Health Care Compliance Challenges in America: A Chief Compliance Officer s View

Transcription

1 Health Care Compliance Challenges in America: A Chief Compliance Officer s View Daniel P. Garcia Senior Vice President and Chief Compliance Officer, Kaiser Foundation Health Plan, Inc. Kaiser Foundation Hospitals April 14,

2 Main Objectives 1. Provide Brief Description of Kaiser Permanente System 2. Describe Our Approach to Compliance Infrastructure and Coordination 3. Share Approach to Identify Compliance and Fraud, Waste, and Abuse Risks 4. Provide Overview of Effective Tools: Metrics, Assessments, Audits and Other Tools 5. Share How to Engage and Interact With Your Board of Directors

3 Brief Description of Kaiser Permanente System

4 Who is Kaiser Permanente? Kaiser Permanente is an integrated health care provider, health plan, and hospital proprietor Number of Employees Number of Physicians Number of Nurses Members Regions States Hospitals MOB/Clinics Members enrolled in Medicare Part D ~158,000 ~13,700 ~31, Million 8 Regions 10 States 37 Medical Centers ,000 Annual Operating Revenue (2006) External Services Vendors $34.4 Billion $11 Billion 380,000 Massive design and construction and IT capital expenditures Multi-billion dollar dispenser of pharmaceuticals

5 Kaiser Permanente s Product Profile is Changing Historically pure HMO capitated payments; one fee pays for all services Market focus has changed so now Kaiser Permanente has changed: Traditional HMO Commercial Products Medicare Advantage Medicare Fee-for-Service (< 2% of income) New commercial products: Deductible Health Reimbursement Account (HRA) Health Savings Account (HSA) Deductible HMO (DHMO)

6 Approach to Compliance Infrastructure and Coordination

7 Our Approach to Compliance Kaiser Permanente Compliance Structure Relationship to regions and national departments National Compliance Office (NCO) Regional Compliance Officers (RCO s) National Department Compliance Medical Center Compliance Officers Operations IT Human Resources National Facilities Services Compliance Marketing, Sales, and Service Administration CA Pharmacy KP HealthConnect National Environmental Health and Safety Community Benefit

8 Compliance Infrastructure Regional Compliance Officers (RCO s) Report to Regional President and Chief Compliance Officer Examples of Compliance Committees in regions: Medicare Part D Compliance Committees Coding and Documentation Committees Scope of Practice Committees Privacy and Security Committees Full Time Compliance staff for each region range between 8 and 56 National Departments Compliance Officers Report to Chief Compliance Officer and Department Leader Medical Center Compliance Officers Report directly to Regional Compliance Officers Full-time Compliance Officer at each Medical Center Oversees and monitors the implementation of the compliance programs at the medical center level

9 Compliance Infrastructure : National Compliance Office National Compliance Office Teams and Their Work Operations Operations Trakweb deployment Support and coordinate FDCU data mining national deployment Privacy Privacy // Security Security P and P Risk assessments KPIT security projects Data security management Training, Training, Communications Communications and and Integrity Integrity Audit Audit Medicare Medicare and and Federal Federal Programs Programs General compliance training Hotline refresh POR, COI deployment Videos, Posters, Website Policies and Vendor Integrity CoMSAT II KP HealthConnect CAP validation Medicare Audits Claims Vendor relationships CMS audit response/remediation List validation and reporting Medicare monitoring Medicare and MMA implementation Mock CMS audits Health Health Care Care Delivery Delivery Fraud Fraud Control Control NCO NCO Leadership Leadership and and Bus Bus Svs Svs Toolkits Standards-clinical areas Hospital Assessments KPHC Assessments Scope of Practice Care Delivery Compliance Video Coding and medical record standards Training programs Deploy to all regions/ Medical Centers Build Med Ctr investigation skills Board Reports Conferences and forums Coordination

10 Compliance Coordination and Communication National Annual Compliance Summit (300 attendees) Semi-annual NCO-RCO meetings Annual work plans: national and regional compliance offices worked together to create one joint Compliance Plan Some functions nationalized: Auditing Conflict of Interest Data mining (fraud detection) Special Investigations (fraud control) Principles of Responsibility/ Code of Conduct Compliance Hotline RCOs report to CCO and Regional Presidents NCO senior team leads RCOs interface with one another Numerous joint efforts (e.g., Privacy and Security)

11 Overview of Fraud Detection Control

12 In-Depth Examination of One National Compliance Effort Fraud Detection and Fraud Control Two Major Contributing Resources: A. TRAP Data Mining Process of searching large volumes of data for patterns and finding relationships within those patterns. Delivers results that can be either used in an automated decision support system or assessed by a human analyst. Or, more simply: It is the process of finding and extracting useful information from raw data sets. Use is broader than just fraud detection Major help in identifying trends, statistical anomalies

13 In Depth Examination of One National Compliance Effort Fraud Detection and Fraud Control B. Fraud Control Team has two units NCO Fraud Control Program Unit - Proactive Fraud schemes Committees Trends Identification Corrective Action Coordinates with external groups National Special Investigations Unit (NSIU) - Reactive Highly experienced Detection, investigation, prosecution, recovery and compliance Consult with investigative groups (including law enforcement) Recovery and restitution

14 TRAP Data Analysis Partnership Approach Kaiser Permanente Activity Note concerns Review algorithms Identify Pattern TRAP Systems Activity Monitor industry practice Implement algorithm logic Run algorithms Consult subject matter experts Review documents Contact parties involved Analyze and Verify Deploy results Support analysis tools Conduct follow up analysis Pursue fraud prosecution Recover overpayments Improve process Act Help document cases Assist with recoveries Monitor progress in data

15 TRAP and Data Mining: Examples Data Mining Examples: Pharmacy In / Out - To identify drug diversion Claims Acceleration Study - To research spike in costs ESRD (Dialysis Centers) Fraud, Waste, and Abuse monitoring Terminated Members - Services and charges incurred post-termination Workers Compensation - Claims that should be paid by Workers Compensation Carrier Example Rx Pharmacy Viagra 100mg Tab Pharmacy 11 M onth Variance Report 2,500 2,000 # of Tab 1,500 1, Jan Feb M ar Apr May Jun Jul Aug Sep Oct Nov Month Qty Disp (tab) Qty Rec (tab) 15

16 National Special Investigations Unit (NSIU) Initiating information for investigations: Hotline Whistleblowers Regulators Leadership NSIU Investigations Pharmacy Theft / Drug Diversion Embezzlement Member Fraud Identity Theft Cash / Check Fraud Health Care / Claims Fraud Vendor Fraud Kickbacks Privacy / Computer Fraud Other Major Crimes

17 Overview of Effective Tools: Metrics, Assessments, Audits and Other Tools

18 National Special Investigations Unit NSIU Investigators have strong backgrounds: 6 Former FBI Special Agents Narcotics Detectives IRS Investigator Homicide Investigator Experience with criminal law and criminal procedures Liaison work on criminal cases helps to understand and better coordinate with government agencies Law enforcement contacts often have more comfort interfacing with NSIU as former law enforcement officers

19 EXAMPLE: Pharmacist caught on tape working from a shopping list 19

20 Sources for Identifying Compliance Risks 1. Government work plans and notices 2. Past regulatory issues 3. Findings and deficiencies from audits, investigations, and assessments 4. Metrics 5. Hotline calls/substantiated findings 6. Data mining findings 7. Industry information

21 Tools To Convey Breath of Compliance Risks EXAMPLE

22 Tools for Integrating Compliance Into Your System What you may want to consider in your auditing process and in determining compliance work plan elements. UNIVERSE INHERENT BUSINESS RISK RATING INTERNAL CONTROL ENVIRONMENT RATING RISK RATING Components Categories Factors Frequency Input from Chief Compliance Officer and Teams Hotline calls or cases Interview Management Survey key business owners Health Plan functions Care Delivery functions Your Compliance Program Mission and Reputation Financial Legal/Regulatory (OIG Work Plan, CIA) Quality of Care Fraud, Waste and Abuse Governance Information Technology External Audit and Regulatory Findings Repayments or Disclosures Assessments performed by external parties Internal Investigations Compliance Program Assessments Severity of Impact Level of Exposure Likelihood of Occurrence Controls in Place Level of Risk Mitigation

23 Tools for Integrating Compliance Into Your System Tool 1. Compliance Audit 2. Medicare Monitoring Program 3. Revenue Cycle Compliance Standards 4. Hospital Assessments 5. Care Delivery Tool Kits Objectives Validate performance against compliance program and/or operations standards Measure performance proactively against Part C and Part D standards Establish compliance expectations for billing compliance Measure compliance against care delivery compliance standards Establish compliance expectations for specialty care areas

24 1. Compliance Audit Audit Teams are an integral part of any compliance office It is important to validate compliance performance against: federal, state and local laws and regulations licensing requirements accreditation standards organizational policies National Compliance audits help to identify risks, measure performance, and test controls

25 Examples of Compliance Audits Examples of Audits MEDICARE (MOCK CMS) AUDITS Claims Member Services Part D HCCs QUALITY OF CARE REVIEWS REVENUE CYCLE RELATED AUDITS Cost Sharing Validation Self-funded SECURITY RELATED AUDITS KP Health Connect HIPAA Applications Rationale for Audits Identified as high risk areas by the regions and senior leadership OIG Work Plan Prior CMS findings CMS Corrective Action Plan validation Ensure proper reimbursement Enables NCO to review effectiveness of Compliance Mgmt. system Assessments which were conducted based on the OIG 7 elements Significant findings/issues arising from the following: Department of Managed Health Care findings/quality Audits CMS Findings Member Complaints OIG 2007 Work Plan Kaiser Permanente is required to comply with federal and state requirements with respect to proper billing and reimbursement. These audits support the strategic initiatives for Kaiser Permanente to remain competitive. Increased scrutiny by state and federal regulators over its data handling practices Identified as high-risk area by the regions and senior leadership

26 Compliance Management System Assessments (CoMSAT) performed in all regions Objectives: Determine whether the region s compliance and ethics program provides reasonable assurance of compliance with organizational policies and applicable laws and regulations based on the NCO Compliance Framework. Evaluate the region s progress in implementing corrective action plans Validate that major risks identified in the 2002 CoMSAT report have been mitigated Measure the level of awareness and understanding of compliance through inquiries of employees perception of the Kaiser Permanente s compliance culture and environment? Establish Compliance Infrastructure Integrate Compliance into Operations Validate Compliance Performance

27 Compliance Framework Used in CoMSAT

28 Example: CoMSAT Results Consolidated CoMSAT Scores by Compliance Framework Element Compliance Elements R1 R2 HEALTH PLAN OPERATIONS R3 R4 R5 R6 R7 R8 National Rating Accountability Y Y G G Y G G G MET EXPECTATION Resources & Support Y R Y G Y G Y Y SATISFACTORY Specialized Training Y R G Y Y Y Y R SATISFACTORY CAP Monitoring G Y G G G Y G Y MET EXPECTATION Risk Assessment R Y G Y R R R R NOT MET EXPECTATION Accountabilities: the extent to which compliance responsibilities are included in job descriptions and performance evaluations. Resources and Support: the extent to which compliance resources are designated and available. Specialized Training: the extent to which specialized training is tracked and monitored. CAP Monitoring: the extent to which corrective action plans are formally developed and tracked. Risk Assessment: the extent to which compliance risk assessments are conducted. EXAMPLE

29 Example: CoMSAT Results CoMSAT Functional Results by Compliance Framework Element ACCOUNTABILITY RESOURCES & SUPPORT Health Plan Operations R1 R2 R3 R4 R5 R6 R7 R8 R1 R2 R3 R4 R5 R6 R7 R8 Appeals R N/A Y N/A N/A G N/A Y N/A N/A Benefits R R G Y G R R G Billing & Reimbursement Y G R Y R G Y Y R G R G Y Y Y Y Claims R Y Y G G R G R Y R Y Y G R G R Contracts G G Medicare Finance Y R Y R Member Services / Rights G R G Y R G G Y Y R Y G G Membership G Y N/A R G Y R G N/A G Y R Pricing & Underwriting R R G G Y R G Y G Y Y G R Y G G Procurement (Non-Pharmacy) G Y R Y G R G R G Y G Y Products R Y G Y R Y R G R Y Y Y R G Y R Provider Contracting Y G G N/A G Y R G N/A Y Quality Resource Mngt R R Y G Y G Y R G Y Sales & Marketing R Y G R G Y R G Y R G R Sales & Marketing (Medicare) R G R Y Sales & Marketing (Commercial) Y R Y R Utilization Management G Y G Y Underwriting Procurement (Contracts) R Y R G * Surveys performed from 2005 through 2007 EXAMPLE

30 Example: CoMSAT Results CoMSAT Functional Results by Compliance Framework Element SPECIALIZED TRAINING CAP MONITORING RISK ASSESSMENT Health Plan Operations R1 R2 R3 R4 R5 R6 R7 R8 R1 R2 R3 R4 R5 R6 R7 R8 R1 R2 R3 R4 R5 R6 R7 R8 Appeals Y N/A G N/A N/A G N/A G N/A N/A R N/A G N/A N/A Benefits G Y G R R Y R Y G R G R Y R Billing & Reimbursement Y R Y Y R R Y Y R G Y G Y R G Y Y Y G G Y Y G R Claims R G R G Y G R G G R G Y G Y R G G R Y G Y R R G Contracts R R R Medicare Finance Y G Y G G G Member Services / Rights G R Y G Y Y G Y R G N/A G R Y Y Y R Y Membership Y G N/A R G R Y N/A N/A R G R G R N/A Y Y R Pricing & Underwriting R R G G Y G Y G N/A R G Y G R Y G Y Y G R R G R Y Procurement (Non-Pharmacy) Y G R Y R G R R Y G Y Y R R Y R Y G G Products R Y Y Y G R Y Y G N/A N/A N/A R G Y Y R G Y G R Y R Provider Contracting G Y G N/A R N/A Y R N/A G R G Y N/A R Quality Resource Mngt Y R R G G R G G R Y Y G Y G R Sales & Marketing R G G Y R R N/A N/A G N/A G R R R G R G R Sales & Marketing (Medicare) Y G Y G R G Sales & Marketing (Commercial) G R R Y G R Utilization Management R Y G R Y G Underwriting Procurement (Contracts) Y R Y G G R EXAMPLE

31 2. Medicare Monitoring Program Objectives A Medicare Performance Monitoring Program for all Kaiser Permanente regions has been implemented to meet the Office of Inspector General s (OIG) expectation of monitoring by Medicare participating programs. The program requires designated functional areas (such as claims or benefits) to periodically assess their compliance with particular Medicare requirements. The results of those assessments are entered into metrics within a common software platform called ActiveStrategy, and are available for certain compliance and operations personnel to monitor. This work helps us track Medicare metrics * to fix any internal deficiencies early on rather than waiting for findings CMS identifies in its audits. * A Metric for the Medicare Monitoring Project: A metric for this project is what should be MEASURED to determine if an activity is COMPLIANT with the requirement ( element ) in the CMS Monitoring Review/Audit Guides

32 Medicare Monitoring Program Medicare Monitoring Program components Metrics measuring compliance with CMS requirements Part C Monitoring Review Guide and Part D Audit Guide Comprehensive and consistent At least one metric for every CMS element Common elements across all of our 8 Regions Integrated with Operations Functional areas (e.g., Member Services, Claims) collaborated with Compliance on developing the metrics Functional areas will own the metrics once implemented Reviewed by Regional and Functional Departments at least quarterly Reviewed by National Medicare Leadership and NCO quarterly Metrics are in the ActiveStrategy software Enterprise-wide software for data entry, reporting, and interactive discussion, with drill-down to root causes Enables comparative views across functions and Regions Puts compliance metrics on same platform as many operational metrics Aligns with business metrics setting targets/goals as an indicator system Data correlates to audit worksheets but shows results in terms of goal percentage instead of met or not met

33 Example Claims Stoplight Chart for Q2 (EXAMPLE) Reg 1 Reg 2 Reg 3 Reg 4 Reg 5 Reg 6 Reg 7 Reg 8 C-OCO2 Medicare rates for noncontracted claims N/A No No No C-OCO3 Timely payment-clean claims C-OCO4 Interest on claims paid late D-CDO4 timely notification coverage determination requests regarding payment No** No No C-OCO6 Claims denials- notice content N/A ** See next Slide N/A= No or partial reporting

34 EXAMPLE: Under Performing Measure from ActiveStrategy Scorecard Status Name Actual Target Variance Date Owner D-CDO4.2 timely notification of coverage determination requests regarding payment (Sample) (QTr) (Reg 3) 87% 90% (3)% Sep 07 John to report Variance Report Comments Measure not met this quarter. The low volume of claims in this sample requires 100% compliance or the target cannot be met. Member requests for reimbursement find their way to KP-Reg 3 through a variety of doors, and the timeliness clock on these claims starts at the KP-Reg 3 entry point. Claims that take longer than 2 working days to reach the Claims Department will automatically result in a failure of this measure. This measure is a result of an need-to-end organizational process and not a process that is wholly within the control of the Claims Department. PLAN: continued prompting to other areas to fax claims to Claims Dept and NOT to rely on interoffice mail Additional note: these claims are also included in the monthly ActiveStrategy BPR reporting and are reviewed on a concurrent basis EXAMPLE

35 3. Revenue Cycle Compliance Historically Kaiser Permanente focuses almost exclusively on HMO products which do not require coding, etc. as in Fee-for-Service business. The Market and government forces have caused Kaiser Permanente to broaden its product portfolio. So now Kaiser Permanente is working to ensure its clinical services and health plan functions meet all legal requirements. Revenue Cycle accurate and timely collection of non-dues revenue must become a core competency for the organization to grow. It is not a project, but an on-going organizational competency. A business model critical to offering new health care products and administering the existing deductible health plans. More than coding and billing. It is an end-to-end process that begins with accurate enrollment and registration data and ends when the account balance equals zero. Revenue cycle represents a transformation in Kaiser Permanente s operational model

36 Revenue Cycle Compliance Standards The front-end policies define the requirements for effectively and compliantly performing key activities in a manner that aligns with the Kaiser Permanente vision and objectives. NCO has provided eight checklists for the Revenue Cycle for Professional Services billing based on regulatory rules and 2005 assessment findings. Hospital (facility) requirements are anticipated for General Compliance Regulatory Tracking, Records Retention, Facility/Service Change Notification, Job Descriptions, Data Systems and Interfaces accountability Front End Middle Back End Processes Review Enrollment Scheduling Pre-Reg & Financial Counseling Registration CDM / Fee Schedule Documentation & Coding Charge Capture Billing Collections & Bad Debt Payment Processing Denial Mgmt A/R Finance Ops Practitioner/Facility Practitioner/Facility 2. Practitioner/Facility License License Enrollment Enrollment License Enrollment Provider Licenses, Certifications, NPI, Line of Business ID numbers, Provider Licenses, CPM Accuracy Certifications, (Fac/Org-Site NPI, Line of Service, of Business ID Providers), numbers, Licenses, CPM Provider Accuracy Certifications, Contractors; (Fac/Org-Site NPI, Facility Line of Licensure/ Service, of Business ID Enrollment numbers, Providers), CPM Provider in Government Accuracy Contractors; (Fac/Org-Site Programs Facility of Licensure/ Service, Providers), Enrollment Provider in Government Contractors; Programs Facility Licensure/ Enrollment in Government Programs Scheduling/Registration Scheduling/Registration 3. Scheduling/Registration Patient ID, Pt. Demographics, Insurance Verification/COB, Clinical Patient ID, Trials, Pt. Insurance Demographics, Authorizations Insurance and Verification/COB, Referrals, Excluded/Non Patient Clinical ID, Trials, Pt. Insurance Approved Demographics, Services, Authorizations Insurance Medicare: and Verification/COB, Referrals, AOB, MSP, Clinical Excluded/Non ABNs, Cost Trials, Sharing/Liability, Insurance Approved Services, Authorizations Registration, Medicare: and Cancellation/No Referrals, AOB, MSP, Shows, Excluded/Non ABNs, Cost Practitioner Sharing/Liability, Approved Linked Services, to Registration, Encounter, Medicare: Billable Cancellation/No AOB, Encounter MSP, ID Shows, ABNs, Cost Practitioner Sharing/Liability, Linked to Registration, Encounter, Billable Cancellation/No Encounter Shows, ID Practitioner Linked to Encounter, Billable Encounter ID 8. Surgery and Anesthesia Clinical Clinical Practice Practice & 4. Clinical Documentation Documentation Practice & Documentation SOP (Regional view), Supervision, Codeable Covered SOP (Regional Services, view), Documentation Supervision, Supports Codeable Codes, SOP Covered (Regional Diagnosis Services, view), Assignment, Documentation Supervision, Timely Supports Codeable Covered Codes, Authenticated Diagnosis Services, Documentation, Assignment, Timely Provider Supports & Orders, Certifications Codes, Authenticated Diagnosis Obtained Documentation, Assignment, Timely Provider & Orders, Certifications Authenticated Obtained Documentation, Provider Orders, Certifications Obtained Charge Charge Capture Capture & Coding Coding CDM, UCOA, Standard Code sets, Point of 5. Charge CDM, UCOA, Standard Capture Code sets, & Point Coding of Service Charge Capture Coding, Routing of Charges, CDM, Service UCOA, Charge Units Standard of Capture Service Code & Accuracy, Coding, sets, Point Routing of of Credits/Returns, Service Charges, Charge Units of Capture Place Service of & Service Accuracy, Coding, Accuracy, Routing of Coding Charges, Credits/Returns, Edits Units of Place Service of Service Accuracy, Accuracy, Credits/Returns, Coding Edits Place of Service Accuracy, Coding Edits Building on prior 7, additional specific requirements to rules for these services given significant compliance gaps identified Billing Billing 6. Billing Insurance Verification, Appropriate Form Used/Complete, Insurance Verification, Billing Appropriate Edits, Duplicate Form Billing, COB, Insurance Used/Complete, Timeliness, Verification, Billing Resubmissions, Appropriate Edits, Duplicate Modifications Form Billing, COB, Voids Used/Complete, Timeliness, Resubmissions, Billing Edits, Modifications Duplicate Billing, & Voids COB, Timeliness, Resubmissions, Modifications & Voids Payment Payment & Collections Collections 7. Payment & Collections All Activity posted to account, Adjustments, Write off Disputed All Activity Charges, posted to Unapplied account, Cash/Suspense Adjustments, Write Accts, off & Credit Disputed All Activity Balance Charges, posted Resolution, to Unapplied account, Denials Cash/Suspense Adjustments, Follow Write up, Accts, off & Collection Disputed Credit Balance Charges, Bad Resolution, Debt Unapplied Assignment Denials Cash/Suspense & Follow up, Accts, Credit Collection Balance & Bad Resolution, Debt Assignment Denials & Follow up, Collection & Bad Debt Assignment

37 Proactively Building in Compliance Requirements Revenue cycle policies and procedures KP HealthConnect system design and implementation Operations monitoring and reporting

38 Compliance Attestation by Medical Center Compliance Attestation by Medical Center Leadership Coding Scope of Practice Oversight and Control Payer Supervision Rules

39 Ongoing Auditing with Revenue Cycle Partners By High-Risk Attributes Appropriate performing/rendering provider name Correct days/units of service Documented treatments/service authorization CPT codes accurately reported by medical record Medical record completeness Correctly assigned diagnosis Site-of-Service management Scheduling and registration Scope of practice By Line of Business Medicare Medicaid

40 4. Hospital Assessments Members of the Care Delivery, Fraud Control, Privacy and Security and Audit teams spend 3-4 days onsite at each Hospital Discovered compliance risks, any statement of deficiencies or high-risk areas prepared by hospital Topics to be reviewed: Scope of practice, compliance structure, patient safety, information management, billing/coding, regulatory enforcement activity, OIG work plan, fines and penalties, compliance risks and requirements, and workplace safety Plan Develop a Compliance Infrastructure The assessments cover the efficiency and effectiveness of the medical center s compliance infrastructure. Implement - Integrate Compliance into Operations Covers management s integration of compliance into day-to-day operations

41 Conceptual Model for NCO Hospital Assessment Visits External Oversight NCQA JCAHO OSHPD People Pulse NEHS Reviews FED IRS Patient Satisfaction Imaging Pharmacy Boards Hospital Indicators Rehabilitation Services Member Rights Kaiser Permanente Internal Oversight Respiratory Care Scope of Practice Information Management Human Resources Nutritional Services Competency Assessments QIO NEHandS Infection Control Hospital Services Internal Priority Structures Leadership Governing Body Patient Safety Patient Care Services Significant Events Risk Patient Rights Medical Staff Anesthesia Billing Quality/ UM Laboratory EOC Emergency Department Home Care JCAHO ORYX Compliance DHS Finance and Visits Medication Billing Management Boards ED Indicators PCEs CLIA DHS Claims CMS Visits FDA DMHC CAP Model depicts the following: External oversight bodies define compliance requirements Internal oversight processes provide some compliance performance information Hospital services have specific compliance requirements Programs have specific compliance requirements CMS Cynthia Hartman, MSN, CNAA, BC National Compliance, Ethics and Integrity Office

42 5. Care Delivery Tool Kits Why Tool Kits? Internal and external assessments and audits were conducted and findings were numerous and varied across medical centers and regions. Did not have standards against which we could systematically assess compliance risk Did not yet have best industry approach to perform health care delivery compliance risk assessments effectively

43 A Tool Kit Plan Develop Standards KP and External Legal Resources, RCOs & SMEs Build Toolkits People, Place, Service, Specialty Areas, Training Implement Standards & Toolkits KP Hospitals And Medical Centers A Tool Kit Plan Monitoring & Reporting Regional and National Compliance

44 Tool Kits: Purpose Compliance means following all federal and state laws and regulations. These rules provide guidelines to ensure that: The RIGHT practitioner Is performing the RIGHT clinical service At the RIGHT time and place On the RIGHT patient With the RIGHT documentation Modules based on subject matter, which address the laws governing clinical departments. Designed to deliver the law in clear and concise language Provide a process by which Compliance awareness, education, risk identification, and risk reduction are enhanced

45 Tool Kits: What are we working on? Developing Standards A Collaborative Process - Compliance, Legal, outside council, and regional Subject Matter Experts (SME s) partner on developing Tool Kits for the services listed Anesthesia Radiology Laboratory PATH Physical Therapy Occupational Therapy These services were chosen based on the following criteria: Prior assessments and findings by Compliance, outside consultants, DHS and CMS High risk (Regulatory oversight) High volume (Number of patients and services provided) High dollar (Medicare and Medi-Cal billings)

46 How To Engage and Interact With Your Board of Directors

47 How to Engage and Interact with Your Board Detailed reporting calendar to Audit and Compliance Committee Compliance provides detailed reports to our Board throughout the year: Compliance Operations Focus Significant Regulatory Updates Health Plan Update MMA Report Medicare and Federal Programs Privacy and Security Updates Health Care Delivery Report Compliance Management System Audit Report Hotline Report Fraud Control and Investigations SOX Violations Compliance Hotline Reports Additional Comments

48 Questions?