medicaid , medicare & third-party biller Compliance Training

2013 Annual Mental Health Compliance Training

medicaid, medicare & third-party biller Compliance Training

Medicaid, medicare & third-party biller Compliance Training Annual Compliance TrainingNavigation TipsYou must have your PCs sound on and close out all other programs from your PC.The navigation bar at the bottom of the slide will guide you through the training. When you finish the training course, you must complete and submit a certification/Acknowledgement Form in Module 5.

ANNUAL COMPLIANCE TRAINING Annual Compliance TrainingNavigation TipsYou must have your PCs sound on and close out all other programs from your PC.The navigation bar at the bottom of the slide will guide you through the training. When you finish the training course, you must complete and submit a certification/Acknowledgement Form in Module 5.EXITPREPARATIONCoordinate with your supervisor to have your phone covered/forwarded so you wont be interrupted.Schedule approximately 1 hour to complete the training.The training is narrated so headphones may help you focus and avoid distracting your co-workers.Have a pen and paper handy. If you have questions, write them down and at the end of the training, call or email the Compliance Officer.You must complete this entire mandatory training program before completing the Acknowledgement Form. Annual Compliance Training

PREPARATIONCoordinate with your supervisor to have your phone covered/forwarded so you wont be interrupted.Schedule approximately 1 hour to complete the training.The training is narrated so headphones may help you focus and avoid distracting your co-workers.Have a pen and paper handy. If you have questions, write them down and at the end of the training, call or email the Compliance Officer.You must complete this entire mandatory training program before completing the Acknowledgement Form. Annual Compliance TrainingEXITANNUAL COMPLIANCE TRAININGCOMPLIANCE OFFICE STAFF

Compliance Officer Barb [email protected](920) 674-8151

Compliance Analyst Attorney Scott [email protected](920) 674-8635

annual compliance training

COMPLIANCE OFFICE STAFF

Compliance Officer Barb [email protected](920) 674-8151

Compliance Analyst Attorney Scott [email protected](920) 674-8635

annual compliance trainingEXITTRAINING MODULES annual compliance training

What is Compliance?

Countys Compliance Program

False Claims Act

Integrity Agreement

Certification

ANNUAL COMPLIANCE TRAININGTRAINING MODULES annual compliance training

What is Compliance?

Countys Compliance Program

False Claims Act

Integrity Agreement

CertificationEXITMODULE 1

WHAT IS COMPLIANCE? annual compliance training

MODULE 1

WHAT IS COMPLIANCE? annual compliance trainingEXITWHAT IS COMPLIANCE?

Knowing and following Federal, State and County laws, regulations, rules, guidelines, policies and procedures that apply to our jobs.Think about the agencies that regulate or oversee your activities.Compliance is throughout all departments, divisions, programs that provide Mental Health Services.Includes contractors, their employees and subcontractors.annual compliance training

WHAT IS COMPLIANCE?

Knowing and following Federal, State and County laws, regulations, rules, guidelines, policies and procedures that apply to our jobs.Think about the agencies that regulate or oversee your activities.Compliance is throughout all departments, divisions, programs that provide Mental Health Services.Includes contractors, their employees and subcontractors.annual compliance training

EXITOVERVIEW OF THE HEALTH CARE INDUSTRY

Healthcare is Under Increased Scrutiny from Federal & State Governments.Estimated 10% of 1 Trillion spent on healthcare fraud/waste or abuseFederal and State healthcare programs facing financial difficulty

Government ResponseHealthcare is enforcement priorityGovernment personnel added and coordinated efforts (e.g. FBI, DOJ, OIG)New/tougher laws & regulations enacted including the Patient Protection & Affordable care Act of 2010 (the Healthcare Reform Act). The Act contains numerous provisions relating to healthcare fraud/waste/abuse, program integrity and new enforcement measures and resources. Also requires all healthcare providers participating in federal programs to establish and maintain a compliance program as a condition of their continued participation. annual compliance training

OVERVIEW OF THE HEALTH CARE INDUSTRY

Healthcare is Under Increased Scrutiny from Federal & State Governments.Estimated 10% of 1 Trillion spent on healthcare fraud/waste or abuseFederal and State healthcare programs facing financial difficulty

Government ResponseHealthcare is enforcement priorityGovernment personnel added and coordinated efforts (e.g. FBI, DOJ, OIG)New/tougher laws & regulations enacted including the Patient Protection & Affordable care Act of 2010 (the Healthcare Reform Act). The Act contains numerous provisions relating to healthcare fraud/waste/abuse, program integrity and new enforcement measures and resources. Also requires all healthcare providers participating in federal programs to establish and maintain a compliance program as a condition of their continued participation.annual compliance trainingEXITHEALTHCARE FRAUD & ABUSE

FRAUD

False statements of representation of facts to obtain payment/benefit to which not otherwise entitled.Committed for ones own benefit or on behalf of another.Must establish acts were performed knowingly, willfully and intentionally.Civil fraud violations have a lower standard of proof.Usually involve sanctions and financial penalties.

ABUSE

Practices that directly or indirectly result in unnecessary increased costs to clients.Medically unnecessary over- utilization.Not in conformance with industry standards.Fees that are unreasonable or unfair.Restrictive of patient choice.


HEALTHCARE FRAUD & ABUSE

FRAUD

False statements of representation of facts to obtain payment/benefit to which not otherwise entitled.Committed for ones own benefit or on behalf of another.Must establish acts were performed knowingly, willfully and intentionally.Civil fraud violations have a lower standard of proof.Usually involve sanctions and financial penalties.

ABUSE

Practices that directly or indirectly result in unnecessary increased costs to clients.Medically unnecessary over- utilization.Not in conformance with industry standards.Fees that are unreasonable or unfair.Restrictive of patient choice.

annual compliance trainingEXITRELEVANCE OF COMPLIANCE PROGRAMS

Government believes the best way to protect public healthcare dollars is to prevent fraud/abuse.

Educating individuals on the laws, regulations and organizations standards that apply to them in the workplace.

Encouraging individuals to ask questions or voice their concerns to the compliance officer.


RELEVANCE OF COMPLIANCE PROGRAMS

Government believes the best way to protect public healthcare dollars is to prevent fraud/abuse.

Educating individuals on the laws, regulations and organizations standards that apply to them in the workplace.

Encouraging individuals to ask questions or voice their concerns to the compliance officer.

annual compliance trainingEXITWHY ARE COMPLIANCE PROGRAMS IMPORTANT?

Promote open communication and problem resolution.

Maintain Federal, State, County and industry standards to comply with increased government regulations.

Demonstrate organizations commitment to comply with all legal and ethical responsibilities.

Keep pace with trend in the health care industry.


WHY ARE COMPLIANCE PROGRAMS IMPORTANT?

Promote open communication and problem resolution.

Maintain Federal, State, County and industry standards to comply with increased government regulations.

Demonstrate organizations commitment to comply with all legal and ethical responsibilities.

Keep pace with trend in the health care industry.

annual compliance trainingEXITELEMENTS OF A COMPLIANCE PROGRAM

annual compliance trainingCode of Conduct EthicsEmployees & Contractors

ELEMENTS OF A COMPLIANCE PROGRAM

annual compliance trainingCode of Conduct EthicsEmployees & ContractorsEXITMODULE 2JEFFERSON COUNTYS COMPLIANCE PROGRAM annual compliance training

MODULE 2JEFFERSON COUNTYS COMPLIANCE PROGRAM annual compliance trainingEXITANNUAL COMPLIANCE TRAININGJEFFERSON COUNTYS COMPLIANCE PROGRAM

Required by Title 42 CFR Section 438.6087 Specific RequirementsStandards & ProceduresCompliance Officer and CommitteeTraining and EducationCommunicationEnforcementInternal Monitoring/AuditingPrompt response/corrective action


JEFFERSON COUNTYS COMPLIANCE PROGRAM



JEFFERSON COUNTYS COMPLIANCE PROGRAM


annual compliance trainingEXITCOMPLIANCE REQUIREMENT #1: Standards & Procedures

Mission StatementCode of ConductCode of Ethics (For County employees only)

Click on the link below to view document at the end of training:Code of Conduct for Employees (section only)


COMPLIANCE REQUIREMENT #1: Standards & Procedures

Mission StatementCode of ConductCode of Ethics (For County employees only)

Click on the link below to view document at the end of training:Code of Conduct for Employees (section only)

annual compliance trainingEXITCOMPLIANCE REQUIREMENT #1: Standards & Procedures

Mission Statement: Jefferson County Human Services Department will comply with applicable laws, regulations, rules or guidelines governing the provision of mental health services. All employees and contractors, who provide and receive payment for mental health services, are expected to conduct themselves honestly, fairly and with a high degree of integrity.

Accordingly, the County has implemented a Compliance Program to ensure, to the extent reasonably possible, that all employees invoke a high degree of business honesty and integrity required of health care professionals and providers. In addition, this program has been instituted as a means of preventing fraud, abuse and false billings to any third-party payer.

Strict adherence to the Compliance Program is expected of all mental health employees and contractors.


COMPLIANCE REQUIREMENT #1: Standards & Procedures

Mission Statement: Jefferson County Human Services Department will comply with applicable laws, regulations, rules or guidelines governing the provision of mental health services. All employees and contractors, who provide and receive payment for mental health services, are expected to conduct themselves honestly, fairly and with a high degree of integrity.

Accordingly, the County has implemented a Compliance Program to ensure, to the extent reasonably possible, that all employees invoke a high degree of business honesty and integrity required of health care professionals and providers. In addition, this program has been instituted as a means of preventing fraud, abuse and false billings to any third-party payer.

Strict adherence to the Compliance Program is expected of all mental health employees and contractors.

annual compliance trainingEXITCOMPLIANCE REQUIREMENT #1: Standards & ProceduresConduct Standards

The County is committed to full compliance with all applicable laws, regulations, rules and guidelines that apply to its mental health operations and services.Employee and contractor conduct is at the core of this commitment.County employees and contractors must adhere to:The Code of Conduct and the Compliance ProgramCounty employees must also adhere to the countys Code of Ethics.


COMPLIANCE REQUIREMENT #1: Standards & ProceduresConduct Standards

The County is committed to full compliance with all applicable laws, regulations, rules and guidelines that apply to its mental health operations and services.Employee and contractor conduct is at the core of this commitment.County employees and contractors must adhere to:The Code of Conduct and the Compliance ProgramCounty employees must also adhere to the countys Code of Ethics.

annual compliance trainingEXITCOMPLIANCE REQUIREMENT #1: Standards & ProceduresCode of ConductCountys behavior expectationsCountys commitment to its employees and contractors and to promote compliance with all applicable laws, etc.Familiarize staff with the basic legal principles of ethical standards of behavior expected in the provision, documentation, coding or billing of mental health services.Code of EthicsEstablished by the Board of SupervisorsApplies to all county employees


COMPLIANCE REQUIREMENT #1: Standards & ProceduresCode of ConductCountys behavior expectationsCountys commitment to its employees and contractors and to promote compliance with all applicable laws, etc.Familiarize staff with the basic legal principles of ethical standards of behavior expected in the provision, documentation, coding or billing of mental health services.Code of EthicsEstablished by the Board of SupervisorsApplies to all county employees

annual compliance trainingEXITCOMPLIANCE REQUIREMENT #1: Standards & ProceduresCertification

All employees and contractors must sign the Acknowledgement and Agreement Form and submit it to the Compliance Officer.

Form and instructions are in Module 5.


COMPLIANCE REQUIREMENT #1: Standards & ProceduresCertification

All employees and contractors must sign the Acknowledgement and Agreement Form and submit it to the Compliance Officer.

Form and instructions are in Module 5.

annual compliance trainingEXITCOMPLIANCE REQUIREMENT #1: Standards & ProceduresDocumenting Compliance Activities

Protects integrity of the compliance process and confirms the effectiveness of the Compliance Program.Must document, at a minimum:TrainingsInvestigationsAnonymous ReportingSelf-disclosureModifications to the Compliance ProgramResults of the Countys auditing/monitoring efforts


COMPLIANCE REQUIREMENT #1: Standards & ProceduresDocumenting Compliance Activities

Protects integrity of the compliance process and confirms the effectiveness of the Compliance Program.Must document, at a minimum:TrainingsInvestigationsAnonymous ReportingSelf-disclosureModifications to the Compliance ProgramResults of the Countys auditing/monitoring efforts

annual compliance trainingEXITCOMPLIANCE REQUIREMENT #2: Compliance Officer and CommitteeCompliance Officer Responsibilities

Oversight of the Compliance ProgramEstablish and maintain the Code of Conduct & Policies and ProceduresChair the Compliance CommitteeEnsure an ongoing training/education programEstablish auditing/monitoring proceduresCompliance investigationsPromote awareness and understanding of the positive, ethical and moral practices consistent with the mission and values of the county and those required by applicable laws, regulations, rules or guidelines.Report findings to the Agency Director. annual compliance training

COMPLIANCE REQUIREMENT #2: Compliance Officer and CommitteeCompliance Officer Responsibilities

Oversight of the Compliance ProgramEstablish and maintain the Code of Conduct & Policies and ProceduresChair the Compliance CommitteeEnsure an ongoing training/education programEstablish auditing/monitoring proceduresCompliance investigationsPromote awareness and understanding of the positive, ethical and moral practices consistent with the mission and values of the county and those required by applicable laws, regulations, rules or guidelines.Report findings to the Agency Director. annual compliance trainingEXITCOMPLIANCE REQUIREMENT #2: Compliance Officer

The Compliance Officer has the full authority to stop any work process that may be the cause of, or is contributing to non-compliance, until the process has been reviewed and/or corrected, if needed. annual compliance training

COMPLIANCE REQUIREMENT #2: Compliance Officer

The Compliance Officer has the full authority to stop any work process that may be the cause of, or is contributing to non-compliance, until the process has been reviewed and/or corrected, if needed. annual compliance training

EXITCOMPLIANCE REQUIREMENT #2: Compliance Officer & CommitteeCompliance Committee

Responsibilities include:Organizational SupportPromote awareness of the Compliance ProgramAdvise the Compliance OfficerImplement the Compliance ProgramMonitor/assess effectiveness of compliance with applicable laws, etc.Address areas of concern or risk


COMPLIANCE REQUIREMENT #2: Compliance Officer & CommitteeCompliance Committee

Responsibilities include:Organizational SupportPromote awareness of the Compliance ProgramAdvise the Compliance OfficerImplement the Compliance ProgramMonitor/assess effectiveness of compliance with applicable laws, etc.Address areas of concern or risk

annual compliance trainingEXITEmployee & Contractor Roles & Responsibilities in Compliance

Help the county operate a successful Compliance ProgramComply with the Code of Conduct & Code of EthicsAdhere to the Compliance Program and all applicable laws, rules, regulations, guidelines, policies and proceduresReport a violation or suspected violation. annual compliance training

Employee & Contractor Roles & Responsibilities in Compliance

Help the county operate a successful Compliance ProgramComply with the Code of Conduct & Code of EthicsAdhere to the Compliance Program and all applicable laws, rules, regulations, guidelines, policies and proceduresReport a violation or suspected violation. annual compliance trainingEXITCOMPLIANCE REQUIREMENT #3: Training & Education

All county employees and contractors, including contractors employees and subcontractors, must be trained and retrained to keep abreast of changes in Federal, State and County laws, rules regulation, policies and procedures.


COMPLIANCE REQUIREMENT #3: Training & Education

All county employees and contractors, including contractors employees and subcontractors, must be trained and retrained to keep abreast of changes in Federal, State and County laws, rules regulation, policies and procedures.


EXITCOMPLIANCE REQUIREMENT #3: Training & Education

Timelines:Within 30 days of hire or contract effective dateAnnually

General Compliance Training

Mandatory for all employees & contractors who:Provide mental health servicesWork in any mental health program or paid with MH $$Are responsible for the billing, claiming, accounting or cost reporting of mental health services


COMPLIANCE REQUIREMENT #3: Training & Education

Timelines:Within 30 days of hire or contract effective dateAnnually

General Compliance Training

Mandatory for all employees & contractors who:Provide mental health servicesWork in any mental health program or paid with MH $$Are responsible for the billing, claiming, accounting or cost reporting of mental health services

annual compliance trainingEXITCOMPLIANCE REQUIREMENT #4: Communication

Maintain open lines of communicationAnnual trainingsPost the Code of Ethics and Code of ConductPost information regarding options for reporting compliance violations or concerns anonymouslyNon-retaliation Policy


COMPLIANCE REQUIREMENT #4: Communication

Maintain open lines of communicationAnnual trainingsPost the Code of Ethics and Code of ConductPost information regarding options for reporting compliance violations or concerns anonymouslyNon-retaliation Policy


Reporting Violations

Employees and contractors are EXPECTED To report any activity that may violate the Compliance Programs mission, standards and any applicable law, regulation, rule or guideline. annual compliance training


Reporting Violations

Employees and contractors are EXPECTED To report any activity that may violate the Compliance Programs mission, standards and any applicable law, regulation, rule or guideline. annual compliance training

EXITCOMPLIANCE REQUIREMENT #4: Communication

Non-Retaliation Policy

Jefferson County prohibits retaliation against any person making a report.Any employee engaging in any form of retaliation will be subject to disciplinary action.For a contractor engaging in any form of retaliation, termination of their contract may result.



Non-Retaliation Policy

Jefferson County prohibits retaliation against any person making a report.Any employee engaging in any form of retaliation will be subject to disciplinary action.For a contractor engaging in any form of retaliation, termination of their contract may result.


Disclosure Program

Reporting MethodsAnonymously:Mail: Barb Mottl, Compliance Officer 1541 Annex Road Jefferson, WI 53549

Direct to the Compliance OfficerPhone (920) 674-8151Email: [email protected]



Disclosure Program

Reporting MethodsAnonymously:Mail: Barb Mottl, Compliance Officer 1541 Annex Road Jefferson, WI 53549

Direct to the Compliance OfficerPhone (920) 674-8151Email: [email protected]

annual compliance trainingEXITAnonymous Reporting Scenario

Steve White has falsified documentation. He documented and billed for services for days he wasnt even at work. His supervisor lets him get away with it. Someone needs to look into this.

Q) Does this report contain sufficient information to begin an effective investigation? annual compliance training

Anonymous Reporting Scenario


Q) Does this report contain sufficient information to begin an effective investigation? annual compliance training

EXITAnonymous Reporting Scenario


A) No - the information provided lacks the detailed need to effectively investigate the concern: Who? What? Where? When? Why? How?




A) No - the information provided lacks the detailed need to effectively investigate the concern: Who? What? Where? When? Why? How?



Steve White, an LCSW who works for the ABC Clinic on Plaza Street, has falsified documentation. He documented and billed for services for 11/20, 12/7 & 8 which are days he wasnt even at work. I mentioned my concern to Ron Wood, his supervisor, but Ron said that hes too busy to keep track of everyone and besides, he trusts Steve.

Q) Does the anonymous report contain sufficient information to begin an effective investigation? annual compliance training



Q) Does the anonymous report contain sufficient information to begin an effective investigation? annual compliance training



A) Yes, it provides answers to Who? What? Where? When? Why? How?




A) Yes, it provides answers to Who? What? Where? When? Why? How?


EXITCode of Conduct

Question:

You have a compliance concern and/or believe that a fraudulent activity is occurring. What should you do?

Select the best answer below:Dont report and see if the fraudulent activity stops.Report your concerns to your supervisor or department head.Immediately report your concerns to the Compliance Officer.Any of the above.


Code of Conduct

Question:

You have a compliance concern and/or believe that a fraudulent activity is occurring. What should you do?

Select the best answer below:Dont report and see if the fraudulent activity stops.Report your concerns to your supervisor or department head.Immediately report your concerns to the Compliance Officer.Any of the above.

annual compliance trainingEXITCOMPLIANCE REQUIREMENT #5: Enforcement

Fair, reasonable but enforcedCommunicate enforcement & discipline standardsProhibits prejudice, bias or other non-standard conductEmployee subject to appropriate disciplinary action by his/her department head

County Personnel Rules (HR0540) and progressive discipline used:Oral, Written, Suspension w/o pay, Salary Reduction, Demotion, Dismissal annual compliance training

COMPLIANCE REQUIREMENT #5: Enforcement

Fair, reasonable but enforcedCommunicate enforcement & discipline standardsProhibits prejudice, bias or other non-standard conductEmployee subject to appropriate disciplinary action by his/her department head

County Personnel Rules (HR0540) and progressive discipline used:Oral, Written, Suspension w/o pay, Salary Reduction, Demotion, Dismissal annual compliance trainingEXITCOMPLIANCE REQUIREMENT #6: Internal Monitoring & Auditing

Reviews conducted to measure compliance with:Billing and CodingExclusion ListCompliance EducationMedical ReviewsOperating Licenses Clinical Staff LicensureCorrection Documentation

Report findings to Compliance Officer, Compliance Committee and Director, as required.

Click on the link below to view document at the end of training:Internal Compliance Review and Monitoring


COMPLIANCE REQUIREMENT #6: Internal Monitoring & Auditing

Reviews conducted to measure compliance with:Billing and CodingExclusion ListCompliance EducationMedical ReviewsOperating Licenses Clinical Staff LicensureCorrection Documentation

Report findings to Compliance Officer, Compliance Committee and Director, as required.

Click on the link below to view document at the end of training:Internal Compliance Review and Monitoring

annual compliance trainingEXITCOMPLIANCE REQUIREMENT #6: Internal Monitoring & Auditing

Background & Sanction ScreeningLicensing boards and National Practitioner DatabanksEnsures that the county does not hire or contract with an individual or entity that is suspended or excluded from Federal healthcare programs.County's Sanction Screening Policy to identify suspended or excluded persons:Screen all prospective employees, contractors and volunteers/interns against the exclusion list prior to hire/contract/engaging their services and bi-annually thereafter.Exclusions lists:HHS OIG List of Excluded Individuals/Entities (LEIE)System for Award Management Exclusion Report (SAM)



Background & Sanction ScreeningLicensing boards and National Practitioner DatabanksEnsures that the county does not hire or contract with an individual or entity that is suspended or excluded from Federal healthcare programs.County's Sanction Screening Policy to identify suspended or excluded persons:Screen all prospective employees, contractors and volunteers/interns against the exclusion list prior to hire/contract/engaging their services and bi-annually thereafter.Exclusions lists:HHS OIG List of Excluded Individuals/Entities (LEIE)System for Award Management Exclusion Report (SAM)

annual compliance trainingEXITCOMPLIANCE REQUIREMENT #6: Internal Monitoring & Auditing

Other areas monitored/audited:Disclosure ProgramBilling Committee decisionsBusiness Office functions/processesModifications/updates to EHR systemCost Reports annual compliance training


Other areas monitored/audited:Disclosure ProgramBilling Committee decisionsBusiness Office functions/processesModifications/updates to EHR systemCost Reports annual compliance trainingEXITCOMPLIANCE REQUIREMENT #7: Response & Corrective Action

Prompt InvestigationCorrective ActionFollow-upFurther ActionPrompt Refund of Overpayments annual compliance training

COMPLIANCE REQUIREMENT #7: Response & Corrective Action

Prompt InvestigationCorrective ActionFollow-upFurther ActionPrompt Refund of Overpayments annual compliance trainingEXITCOMPLIANCE PROGRAM REVIEW

The purpose of the Countys Code of Conduct is to:Promote the countys commitment to compliance.State the countys behavior expectations, legal standards and ethical requirements.Address all county mental health employees, volunteers and contractors (including contractors staff).All of the above. annual compliance training

COMPLIANCE PROGRAM REVIEW

The purpose of the Countys Code of Conduct is to:Promote the countys commitment to compliance.State the countys behavior expectations, legal standards and ethical requirements.Address all county mental health employees, volunteers and contractors (including contractors staff).All of the above. annual compliance trainingEXITCOMPLIANCE PROGRAM REVIEW

The purpose of the Countys Code of Conduct is to:Promote the countys commitment to compliance.State the countys behavior expectations, legal standards and ethical requirements.Address all county mental health employees, volunteers and contractors (including contractors staff).All of the above. annual compliance training


The purpose of the Countys Code of Conduct is to:Promote the countys commitment to compliance.State the countys behavior expectations, legal standards and ethical requirements.Address all county mental health employees, volunteers and contractors (including contractors staff).All of the above. annual compliance trainingEXITCOMPLIANCE PROGRAM REVIEW

What is the role of the Compliance Committee? To assist and advise the Compliance Officer.To assist in the development or review of compliance related policy and procedures.To rule on appropriate discipline for compliance violation issues.To assist in the implementation of the Compliance Progam.All of the above.A, B & D only. annual compliance training


What is the role of the Compliance Committee? To assist and advise the Compliance Officer.To assist in the development or review of compliance related policy and procedures.To rule on appropriate discipline for compliance violation issues.To assist in the implementation of the Compliance Progam.All of the above.A, B & D only. annual compliance trainingEXITCOMPLIANCE PROGRAM REVIEW

What is the role of the Compliance Committee? To assist and advise the Compliance Officer.To assist in the development or review of compliance related policy and procedures.To rule on appropriate discipline for compliance violation issues.To assist in the implementation of the Compliance Progam.All of the above.A, B & D only. annual compliance training


What is the role of the Compliance Committee? To assist and advise the Compliance Officer.To assist in the development or review of compliance related policy and procedures.To rule on appropriate discipline for compliance violation issues.To assist in the implementation of the Compliance Progam.All of the above.A, B & D only. annual compliance trainingEXITCOMPLIANCE PROGRAM REVIEW

We have the right to report breaches without fear of retaliation?

TRUEOrFALSE annual compliance training



TRUEOrFALSE annual compliance trainingEXITCOMPLIANCE PROGRAM REVIEW






For county employees, discipline for a violation of a compliance issue falls outside the normal disciplinary process?









TRUEOrFALSE annual compliance trainingEXITMODULE 3False Claims Act annual compliance training

MODULE 3False Claims Act annual compliance trainingEXITFALSE CLAIMS ACT

Accuracy is critical in our billing/claim documents because the specific intent to defraud is NOT required under the Federal and State False Claims Act.


FALSE CLAIMS ACT

Accuracy is critical in our billing/claim documents because the specific intent to defraud is NOT required under the Federal and State False Claims Act.

annual compliance trainingEXITFederal Civil False Claims31 U.S.C. SECTION 3729(A)

Any person who knowingly presents, or causes to be presented to the Federal Government a false claim, is liable to the U.S. Government for a civil penalty, for EACH claim of not less than $5,000 and not more than $10,000, plus three times the amount of the damages.

For Example: Erroneous billings of 120 claims for $12,000 could result in a penalty of over $1.2 million. annual compliance training

Federal Civil False Claims31 U.S.C. SECTION 3729(A)

Any person who knowingly presents, or causes to be presented to the Federal Government a false claim, is liable to the U.S. Government for a civil penalty, for EACH claim of not less than $5,000 and not more than $10,000, plus three times the amount of the damages.

For Example: Erroneous billings of 120 claims for $12,000 could result in a penalty of over $1.2 million. annual compliance trainingEXITFederal False Claims Act31 U.S.C. SECTION 3730

Includes provisions that allow a private citizen (relator) to file suit alleging false claims on behalf of the relator and the government. This is known as:Qui Tam Action annual compliance training

Federal False Claims Act31 U.S.C. SECTION 3730

Includes provisions that allow a private citizen (relator) to file suit alleging false claims on behalf of the relator and the government. This is known as:Qui Tam Action annual compliance trainingEXITFederal Whistleblower Protection31 U.S.C. SECTION 3730(h)

Provides protection to employeesagainst discharge, demotionsuspension, threats, harassmentor discrimination by the employer,for cooperating with or stating aFalse Claims Act investigation. annual compliance training

Federal Whistleblower Protection31 U.S.C. SECTION 3730(h)

Provides protection to employeesagainst discharge, demotionsuspension, threats, harassmentor discrimination by the employer,for cooperating with or stating aFalse Claims Act investigation. annual compliance training

EXITFederal Criminal False Claims18 U.S.C. SECTION 1035

Criminalizes false or fictitious statements involving a Federal health care benefit program.

PENALTIESup to 5 years in prison, and/or$25,000 fine. annual compliance training

Federal Criminal False Claims18 U.S.C. SECTION 1035

Criminalizes false or fictitious statements involving a Federal health care benefit program.

PENALTIESup to 5 years in prison, and/or$25,000 fine. annual compliance trainingEXITEXITWisconsin False Claims Act2007 Wisconsin Act 20

Section 20.931 of Wisconsin Statutes applies to claims made to any officer, employee or agency of this state.. annual compliance training

Wisconsin False Claims Act2007 Wisconsin Act 20

Section 20.931 of Wisconsin Statutes applies to claims made to any officer, employee or agency of this state.. annual compliance training

EXITWisconsin False Claims Act

The federal Deficit Reduction Act of 2005 provided states with a financial incentive to pursue more civil fraud cases against Medical Assistance providers.

WI Act 20:Establishes civil liability for individuals or entities that submit false or fraudulent claims to the Medical Assistance program;

Requires civil penalties of three times the amount of damages sustained by the State, and assessments of at least $5,000 but no more than $10,000 for each violation; and

. annual compliance training

Wisconsin False Claims Act

The federal Deficit Reduction Act of 2005 provided states with a financial incentive to pursue more civil fraud cases against Medical Assistance providers.

WI Act 20:Establishes civil liability for individuals or entities that submit false or fraudulent claims to the Medical Assistance program;

Requires civil penalties of three times the amount of damages sustained by the State, and assessments of at least $5,000 but no more than $10,000 for each violation; and

. annual compliance trainingEXITWisconsin False Claims Act

The Wisconsin False Claims Act also includes provisions that allow a private citizen to bring a civil action for violation of this article as a qui tam plaintiff

The Act rewards individuals who bring a case to civil court on the States behalf against another person or entity for making a false or fraudulent claim for Medical Assistance, including rewards of at least 15% but not more than 30% of any proceeds of the action or settlement of the claim.

. annual compliance training

Wisconsin False Claims Act

The Wisconsin False Claims Act also includes provisions that allow a private citizen to bring a civil action for violation of this article as a qui tam plaintiff

The Act rewards individuals who bring a case to civil court on the States behalf against another person or entity for making a false or fraudulent claim for Medical Assistance, including rewards of at least 15% but not more than 30% of any proceeds of the action or settlement of the claim.

. annual compliance trainingEXITWisconsin Whistleblower ProtectionsAn employer may not discharge, discipline, retaliate against or otherwise discriminate against an employee because the employee has exercised certain rights, filed a complaint, or testified or assisted in an enforcement action relating to a violation of the states labor laws. Government workers are also protected if they exercise their free speech rights by publicly disclosing information about believed violations of any state or federal law; mismanagement or abuse of authority in state government; a substantial waste of public funds; or a danger to public health or safety. In addition, workers may sue their employer in circuit court for damages, court costs and attorney fees. Citations: Sections 46.90, 50.07, 111.322, 230.80-230.89, and 895.65, Wisconsin Statutes.


Wisconsin Whistleblower ProtectionsAn employer may not discharge, discipline, retaliate against or otherwise discriminate against an employee because the employee has exercised certain rights, filed a complaint, or testified or assisted in an enforcement action relating to a violation of the states labor laws. Government workers are also protected if they exercise their free speech rights by publicly disclosing information about believed violations of any state or federal law; mismanagement or abuse of authority in state government; a substantial waste of public funds; or a danger to public health or safety. In addition, workers may sue their employer in circuit court for damages, court costs and attorney fees. Citations: Sections 46.90, 50.07, 111.322, 230.80-230.89, and 895.65, Wisconsin Statutes.

annual compliance trainingEXITRecent Cases/Convictions Related to Healthcare Fraud

MILWAUKEE - September 29, 2009, a Milwaukee business owner entered a plea of guilty to one count of felony Medical Assistance Fraud. The charge is against Quality Life Care Management, a Medicaid funded business entity that was expected to help Medicaid recipients obtain the services they need. According to the Criminal Complaint filed by the Department of Justice, the companys owner billed the Medicaid program for more hours than were actually worked by company employees. Company payroll records show that between June 2005 and November 2005, Medicaid was billed for 5,617 more hours than were actually worked causing $141,275.00 in overpayments by the program.

The business owner was sentenced to 12 months in the House of Corrections and ordered to repay $141,275.00 in the Medicaid program and $14,474 in court obligations. This was investigated by the WI DOJ. annual compliance training

Recent Cases/Convictions Related to Healthcare Fraud

MILWAUKEE - September 29, 2009, a Milwaukee business owner entered a plea of guilty to one count of felony Medical Assistance Fraud. The charge is against Quality Life Care Management, a Medicaid funded business entity that was expected to help Medicaid recipients obtain the services they need. According to the Criminal Complaint filed by the Department of Justice, the companys owner billed the Medicaid program for more hours than were actually worked by company employees. Company payroll records show that between June 2005 and November 2005, Medicaid was billed for 5,617 more hours than were actually worked causing $141,275.00 in overpayments by the program.

The business owner was sentenced to 12 months in the House of Corrections and ordered to repay $141,275.00 in the Medicaid program and $14,474 in court obligations. This was investigated by the WI DOJ. annual compliance trainingEXITRecent Cases/Convictions Related to Healthcare Fraud

Whistle-blower case on hospice fraud settled for $25 million

JS Online: Milwaukee - March 1, 2012 One of the nation's largest providers of hospice care has agreed to pay $25 million to settle a Medicare fraud case initiated after a former company nurse in Milwaukee filed a whistle-blower suit. It was the second such settlement in six years for the healthcare organization which paid the federal government $12.5 million in 2006 after another Wisconsin-based employee sued.

The whistle blowers don't do too badly, either. Under the False Claims Act, they are entitled to a cut of the recovery and will share about $4.6 million. annual compliance training

Recent Cases/Convictions Related to Healthcare Fraud

Whistle-blower case on hospice fraud settled for $25 million

JS Online: Milwaukee - March 1, 2012 One of the nation's largest providers of hospice care has agreed to pay $25 million to settle a Medicare fraud case initiated after a former company nurse in Milwaukee filed a whistle-blower suit. It was the second such settlement in six years for the healthcare organization which paid the federal government $12.5 million in 2006 after another Wisconsin-based employee sued.

The whistle blowers don't do too badly, either. Under the False Claims Act, they are entitled to a cut of the recovery and will share about $4.6 million. annual compliance trainingEXITSummary

Legal authority for government investigations comes from:Federal False Claims ActFederal Criminal False Claims ProvisionsWI Act 20: False Claims ActIntent is NOT necessary for false claims liability. Penalties can be:Civil monetary penaltiesCriminal prosecution and prison timeBoth Federal and Wisconsin laws contain whistleblower protections


Summary

Legal authority for government investigations comes from:Federal False Claims ActFederal Criminal False Claims ProvisionsWI Act 20: False Claims ActIntent is NOT necessary for false claims liability. Penalties can be:Civil monetary penaltiesCriminal prosecution and prison timeBoth Federal and Wisconsin laws contain whistleblower protections

annual compliance trainingEXITMODULE 4Integrity Agreements

integrity1. adherence to moral and ethical principles; soundness of moral character; honesty. 2. the state of being whole, entire, or undiminished: to preserve the integrity of the empire. 3. a sound, unimpaired, or perfect condition: the integrity of a ship's hull annual compliance training

MODULE 4Integrity Agreements

integrity1. adherence to moral and ethical principles; soundness of moral character; honesty. 2. the state of being whole, entire, or undiminished: to preserve the integrity of the empire. 3. a sound, unimpaired, or perfect condition: the integrity of a ship's hullannual compliance trainingEXITWhat is an Integrity Agreement?

Negotiated compliance obligations between the U.S. Office of Inspector General (OIG) and health care providers.Provider consents to these obligations as part of the civil settlement. In exchange, the OIG agrees not to exclude that provider from participation in Federal health care programs (Medicare and Medicaid).OIG has permissive exclusion authority under the False Claims Act or Civil Monetary Penalties Law.Typical term is 5 years.These compliance measures seek to ensure the integrity of Federal health care program claims submitted by the provider.annual compliance training

What is an Integrity Agreement?

Negotiated compliance obligations between the U.S. Office of Inspector General (OIG) and health care providers.Provider consents to these obligations as part of the civil settlement. In exchange, the OIG agrees not to exclude that provider from participation in Federal health care programs (Medicare and Medicaid).OIG has permissive exclusion authority under the False Claims Act or Civil Monetary Penalties Law.Typical term is 5 years.These compliance measures seek to ensure the integrity of Federal health care program claims submitted by the provider. annual compliance trainingEXITIntegrity Agreements are a result of a Medicare or Medicaid fraud investigation when problems are discovered:

Examples of problems:Non-covered services Incorrect units of service Services were not providedDocumentation is missing

Results:Repayment of erroneous billingsPayment of penalties and attorney feesImplement of an Integrity Agreement (5 years)


Integrity Agreements are a result of a Medicare or Medicaid fraud investigation when problems are discovered:

Examples of problems:Non-covered services Incorrect units of service Services were not providedDocumentation is missing

Results:Repayment of erroneous billingsPayment of penalties and attorney feesImplement of an Integrity Agreement (5 years)

annual compliance trainingEXITIf Jefferson County is ever subject to an Integrity Agreement, once it concludes, the county can never be subject to another in the future?

TRUEOfFALSE


If Jefferson County is ever subject to an Integrity Agreement, once it concludes, the county can never be subject to another in the future?

TRUEOfFALSE

annual compliance trainingEXITIf Jefferson County is ever subject to an Integrity Agreement, once it concludes, the county can never be subject to another in the future?

TRUEOfFALSE


If Jefferson County is ever subject to an Integrity Agreement, once it concludes, the county can never be subject to another in the future?

TRUEOfFALSE

annual compliance trainingEXITJefferson County could be excluded from participating in Federal Healthcare Program for failing to meet documentation & Billing Standards during a Federal or State Review?

TRUEOfFALSE


Jefferson County could be excluded from participating in Federal Healthcare Program for failing to meet documentation & Billing Standards during a Federal or State Review?

TRUEOfFALSE

annual compliance trainingEXITEXITJefferson County could be excluded from participating in Federal Healthcare Program for failing to meet Documentation & Billing Standards during a Federal or State Review?

TRUEOfFALSE


Jefferson County could be excluded from participating in Federal Healthcare Program for failing to meet Documentation & Billing Standards during a Federal or State Review?

TRUEOfFALSE

annual compliance trainingEXITMODULE 5Certification


MODULE 5Certification

annual compliance trainingEXITCertification Instructions

Click here to access the Acknowledgement Form.Print, complete and sign the form.Keep a copy for your records.Send the original, signed form to the Compliance Officer:County employees use interoffice mail;Contractors mail to:

Barb Mottl, Compliance Officer1541 Annex RoadJefferson, WI 53549

Press Esc in upper left corner of keyboard to end training


Certification Instructions

Click here to access the Acknowledgement Form.Print, complete and sign the form.Keep a copy for your records.Send the original, signed form to the Compliance Officer:County employees use interoffice mail;Contractors mail to:

Barb Mottl, Compliance Officer1541 Annex RoadJefferson, WI 53549

Press Esc in upper left corner of keyboard to end training

annual compliance trainingEXITIf you have any questions, please contact the Compliance Office:

(920) 674-8151 Barb Mottl

Thank you! annual compliance training

medicaid , medicare & third-party biller Compliance Training

Documents

Transcript of medicaid , medicare & third-party biller Compliance Training