NASVH Corporate Compliance Program Essentials

Corporate Compliance Program
February 28, 2013
Presented by: Eileen Denzel RHIA, CCS
Director of Compliance/Privacy Officer
Long Island State Veterans Home
Stony Brook, New York
[email protected]
(631) 444-8646
Presentation Outline
Why Have a Compliance Program?
Affordable Care Act Compliance Program Mandate for 2013
Elements of a Compliance Program
Required Policy & Procedures
Risk Areas
Resources and Educational Websites
Sanction Screening
Measuring Effectiveness
Compliance Week May 2013
Why Have a Compliance Program?
It is a demonstration to employees and the community at large of the Facility’s
commitment to responsible corporate conduct; It improves our reputation for
integrity and quality, increasing in market competitiveness and reputation in
the community;
It helps obtain an assessment of employee and contractor behavior;
It helps increase the likelihood of identifying and preventing unlawful and
unethical behavior;
It allows a facility to quickly react to employees’ operational compliance
concerns and effectively target resources to address those concerns;
It helps improve the quality, efficiency and consistency of services;
Why Have a Compliance Program?
It encourages employees to report potential problems and allow for appropriate
internal inquiry and corrective action;
The program creates a centralized source for distributing information on
healthcare statutes, regulations and other program directives;
It’s a mechanism to improve internal communications;
It includes procedures that allow prompt and thorough investigation of alleged
It increases the likelihood of preventing unlawful and unethical behavior, or
identifying and correcting such behavior at an early stage;
A compliance program reflects a sincere effort by your Facility to comply with
applicable statues and regulations through the establishment of a compliance
program, and significantly reduces the risk of unlawful or improper conduct.
Affordable Care Act Compliance
March 2013
By March 23, 2013, skilled nursing facilities and other nursing facilities must
have “in operation” a compliance and ethics program that meets the Law’s criteria.
By March 23, 2013, the HHS Secretary shall have completed “an evaluation” of
the compliance and ethics programs that nursing facilities will be required to
Sometime after March 23, 2013, the Secretary must submit an evaluation report to
Congress with recommendations on changes to the regulatory requirements for
nursing facility compliance programs.
Affordable Care Act Compliance
March 2013
For nursing facilities, the Healthcare Reform Law specifies certain
“required components of a compliance and ethics program” that include:
• Compliance standards and procedures for employees and other agents “that
are reasonably capable of reducing the prospect” of criminal, civil, and
administrative law Medicare and Medicaid violations.
• The assignment of overall compliance program oversight to “high-level
personnel” with “sufficient resources and authority” to assure such
• The exercise of “due care” not to delegate “substantial discretionary
authority” to individuals whom the nursing facility knew or should have
known had a “propensity to engage in criminal, civil, or administrative
• The effective communication of compliance standards and procedures to all
employees and agents, including training programs or published materials.
Affordable Care Act Compliance
March 2013
Section 6102 defines a "compliance and ethics program" as a program
"reasonably designed, implemented, and enforced so that it generally will be
effective in preventing and detecting criminal, civil, and administrative violations .
. . and in promoting quality of care." To achieve this, such a program must include
the following elements:
• The establishment of compliance standards and procedures reasonably capable of
reducing the likelihood of violations and promoting quality of care;
• The assignment of specific high-level individuals with overall responsibility to
oversee compliance, and with sufficient resources and authority to enforce the
compliance standards;
• The use of due care to avoid delegating substantial discretionary authority to
individuals known to have a propensity to engage in violations;
• The effective communication of compliance standards and procedures to all
Affordable Care Act Compliance
March 2013
• The establishment of monitoring and auditing systems
designed to detect violations and, in addition to this, a
mechanism through which employees can report violations
without fear of retribution;
• The consistent enforcement of compliance standards through
appropriate disciplinary actions;
• The establishment of a procedure for responding appropriately
to any violation that has been detected and for preventing
further similar violations; and
• The periodic reassessment of the compliance program to
identify changes necessary to reflect changes within the
Compliance Program Elements
A Comprehensive compliance program at a minimum should
include the following seven elements:
1. Written standards of conduct, as well as written policies and procedures;
2. Designation of a Chief Compliance Officer and/or Corporate Compliance
3. Effective education and training programs;
4. Hotline to receive complaints and to protect whistle blowers from
5. System to respond to allegations of improper and/or illegal activities and the
enforcement of appropriate disciplinary action;
6. Audits to monitor compliance; and
7. Investigation and remediation of identified systemic problems and the
development of policies
Required Policies & Procedures
• Compliance program oversight policies and
Compliance officer duties and responsibilities
Confidentiality agreements
Standards of conduct
Compliance education and training
Required Policies & Procedures
Vendor relationships
Responses to complaints
Non-retaliation policy (Whistleblower Protection)
False Claims Act
Deficit Reduction Act
Risk Areas
Resident Safety
The OIG’s September 2008 Supplemental Compliance Guidance
for Nursing Facilities includes resident safety as a “risk area”
upon which providers should focus in their corporate compliance
programs. Resident safety includes both staff-to-resident abuse
and neglect (including injuries of unknown origin) and residentto-resident abuse and/or family-to-resident abuse.
The Federal OBRA regulations which govern nursing facility
care for Medicare and Medicaid-certified providers guarantee
residents the right to be free from abuse and neglect. Based on
this specific resident right, providers have a legal obligation to
take steps to protect residents from abuse and neglect from
anyone coming in contact with a resident, but particularly from
facility staff and other residents.
Risk Areas
Proper Reporting of Case Mix
• The OIG’s 2008 Supplement Compliance Guidance
focuses heavily on false claims, or claims for payment
made to Federal health care programs for services which
were not delivered or not delivered as claimed. One of the
specific risk areas identified by the OIG as a potential
false claim is the inaccurate reporting of resident case mix
and, more specifically, improperly upcoding resident
RUG category assignments. According to a 2006 OIG
report, the OIG found that 22% of SNF RUG claims were
Risk Areas
Restorative and Personal Care
In the restorative and personal care area, the OIG’s Supplemental
Compliance Guidance stresses that facilities are expected to:
Avoid pressure ulcers,
Improve passive range of motion,
Improve ambulation,
Fall prevention management,
Incontinence management, and
Enhance bathing, dressing and grooming activities.
Failure to provide restorative services, yet submitting claims for
such services can create a risk of liability under Fraud and Abuse
and False Claim Statutes.
Risk Areas
Comprehensive Plans
Comprehensive Care Plans are an OIG Focus
Area and a survey and enforcement focus
area. Failure to demonstrate an effective care
planning process could be the basis for fraud and
abuse or false claim actions.
• OIG Program Guidance
• Health Care Compliance Association
• U.S. Department of Health and Human
Services and Department of Justice
• Federal Register
Compliance Education Materials
OIG's Compliance 101
OIG's Compliance 101 Web page. OIG developed the
free educational resources listed on this Web page to
help health care providers, practitioners, and suppliers
understand the health care fraud and abuse laws and the
consequences of violating them. These compliance
education materials can also provide ideas for ways to
cultivate a culture of compliance within your own
health care organization.
Compliance Education Materials
Center for Medicare and Medicaid Services (CMS)
The Medicare Learning Network® (MLN) Products Provider Compliance
page contains educational products that inform providers on how to avoid
common billing errors and other improper activities when dealing with the
Medicare Program. Since 1996, the Centers for Medicare & Medicaid Services
(CMS) has implemented several initiatives to prevent improper payments
before a claim is processed and to identify and recoup improper payments after
the claim is processed. The overall goal of CMS' claim review programs is to
reduce payment error by identifying and addressing billing errors concerning
coverage and coding made by providers.
Sanction Screening
Under Federal law, no payment will be made by any Federal
health care program, including Medicare or Medicaid, for any
items or services furnished, ordered, or prescribed by an
excluded individual or entity. Exclusions from participation in
Federal health care programs are imposed by the Department
of Health and Human Services (DHHS) Office of Inspector
General (OIG). The OIG advises that all current and new
employees, medical personnel, contractors, and vendors
should be screened against the latest version of the OIG List of
Excluded Individuals and Entities (LEIE), which is published
on its web site: on a
monthly basis.
Sanction Screening
• The OIG further recommends regular screening of the General
Services Administration System of Awards Management
(SAM) List of Parties Excluded from Federal Procurement and
Non-procurement Programs). Similarly, the DHHS Centers for
Medicare & Medicaid Services (CMS), has advised that
providers may not employ, contract with or receive Medicare
or Medicaid payments for items or services furnished by
individuals or entities excluded from participation in any
health care program, or debarred by the SAM, or receive
Medicare or Medicaid payments for items or services
furnished, ordered, or prescribed by an excluded individual or
Sanction Screening
• CMS has further advised States that they should require
Medicaid providers to search the OIG’s LEIE on a monthly
basis. In addition, states have independent legal authority to
exclude individuals and entities from participation in their
individual state Medicaid programs. Many states have
developed their own lists of sanctioned and excluded
individuals and entities that should be searched in addition to
the federal OIG and SAM lists. For example, the New York
Office of Medicaid Inspector General (OMIG) issues its own
List of Restricted, Terminated, and Excluded Individuals and
Entities, and advises that health care providers check the
OMIG list, as well as the LEIE and SAM on a monthly basis.
Sanction Screening
Who can be sanctioned and why?
Individuals and businesses/entities.
• Default on health education loan or scholarship obligations.
• Failure to meet statutory obligations of practitioners and providers to
provide' medically necessary services meeting professionally recognized
standards of health care
• Conviction relating to patient abuse or neglect.
• Felony conviction relating to health care fraud.
• Felony conviction relating to controlled substance.
• Claims for excessive charges, unnecessary services or services which fail to
meet professionally recognized standards of health care, or failure of an
HMO to furnish medically necessary services.
Sanction Screening
• Include in employment application: Have you ever been excluded from
participation in the Medicare or Medicaid Program?
• Were you ever registered on the General Services Administration System of
Awards Management (SAM) List of Parties Excluded from Federal
Procurement and Non-procurement Programs?
• Require current employees to report to the nursing facility if, subsequent to
their employment, they are convicted of an offense that would preclude
employment in a nursing facility or are excluded from participation in any
Federal health care program.
• Regardless of the size or resources of the nursing facility, employee
screening is critical. Nursing facilities, like all corporations, must act
through their employees and are held accountable for their actions
Sanction Screening
Section 6501 of the Affordable Care Act states that if an individual or entity is
excluded in one state, then he/she or it, is excluded in all states. This means that
healthcare employers and companies need to make sure their compliance program
includes searching all available state Medicaid exclusion registries as well as the
federal exclusions lists.
States that have Medicaid exclusion registries:
New York
South Carolina
District of Columbia
New Jersey
West Virginia
Measuring Effectiveness
Benefits of Conducting Compliance Effectiveness Audits
Compliance officers believe it is a good learning experience.
It gives senior management and governance a quick picture of effectiveness.
Scoring gets the attention of management and governance.
Results provide a basis for compliance program objectives for the upcoming
Identifies where compliance office support is needed.
Demonstrates good faith to comply with regulations
Measuring Effectiveness
Inclusion of Compliance Questions During the Employee Exit Interview:
Are you aware of the Nursing Home's Compliance Program?
Were you trained/educated in this Program?
Did you receive the Nursing Home's Compliance Handbook?
Are you aware of any potential/actual violations of the Nursing Home's
Compliance Program?
If yes, did you report this to your immediate supervisor, department head,
or the Nursing Home's Compliance Officer?
Is there anything that you would like to report at this time?
Addition of Compliance Component to all Employee Performance
Attended Compliance training and adheres to the policies and procedures.
Commit to “Doing the Right Thing”
Obey the regulations and policies that apply to your job
Make compliance awareness part of your job
Compliance &
HIPAA Privacy Officer
Put your code of Conduct in an accessible spot
Lead by example
If in doubt, check it out
Annual Compliance training
HIPAA Security
Notify supervisor of possible wrongdoings
Communicate openly and honestly
Ethical Behavior is a part of all activities
Compliance &
Compliance Week
Celebrate Corporate Compliance & Ethics Week May 5-11 2013. Corporate
Compliance & Ethics Week is a national week-long event, traditionally held the first
full week in May, which highlights the importance of ethics and compliance in the
Many organizations use the week as an opportunity to raise awareness about
compliance and ethics and engage employees about these difficult yet vitally important
topics. Others use the week to rollout a new compliance training program or hold its
annual compliance training activities.
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