TROKLUS - WARNER -- Compliance 101€¦ · Compliance 101 Debbie Troklus, CHC, University of...
Transcript of TROKLUS - WARNER -- Compliance 101€¦ · Compliance 101 Debbie Troklus, CHC, University of...
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Compliance 101
Debbie Troklus, CHC, University of
Louisville, School of Medicine
and Greg Warner, Mayo
Clinic
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Why Compliance Programs Are Essential
Communicate Organization’s CommitmentRaise AwarenessMitigating FactorAvoid CIAReduce Threat of Qui-Tams
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Compliance ProgramsHow Comprehensive Should They Be?Medicare Billing ComplianceEmployment/Labor LawEMTALASafetyHIPAAResearchOther Federal &/or State Laws
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How to Prevent Qui Tam Suits
Create an atmosphere that encourages compliance
Set up a hotline
Listen to employees
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A Compliance Program Provides:
EducationPreventionEarly DetectionCollaborationEnforcement
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What Is a Compliance Program?
Recommended by the GovernmentEthical and proper way to do businessCommitmentEncourage problems to be reportedA process with constant monitoring
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Who Needs a Compliance Program?Physician PracticesHospitalsLaboratoriesTeaching InstitutionsDME DistributorsHome Health Agencies/ HospicesOthers
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Organizational Steps to an Organizational Steps to an Effective Compliance ProgramEffective Compliance Program
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Gain Support / Commitment
BoardManagementProvidersStaff
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Financial Support
Development/Start-upEducational MaterialsStaffingOngoing Operations
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Develop Code of Conduct
Organizations ethical attitudeAddress weak areasLetter of endorsementChain of command
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Identify Staffing Needs
Appoint compliance officerDevelop job descriptions for staff
Supply vs. demandOversight CommitteeCounsel
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Conduct Internal Assessment
What is an assessment?Employee interviewsIdentify risk areas
– What is currently occurring?– Who is responsible?– What is the information flow?– What are areas for concern?
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Develop Mission and Goals
AchievableMeasurableCommunicate
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PDCA
PlanDo
CheckAct
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Continuous Improvement
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Case Study (30 min)
You are a new Compliance Officer and charged with implementing a compliance program over the next year. Develop a timeline for implementation along with an organizational chart.(“Regional Health System” 450 bed teaching hospital, two physician practices located within a 50 mile radius and one nursing home two blocks from the hospital)
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Seven Essential Elements of a Compliance PlanStandards and ProceduresOversightEducation and TrainingMonitoring and AuditingReportingEnforcement and DisciplineResponse and Prevention
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Standards and Procedures
Code of ConductKeep It SimpleOutline specific legal dutyAttestation
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Oversight
Compliance OfficerOversight CommitteeOther CommitteesBoard
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Education and Training
Communication ProcessInternal Vs. ExternalMandatory Vs. VoluntaryWeb Based TrainingSanctions
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Monitoring and Auditing
Program EffectivenessInternal “Audits”Compliance “Reviews”Outline Audit ProceduresStaff Training
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Reporting and Investigation
HotlinePolicies and Procedures
No Retribution for Reporting– Privacy and confidentiality
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Enforcement and Discipline
Sanctions for non-compliant behaviorConsistencyStand firmOIG sanctions reviews
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Response and Prevention
Internal InvestigationIs it really a problem?How serious is it?Are their enough facts to investigate?
Contact CounselInterviewCreate Policy
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Government Released Programswww.dhhs.gov/oig
Laboratory Hospital Home Health DMEHospice Nursing FacilitiesMedicare + ChoicePhysician OfficesThird Party Billing
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Health Care Fraud Efforts Continue
Enforcement environment --heightened scrutiny
Enforcement activity – Recoveries
Enforcement weapons
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Compliance Program Elements Where is your program?Federal Sentencing Guidelines l991
CEO and Board Oversight– Frequency of Reporting– Governance structure
Ownership-senior level down– Are sufficient resources allocated?– Are the compliance elements
integrated into performance? – How are compliance issues
reported and handled?Compliance Officer
– Is your CO still the “right fit”?– Personal & Professional Risk
OversightResponsibilities
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Compliance Program Elements(cont)
Discretionary authority delegated appropriately
Background checks
Due CareResponsibilities
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Additional “Due Care” Information
Identifying Arrangements with Sanctioned Providers
– Healthcare Integrity and Protection Data Bank
– OIG’s Cumulative Sanction List
– The GSA’s Department List
– Licensing and Certification Bodies at the State Level
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Compliance Program Elements (cont)
Are risk areas identified and policies developed?
Policy and procedure verification.
Policies “reduce” the prospect of criminal conduct?
Continuous evaluation.
ComplianceStandards andProcedures
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Compliance Program Elements(cont)
Commitment still present?Training geared to increasing
compliance knowledge of employees?
Training for high risk areas all covered?
Training incorporated into day to day business aspects?
Proof and documentation
EmployeeTraining
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Compliance Program Elements(cont)
Have you got an auditing plan?
Audit methodology, what type of audits are being done?
Has your program gone beyond the “process” audits?
Proactive vs. reactive audits
Monitoring andAuditing
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Compliance Program Elements(cont)
Audit strategy – protection of
workpapers and findings.
Results Reporting
Corrective Action and
verification.
Monitoring andAuditing
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Compliance Program Elements(cont)
Appropriate and consistent disciplinary mechanisms in place
Tracking system developed for disciplinary actions
Enforcement andDiscipline
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Compliance Program Elements(cont)
Appropriate and
consistent Reponses
Awareness of roles and
responsibilities
Disciplinary measures
Response andPrevention
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Summary
HCCA’s Annual Survey Summary Results
Benchmarking
Effectiveness Evaluations