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Who, What, Why and When?
1.
What is Corporate Compliance and a Compliance Program?
2.
Reasons for and Value of an Effective Compliance Program
3.
Essential Elements of a Comprehensive Compliance Program
4.
Policies, Roles and Responsibilities – Compliance
Committee, Compliance Officer
5.
What are Some Areas Prone to Non-Compliance?
6.
Items or Processes Leading to Non-Compliance
7.
Reporting of Non-Compliance
8.
How do I Know What is Right or Wrong?
The Office of the Inspector General (OIG) lists four aspects of compliance
efforts:
1. Establishes a culture within a health care agency that promotes
prevention, detection, and resolution of instances of conduct that do
not conform to Federal and State law, and Federal, State, and private
payer health care program requirements, as well as the health care
agency’s business policies.
2. Demonstrates the organization’s commitment to ethical conduct.
3. The existence of benchmarks that demonstrate implementation and
achievements are essential to any effective compliance program.
4. Needs to become part of the fabric of routine health care agency
operations.
Federal Register / Vol. 63, No. 152 / Friday, August 7, 1998 / Notices 42411
The OIG’s guidance calls for:
 Setting guidelines for ethical and compliant behavior including how
to report non-compliance
 Taking actions – to measure and inspect what we do
 Using information – benchmarks to improve our daily activities and
processes
 Making compliance a part of our daily behavior
Success is the progressive realization of a worthy ideal.
-- Earl Nightingale
A compliance program provides confidence that the right things are getting
done in our daily activities.
It helps build a culture that strives to do “right” – We will understand what
should be done, how to conduct ourselves, and how to monitor for
inappropriate issues which can arise.
A compliance program will help Ambercare:
 Institute and educate staff on best compliance practices from top to bottom
 Assess and manage our areas at “risk”
 Provide for open communication and properly handle questions/concerns
 Establish methods to monitor compliance performance and conduct
corrective action
1. Helps meet governance responsibilities
“Specifically, compliance programs guide a health care agency’s
governing body, Chief Executive Officer (CEO), senior managers,
clinicians, billing personnel, and other employees in the efficient
management and operation of a health care agency.”
OIG’s Guidelines from Federal Register on August 7, 1998, Vol. 63. No. 152/42412
Example: Ambercare’s Executive Committee
2. Helps meet legal requirements
“It is incumbent upon a health care agency’s corporate officers and
managers to provide ethical leadership to the organization and to
assure that adequate systems are in place to facilitate ethical and
legal conduct.”
OIG’s Guidelines from Federal Register on August 7, 1998, Vol. 63. No. 152/ 42412-3
Example: Ambercare’s Executive Committee
3. Increased enforcement efforts
A.
B.
C.
New funding for Medicare and Medicaid Enforcement
HEAT (Healthcare Fraud Prevention and Enforcement Action
Team) Initiative – OIG, Department of Justice, FBI, CMS
New guidance on suspensions of payments and overpayments –
 HHS may suspend Medicare and Medicaid payments “pending an
investigation of a credible allegation of fraud.”
 Retention of overpayments after 60 days may lead to False Claims Act
liability
D.
E.
 Triple damages
 $5,500 to $11,000 per claim
Amendments to False Claims Act – expands government and
whistleblower options
Multiple and growing number of fraud and recovery auditors
Eyes are everywhere!
4. Other benefits
A.
B.
C.
Fulfill a legal duty to ensure that false or inaccurate claims to
Government and private payers are not being submitted
Realize additional benefits from the effective compliance program
makes good business sense
When we can identify weaknesses in our internal systems and
management, Ambercare can fulfill our fundamental caregiving
mission to our consumers and our community by working more
effectively
List of major legal and regulatory sources requiring
compliance:
 Medicare Conditions of Participation (CoPs)
 Civil Monetary Penalties, SSA 1128(a)(5)
 False Claims Act (FCA) (False Claims Act 31 U.S.C. 3730)
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(includes Qui Tam provisions)
Fraud Enforcement and Recovery Act of 2009 (FERA)
Federal and State Wage and Hour Laws
HIPPA compliance regulations
Patient Freedom of Choice §1802
Self-referral, Kickbacks (Stark, SSA 1877)
State False Claims Laws
With a Compliance Program, Ambercare…
 Demonstrates to the community our strong commitment to
honest and responsible conduct
 Protects against fraud, abuse and waste which furthers our
mission of achieving and providing quality patient and consumer
care
 Provides clarity by establishing consistent codes of conduct and
trust that Ambercare will be consistent and fair with enforcement
of that conduct
At Ambercare…
When our daily, weekly and quarterly activities operate in a
compliant manner, the right things are occurring therefore
risks are low, quality patient care and organizational
effectiveness will be realized.
AND
– bad things, like poor care, fraud, abuse
and waste are not happening in our organization.
OIGs’ seven fundamental elements to an effective compliance
program are:
1.
Implementing written policies, procedures and standards of conduct;
2.
Designating a compliance officer and compliance committee;
3.
Conducting effective training and education;
4.
Developing effective lines of communication;
5.
Enforcing standards through well-publicized disciplinary guidelines;
6.
Conducting internal monitoring and auditing; and
7.
Responding promptly to detected offenses and developing corrective
action.
Federal Register on August 7, 1998, Vol. 63. No. 152/ 42410
EVERYONE!
Compliance involves all of us.
It starts at the top with the leaders and
affects every level of employee
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Ambercare’s mission, values and vision statement
Adherence to laws and regulations
Standards for Business Conduct
Code of Personal Conduct or Code of Ethics
Confidentiality (HIPAA) and in reporting of non-compliance
Billing
Whistleblower protection
Corporate Compliance Plan
Policies are the backbone of the Compliance Program
This committee is comprised of staff members from each department and
functions to support the Corporate Compliance Officer. Together, they
ensure that Ambercare’s compliance program is operating effectively. They
meet at least quarterly and report to the Executive Committee annually or
more often, if needed. They…
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Assess the risks and steps being taken to monitor and report such risks;
Review updates for compliance policies and any codes of conduct and
ethics;
Review any significant items concerning compliance with laws and
regulations;
Evaluate any significant compliance investigations and corrective plans;
and
Review the knowledge, capabilities, resources, independence and past
performance of any external professionals who may be used to assess or
support the status of the compliance program.
“The Compliance Officer must have the authority to review all
documents and other information that are relevant to compliance
activities, including, but not limited to, patient records, billing
records, and records concerning the marketing efforts of the facility
and the home health agency’s arrangements with other parties,
including employees, professionals on staff, relevant independent
contractors, suppliers, agents, supplemental staffing entities, and
physicians. This policy enables the compliance officer to review
contracts and obligations (seeking the advice of legal counsel,
where appropriate) that may contain referral and payment
provisions that could violate the anti-kickback statute, as well as
the Stark physician self-referral prohibition and other legal or
regulatory requirements.”
OIG Guidelines stated in the Federal Register on August 7, 1998, Vol. 63. No. 152/ 42420
Ambercare’s Corporate Compliance Officer is:
Joann Strandberg
She can be reached at:
(505) 861-0060, Ext. 10107
She is the ONLY one who CONFIDENTIALLY MONITORS
OUR COMPLIANCE HOTLINE: 1-855-833-0004
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10.
Billing for items or services not actually rendered
Billing for medically unnecessary services
Giving incentives to actual or potential referral sources
Billing for services to patients that are not homebound or do not
require a qualifying service
Over and under-utilization (visit frequency)
Knowingly billing for inadequate or substandard care
False dating of amendments to nursing notes
Forging beneficiary signatures on visit slips or logs that verify that
services were performed
Untimely and/or forged physician certifications on plans of care
And more
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Lack of updated information - logs, policies, responsibilities
Agreements, activities with no review or prior approvals
Personnel acting outside of their stated level of authorities
Personnel without proper background or training to do the work
Reports or information that is not current or relevant
Excessive or unnecessary reports
Excessive work arounds and duplications of tasks
Poor expenditure control and no budget accountabilities
Complaints / Deficiencies with no corrective action taken
Lack of compliance education and training
No progressive disciplinary guidelines - no linkage to compliance adherence
High levels of billing adjustments, no explanations as to why
Recent and/or repeated turnover, particularly at supervisory levels
Are any of these happening here?
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Bulletin boards postings
Ambernet
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Report ANONYMOUSLY by calling the toll-free Hotline at 855-833-0004
Leave your message with as much detail as possible
o The Corporate Compliance Officer will be the only person accessing
that hotline
o The CCO will investigate and take appropriate action
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Disciplinary Action
o Intent is to improve your performance
o Depends on severity of the misconduct and if the act continues
repeatedly
o Can be a write-up up to termination
o Termination will occur for physical abuse, overt harassment, gross
misuse of position, deliberate acts of non-compliance, etc.
False claims penalties and judgments
Under the False Claims Act the standard of proof for Government
prosecutors is only a preponderance of the evidence. In addition, direct
knowledge of the bad acts is also not necessary as a liability can be
established for "deliberate ignorance" and "reckless disregard" of the truth.
o Damages are treble damages and civil fines of $5,000 to $10,000 per claim.
For qui tam plaintiffs, rewards are between 15–30 percent of the funds
recovered. Also they can receive employment protection for the
whistleblower including reinstatement with seniority status, special
damages, and double back pay.
Defendants in False Claims Action must also pay the successful plaintiff's
expenses and attorney's fees.
Other sanctions and criminal punishments may be involved.
Doing the Right Things Right
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We want to do what is right for our patients, our community,
our organization and ourselves