occurred during the patient visit, and is what
billing is based on- both first and third party billing. Inaccurate
documentation could lead to inappropriately billing the Veteran. Inaccurate
and incomplete documentation could also lead to not enough or too much
reimbursement from third party payers.
CBI Focus Areas (cont’d)
• Coding for medical procedures & visits: After each visit that is billable to
an insurance company, medical coders will receive the medical record
documentation related to that visit and assign numeric and alpha-numeric codes
to the visit. These codes depict the procedures performed and the diagnoses
treated during the visit. Medical coders are responsible for assigning and
validating procedural & diagnostic codes based on provider documentation.
These codes are the basis of insurance company reimbursement. Inaccurate
coding could lead to potential billing fraud , or possibly a loss of third party
revenue.
• Billing for services provided: Billers are responsible for generating timely,
accurate and appropriate bills based on veterans’ eligibility and the service
provided. A Veterans’ eligibility to be charged a co-pay depends on their
disability rating(s), their income status, and the clinic where the appointment
was scheduled. Inaccurate billing could lead to inappropriate co-pay charges to
Veterans or missed billing opportunities from insurance companies.
CBI Focus Areas (cont’d)
• Collections from insurance companies: Staff at the billing unit are
responsible for communicating with insurance companies about verifying
insurance policy coverage and following up on collecting the money owed.
Possible risk areas are retention of overpayment from the insurance
company without the proper documentation showing the approval for
keeping the overpayment, or untimely filing of claims resulting in the
inability to collect any reimbursement from the insurance company.
• Fee Basis (Purchased Care) services: The purchased care program is
widely used in order to provide timely and specialized care to eligible
Veterans who can’t receive that care at a VA facility. This may be due to
geographical distance or a medically necessary service/procedure not being
offered at a VA facility. Part of each VA medical center’s budget is for
purchased care, so it is important that these program dollars are not
erroneously paid for fraudulent or unjustified services and supplies.
Purpose of VHA Compliance Program
Ensure business operations comply with relevant laws,
rules and regulations;
Promote ethical practices and standards of excellence in
patient care;
Help VHA maintain the public’s trust.
Elements of an Effective Compliance
Program
1. Written
policies &
procedures
4. Open Lines
of
Communication
7. Investigation
&
Response
2. Designation
of a CBI
Officer &
Committee
5. Training
& Education
8. Enforcement
&
Discipline
3. Risk
Management
6.
Monitoring
& Auditing
9. Annual
review of
program
effectiveness
Elements of an Effective Compliance
Program (cont’d)
• Written policies and procedures- Policies and procedures communicate
the organizational values and expectations regarding employee behavior. They
also outline the employee’s responsibility to uphold the policies and procedures
set forth by the organization and must be consistent with VHA and compliance
industry standards.
• Designation of a CBI Officer and Committee- The CBI Officer is the
person who manages the day-to-day operations of the CBI program. However, it
is imperative that all program activities be completed in a collaborative and
cooperative environment with full employee participation. The organization’s
Director formally establishes the Compliance Committee to provide advice to
the CBI Officer and organizational leadership on the CBI program.
•
Risk Management- Risk management is an essential element of a
compliance program, as it identifies those areas that may affect the
organization’s reputation, organizational goals and objectives, or violates
regulation and/or law. The goal of risk management is to identify risks to the
organization and to reduce the identified risks to a level that is acceptable to the
organization's leadership.
Elements of an Effective Compliance
Program (cont’d)
• Training & Education- An effective training and education plan provides ongoing education to all levels of the organization. General awareness training
provides an overall view of the organization’s CBI program, while job-specific
training is targeted for employees whose job functions directly influence revenue
cycle operations.
• Open lines of communication- An effective CBI program encourages
employees and other stakeholders to report suspected wrongdoings for
investigation and follow-up. All employees should know how to report a
compliance concern at any level of the organization (see slide 17) . Open lines of
communication demonstrates the principal of if it doesn’t feel right, it probably
isn’t and should be stopped.
• Auditing & Monitoring- Audits and monitors are tools used to mitigate risk.
A monitor tests and an audit confirms compliance with laws, regulations and
policies. An audit may be conducted retrospectively to identify the origin of a
particular issue or concurrently to identify areas of vulnerability. Monitoring is
completed on a recurring basis and is part of normal activities to determine if
internal controls are adequate.
Elements of an Effective Compliance
Program (cont’d)
• Investigation & Response- An effective CBI program has established
processes and procedures to respond promptly to occurrences of suspected or
actual wrongdoing within the organization. Part of the investigation process is
not only to determine if wrongdoing has occurred, but also to determine what
the origin is. Then, steps should be taken to correct the issue and redesign
processes so it doesn’t happen again.
• Enforcement & Discipline- Within VHA, all employees must know and
understand the “Standards for Ethical Conduct for Employees of the Executive
Branch” (see slide 20). Employees who have knowingly violated organizational
policy or laws should be disciplined based upon the infraction committed and
not on the individual or position who committed the infraction.
• Annual Review of Program Effectiveness- CBI Officers should review
their CBI program plans and identify achievements accomplished, opportunities
for improvement, assess the effectiveness of the CBI Program and future
programmatic activities.
Open Lines of Communication
• The VA has a Reporting Mechanism called the “CBI Helpline”
• The telephone number for the CBI Helpline is 1-866-842-4357 (1-866-VHAHELP) , or e-mail to: [email protected]
• The CBI Helpline is available Monday through Friday from 8:00 am to 4:30
pm, EST. Anyone “internal” or “external” to the VA (this includes employees,
patients or contractors) may call the CBI Helpline number to report potential
compliance failures
• The caller may remain anonymous, however, the issue reported can not remain
confidential. Also, people may guess who reported the issue
• The reporter is protected by the facility’s Non-Retaliation Policy, also
known as the Whistleblower Protection Act
Open Lines of Communication (cont’d)
Tell your
supervisor
Call
1(866)VHA
-HELP
It’s our
responsibility
NO FEAR
Is it
reportable?
Do the
right
thing
Call
the CBI
Officer
Tell
your
boss
Talk
to your
supervisor
Duty to
Report
Is it a compliance concern?
High Risk Areas
A high risk area is a clinical or business activity
that may be unethical, illegal, a conflict of interest
or in violation of national and local policies &
procedures.
Employees and contractors should:



Be aware of high risk areas concerning VHA
Not engage in fraud, waste, or abuse against VHA
Take appropriate actions- report all potential
compliance failures to the VHA facility Compliance
Officer and/or the CBI Helpline.
Examples of High Risk Areas
Providing Medically Unnecessary Services: Providing services that the
patient does not need or may cause the harm to the patient.
Failure to Report a Suspected Compliance Violation: knowing about a
potential compliance failure and not reporting it.
Failure to Exert Due Diligence: Contracting with individuals or companies that
have a propensity to engage in illegal activities or with which you have a financial
interest.
Kickbacks and Bribes: Soliciting or receiving payment / gifts in return for
referring a patient to another healthcare provider or for conducting business with a
certain entity.
Appearing on the OIG Sanction List: Sanctioned individuals, entities,
contractors listed on the DHHS Office of inspector General’s (OIG) Exclusionary
List Database or the Excluded Persons (EPLS) database, cannot receive payments
from any federal healthcare programs for services furnished.
Federal Employee and Contractor
Responsibilities
•
Contractors should not offer gifts to federal employees and federal
employees should not accept gifts from entities that do business or
are attempting to do business with the organization
•
Federal employees should excuse themselves from activities in
which they might have a financial interest
•
Federal employees must remain impartial in conducting official
duties
Applicable Laws, Regulations, and
Policies: Code of Conduct
Employees must refrain from conflicts of interest as well as the
appearance of conflicts. This includes:
• Accepting gifts, lunches, tickets and other such items of value
from vendors and contractors with whom we do business
• Giving preferential treatment to any particular vendor or
contractor during the contract process
• Accepting “kick backs” from contractors or vendors
• Remember, when it comes to ethical behavior, appearances
count!
Reference: US Office of Government Ethics’ Employee Standards of
Conduct- http://www.oge.gov/Laws-and-Regulations/Employee-Standards-ofConduct/Employee-Standards-of-Conduct/
Summary
Compliance is Everybody’s Responsibility
Know who the Compliance Officers are
and how to contact them (see slide 2)
Follow your own best instincts
Do your job ethically & legally
Be honest in all business transactions, and
contracts / awards
Now…let’s test your knowledge!
1.
CBI’s major focus of oversight is in which of the following
areas?
A. Business/Revenue Processes
B. Law Enforcement
C. Legal Services
D. Facilities Management
2. What is VHA’s toll free number to report a compliance issue or
concern?
A. 1-800-488-8244
B. 1-866-COMPLY
C. 1-800-CBI-4YOU
D. 1-866-VHA-HELP
Still testing your knowledge…
3.
4.
Which of the following is an example of a high risk area?
A. Giving wrong directions to a patient on purpose
B. Providing medically unnecessary services
C. Taking the last cookie when no one’s looking
D. Not pointing out the toilet paper stuck to your supervisor’s shoe
You work for Radiology and a GE representative wants to
give you a cheap digital camera worth $9.99
A. OK, it’s $10.00 or less
B. Ask for a memory card too
C. No way, decline
D. Exchange for free prints instead
Last question…
5.
What is one purpose of a CBI program?
A. To arrest people for committing policy violations
B. To conduct audits and monitors
C. To help VHA maintain the public’s trust
D. To spoil everyone’s fun