Transcript Compliance Program

Ensure tomorrow...
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Comply today
Corporate Compliance
Board Training
2015
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Upon completion of this presentation
you should:
1. Understand the core requirements of the Agency’s
Corporate Compliance Program;
2. Understand the definitions of fraud, waste and abuse
(FWA) as they pertain to the Agency and its programs;
3. Understand your role in Corporate Compliance;
4. Understand the key processes of the Agency’s
corporate risk management strategy.
What are the key laws that
ACCMHS must comply with?
 Health Insurance Portability and Accountability Act of 1996, (HIPAA)
 Michigan Medical Records Access Act, Public Act 47 of 2004 (i.e. the
Michigan HIPAA Law)
 Michigan Mental Health Code Act 258 of the Public Acts of 1974
 Civil Rights Act of 1964
 Rehabilitation Act of 1973
 Americans with Disabilities Act of 1990
 Social Security Act, specifically 1903(m)(95)(i)
 HHS-OIG Compliance Program Advisories
 Guidelines for Addressing Medicaid Fraud and Abuse in Managed Care
issued by the Department of Health and Human Services (HHS)
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Affordable Care Act (Public Law 111-148; 111-152 of 2010)
Deficit Reduction Act of 2005 (DRA)
Civil False Claims Act of 1863/As amended in 1986 (FCA)
Medicaid False Claims Act of 1977
Michigan False Claims Act (Act 72 of 1977) (MFCA)
Anti-Kickback Statute of 1977
Whistleblowers Protection Act of 1980
Civil Monetary Penalties Law of 1981
Stark I Laws of 1989 and Stark II of 1993
Balanced Budget Act of 1997
HITECH Act of 2009
Healthcare Fraud and Abuse Commission Act of 1993
 MDCH Contract and Medicaid Manual requirements
 Other federal and state laws applicable to health plans
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Part I
Deficit Reduction Act and
other Federal & State Laws
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So…..where did all this begin?
In February 1998, The Office of Inspector
General (OIG) developed voluntary
Compliance Program Guidance (CPG) that
health care plans and providers could use to
detect and address waste, fraud, and abuse.
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In 2005, Congress passed the Deficit
Reduction Act (DRA). The legislation
resulted in the establishment of a 5-year
comprehensive plan to further combat
provider fraud, waste, and abuse in the
Medicaid program.
As a result, Corporate Compliance went
from voluntary to mandatory.
Deficit Reduction Act (DRA)
Federal False Claims Act
 First signed into law in 1863 in the wake of Civil
War Anyone who violates the FCA is liable for a
civil penalty of $5,500 to $11,000 per claim, plus
three times the amount paid.
 A person violating the FCA can be liable for the
costs of a civil action brought to recover any
penalties or damages.
 Violators can be excluded from participating in
Medicare, Medicaid, and other government
programs.
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The Federal False Claims Act applies when
an organization or person:
 Knowingly presents the government with a false claim
for payment;
 Knowingly makes a false statement to get a fraudulent
claim paid;
 Conspires to defraud the government by getting a false
claim paid by the government;
 Knowingly makes a false record or statement to
conceal, avoid, or decrease an obligation to pay the
Government; and/or
 “Causes” a false claim to be submitted.
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Federal False Claims Act
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 “Knowingly” includes:
1. actual knowledge that the information on the claim is
false;
2. acting in deliberate ignorance of the truth or falsity of
the information on the claim; or
3. acting with “reckless disregard” to the truth or falsity
of the claim.
Deliberate intent to defraud is not required.
Michigan False Claims Act
 This law is similar to the Federal False Claims Act.
 Authorizes the Attorney General to investigate
alleged violations of this act.
 Provides for civil actions to recover money received
by reason of fraudulent conduct.
 Provides for certain civil fines; and prescribes
remedies and penalties.
 Prohibits fraud in the obtaining of benefits or
payments in connection with the Medicaid program.
 Prohibits kickbacks or bribes in connection with the
Medicaid program.
 Prohibits conspiracies in obtaining benefits or
payments.
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How common is Fraud?
In 2014, the Office of Inspector General
reported:
Expected recoveries of over $4.9 billion,
consisting of nearly $834.7 million as a
result of ongoing audits, and about $4.1
billion as a result of fraud investigations.
Identified about $15.7 billion in savings on
the basis of prior legislative, regulatory, or
administrative actions.
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How common is Fraud? (con’t)
In 2014, the Office of Inspector General
reported:
Exclusions of 4,017 individuals and entities
from participation in federal healthcare
programs;
971 criminal actions against individuals or
entities;
533 civil actions, which included settlements,
as a result of self disclosures or administrative
recoveries.
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“Hot” Fraud Areas in the US
The OIG’s HEAT Program (Health Care
Fraud Prevention and Enforcement Action
Team) has identified:
Top 3 Fraud Prone States as Florida,
Louisiana, and Texas.
Top 10 Fraud Prone Cities include
Detroit and Chicago.
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Fraud in the mental health field??
Sorry, but yes……
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 February 2015 – Detroit – Psychotherapist admitted to using
Medicare information and identities of hundreds of
Medicare beneficiaries, without their consent, to submit
claims for psychotherapy services not provided. Also
admitted to using personal information of licensed social
workers, without their consent , which he used to submit
false claims to Medicare. Social workers had not provided
the care for which he submitted claims. Admitted to
submitting $3.3 million in fraudulent claims, and Medicare
paid $1,453,064 for those claims.
Fraud in the mental health field… (con’t)
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 October 2014 – Miami – Physician Assistant at a MH
partial hospitalization program. PA and conspirators
submitted false and fraudulent claims. PA and other
medical professionals fabricated and signed fraudulent
medical documents and patient files to justify billings to
Medicare. This included submitting claims for patients
who were ineligible for PHP treatment because of
‘vegetative states, in the late stages of disease causing
permanent cognitive memory loss, or had substance abuse
issues and were living in halfway houses.”
Fraud in the mental health field… (con’t)
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January 2013 – Missouri Mental Health Clinic –
Psychotherapist sentenced to 36 months imprisonment and
ordered to pay $1 million in restitution for fraud. Submitted
claims for daily or near daily psychotherapy services for
which he was paid $1.3 million. He admitted to seeing clients
less frequent and admitted to forging or causing another
person to forge signatures on sign-in sheets.
June 2013 – Florida Psychiatric Hospital – CEO and 3
hospital executives were convicted of a $67 million Medicare
fraud scheme. Unlawfully obtained Medicare payments by
fraudulent claims, falsified patient records, and administering
of unnecessary psychotropic medications.
Whistleblowers’ Protection Act
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 A law that provides protection to employees who report a
violation or suspected violation of state, local, or federal
law.
 Provides protection to employees who participate in
hearings, investigations, legislative inquiries, or court
actions; and prescribes remedies and penalties.
 An employer shall not discharge, threaten, or otherwise
discriminate against an employee because the employee
reports or is about to report a violation.
 An employer shall post notices and use other appropriate
means to keep employees informed of Whistleblowers’
protections.
Part II
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Corporate
Compliance
Program
So, why should ACCMHS have a
Compliance Program?
Required by law for agencies receiving over $5.0
million dollars in Medicaid and/or Medicare
funding;
Reduces the risk of unlawful or improper conduct;
Establishes an effective method to assess and
manage risks;
Reduces the potential for civil suits liability if
violations occur, and financial and other costs of
litigation;
Establishes a mechanism for employee training
thereby increasing their awareness and decreasing
the possibility to breach the law.
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What are the Seven Elements of an
Effective Compliance Program?
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From the OIG Compliance Program Guidelines and the
Affordable Care Act:
1. Implement a written Compliance Program, Policies, and
Plan.
2. Designate a Compliance Officer and Compliance
Committee.
3. Conduct effective training and education.
4. Maintain effective communication.
5. Perform internal monitoring and auditing.
6. Enforce standards through well-publicized disciplinary
guidelines.
7. Respond promptly to detected offenses.
Who is responsible for ensuring the
effectiveness of the compliance program?
Everyone!!!!!!
ACCMHS:
 Board
 Management Team
 Consumers
 Supervisors
 Staff
 Providers
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Who is responsible for ensuring the
overall management of the ACCMHS
Compliance Program?
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The Compliance Director and the Compliance
Officer: serve as the focal points for all Agency
compliance activities.
The Compliance Director and the Compliance
Officer: must be high-level staff with direct access to
the Executive Director and the ACCMHS Board.
Who Has Specific Responsibilities for Ensuring
the Effectiveness of the Compliance Program?
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Corporate Compliance Committee
 Compliance Director - Debra Trout
 Compliance/Security Officer - Patrick Thebert-Wright
 Privacy Officer – Angela Weeks
 Reimbursement Coordinator - Lynn Yetman
Ad Hoc Members
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Executive Director - Marianne Huff
Finance Director – Gary Smith
Clinical Director – Richard Thiemkey
Director of DD Services – Robin Lavender
Human Resource Director - Nan Lawrence
RR Officer – Meghan Launius
Compliance Program Functions
Train ACCMHS Board, staff, and providers in
the culture of compliance.
Use audits and monitoring techniques to identify
agency risks.
Investigate allegations of waste, fraud, abuse, and
other compliance infractions.
Take corrective action, including recommending
staff discipline, claims paybacks/adjustments, and
changes to address systemic problems.
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What is Fraud?
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Per 42 CRF (Code of Federal Regulations):
Fraud is an intentional deception or misrepresentation made by
someone with knowledge that the deception will result in benefit
or financial gain.
Per Michigan statute and case law interpretation:
Under Michigan Law, a finding of Medicaid fraud can be based
upon evidence that a person ‘should have been aware that the
nature of his or her conduct constituted a false claim for
Medicaid benefits.” But errors or mistakes do not constitute
‘knowing’ conduct necessary to establish Medicaid fraud, unless
the person’s “course of conduct indicates a systematic or
persistence tendency to cause inaccuracies to be present.”
Fraud Examples
 Billing for services that were never provided.
 Billing for individual therapy when group therapy
was provided.
 Billing for Durable Medical Equipment (“DME”)
and supplies were never obtained.
 Documentation of a service provided is proof
that the service occurred; consequently, billing for
a service without documentation may be
construed by the Centers for Medicaid and
Medicare Services as fraud.
“If it’s not documented, it didn’t happen.”
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What is Abuse?
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 “Abuse” is
provider practices that are inconsistent
with sound fiscal, business, or clinical practices, and
result in an unnecessary cost to the Medicaid
programs, or in reimbursement for services that are
not medically necessary or that fail to meet
professionally recognized standards of care. It also
includes beneficiary practices that result in
unnecessary cost to the Medicaid program.
 Red Flag Caution: Provider ignorance is not always accepted
by the OIG. The matter may be reclassified to fraud if the
auditor believes the staff/provider did not make an attempt or
take prudent action to learn the rules important to their
organization’s federally funded business. (i.e., having an ongoing staff training program on corporate compliance laws
helps keep findings classified as abuse.)
Potential Fraud/Abuse Examples
Improper behaviors or billing practices;
physician kickbacks for unnecessary services,
illegal referrals including physicians who refer
for health care services to entities in which the
physician has a financial interest.
Assumption that billing is being done correctly
as long as claims were paid; no internal checks
are implemented to validate claims submissions.
Inflation of costs for services, medical
equipment, drugs, etc. without documentation to
substantiate those costs.
Providing services at an inflated rate and that are
not medically necessary, in order to obtain
additional revenue.
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Waste
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 Waste includes any practice that results in an unnecessary
or consumption of federally-funded financial or clinical
resources.
Examples:
 Supporting individual copiers and printers with a diversity of
cartridge and toner needs, rather than pursuing a cost-savings by
installing suite-wide copiers/printers.
 No comparative pricing and/or excessive use of office supplies.
 Scheduling consumer contacts in the community without
considering the possibility of scheduling according to proximity
within the county. This increases both staff time and mileage
reimbursement.
 Meetings that are non-productive or could be shortened in
length.
ACCMHS Action and
Coordination with Law Enforcement
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ACCMHS will always investigate suspected fraud and
abuse, as appropriate, report to and cooperate with the
PIHP, Federal and State agencies, including MDCH,
OIG, AG, CMS, and/or law enforcement.
ACCMHS will require corrective action with any
staff/provider when either fraud, abuse or waste issues are
substantiated, up to and including termination of
employment or termination of the contract.
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Board, Staff and Providers Reporting of Compliance Issues
Everyone has an obligation to make a
good faith effort to report any activity
that appears to violate compliance
policies and/or procedures.
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Board, Staff and Providers – Reporting of
Potential Compliance Issues (con’t)
Anyone may report potential compliance issues to
ACCMHS by:
• Notifying their supervisor,
• Contacting the ACCMHS Compliance Officer,
• Contacting any member of the ACCMHS
Corporate Compliance Committee.
If preferred, potential compliance issues may be reported to
the Lakeshore Regional Partners PIHP.
Nothing will happen to anyone who reports in good faith.
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Board, Staff and Providers Reporting Potential Compliance Issues (con’t)
To contact ACCMHS Compliance Officer:
• Phone: 269-673-6617, ext. 2722
• E-mail: [email protected]
• In writing (either anonymously or with your name): use
interoffice mail addressed to Compliance Officer at
CSB. The CC Suspected Violation form may be used,
but any other format is also acceptable.
• PIHP (Lakeshore Regional Partners) 1-855-350-5501
Part III
Corporate Compliance includes:
RISK MANAGEMENT
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Risk Management
A Risk Management Program is a sub-part of the
Compliance Program and must be established in
accordance with the Medicaid Managed Specialty
Supports and Services Concurrent 1915 (b)/(c) Waiver
and the MDCH/PIHP Contract.
RISK MANAGEMENT is a logical and systematic
method of identifying, analyzing, prioritizing,
treating, and monitoring the risks involved in any
organizations activities or processes.
Risk Management Process
Eight Components:
1) Establish the Context (risk categories)
2) Identify the Risks
3) Analyze the Risks
4) Evaluate (Prioritize) the Risks
5) Treat the Risks
6) Communicate & Consult (on-going)
7) Monitor and Review (on-going)
8) Reassess risk categories (start cycle over)
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Categories of Risks
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There are a number of categories within risk management.
These include:
 Risks of injury (to persons served, staff and the public)
 Risks to the service user experience (appeals/complaints)
 Risks to compliance with standards and regulations
 Risks to business organization (e.g. lawsuits; bankruptcy)
 Risks to organizational reputation
 Risk to finances (claims payback, audit adjustments, fines)
 Risk to the program environment (hazards, fires, threats, etc.)
 Risks to the Workforce (turnover, absenteeism, sick time,
lack of skill sets/trainings)
 Other Risks not included above.
Risk Management Process
Identify the Risks
• Determine the type of risks by risk category
e.g. “strategic” or “financial” risks to the Agency;
• Identify the Stakeholders, i.e. who is involved,
who is affected;
• Identify past events; anticipate future
developments.
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Risk Management Process
Analyze the Risks
• How likely is the risk event to happen, (i.e.
frequency, probability)?
• What would be the impact, cost or
consequence if event occurred ( i.e. financial,
political, social)?
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Risk Management Process
Evaluate the Risks
Rank the risks in each risk category according to:
• Agency strategic priorities;
• Rated likelihood of occurrence and severity of
possible costs or consequence.
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Risk Management Process
Treat the Risks
• Develop & implement a plan to address the
identified risks.
• Consider:
• Agency Priorities (strategic and operational)
• Resources (human, financial, technical)
• Risk Acceptance (low…high)
• ROI (Return On Investment)
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Risk Management Process
Throughout the process:
•Communicate and Consult
•Monitor and Review
•Reassess risk categories (start cycle over)
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Part III
Board
Roles
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Role of the ACCMHS Board
Understand that you are the oversight board for
the Agency’s Corporate Compliance Program.
Understand the roles and purposes of the
Compliance Program.
Hold the Agency accountable for the effective
management of the Compliance Program.
Receive periodic reports about the Program.
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Role of the ACCMHS Board (con’t)
Ask questions about the Compliance Program.
Ensure the seven required elements of a
Compliance Program are addressed in training,
policies, procedures, etc.
Ensure Management is addressing key issues and
findings.
Require an Annual Report be submitted.
Require the Risk Management Plan be updated
with new risk targets, and then implemented and
reported upon.
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Role of Individual Board Members
Learn about the Corporate Compliance Program;
Maintain a commitment to organizational
compliance;
Maintain ethical behavior in decisions;
Hold self accountable to Agency policies;
Assist the Agency in assuring the highest standard of
care for the residents of Allegan County.
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Board Summary
 Understand why the Agency’s Corporate
Compliance Program is important.
 As desired, ask questions about the Program.
Patrick and Deb are here to help you better
understand the compliance program.
 Hold your compliance program accountable.
Require periodic reports from the Compliance
Director.
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QUESTIONS