Compliance Program Basics
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Transcript of Compliance Program Basics
PRESENTED BYSHARLENE EVANS CPC, CPC-H, CHC
Compliance Program Basics
Disclaimer
Views expressed in this presentation are those of the speaker and do not necessarily reflect the views of Catholic Health Initiative (CHI) or any of CHI affiliations.
Agenda
Getting to know meGetting to know youWhy is a Corporate Responsibility Program
Important8 Elements of an Effective Compliance
ProgramNot all Compliance Programs are Built the
SameA Coder’s Path to Compliance
Introduction – Getting to Know Me
My Journey to ComplianceWhy Healthcare Compliance
Getting to Know You
1. How many are from Hospitals?2. How many are from Physician Practices?3. Other areas?4. Who’s hospital/practice has a Compliance
Program?5. Who knows what a Compliance Department
does? Other Names used
Corporate Responsibility Office Integrity Office Compliance & Ethics Department
Why have an Effective Compliance Program?
Why have an Effective Compliance Program?
1. Regulatory requirements & guidance Federal Sentencing Guidelines, OIG and
Affordable Care Act
Federal Sentencing Guidelines
Federal Sentencing Guidelines – Chapter 8 An organization shall exercise due diligence to
prevent and detect criminal conduct; and otherwise promote an organizational culture
that encourages ethical conduct and commitment to compliance with the law.
Affordable Care Act
Section 6401 of the Affordable Care Act “A provider of medical or other items or services or
supplier within a particular industry sector or category” shall establish a compliance program as a condition of enrollment in Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP).”
An enforcement date for provider compliance plans as mandated in the Affordable Care Act not yet to been issued.
Office Of Inspector General (OIG)
The OIG has been advising providers to voluntarily adopt compliance plans, since the 1990’ds and has issued several compliance program guidance (CPG’s) for particular provider types, including hospitals, nursing homes, pharmaceutical manufactures, and physician group practices.
The CPG’s identify specific risk areas for the particular provider types and offer compliance tips.
OIG Website: https://oig.hhs.gov/compliance/compliance-guidance/index.asp
Why have an Effective Compliance Program?
2. Studies suggest that a strong ethical culture can reduce the risk of fraud, waist and abuse
3. Impact from unethical conduct Loss of employee faith and commitment Reputation risk
4. Level of enforcement activities, already high, likely to grow
5. Promote patient safety and ensure delivery of high quality patient care.
*Effective Compliance Programs are an essential tool for identifying and mitigating audit risks
OIG STATES - THERE IS NO SINGLE “BEST” COMPLIANCE PROGRAM,
GIVEN THE DIVERSITY WITHIN THE INDUSTRY
Elements of an Effective Compliance Program
8 Elements of an Effective Compliance Program
1. Written Policies, Procedures and Standards of Conduct
2. Compliance Program Oversight3. Education and Training4. Reporting/Communication5. Enforcement and Discipline6. Monitoring and Auditing7. Response to Detected Offenses and Prevention8. Ongoing risk assessment – added in 2004**Federal Sentencing Guidelines, 1991, United states Sentencing Commission Revision,
2004
8 Elements of an Effective Compliance Program
1. Written Policies and Procedures Code of conduct which addresses compliance
expectations State the organization's mission, goals and
ethical requirements of compliance Articulate the commitment to comply with all
Federal and State Standards Emphasis on preventing fraud waste and abuse
Employee’s should be required to acknowledge that they have read & understand the Code of Conduct
8 Elements of an Effective Compliance Program
Compliance-related policies for operational high risk areas
Accurate billing and coding Payments and collections Credentialing Anti-Kickback & Stark Record Retention Cost Reports
Policies and Procedures should be: written clearly, be concise, in non-technical language which is easily understood by all.
8 Elements of an Effective Compliance Program
2. Compliance Program Oversight Designate a Compliance Officer who serves as the focal point
for compliance Responsibility may be the only duty they have or in smaller
organizations this duty is added to other management responsibilities.
Has a leadership role that is recognized and promoted by senior management. Access to the hospitals governing body and the CEO
Relationship to General Counsel/Legal and Chief Financial Officer Conflict of interest for compliance officers to be under legal
or finance Most Corporate Integrity agreements prohibit the compliance
officer be under legal or finance or have combined roles.
8 Elements of an Effective Compliance Program
Compliance Committee The OIG recommends that a compliance committee be
established to advise the compliance officer and assist in implementation of the compliance program.
Leaders who should be on the Committee Compliance Officer President/CEO Chief Operations Officer (CEO) Chief Financial Officer (CFO) Human Resources Department Management
Names for the Committee Audit & Compliance Committee
8 Elements of an Effective Compliance Program
3. Education and Training Training should highlight
The compliance program, Fraud and abuse laws, Coding requirements Claim development & submission process marketing practices
1-2 hours general compliance training• Include all employee’s, board members, executives, volunteers
8 Elements of an Effective Compliance Program
Various methods for training Web-based interactive New employee orientation Staff meetings
Be effective – testing, knowledge Separate Specialized high risk area training
Example: Billing, Coding, Cardiology –ICD’s Attendance and participation in training
programs should be a condition of continued employment. Failure to comply with requirements could result in
disciplinary action, including possible termination.
8 Elements of an Effective Compliance Program
4. Reporting/Communication Access to the Compliance Officer
Open lines of communication to the Compliance Officer should be established. “Open Door” policy
Several options should be available for employees to report compliance issues
In-person – Supervisor, Manager, Compliance Officer Electronically – e-mail Anonymously
Hotline – number should be posted for employees Locked drop boxes
Written confidentiality and non-retaliation policies should be developed and distributed to all employees.
8 Elements of an Effective Compliance Program
5. Enforcement and Discipline Disciplinary policies outline disciplinary actions that
may be imposed. Failing to report a potential compliance issue Participation in non-compliant behavior
Level of discipline is consistent regardless of status Compliance Officer does not carry out discipline, they only
recommend. New Employee’s
Background investigations Disclose criminal convictions or exclusions
List of Excluded Individuals & Entities – LEIE https://oig.hhs.gov/exclusions/index.asp
8 Elements of an Effective Compliance Program
6. Monitoring and AuditingDifference between Monitoring & AuditingMonitoring - includes regular reviews performed as
part of normal operations to confirm ongoing compliance. Occurs on a regular basis (daily, weekly, monthly)
during normal day to day operations Are performed by staff Checks to see if procedures are working Follow-up on recommendations and corrective
action plans to ensure they are being implemented
8 Elements of an Effective Compliance Program
Auditing – includes formal reviews of compliance with a particular set of standards as base measures. Ensures compliance with a range of statutory and
CMS requirements in critical operational areas Includes regular, periodic evaluations of the
compliance program to determine the programs overall effectiveness
Is performed at least annually, or ore frequently as appropriate
May include a variety of audit methods (desk, onsite, internal, or external)
Includes written reports containing findings, recommendations and proposed corrective actions
8 Elements of an Effective Compliance Program
Audits can be performed by internal or external auditorsAuditors should:
Be independent of and not employed in the department being audited Be competent to identify potential issues within the critical review
areasAudits should be designed to address compliance with:
Kickback arrangements Stark – Physician self-referrals CPT/HCPS/Diagnosis Coding Claim development and submission Reimbursement Cost Reporting Marketing
8 Elements of an Effective Compliance Program
Other references you can use for audit plans: OIG Work Plan -
https://oig.hhs.gov/reports-and-publications/workplan/index.asp
Medicare Administrative Contractor –MAC LCD’s, CERT
Recovery Audit Contractors – RAC https://racinfo.healthdatainsights.com/home.aspx?Return
Url=%2f List of Excluded Individuals & Entities – LEIE
https://oig.hhs.gov/exclusions/index.asp
8 Elements of an Effective Compliance Program
Compliance Program Effectiveness At least annually, include the basic elements Measurement of various outcomes
Billing and Coding error rates Identified overpayments Audit results Training/Education
Reported out to the Audit and Compliance Committee and Board
8 Elements of an Effective Compliance Program
7. Response to detected offenses and prevention
Detected but uncorrected misconduct can seriously endanger the mission, reputation and an entities legal status
Steps to investigate the conduct in question is necessary to determine whether a violation has occurred
If a violation has occurred steps to correct the violation must be taken. These could included:
Referral to criminal and/or civil law enforcement Corrective Action Plan Reporting & Repayments of Overpayments – 60 days
8 Elements of an Effective Compliance Program
8. Ongoing risk assessment Conducted annually Focus is on identifying risk areas Identified by high, medium and low Includes face-to-face interviews with senior
leaders Revenue cycle Risk management Lab Pharmacy
Results of the risk assessment are used to develop compliance work plans and annual audit reviews.
LETS TAKE A CLOSER LOOK AT A FEW OF THE ELEMENTS
Not all Compliance Programs are Built the
Same
Hospital Physician Group/Office
Code of Conduct Complex, lengthy covering
multiple risk areas Professional production,
printed and/or distributed to all employees
Posted on the IntranetMade available or distributed to:
Board and Board committees
Medical Staff members Volunteers, Students,
Vendors, others
Code of Conduct Simple & Short Create a Word document
and print a few copies to have at the front desk and nursing station
Hold a meeting to implement to all employees
Element #1 – Written Policies and Procedures
Hospital Physician Group/Office
Policies and Standards• High, medium and
even lower risk areas• Areas requiring
special guidance• Address consistent
approach
Policy and StandardsMinimal written
policiesVery operations
focused
Element #1 – Written Policies and Procedures
Hospital Physician Group/Office
Billing for items or services not provided
Up-coding/Under-coding (Medical Necessity
DRG CreepCost ReportingRevenue Cycle AreasExcluded
Provider/Background Checking
Billing for items or services not provided
DocumentationMedical NecessityUp-coding/Under-codingMisuse of provider
identification numbersUnbundlingDouble-billing resulting
in duplicate payment
Risk Areas Addressed in Policies Include:
Hospital Physician Group/Office
Where does this person report? What is the line to the Board?
What other hats does the Compliance Officer wear? None Full time with additional staff
What is the committee structure and what is their charter? Board Audit and Compliance
committee Senior Leader Compliance
committee
Practice Manager will most likely oversee the compliance efforts and report to the ownership.
It is highly unlikely a compliance committee will exist.
Benefits – react to change quickly and low cost
Challenges – Lack of independence and will staff actually raise issues – due to fear of retaliation.
Element #2 – Compliance Program Oversight
Hospital Physician Group/Office
Use of on-line based learning
Annual Education Role based
education as neededPhysician education
programNewsletters and
Bulletins
Education at the time of employment
Education on the Code of conduct is enough
Conversations at staff meetings surrounding specific topics
Element #3 – Education and Training
Hospital Physician Group/Office
Formal Audit work planIncludes focus reviews
on high risk areas: Revenue Cycle Lab Pharmacy Physician Contracts
Regular reporting to Board, Audit and Compliance committee and senior leadership
Uses third-party billing company to perform periodic reviews of documentation and coding
Element #4 – Auditing and Monitoring
Hospital Physician Group/Office
Anonymous reporting
External hotlineFocus on non-
retaliationPoster in break
rooms or by time clocks
Lock box which can only be accessed by compliance officer
Physician(s) should help support a focus of non-retaliation during staff meetings.
Element #5 – Reporting/Communication
Implementation of a Compliance Program
Send a message that your organization operates in an ethical manner and is committed to quality customer and patient care.
Be there to Protect and Serve, not be there to police and intimidate
WHAT EXPERIENCE DOES A CODER NEED TO ENTER THE COMPLIANCE FIELD?
Coding Career Path to Compliance
Coding Career Path to Compliance
Compliance Specialist/Analyst Coding experience & Auditing Experience
Certified (CCS, CPC, CPC-H) and or RHIT is normally preferred 3 – 5 years in healthcare compliance, internal audit, coding, billing, finance
Data analytics Run reports and pick samples
Certified in Healthcare Compliance (CHC or equivalent) - normally don’t have to have it when hired, but within a certain time frame.
Ability to multi – task Multiple projects Putting out multiple “Fires” – start the day with a plan, this may
changeCommunication
Be able to deliver a concise message. Able to speak to an audience, at their level.
Coding Career Path to Compliance
Do you like to read the Federal Register and/or State and Federal Laws?
Are you able to interpret the regulations? http://www.cms.gov
Manuals Physician Fee Schedule Conditions of Participation – CoPs Conditions of Coverage - CfCs
https://www.federalregister.gov – Proposed and Final Rules Inpatient Perspective Payment System - IPPS Outpatient Perspective Payment System -OPPS
Coder Career Path to Compliance
Revised Code of Washington – RCW http://app.leg.wa.gov/rcw
Washington Administrative Code - WAC http://app.leg.wa.gov/wac/
Washington Healthcare Association http://www.hca.wa.gov/
Noridian Healthcare Solutions, LLC – A & B https://www.noridianmedicare.com/
Coder Career Path to Compliance
American Academy of Professional Coders – AAPC Certified Professional Compliance Officer –CPCO https://www.aapc.com
Health Care Compliance Association – HCCA CHC – Certified in Healthcare Compliance CHRC – Certified in Healthcare Research Compliance CHPC – Certified in Healthcare Privacy Compliance CCEP – Certified Compliance and Ethics Professional http://www.hcca-info.org
University of Washington Certificate in Healthcare Regulatory Compliance –
Continuing Education http://www.pce.uw.edu/certificates/health-care-regulatory-co
mpliance.html
Questions