9/10/2012. Compliance Effectiveness and Auditing. James Madison. Shawn Y DeGroot, CHC-F, CCEP, CHRC Vice President Corporate Responsibility

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1 Compliance Effectiveness and Auditing Shawn Y DeGroot, CHC-F, CCEP, CHRC Vice President Corporate Responsibility James Madison Warned in the Federalist Papers about laws so voluminous that they cannot be read, or so incoherent that they cannot be understood. 1

2 HCCA Tracking of CEU & Renewal of Certifications Photos For Online Profile Call For Speakers Automated Speaker Review Process HCCA GROWTH HCCA Individual Members HCCA Growth 2500 Paid CI Attendees

3 HCCA GROWTH 600 People who passed the CHC each year HCCA GROWTH No. of people who passed the CHPC HCCA GROWTH 650,000 HCCA Website Views a Year 600, , , , , , ,

4 Effective Producing a decided, decisive or desired effect capable of producing a result. Webster s Dictionary Why Effectiveness Matters 1991 Federal Sentencing Guidelines Implementation of an effective Compliance & Ethics Program Requires an organization to establish and maintain an effective Compliance & Ethics Program to prevent and detect criminal conduct for purposes of mitigating its sentencing culpability for an offense. Adopted DOJ, DHHS, SEC, EPA Federal Sentencing Guidelines An effective program to prevent and detect violations of law means a program that has been reasonably designed, implemented, and enforced so that it generally will be effective in preventing and detecting criminal conduct [DESIRED EFFECT]... 4

5 Federal Sentencing Guidelines The hallmark of an effective program... is that the organization exercised due diligence in seeking to prevent criminal conduct by its employees and other agents. Due diligence requires at a minimum that the organization must have taken the following types of steps: [seven elements are then enumerated] Federal Sentencing Guidelines Hallmarks of an effective program are those that encourage compliance with the law and ethical conduct. Why Effectiveness Matters 1999 GAO Report to Congress: The principal measure of a compliance program s effectiveness is its ability to prevent improper Medicare payments. 5

6 Why Effectiveness Matters 1999 OIG Response with Objectives: Increased employee awareness of laws/rules/risk areas Creating central source for disbursement of new rules Facilitating prompt/consistent investigation of impropriety Methodology that encourages reporting Why Effectiveness Matters 1999 OIG Response with Objectives: Identifying and preventing misconduct Demonstrating commitment to proper conduct Mitigating against bad intent (& reduced sanctions) Limiting corporate director liability Why Effectiveness Matters 2012 Health Care Reform: Measure effectiveness of compliance programs and quality of care Measure effectiveness of compliance programs and quality of care 6

7 Compliance Effectiveness Health Care Reform: Overpayments Effectiveness: Element #1 Standards & procedures Code of Conduct Internal controls: System-wide risk assessments Corrective action plans Communication line Monitoring plan Effectiveness: Element #2 Resources & Structure High level personnel 8B2.1(b)(1) Adequate resources 8B2.1(b)(2)(c) Reporting relationship Report to governing authority 8B2.1 7

8 Effectiveness: Element #3 Substantial Authority Personnel Personnel who knew/should have known Supervisory authority Plant manager Materials management Individual in a position to negotiate Drafts contracts, set prices, approves contracts Effectiveness: Element #4 Education Test staff knowledge, benchmark and trend Pre-Post competency tests Audience response system Questionnaires High level personnel and governing authority Periodic updates Effectiveness: Element #5 Reasonable Steps to Achieve Reporting system for employees Fear of retribution Anonymous compliance communication line Survey the caller 8

9 Effectiveness: Element #5 Reasonable Steps to Achieve Reporting system for employees Fear of retribution Anonymous compliance communication line Survey the caller Effectiveness: Element #5 Compare issues year to year Track and trend complaints and hotline calls Review audit results and trends Monitor Successful audit effectiveness Audit Basics Internal and External Establish objectives and responsibilities Trained auditors Foundation for audit Budget Retro or concurrent 9

10 Successful audit effectiveness Determine the nature of the audit Financial Medical Services Privacy and security Research Audit Development & Scope Process and timeframe Scope: Time period and reason why Statistical: Physician clinic billing Non-statistical: credential files Contract Audit Effectiveness Audit Checklist Plan, Do, Check, Act Pre-audit Discussion Fieldwork and schedule Work-papers (upload to electronic file) Report (draft, review, final) 10

11 \ Questions? 11