SC Data and Compliance 2014

What Works Today?

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Michelle Sipple, Familylinks

Mary Jane Fletcher, Lenape Valley Foundation

Dan Sausman, CMU

Joel Goldberg, Quality Progressions

Presenters

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Is this YOU?

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Compliance plans establish guidelines and policies around Standards of Conduct:◦ Quality of Care and Services◦ Coding and Billing◦ Workplace Conduct and Employment Practices◦ Adhering to Laws and Regulations◦ Potential Conflict of Interest◦ Protecting Agency Assets

◦ A good compliance plan is the cornerstone of your agency and establishes a culture of accountability.

What do we mean by Compliance?

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The agency has a commitment to ethical business practices

Encourages a culture of awareness and quality It is important to follow local, state, and

federal regulatory standards Documentation needs to be accurate What we do is important and matters-we are

professionals who are held to high standards We have policies that reflect this message We monitor ourselves

An Enforced Compliance Plan Shows:

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Introduction/Purpose Items to consider:

Policies and Procedures Risk HIPAA Security Need for compliance officer/committee Training and education Communication Disciplinary action Auditing and Monitoring Self-reporting

General Outline of a Compliance Plan:

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Review Compliance plan and policies and have staff sign-off on acknowledgement

Review internal policies related to compliance

Review applicable laws and regulations

Review internal procedures for monitoring and oversight of compliance

The plan should be reviewed and updated at least annually

Be proactive-not reactive

Best Practice Procedures

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“Whistleblower” (43 Pa. Cons. Stat. §§ 1421 to 1428)

Work Conduct Billing Harassment Confidentiality and HIPAA Fraud, Waste, and Abuse Diversity and Inclusion Grievance Resolution Conflict of Interest

Policy checklist

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Show the Good, the Bad and the Ugly Snapshot of Where We Are Now Tools for Performance Evaluations – more

objective than subjective Improved Fiscal Accountability Allows for a quick response when things

aren’t going well Shows which staff are on the mark and

helps pinpoint who isn’t and what areas need improvement

Compliance Plans:

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Build your plan based on ODP mandated timelines, frequencies and quality mandates.◦ Monitoring – frequency and location◦ Monitoring – 14 days◦ Service notes – content and timeframe (7 days)◦ ISP’s

90, 45, 30 days out Invitation letters Meeting Date

◦ PUNS – 364 days ◦ SCO Monitoring◦ Customer Satisfaction Surveys

SCO’s and Compliance

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Balancing act between fiscal viability, quality and compliance You can do all three – but it’s not easy:

◦ Mandates change◦ Inconsistencies between AE’s, counties, and

regions◦ Staff change◦ Policies change◦ Conflict between what Providers want and what

AE’s tell SCOs to do

SCO’s and Compliance

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One goal…create a compliance plan

How each agency began and implemented their plans….

Four agencies….

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Corporate Compliance Plan ◦ Created to meet the needs of the MH, ID and EI Departments

globally SCO Compliance plan

◦ Created to meet ODP required standards and measures◦ Specific to SCO’s needs◦ Moving Target – changes as ODP changes◦ Requires intense quality management and tools◦ Quarterly and Annual QM Plan Reviews

Both Plans◦ Reviewed Annually and updated as needed◦ Quality stems from compliance◦ Agency culture at all levels◦ Annual training for SCs on both plans

One Agency-Two Plans

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Timeline Cheat Sheet Checklist Cheat Sheet ISP Timeline Spreadsheet Monitoring Spreadsheet Service Note Log Service Note Templates Productivity Calendar PUNS Due Date Cheat Sheet 6 Month Reviews List

Tools for Staff

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Pre-populated Supervision Note Weekly Individual SC Unit Review Data Warehouse & HCSIS reports –

manipulated to give individual statistics Monthly “Chart” Compliance Reviews

◦ Includes consumer/family satisfaction calls Weekly

◦ Unfinalized PUNS◦ Pending Monitors◦ Units per week by each SC

Tools for Management

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Monthly Utilization Reviews◦ Weekly during 4th quarter of FY

Data Extract Reviews – billable vs non-billable, units billed, zero units review

Quality reviews of service notes, ISP content, monitoring tools, closing the loop

Performance Improvement Plans SC Performance Checklist – reviews all

aspects of the job and scores them.

More Reviews and Tools

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Corporate Compliance Plan (2005)

◦ Establishes Corporate Compliance Plan Committee – Monthly meeting.

◦ Promotes agency culture of “prevention, detection & resolution.”

◦ Directs the operation of routine, ongoing monitoring & auditing procedures.

◦ Assures training at hire and on an annual basis, at minimum, for all staff.

CMU

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Compliance Reports

◦ SC Service Compliance Reviews: Provided directly to SCs & SC Supervisors. Incorporated into 1:1 supervision with SCs by the

SC Supervisors.

HCSIS Extract Reports

◦ Service Notes: Timeliness Productivity

CMU

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Random Customer Service/Compliance Reviews:

◦Completed by SC Supervisor - Contact with individual/family. Satisfaction. Verification of contact.

◦Audit of supporting documentation - Review of HCSIS Documentation, Quality of

Service Note. Crosswalk to time sheet. Crosswalk to travel log.

CMU

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Incorporate culture of compliance into all activities:◦ Routine support & supervision for SC’s.◦ Training / Staff Meetings.◦ Claims review/resolution activities.

Set high standards & be true to them: ◦ Talk about it all the time – assure SC’s not only

understand what, but also understand why. ◦ Proactive: Training & counseling.◦ Reactive: Discipline/Termination.

CMU

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• Agency started in 2004.

• Standards developed from the beginning

• Standards and expectations have evolved as has ODP

• Balance quality and compliance

• Make a difference

Organizational Overview

Standards & Expectations

• Standards and expectations are trained upon hire.

• All staff members are re-trained on an annual basis.

• By all managers with different parts of orientation.

• Training is focused on integrity and

compliance.

• Integrity is also discussed at all monthly staff

meetings.

• Agency reputation is at stake!

QP Online Database

• ISP Compliance

• Service Notes/ Units

• PUNS

• Utilization

• Monitoring Compliance

• Eligibility (Physicals, Recertifications,

Redeterminations)

Service Notes

• Quality - Documenting service delivery and issues

• Outcome progression and issue resolution

• Compliance - Acting as a Medicaid claim

• Productivity – Oversight and assurance of TSM

productivity

standards and billing integrity

• Timeline Compliance/ weekly reconciliation of work

time

Remember

• Be accurate

• Be honest

• Make a difference in the lives of consumers

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Created in 2009

Annual Training for SC’s and part of our new hire orientation

Work with our Director of QI around accreditation and CQI

Has assisted in terminations/unemployment

Familylinks Plan

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ISP Clean up report-monthly ISP Outstanding report-monthly ISP Monthly report-monthly for following month due dates Bi-annual compliance report Service note management review-monthly to check billing

status SC utilization report-monthly or weekly (last quarter of fiscal

year) Pending Revision report-daily Unit Discrepancy Report-weekly (compares DOS to units billed) Waiver/Sub-category discrepancy report (compares TSM

category to waiver category in HCSIS)-weekly Service Note Review-weekly for quality and compliance Monthly Compliance Reports-7 areas of compliance

Familylinks SC Sample Reports that can assist in monitoring compliance:

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Office of Inspector General www.oig.hhs.gov

Health Care Compliance Association www.hcca-info.org

Laws relevant to compliance--Federal laws identified in Section 6032(A); Pennsylvania laws imposing civil or criminal penalties for false claims and statements, and about whistleblower protections under such laws, including 62 P.S. §§ 1407 (relating to provider prohibited acts, criminal penalties and civil remedies) and 1408 (relating to other prohibited acts, criminal penalties and civil remedies), and the Pennsylvania Whistleblower Law, 43 P.S. §§ 1421-1428;

Resources

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Where are we now…Concluding thoughts

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Questions/ Comments?

Conclusion