NAHC-Audio Compliance - Health Care Compliance Association

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The Gentiva Compliance Program
Introduction

Corporate criminal liability

Federal sentencing guidelines

Compliance program protection

Background

Requirements

Effect of program

HIPPA Introduction

Closing comments/questions
© Gentiva Health Services, 2002
2
Corporate Criminal Liability
A
corporation is liable for any act committed by
an employee which has the actual or intended
effect of benefiting the company
 The
act must be within the scope of the
employee’s actual or apparent authority
© Gentiva Health Services, 2002
3
Department of Justice/CMS

New audit approach
focusing on fraud and
abuse issues

OIG permitted to refer
cases directly to DOJ

FBI involvement/ health
care fraud teams

Operation restore trust

Auditor focus: recovering
funds

Health care #3 national
priority

New emphasis on closing
down agencies

Increased criminal
prosecution
© Gentiva Health Services, 2002
4
Federal Sentencing Guidelines
© Gentiva Health Services, 2002
5
Sentencing Guidelines
 Comprehensive
crime control act of 1984
enacted guidelines for individuals
 Proposed
guidelines for sentencing
organizations became law in November 1991
 Philosophy
 Just
: carrot and stick approach
punishment
 Adequate
deterrence
© Gentiva Health Services, 2002
6
Purpose

Incentives for
organizations to maintain
internal mechanisms






© Gentiva Health Services, 2002
Preventing
Detecting
Reporting criminal conduct
Standard requirements
Customized to each
organization
Each step is valued
towards demonstrating
effectiveness of program
7
Mitigating Factors
 Compliance
program
 An
effective compliance program to prevent and
detect violations of the law, within the meaning
set out in the guidelines, is the only mitigating
element that can be implemented by a
corporation prior to the criminal acts that give
rise to prosecution
© Gentiva Health Services, 2002
8
Compliance Program
100
$ Millions
80
60
40
20
0
With a Program
© Gentiva Health Services, 2002
Without a Program
9
Compliance Standards

Medicare fraud and abuse laws

Federal false claims act

Anti-kickback act

Stark I & II (III?)

Conditions of Participation

Wedge audits

Licensure

Labor/ wage and hour

Anti-trust
– Etc.
© Gentiva Health Services, 2002
10
Program Oversight
COMPLIANCE PROGRAM STRUCTURE
Gentiva Health Services
Board of Directors
Audit Committee
President/CEO
Chief Compliance Officer
Chief Financial Officer
Chief Operating Officer
Finance/Reimbursement
Operating Directors
© Gentiva Health Services, 2002
11
Employee Training
 Compliance
employees
policies must be distributed to all
 Mandatory
compliance training: VP’s, Branch
Directors, Field Staff
 Additional
training through in-services, flyers,
memorandum, bulletins, newsletters, Gentiva
University, etc.
 Compliance
 Managers
testing
training series
© Gentiva Health Services, 2002
12
Delegation of Authority
 Monitoring
of employees with respect to
compliance standards
 Employee
screenings (in accordance with
applicable laws)
 Performance
evaluation including adherence to
compliance standards
© Gentiva Health Services, 2002
13
Enforcement & Discipline
 Penalty
 Range
 “Due
matches offense
of sanctions
process”
 Self-disclosure
 Management
subordinates
 See
(mitigating factor)
responsible for misconduct of
progressive disciplinary policy
© Gentiva Health Services, 2002
14
Response & Corrective Action

Who’s involved?

What happened?

Who follows up?

Plan of action

Legal counsel?

Notify authorities

Corrective action

Preventive measures
© Gentiva Health Services, 2002
15
Effect of Program

Reduced risks and
exposures

Reduce corporate
liabilities

Enhances image with
intermediaries

Public image

Increase quality

Increase profitability
© Gentiva Health Services, 2002
16
Compliance Circle
COMPLIANCE
Compliance IS Quality in
ACTION
QUALITY
© Gentiva Health Services, 2002
17
Closing Comments/Questions
 Additional
Questions
 1-631-501-7390
– Chris Anderson
 [email protected]
© Gentiva Health Services, 2002
18
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