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Corporate Compliance

Corporate Compliance . What You Need to Know . Corporate Compliance. Why Have this Training ? It is required by federal law. Employees have a duty to identify and report Medicaid fraud, waste and abuse.

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Corporate Compliance

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  1. Corporate Compliance What You Need to Know

  2. Corporate Compliance • Why Have this Training? • It is required by federal law. • Employees have a duty to identify and report Medicaid fraud, waste and abuse. • By safeguarding Medicaid and all other state and federal funding, we are better able to serve our consumers.

  3. Corporate Compliance • What will you learn? • You will have basic knowledge of the federal and NY False Claims Acts. • You will increase your understanding of your role in safeguarding Medicaid and other funding. • You will be able to identify resources available to assist you in this role. • You will have an increased understanding of the current audit environment and the changing Corporate Compliance landscape in NY State.

  4. Corporate Compliance • The Audit Environment and Changing Corporate Compliance Landscape in NY: • Accountability, Accountability, Accountability! • Public demand for greater accountability across the board. • Budget deficits putting great pressure on non-profit agencies. • Federal government pressing NY to control Medicaid fraud. Feds. want a reduction in Medicaid costs.

  5. Corporate Compliance • What has changed? • Until 2005, Medicaid fraud control and oversight was limited. There was virtually no public awareness or demand for control. NY did not have enough staff to complete audit objectives. • 2006 = the year of change. Why? The passage of the Deficit Reduction Act in 2005. • Message from the DRA: 1. To States: You need reporting and enforcement systems and accountability standards. 2. To Providers: You need to tell your employees how to blow the whistle on you and each other.

  6. Corporate Compliance • Because of the DRA… • Federal and NY False Claims Acts are born. • Greater fiscal pressure on NY translates into greater scrutiny by government. • Now, more than ever, agencies must demonstrate accountability for the expenditure of public funds. • Mandatory Corporate Compliance programs.

  7. Corporate Compliance • What is the relationship between Medicaid and the False Claims Acts? • Participation in the Medicaid program is a voluntary, contractual relationship between the provider of service (CWI) and the State of New York. Continued participation by any provider of service is conditioned upon satisfactory compliance with the rules and regulations of the Medicaid program.

  8. Corporate Compliance • By choosing to bill Medicaid, a provider assumes responsibility for meeting all requirements as a pre-requisite to payment and continued status as an enrolled provider. • Medicaid $$ = Medicaid Rules!!

  9. Corporate Compliance • So, the relationship between Medicaid and False Claims Acts is this: Any agency that receives Medicaid funding has a duty to ensure that Medicaid rules are followed before claims are submitted for payment. If there is suspected abuse or fraud of Medicaid funding, employees have a duty to report the suspected activity.

  10. Corporate Compliance • Who or What is O.M.I.G.? • OMIG is the Office of the Medicaid Inspector General. This office has been a distinct entity since November 2006. The OMIG, through audits and enforcement efforts, recovers state funds that have been inappropriately claimed by individuals and providers. It is the authority in NYS for all Medicaid oversight activities.

  11. Corporate Compliance • More on O.M.I.G… • OMIG is funded by the Center for Medicare and Medicaid Services (CMS) of the US Department of Health and Human Services. OMIG’s primary goal is to enhance NY’s ability to fight Medicaid fraud by increase Medicaid compliance by providers.

  12. Corporate Compliance • NY’s Medicaid Program (Annually): • Cost $48 billion dollars. It is one of the most expensive programs in the nation. • Processes 350 million claims and payments. • Provides health care to 4 million recipients through 60,000 active providers of service.

  13. Corporate Compliance • NY is committed to make “Fraud and Abuse Recoveries” in specific $$ amounts as follows: Fiscal Year 2008: 213 million Fiscal Year 2009: 322 million Fiscal Year 2010: 429 million Fiscal Year 2011: 644 million NY SEEKS 1.6 BILLION IN RECOVERIES IN 4 YEARS STARTING THIS YEAR!

  14. Corporate Compliance • HOW WILL NY/OMIG FIND 1.6 BILLION DOLLARS?

  15. Corporate Compliance • HERE’S HOW: 1. OMIG has authorization to hire over 250 new employees to perform audits, reviews, investigations and administrative functions. 2. There will be increased audits. 3. There will be increased standards. 4. There will be increased scrutiny of data and claims. 5. There will be increased enforcement and investigations.

  16. Corporate Compliance • What are the Outcomes the OMIG is looking for? Bottom Line: • To ensure the public is getting what it is paying for. • Better quality and patient outcomes. • To Bottom 10% of agencies – get better or get out! • Support for internal quality and reporting efforts by agencies.

  17. Corporate Compliance • What are the False Claims Acts? • The federal and NY False Claims Acts are laws that were enacted to combat fraud. The NY law mirrors federal law. • Main Tenets: 1. All employees have a duty of service to prevent fraud, waste and abuse of taxpayer dollars. 2. All employees are responsible for reporting suspected fraud, waste and abuse of government funding, including Medicaid.

  18. Corporate Compliance • Federal False Claims Act Prohibits: • Knowingly presenting or causing to present a false of fraudulent claim. • Knowingly making or using or causing to be used, a false record or statement to obtain payment from the government. • Conspiring to defraud the government by getting a false claim paid. • Giving a receipt without completely knowing the accuracy of the receipt. • Buying or receiving government property from an unauthorized person. • Making a false record to avoid or reduce government obligation.

  19. Corporate Compliance • Under the Act, the terms “knowing” and “knowingly” mean that a person, regarding the information on a claim… 1. Has actual knowledge the information is false. 2. Acts in deliberate ignorance of whether the information is true or false; or 3. Acts in “reckless disregard” of whether the information is true or false.

  20. What is “Reckless Disregard” for the Truth? Completing claims with little or no factual basis. Failing to document actual time spent on a service. Poor record keeping. Approving claims without reviewing them for accuracy. Corporate Compliance

  21. Corporate Compliance • Under the FC Act… • “Person” means both your employer as an entity and individual employees themselves. • And since you have to “knowingly” present a false or fraudulent claim for payment in order to violate the Act…..

  22. Corporate Compliance • IS IGNORANCE BLISS?? • …”if anyone ever asks us about it, we’ll just plead ignorance or say we didn’t get trained…” • …”because if we don’t know the rule, there isn’t a problem…” ………..Right????..............

  23. Corporate Compliance WRONG!!!!

  24. Corporate Compliance AND…there does not have to be proof of a specific intent to defraud the government!

  25. Corporate Compliance SO…If we/you violate the Act…..

  26. Corporate Compliance • Civil Penalties Can Be Incurred! • 3X damages PLUS • $5,500 to $11,000 per claim PLUS • Potential exclusion from participation in the Medicaid program and • The amount of the false claim doesn’t matter!

  27. Corporate Compliance • Reduction of Liability? If a false claim occurs, the court may assess “not less than” double damages and costs IF within 30 days of discovery: • We self-report. • We fully cooperate with any investigation. • No legal proceeding has been commenced regarding the violation and we have no knowledge of a governmental investigation of the violation.

  28. Corporate Compliance • Compliance Programs: Required Elements: • Written Policies and Procedures. • A Corporate Compliance Officer. • Training and education of employees/contractors. • Open communication lines to the COO. • Disciplinary policies to encourage good faith compliance program participation. • A system to routinely identify compliance risk areas. • A system for responding to compliance issues as they arise. • A policy of non-intimidation and non-retaliation for good faith compliance participation.

  29. Corporate Compliance • Safeguarding Public Funding: Whistleblowing! • The federal False Claims Act allows individuals to file “qui tam” or “whistleblower” lawsuits against organizations that have defrauded the government. • In a qui tam action, an individual with direct knowledge of fraud files a lawsuit on behalf of the government.

  30. Corporate Compliance • Blowing the Whistle! • Individuals filing qui tam lawsuits may share in the government’s monetary recovery. • Generally, the individual is entitled to between 15 and 35% of the funds recovered by the government.

  31. Corporate Compliance • Protecting Whistleblowers. • Individuals who file whistleblower lawsuits are protected from retaliation by federal law. • Any employee who is discharged or discriminated against based upon the filing of a whistleblower lawsuit, is entitled to all relief necessary to make the employee whole.

  32. Corporate Compliance • The NY False Claims Act • Similar to the federal False Claims Act • It imposes penalties and fines on individuals and entities that file false or fraudulent claims for payment from any state or local government, including Medicaid. The penalty for filing a false claim is $6,000 - $12,000 per claim and the recoverable damages are between two and three times the value of the amount falsely received.

  33. Corporate Compliance How Do I Report a Complaint? If you need to file a complaint about fraud, waste or abuse of CWI funds, or if you just want to talk about a concern, please call: • Kris Walterich, Director of Quality Assurance/Corporate Compliance Officer at 793-4700 X 123. • Or email Kris at kwalterich@cwinc.org

  34. Corporate Compliance • YOU CAN ALSO MAKE AN ANONYMOUS REPORT BY CALLING 793-4700 X 168 (Hotline)

  35. Corporate Compliance • All Complaints regarding potential fraud, waste and abuse of program funding are taken seriously and will be investigated.

  36. Corporate Compliance Won’t I get in trouble if I call???

  37. Corporate Compliance NO! The law prohibits retaliation against any employee who reports a compliance issue in good faith.

  38. Corporate Compliance Please Remember: • YOU know the programs better than anyone else. • YOU know when there is a problem or concern. • The best prevention against false claims is YOUR awareness and diligence.

  39. Corporate Compliance • YOU are the first line of defense against inappropriately claims services or inappropriately used funds!

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