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Minutes of the meeting of the Audit and Compliance Committee of the Board of Directors of the Cook County Health and Hospitals System held Thursday, June 16, 2016 at the hour of 8:30 A.M. at 1900 W. Polk Street, in the Second Floor Conference Room, Chicago, Illinois.
I. Attendance/Call to Order
Chairman Velasquez called the meeting to order. Present: Chairman Carmen Velasquez and Director Ada Mary Gugenheim (2) Absent: Director Emilie N. Junge (1) Additional attendees and/or presenters were: Cathy Bodnar – Chief Corporate Compliance and
Privacy Officer Douglas Elwell – Deputy CEO of Finance and
Strategy
Pat Kitchen - RSM Jeff McCutchan – Interim General Counsel Deborah Santana – Secretary to the Board Tom Schroeder – Director of Internal Audit
II. Public Speakers
Chairman Velasquez asked the Secretary to call upon the registered public speakers. The Secretary responded that there were none present.
III. Report from Chief Corporate Compliance and Privacy Officer (Attachment #1)
Cathy Bodnar, Chief Corporate Compliance and Privacy Officer, provided an overview of the information contained in the report. The Committee discussed the information. The report included information on the following subjects:
• Fiscal Year to Date 2016 Corporate Compliance Provider Metrics
-Reactive Corporate Compliance Volumes -Reactive Issue Breakdown by Category -Status Report of Issues
• Infusion Clinic Review -Recovery Audit Contractors -Corporate Compliance Process -Infusion Clinic Review Results
During the discussion of the information on the Infusion Clinic Review, Chairman Velasquez inquired regarding other audits planned for the future by Corporate Compliance. Ms. Bodnar responded that the Department plans to look at some evaluation and management of outpatient activity; this involves evaluation and management codes and outpatient procedures. A probe review will be done; she has proposed looking at 25 providers and 25 claims. She has just started to discuss the plans for the review, and will be speaking with Debra Carey, Chief Operating Officer, Ambulatory Services, and Dr. Claudia Fegan, Executive Medical Director/Medical Director-Stroger, to see if perhaps there are certain areas that they would like Corporate Compliance to look at. Chairman Velasquez stated that, in addition, she would like an audit done on ICD-10; she is aware that the organization has embraced ICD-10, but the Committee needs to know how it is being implemented. Ms. Bodnar responded affirmatively; she will work with the Finance Department to plan and complete the review.
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Minutes of the Meeting of the Audit and Compliance Committee Thursday, June 16, 2016
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IV. Action Items
A. Minutes of the Audit and Compliance Committee Meeting, May 19, 2016
Director Gugenheim, seconded by Chairman Velasquez, moved to accept the minutes of the Audit and Compliance Committee Meeting of May 19, 2016. THE MOTION CARRIED UNANIMOUSLY.
B. Any items listed under Sections IV and V
V. Closed Meeting Items
A. Report from Director of Internal Audit
B. Discussion of draft CCHHS Audited Financial Statements, for the year ended November 30, 2015, with external auditors
C. Discussion of Personnel Matters
Director Gugenheim, seconded by Chairman Velasquez, moved to recess the open meeting and convene into a closed meeting, pursuant to the following exceptions to the Illinois Open Meetings Act: 5 ILCS 120/2(c)(1), regarding “the appointment, employment, compensation, discipline, performance, or dismissal of specific employees of the public body or legal counsel for the public body, including hearing testimony on a complaint lodged against an employee of the public body or against legal counsel for the public body to determine its validity,” and 5 ILCS 120/2(c)(29), regarding “meetings between internal or external auditors and governmental audit committees, finance committees, and their equivalents, when the discussion involves internal control weaknesses, identification of potential fraud risk areas, known or suspected frauds, and fraud interviews conducted in accordance with generally accepted auditing standards of the United States of America.” THE MOTION CARRIED UNANIMOUSLY. Chairman Velasquez declared that the closed meeting was adjourned. The Committee reconvened into the open meeting.
VI. Adjourn
As the agenda was exhausted, Chairman Velasquez declared that the meeting was ADJOURNED.
Respectfully submitted,
Audit and Compliance Committee of the Board of Directors of the Cook County Health and Hospitals System XXXXXXXXXXXXXXXXXXXXXX Carmen Velasquez, Chairman
Attest:
XXXXXXXXXXXXXXXXXXXXXX Deborah Santana, Secretary
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Cook County Health and Hospitals System Audit and Compliance Committee Meeting Minutes
June 16, 2016
ATTACHMENT #1
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AUDIT & COMPLIANCE COMMITTEE OF THE CCHHS
BOARD OF DIRECTORS
Corporate Compliance Report June 16, 2016
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To Receive and File: § Fiscal Year to Date (F-‐YTD) 2016 Corporate Compliance
Provider Metrics o 1st & 2nd Quarter 2016 (December 1, 2015 – May 31, 2016)
To provide: § Results of Infusion Clinic Probe Review
MeeMng ObjecMves
Audit & Compliance CommiRee of the Board I June 16, 2016 2
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FY 2010 FY 2011 FY 2012 FY 2013 FY 2014 FY 2015 F-‐YTD 16
88 121 196 210
358 371 273
ReacMve Corporate Compliance Volumes Comparison of First 6-‐Months F-‐YTD to F-‐YTD
December 1, 2015 – May 31, 2016
Audit & Compliance CommiRee of the Board I June 16, 2016 3
The addiMon of CountyCare reacMve issues � the count to 346
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HIPAA 38%
Accurate Books 6%
Conflict of Interest 7%
HC Fraud 4%
Human Resources
21%
Research 1%
Other 12%
The] 1%
Regulatory/Policy 10%
False Claims 1%
Category Count1
Privacy (HIPAA) 104 Conflict of Interest 20 False Claims 3 Other 33 Human Resources 55 Accurate Books 17 Theft 3 Regulatory/Policy 27 HC Fraud 10 Research 1
1 This is a total count of new issues raised to Corporate Compliance. Not all issues are validated/substantiated. 4
ReacMve Issue Breakdown by Category 2731 ReacMve Corporate Compliance Issues raised in the first 6-‐months of FY 2016
Audit & Compliance CommiRee of the Board I June 16, 2016
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20 or 7% Open Issues
153
55
45
253 or 93% Resolved
Issues Managed Internally Partnered with Another Area Referred to Other Areas
The majority of the resolved issues, 86%, were either managed solely by Corporate Compliance or Corporate Compliance partnered with another area to address the concern raised.
5 Audit & Compliance CommiRee of the Board I June 16, 2016
Status Report of Issues Of the total number of reacMve issues addressed in the first 6-‐months of FY 2016
93% or 253 issues were resolved
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QuesMons?
6 Audit & Compliance CommiRee of the Board I June 16, 2016
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Claims accuracy analysis § What? Chemotherapy medicaMon (HercepMn) for breast cancer that has
spread to other parts of the body.
Audit & Compliance CommiRee of the Board I June 16, 2016 7
Infusion Clinic Review
§ Why? � Medicare only pays for the exact amount administered. The
medicaMon is dispensed in mulMuse vials. � PrompMng increased government scruMny. � Recovery Audit Contractor (RAC) acMvity at CCHHS.
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§ Who? � Four (4) private companies that run Medicare’s Recovery Audit
Program.
§ What do RACs do? � Review claims on a post-‐payment basis. � IdenMfy improper payments from Medicare Part A and B claims. � Request and analyze provider claim documentaMon to ensure
services provided were reasonable and necessary.
Audit & Compliance CommiRee of the Board I June 16, 2016 8
Recovery Audit Contractors
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Audit & Compliance CommiRee of the Board I June 16, 2016 9
Corporate Compliance Process
IdenCfy Focus Area/ Develop Plan
Select Sample
Obtain Complete Records
Perform Review
Analyze Data & Generate Reports
Report Findings
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Audit & Compliance CommiRee of the Board I June 16, 2016 10
Infusion Clinic Review Results
§ Sample: 20 claims based on a staMsMcally valid random test sample.
§ Results: Financial Error Rate 0%
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QuesMons?
11 Audit & Compliance CommiRee of the Board I June 16, 2016
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