CORPORATE COMPLIANCE TRAINING

1. CORPORATE COMPLIANCE TRAINING Community Mental Health and Substance Abuse Services of Saint Joseph County TDantlzerDraft 03/14/13

2. Why we need training in Corporate Compliance • There are specific expectations from the federal government that entities train staff, contractors, and volunteers about the importance of compliance as it relates to Fraud, Waste and Abuse (FWA). • Our responsibilities regarding proper conduct, stewardship of the funds provided, and the laws we are required to follow are also training requirements.

3. How we stay Compliant Specific policies, procedures, and activities targeted at reducing the likelihood of health care waste, abuse and fraud: • Conduct training on a variety of specifically-targeted activities to systemically respond to allegations of improper/illegal activities and enforcement of appropriate disciplinary action against programs, contracts, and employees that have violated compliance policies. • Provide training on federal compliance guidelines and compliance expectations and processes. • Use audits and monitoring techniques to identify risks and reduce problems. • Investigate and remediate procedures for identified systemic problems. • Taking corrective action, including staff discipline, claims paybacks/adjustments and other corrective measures.

4. OIG’s Guidelines for Compliance are the Framework for our Compliance Program Office of Inspector General’s Compliance Plan Guidance follows the 7 steps of the Federal Sentencing Guidelines inline with 42 CFR 608 • Establish standards for conduct and related Compliance Policies – • Appoint a Compliance Officer • Educate and Train • Establish a process to receive reports • Establish a system to respond to reports • Investigate and take corrective action • Establish and maintain monitoring and audit systems, conduct a RISK assessment periodically

5. Program Integrity Requirements 42 CFR 608 also includes: • Designation of a compliance committee that are accountable to senior management • Effective lines of communication between the compliance officer and the organizations employees • Enforcement of standards through well-publicized disciplinary guidelines

6. Standards of Conduct • The interest of the person served shall always be respected and in their best interest. Their rights, including appropriate care, confidentiality, informed consent, self-determination, and access to records are guaranteed. • Activities shall reflect the best interest of the general public. Accountability to the community is recognized in the priorities, policies and programs. Prevailing legal and moral standards shall be upheld. Public’s right to information about program finances, policies and procedures is acknowledged. • Respect the privacy of all consumers and uphold confidentiality standards as described in the Mental Health Code, HIPAA, HITECH and other protective laws. • High professional standards will be maintained and promoted through acceptable principles and professional standards of practice. • CMHSAS-SJC also has its own Code of Conduct, found in the Compliance Plan.

7. Key Laws that shape compliance • Civil False Claims Act of 1863/as Amended in 1986(FCA) • Medicaid False Claims Act • MI False Claims Act of 1977 • Anti-Kickback Statute of 1977 • Whistleblowers’ Protection Act of 1980 • The Civil Monetary Penalties Laws of 1981(CMPL) • Stark Laws of 1989 and Stark II of 1993 • US Organizational Sentencing Guidelines • Health Care Fraud and Abuse Commission Act of 1993 • The Balanced Budget Act of 1997(BBA) • The Deficit Reduction Act of 2005(DRA) • Affordable Care Act of 2010 (ACA) (Public Law 111-152) • HITECH Act of 2009

8. False Claims Act: What it means to you • Federal law that imposes liability on persons and companies who defraud governmental programs. • Knowingly presenting, or causing to be presented a false claim for payment or approval. • Knowingly making, using, or causing to be made or used, a false record or statement material to a false or fraudulent claim.

9. Whistleblowers’ Protection Act“It’s About You” • To provide protection to employees who report a violation or suspected violation of state, local, or federal law; • To provide protection to employees who participate in hearings, investigations, legislative inquiries, or court actions; and • To prescribe remedies and penalties.

10. FRAUD, WASTE AND ABUSE (FWA) Let’s talk about the difference between FWA: Healthcare Fraud Healthcare Waste Healthcare Abuse.

11. Healthcare Fraud Healthcare Fraud consists of: • An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit (payment) to him/herself or some other person. It also includes any act that constitutes fraud under any applicable federal or state heath care fraud laws. There is no monetary threshold for Healthcare Fraud.

12. Examples of Healthcare Fraud(no monetary threshold necessary) • Billing and subsequently being paid for Home-Based services that were NEVER provided; yet documentation of such services was falsely created • Knowingly providing Psychological testing by a licensed bachelor’s social worker (96102, billing code) and subsequently billing and being paid for psychological testing provided by a psychologist (96101 billing code)

13. The cost of Fraud are high! • Michigan/Federal Medicaid Fraud and Abuse: • Fines and Penalties • Federal Law • Up to $10,000; or • Jail time up to one (1) year • Michigan State Law • Jail time up to four (4) years • Fines • Repayment

14. Healthcare Waste Healthcare Waste: Practices that are inconsistent with sound fiscal, business or clinical (medical) practices, and result in unnecessary costs to public agencies (e.g. CMS, MDCH, SMA/PIHP, ETC), including , but not limited to practices that result in reimbursement for services that are not medically necessary, or that fail to meet professionally recognized standards for health care.

15. Examples of Healthcare Waste • Providing a service in one part of your service area, driving 30 miles across the county to see another consumer then driving back across the service area to see another consumer when the first and third consumers could have been scheduled back to back . Efficiency and mileage waste. • Change in determination: Waste concerns can be determined to be Abuse or Fraud upon further review.

16. Healthcare Abuse As it pertains to compliance, means a pattern of behavior resulting in the submission of inappropriate, unfounded, or illegal claims, with a frequency greater than that which could be reasonably considered a mistake. Basically abuse of resources.

17. Examples of Healthcare Abuse • Providing Community Living Supports and Personal care in a Specialized Residential setting without documenting the services/supports you are providing on a daily basis per the individual’s person-centered plan • Providing Intensive Outpatient Therapy without the appropriate credentials or an approved professional development plan in place (these services MUST be provided by a clinician who meets the provider qualifications) • Providing an 8-week group therapy session to 4-6 individuals without documenting appropriately

18. So - what do we do in response?? • Follow the rules • Establish systems (based on the OIG’s “Guidelines for Compliance”) to make sure that we do • Document what we have done (both good and bad) • Take corrective action when we fall short • Discipline appropriately and consistently

19. How/Where do I report a concern? Should you suspect a violation it is your duty to report – you may use any of the methods below to make a report: Compliance Hotline (at the PIHP) 1-800-783-0914 CMHSAS-SJC Compliance Officer 269-467-1001, ext 320 Report, it’s your duty and you are protected from retaliation.