Powerpoint Templates

1. Corporate Compliance Powerpoint Templates

2. Corporate Compliance : What Is it? What Does It Mean To Me?

3. Purpose Of This Session : • To provide attendees with an understanding of the regulatory environment in which the Agency operates • To provide an overview of Corporate Compliance and the components of a Corporate Compliance Plan • To provide attendees with an understanding of documentation requirements

4. Laws and Regulations : • Employment and discrimination • Governance, licensing & certification • Protection from abuse • Health and safety • Physical environment • Service provision • Billing and reimbursement

5. Laws and Regulations : • To comply with the laws and regulations, the Agency develops: • Policies, • Procedures, and • Practices

6. Regulatory History : • Health Insurance Portability and Accountability Act of 1996 (HIPAA): • Increased resources for detecting fraud • Expanded power and authority of enforcement agencies • Creation of Health Integrity and Protection Data bank

7. Who’s Who? • Office of Inspector General (OIG) • Health and Human Services (HHS) • Center for Medicaid Services (CMS) • Department of Justice (DOJ) • Federal Bureau of Investigation (FBI) • NYS Office of the Attorney General - Medicaid Fraud Control Unit (MFCU) • NYS Office of Medicaid Inspector General (OMIG) • OMH/OPWDD/DOH/OASAS/SED

8. Office of the NY State Medicaid Inspector General (OMIG) : • “To coordinate the Medicaid fraud, waste and abuse control activities of…DOH, OMH, OMPWDD, OASAS, OCFS, SED”

9. The False Claims Act : What Does It Mean To Me?

10. The False Claims Act : - presenting a claim that the person knows or should know is false; - presenting a claim for services not provided as claimed; - upcoding; - presenting claims for physician services not provided by a physician; - violation of anti-kickback legislation; - contracting with someone excluded from a federal health care program; - inducements to referrals or recipients of service

11. Common Examples : • Billing for a service that was not provided • Billing for days the person was in hospital • Documentation that is false or inaccurate • Billing for more service than provided • Service is provided by unqualified staff • Billing for service that is not authorized or medically necessary • Billing twice for the same service

12. The False Claims Act Penalties : • This statute has teeth: • it provides for treble (triple damages) damages and, • civil penalties of $5,500–$11,000 for each false or fraudulent claim presented for payment • Provider entities or individuals can face criminal or civil prosecution

13. Fraud : “...a misrepresentation, omission, or concealment calculated to deceive.” Abuse : “...performing acts that are inconsistent with acceptable business practices.”

14. Innocent Errors : • No civil or criminal penalties. • Provider must return the funds erroneously claimed. • Prosecution would require: • criminal intent to defraud (criminal) OR • actual knowledge of the claim being false, reckless disregard or deliberate ignorance of the false claim (civil).

15. No One is Perfect!!! Honest Mistakes and Innocent Errors Happen • You must be able to demonstrate how your internal controls are designed to assure compliance • Policies and Procedures relative to returning funds once errors are found • Demonstrate that $$$ has been returned in the past

16. Protections and Safeguards : • Agency policies, procedures and practices • Educated, qualified and trained staff, • Communication between management, billing and program staff • Internal controls • Auditing and monitoring activities

17. What is Corporate Compliance? • A long term commitment by an organization to conduct business in a manner that: • promotes compliance, • continually monitor for compliance, and • create systems that allow it to be responsive to changes in the regulatory environment.

18. Benefits of a Compliance Plan: • Promotes ethical conduct • You find your ‘weaknesses’ before Medicaid does (Early detection) • Communicates agency’s commitment to regulatory compliance • Educated staff (Whistleblower lawsuit protection) • Drives more efficient and effective operations • Improves financial health of agency • Defends the organization; may mitigate paybacks/fines

19. 7 Elements of a Compliance Plan: 1. Written Policies and Procedures 2. Compliance Program Oversight 3. Training and Education 4. Effective, Confidential Communications 5. Enforcement of Compliance Standards 6. Auditing and Monitoring 7. Responding to Offenses/Developing a Corrective Action Plan

20. 1. Written Policies and Procedures • Based on Laws, Regulations and Practices • need to be updated as laws and regulations change • Provides direction and guidance to staff • all employees must adhere to them • Revised as necessary • based on results of internal or external reviews

21. 1. Written Policies and Procedures • Code of Conduct • Conflict of Interest • Billing and Reimbursement • Education and Training • Expense Reimbursement • Exclusion/Sanction Screening • Auditing and Monitoring • Internal Reporting Mechanisms • Responding to Gov’t Investigations • Document Retention/Destruction • Enforcement of Compliance Standards and Discipline

22. 2. Compliance Oversight: • Compliance Officer and Compliance Committee • Board and Management Staff • Effective methods to report compliance-related issues

23. Compliance Officer Duties: • Developing and implementing policies and procedures (P&P). • Overseeing and monitoring the implementation of the compliance plan on a regular basis. • Directing agency internal audits established to monitor effectiveness of compliance standards. • Providing guidance to management, medical/clinical personnel and individual departments regarding P&P and governmental laws, rules and regulations • Investigating compliance-related issues

24. 3. Training and Education: • Is Mandatory and Regular • Content of Agency’s compliance plan • Overview and importance of compliance • Department specific risk areas • Summary of fraud and abuse laws • How to report non-compliance • Confidentiality and non-retaliation for reporting

25. 4. Effective, Confidential Communications: • “Open Door” Policy to raise issues with management • Methods to report actual or suspected non-compliance confidentially or anonymously • Non-retaliation for reporting actual or suspected non-compliance

26. Reporting • If an employee, contractor or agency witnesses, learns of, or is asked to participate in potential non-compliant activities, he or she must immediately contact the Compliance Officer • In person or • Calling the Corporate Compliance helpline

27. Corporate Compliance Helpline 283-6500 x266 • Voicemail system available 24 hours a day • Caller ID is NOT active on this line • Callers can remain anonymous

28. 5. Enforcement of Compliance Standards: • Clear guidance for staff • Supervision and monitoring • Disciplinary action for: • failing to report actual or suspected non-compliance • non-compliance with laws, regulations, policies, procedures and practices

29. 6. Internal Auditing and Monitoring: • Objective is to close gap between service delivery and billing through a process to assure/identify: • Authorization for service (Signed, effective service and treatment plans) • Documentation to support claims • Staff meet qualifications • There are systems that promote adherence and report shortcomings back to programs • Systemic and process problems

30. 6. Internal Auditing and Monitoring: • Findings are then analyzed and may lead to: • Training • Re-evaluation of systems

31. 7. Follow-up and Corrective Actions: • Investigate reports of actual or suspected non-compliance • Report findings • Develop corrective action plans • Review for effectiveness

32. Questions/Discussion