Corporate Compliance

What Is it?

What Does It Mean To Me?

Purpose Of This Session

To provide attendees with an understanding of the regulatory environment in which the Agency operates

To provide an overview of Corporate Compliance and the components of a Corporate Compliance Plan

To provide attendees with an understanding of documentation requirements

Laws and Regulations

Employment and discrimination Governance, licensing & certification Protection from abuse Health and safety Physical environment Service provision Billing and reimbursement

Laws and Regulations

To comply with the laws and regulations, the Agency develops: Policies, Procedures Practices

What is Corporate Compliance?

A long term commitment by an organization to conduct business in a manner that promotes compliance, continually monitor for compliance, and create systems that allow it to be responsive to changes in the regulatory environment.

Regulatory History

Health Insurance Portability and Accountability Act of 1996 (HIPAA) Increased resources for detecting fraud Expanded power and authority of enforcement

agencies Creation of Health Integrity and Protection Data bank

Balanced Budget Act of 1997 (BBA) Agencies work together/share information Enhanced authority for exclusions Beneficiary Incentives 1-800 hotline for reporting fraud

Regulatory History

False Claims Act Enacted during Civil War, revised in

1986 Prohibits the submission of a false

claim or making a false statement in order to secure payment of a false or fraudulent claim from the Government

Fines of $5,500 - $11,000/claim

Medicaid

New York State by far spend the most in Medicaid dollars.

50 Billion Dollars. An average of $2000.00 per person in

Medicaid spending.

Qui Tam Actions

Under the False Claims Act, private persons file on behalf of the government. The qui tam relator (whistleblower) is entitled to 15%-25% of the amount if the government proceeds with the action, or 25%-30% of proceeds if the government does not proceed.

Deficit Reduction Act of 2006

Policies and Procedures are now a requirement for all applicable Medicaid Service providers

Emphasis is on fraud detection and prevention Training and Education of Staff regarding

False Claims Act Requirement for Protection of Whistleblowers Encourages State level “qui tam” actions under

False Claims Act provisions Enforcement of State Medicaid laws and

regulations is expected/required

Who’s Who?

Office of Inspector General (OIG) Health and Human Services (HHS) Center for Medicaid Services (CMS) Department of Justice (DOJ) Federal Bureau of Investigation (FBI) NYS Office of the Attorney General - Medicaid Fraud

Control Unit (MFCU) NYS Office of Medicaid Inspector General (OMIG) OMH/OPWDD/DOH/OASAS/SED

Office of the NY State Medicaid Inspector General (OMIG)

Created in 2005, is the first OMIG in nation at the state level

“To coordinate the Medicaid fraud, waste and abuse control activities of…DOH, OMH, OMR/DD, OASAS, OCFS, SED”

The False Claims Act

This statute prohibits, among other things:

knowingly presenting or causing to be presented a false or fraudulent claim for payment to the United States;

knowingly making or using, or causing to be made or used, a false record or statement to obtain payment on a false or fraudulent claim;

conspiring to defraud the United States by getting a false or fraudulent claim to be allowed or paid; and

knowingly making or using, or causing to be made or used, a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money or property to the government.

In Other Words ...

presenting a claim that the person knows or should know is false;

presenting a claim for services not provided as claimed;

upcoding; presenting claims for physician services not

provided by a physician; violation of anti-kickback legislation; contracting with someone excluded from a

federal health care program; and inducements to referrals or recipients of

service

Common Examples

Billing for a service that was not provided Billed for days the person was in hospital Documentation is false or inaccurate Billed for more service than provided Service is provided by unqualified staff Billed for service that is not authorized or

medically necessary Billed twice for the same service

The False Claims Act Penalties

This statute has teeth; it provides for treble (triple damages) damages and civil penalties of $5,500–$11,000 for each false or fraudulent claim presented for payment

Provider entities or individuals can face criminal or civil prosecution

Fraud

misrepresentation, omission, or concealment calculated to deceive.”

Abuse“...performing acts that are inconsistent with acceptable

business practices.”

Innocent Errors

No civil or criminal penalties. Provider must return the funds

erroneously claimed. Prosecution would require criminal

intent to defraud (criminal) or actual knowledge of the claim being false; reckless disregard or deliberate ignorance of the false claim (civil).

No One is Perfect!!!

Honest Mistakes and Innocent Errors Happen

You must be able to demonstrate how your internal controls are designed to assure compliance

Policies and Procedures relative to returning funds once errors are found

Demonstrate that $$$ has been returned in the past

Protections and Safeguards

Agency policies, procedures and practices

Educated, qualified and trained staff, Communication between

management, billing and program staff Internal controls Auditing and monitoring activities

Common Mistakes

Not documenting allowable services Not proving medical necessity Not supporting provision of planned services Allowing ineligible/inappropriate providers to

provide billed services Implementing unauthorized or expired

service/treatment plans Service/treatment plans lack specific

interventions/ activities Billing without service documentation

Service Documentation

Services must be documented “contemporaneously” with service delivery (at the same time or in close proximity)

Documentation must include required elements

Documentation must be permanent and legible (able to be read by a reviewer)

Documentation Do’s and Don’ts

DO Use full date (mm/dd/yy) Use signature and title on all entries Include date with your signature Use ink not pencil in records No use of “white out,” black markers, or

scribbling over….Draw a line, note error, sign and date!

Assure documentation is accurate

Documentation Do’s and Don’ts

DO Document service delivery promptly Document only for services you provided Only submit claims (billing) for services

provided Obtain proper authorization for services

Documentation Do’s and Don’ts

Don’t: Document in colored ink or pencil Document anything you have not actually

done or observed Leave labeled fields blank Use initials without corresponding signature

key Attempt to obliterate errors Alter previous documentation

Service Planning and Delivery

Services must be medically necessary Services must be authorized

ISP, IEP, Treatment Plan, Habilitation Plan, Service Plan, Prescription, MD order

Services must be reviewed as required

Service Planning and Delivery

Services must be delivered by trained and qualified staff and as specified in the service/treatment plan

The effectiveness of the service/treatment plan must be reviewed on a frequent and regular basis

The plan must be revised as necessary

Medical Necessity

Medicaid only pays for medically necessary services

Allowable services Based on diagnosis or disability Staff actions Goal driven Measurable Meaningful

Medical necessity must be clearly documented in every plan, note and summary in your program records to someone outside your program.

Keep in Mind…

Provider agrees to:(a) Prepare and maintain contemporaneous records demonstrating their right to receive payment…and keep, for 6 years from date care/service furnished, all records necessary to disclose the nature & extent of the service furnished and all information regarding claims for payment by, or on behalf of, the provider…

NYCRR Title 18, Section 504.3

Keep in Mind…

Provider agrees:(e) To submit claims for payment only for

services actually furnished and which were medically necessary…

(h) That the information provided in relation to any claim for payment shall be true, accurate and complete; and

(i) To comply with the rules, regulations and official directives of the department.

NYCRR Title 18, Section 504.3

Code of Conduct

Distributed to all employees with signed acknowledgment of receipt

Written in plain, understandable language Reviewed and revised with changes in

laws and regulations Written policies and procedures that

address key points in the Code of Conduct

Code of Conduct

Written code - applies to all employees and independent contractors

Clearly expresses commitment to compliance by board, management and all employees

Communicates commitment to comply with all federal and state laws, standards and regulations and the prevention of fraud and abuse

Clear expectations for board, management, employees, contractors and agents

Your Responsibilities

Attend required training(s) Read Agency’s Corporate Compliance Plan Read and follow Code of Conduct Comply with laws, regulations, and Agency’s

policies, procedures and practices Provide and document services according to

Service/Treatment Plans Report any issues, concerns or possible violations Keep in mind this training needs to be conducted on

an annual basis. Any Questions

Recent Events

NYS Attorney General Press Releases

AG Recovers $3.4 Million in Settlement from Buffalo-Area Mental Health Provider for Medicaid Over billing

7/14/00

Recent Events

AG Recovers $670,000 In settlement with Ulster County Alcoholism Treatment Center.

3/14/01

State Told to Pay Medicaid 436 Million Dollars

6/23/05 NY improperly billed Medicaid for Speech Therapy for services billed by NYC Dept of Education. Could not verify that services were

provided by qualified staff. 42 of 100 claims (42%) lacked adequate

documentation to determine if services were actually provided.

Recent Events

AG recovers $2.3 Million in settlement with Long Island

Substance Abuse Treatment Center

3/15/01

Recent Events

3/27/03 MSC arrested and charged with

$50.000 Medicaid fraud for billing for services documented but not provided.

3/19/04 Westchester Nurse Pads work Hours

in Health Care Fraud, receives $12,000 in funds.

Any questions

Thank You

Corporate Compliance Program

Definition

…is a set of formal organizational systems intended to prevent, detect and respond to misconduct committed by employees and other agents.

Benefits of a Compliance Plan

You find your ‘weaknesses’ before Medicaid does

(Early detection) Promotes ethical conduct Communicates agency’s commitment to

regulatory compliance Educated staff (Whistleblower lawsuit protection) Drives more efficient and effective operations Improves financial health of agency Defends the organization; may mitigate

paybacks/fines

7 Elements of a Compliance Plan

1. Written Policies and Procedures

2. Compliance Program Oversight

3. Training and Education

4. Effective, Confidential Communications

5. Enforcement of Compliance Standards

6. Auditing and Monitoring

7. Responding to Offenses & Developing a Corrective Action Plan

Written Policies and Procedures

Based on Laws, Regulations and Practices

Provides direction and guidance to staff Must adhere to them Need to be updated as laws and

regulations change Revise as necessary based results of

internal or external reviews

Corporate Compliance Policies and Procedures

Code of Conduct Conflict of Interest Billing and Reimbursement Education and Training Expense Reimbursement Exclusion or Sanction Screening Auditing and Monitoring Internal Reporting Mechanisms Responding to Governmental Investigations Document Retention and Destruction Enforcement of Compliance Standards/Discipline

Compliance Oversight

Compliance Officer and Compliance Committee

Board and Management Staff Effective methods to report

compliance-related issues

Compliance Officer Duties

Developing and implementing policies and procedures (P&P).

Overseeing and monitoring the implementation of the compliance plan on a regular basis.

Directing agency internal audits established to monitor effectiveness of compliance standards.

Providing guidance to management, medical/clinical personnel and individual departments regarding P&P and governmental laws, rules and regulations

Investigating compliance-related issues

Training and Education

Is Mandatory and Regular Includes

Content of Agency’s compliance plan Overview and importance of compliance Department specific risk areas Summary of fraud and abuse laws How to report non-compliance Confidentiality and non-retaliation for reporting

Effective, Confidential Communications

“Open Door” Policy to raise issues with Management

Methods to report actual or suspected non-compliance confidentially or anonymously

Non-retaliation for reporting actual or suspected non-compliance

Enforcement of Compliance Standards

Clear guidance for staff Supervision and monitoring Disciplinary action for non-compliance

with laws, regulations, policies, procedures and practices

Disciplinary action for failing to report actual or suspected non-compliance

Internal Auditing and Monitoring

Objective: Close gap between service delivery and billing Assure authorization for service (NOD. MD order, signed,

effective service/treatment plans) Process to assure documentation to support claims Staff meet qualifications Develop system that promotes adherence and reports

shortcomings back to programs Identify systemic and process problems Internalize findings Train Re-evaluate

Follow-up and Corrective Actions

Investigate reports of actual or suspected non-compliance

Report findings Develop corrective action plans Review for effectiveness