Webinar: Tips For Your 2012 Compliance Workplan

20 October 2011

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The Question:

What are you doing about, and how comfortable are you that, your current licensed staff is continuously qualified?

• Properly licensed• Have no Sanctions or Disciplinary Actions• Maintain required Certificates (ACLS, BLS, CPR)• Not Excluded or Debarred by OIG/GSA• Maintain proper Continuing Education• Files are ready for Joint Commission audit

Do you have one place to go to determine the above across your entire organization?

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HealthCare Qualification Challenges

• Licenses and Certificates managed separately• Government regulation of licenses & certificates • Reimbursement oversight (Medicare & Medicaid requirements)• Legal liability- Negligent Hire/Retention• Exposure to costly fines & judgments (OIG- CMP)• States do not alert employers of disciplinary action• New laws expand exclusions and scope of search• Joint Commission and State Audit- are you ready?

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The Law

• PPACA 6501- Excluded in One, Excluded in All

• CMS Guidelines- recommends, with guidance, monthly monitoring for exclusions

• State Medicaid Director Letter June 2009• Directing States to remind Providers (Employers) obligation to monitor

• State Medicaid Bulletins to Providers• Some states extend exclusions to referring or ordering physicians• NY requires searching for exclusions in adjacent States

Poll Question 1

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Fiscal Year 2012 HHS OIG Work Plan-Impact on Your Organizational Compliance

OIG will continue to pursue and fine organizations for Civil Fines and Penalties for non- compliance for Fraud and Abuse.

Billing CMS for services (directly or indirectly) by Excluded individuals/entities is considered Fraud and Abuse.

Your task is to ensure that your organization is not billing for Ineligible Persons who have been:

1. Excluded at a State or Federal Agency

2. Sanctioned or Disciplined-resulting in license revocation, suspension or exclusion

3. Not properly licensed to provide care

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What are your Risks?

• Inconsistent processes applied across the organization

• Not searching for records/sanctions/exclusions outside state of residence

• Reliance solely on the OIG LEIE and GSA Debarment lists

• Searching for exclusions upon hire and then not until renewal

• No reserves for Civil Fines and Penalties

• Staff is not properly trained on how to search or review possible matches

• Loss of CMS billing Privileges under PPACA 6502

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Risk Exposure: The cost of not “knowing”

Medicare/Medicaid billing participation• Up to $10,000 fine for each item/service billed• Treble (3x) damages• Possible exclusion• Charges under Federal False Claims Act

Legal liability • Negligent hire or retention• Loss of CMS Reimbursement Privileges (PPACA 6502)• State fines for practicing without a license

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Nationwide Exclusions Search: Why relying only upon OIG (LEIE) is a Risk

Audit: States reporting only 60.6% Exclusions/Sanctions to OIG

Note: • 11 States reported < 25%, 9 States reported > 75%• 19 State Medicaid Abuse Registries

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Why are persons excluded?

• Sexual Assault

• Patient Abuse

• Fraudulent Billing

• Failure to pay HEAL loans (NEW in 2011)

• Criminal convictions related to program

• Controlled Substance criminal convictions reported to Boards

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Most common Exclusion: License Revocation, Suspension

Poll Question 2

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Case Studies:

ProviderTrust experience: 2-3% in any organization experience some form of the following

• Disciplinary actions• Multi-state complaints and actions• Drug and alcohol disciplinary actions• Revoked licenses• Abuse reports• False Social Security numbers• Denied reinstatement

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2 Providers, Similar Exclusions, Different Treatment by OIG

• A recent case highlights the importance of timely self-disclosure when an employer discovers it has billed CMS for services provided by an Excluded Provider as well as how fines may differ for similar exclusions.

• In Maryland, two separate healthcare companies each employed and billed CMS for reimbursement of excluded providers.  However, each company approached the violation and reporting in different ways.  Their treatment by OIG reflects how they opted to cope with and self-disclose the issue.

• http://aishealth.com/archive/nmcn0711-01

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Licensed Employees Only?

American Senior Communities recently settled with the OIG for $376,000 for employing 7 excluded providers. Fines included CNAs and kitchen staff. oig.hhs.gov/publications/docs/press/2010/asc_cmp.pdf

Lessons Learned:

1. Better to self disclose than to be found by Medicaid Fraud Control Unit Investigators

2. Civil and Monetary Fines can, have been and will be imposed against non-licensed healthcare excluded workers (kitchen staff)

3. Providers must screen all employees for and against exclusions, regardless of title or function

4. No excuse for not knowing: Standard is 'knew or should have known”

5. Even though some excluded employees services are not directly reimbursed by CMS, fines and penalties are still imposed as “contributors” of care.

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What about Vendors/Suppliers?

• They can be excluded or debarred

• CMS recommends monthly monitoring for exclusions or debarments

• OIG can fine owners of Vendors/Suppliers• Important if company is sole proprietorship as well as if owner has been

excluded from large company

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What should your organization be doing and how often?

Match your facility or company requirement policies to primary source license and sanction data and required documents, certifications or education on healthcare professionals and vendors.

• On a monthly basis • Across all 50 States and applicable Federal data sets such as Medicaid, Medicare,

Licensing and Disciplinary Boards, and Excluded Parties (individuals and entities)• Covering approximately 1,400 Primary Source data sources.• Reporting matched cases for actionable decisions

• Ensuring your compliance with CMS Guidelines and the PPACA 6501 & 6502 at all

times.  

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Ensure Ongoing, Qualified Providers: Best Practice

• Ongoing monthly sanction & exclusion screening- All Employees/Vendors/Entities

• Ongoing monthly license verification-Licensed Employees

• Web-based Management of license/Certificate expirations

• Meet new Federal requirements under CMS guidelines & PPACA

• Consistent and Defensible Processes throughout Organization

ProviderTrust Demo

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Compliance Dashboard

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Monitor Dashboard

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Monitor Result Overview

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Monitor Result Overview