The Eight Elements of a Compliance Plan and What Has Changed
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1 The Eight Elements of a Compliance Plan and What Has Changed Lori Laubach, CHC Principal Thursday, June 9 8:30AM 10AM 1 The material appearing in this presentation is for informational purposes only and should not be construed as advice of any kind, including, without limitation, legal, accounting, or investment advice. This information is not intended to create, and receipt does not constitute, a legal relationship, including, but not limited to, an accountant client relationship. Although this information may have been prepared by professionals, it should not be used as a substitute for professional services. If legal, accounting, investment, or other professional advice is required, the services of a professional should be sought. 2 1
2 SESSION AGENDA Background Eight elements o OIG & HEAT Expectations Practical tips Emerging risks areas 3 BACKGROUND 4 2
3 EFFECTIVE COMPLIANCE PLAN OIG has suggested that an effective Compliance Plan is put in place to detect, prevent and correct violations Definition and standards for effective Reference to effectiveness but not guidance Initiation of plan, unable to sustain = no compliance plan Consistent and open communication Establishes expectation to operate ethically and consistently with fiduciary and legal obligations Focuses on behavior, attitudes, and culture Action oriented Builds on and reinforces existing compliance related activities and procedures 5 HHS/DOJ HEALTH CARE FRAUD PREVENTION AND ENFORCEMENT ACTION TEAM'S ("HEAT") Measuring Effectiveness Develop compliance program with benchmarks and measurable goals. Set up a system to measure how well you are meeting those goals. Involve the Board in creating the program and regularly update the Board regarding compliance risks, audits, and investigations. If one or more goals are not met, investigate why and how to improve in the future. Assess whether the compliance program has sufficient funding and support. 6 3
4 TIPS FROM OIG Five Practical Tips for Creating A Culture of Compliance 1. Make compliance plans a priority now. 2. Know your fraud and abuse risk areas. 3. Manage your financial relationships. 4. Just because your competitor is doing something doesn t mean you can or should. Call HHS TIPS to report suspect practices. 5. When in doubt, ask for help. 7 EIGHT ELEMENTS TO AN EFFECTIVE COMPLIANCE PROGRAM 8 4
5 SEVEN ELEMENTS 1. Implementing written policies, procedures, and standards of conduct; 2. Designating a compliance officer and compliance committee; 3. Conducting effective training and education; 4. Developing effective lines of communication; 5. Enforcing standards through well publicized disciplinary guidelines; 6. Conducting internal monitoring and auditing; and 7. Responding promptly to detected offenses and developing corrective action. Federal Register / Vol. 65, No. 52 / Thursday March 16, 2000/ Notices 9 NEW ELEMENT PLUS POTENTIAL 8. The organization must periodically undertake reassessment of its compliance program to identify changes necessary to reflect changes within the organization and its facilities. Additional element for future Data mining 10 5
6 IMPLEMENTING WRITTEN POLICIES, PROCEDURES, AND STANDARDS OF CONDUCT 11 OIG RECOMMENDS: Develop and distribute written compliance standards, procedures, and practices that guide the nursing facility and the conduct of its employees throughout day to day operations Clinical, financial, and administrative functions of a nursing facility A binder of resources: standards & procedures, Medicaid rules applicable to the provider type Federal Register / Vol. 65, No. 52 / Thursday March 16, 2000/ Notices II.B 12 6
7 PER HEALTH ENFORCEMENT ACTION TEAM (HEAT) Regularly review and update with department managers and Compliance Committee. Assess whether they are tailored to the intended audience and their job functions. Ensure they are written clearly. Include real life examples. compliancetraining/files/operatinganeffectivecomplianceprogramfinalbr508.pdf 13 IDEAS ON SPECIFIC POLICIES AND PROCEDURES 14 7
8 OIG RECOMMENDED POLICIES/PROCEDURES Code of Conduct Specific Risk Areas 15 EFFECTIVE CODE OF CONDUCT Helps organization define itself o How it operates and integrates core values into business operations o How it relates to important stakeholders Demonstrates to employees organization s commitment to promotions of values and ethics Customers prefer businesses that consistently behave in compliant manner Reassures investors and creditors 16 8
9 RISK AREAS Quality of care and residents rights o Sufficient staffing o Comprehensive Resident Care Plans o Medication Management o Appropriate Use of Psychotropic Medications o Resident Safety Submission of Accurate Claims o Proper reporting of Resident Case Mix by SNFs o Therapy Services o Screening for Excluded Individuals and Entities o Restorative and Personal Care Services 17 OIG ORIGINAL ADDITIONAL RISK AREAS Employee screening, Kickbacks, Inducements and Self Referrals Vendor relationships, Billing and cost reporting, and Record keeping and documentation 18 9
10 WHAT NEXT? Inventory & assess current policies & procedures Develop Code of Conduct Determine additional policies & procedures to add /spotlight/2013/snf.asp 19 DESIGNATING A COMPLIANCE OFFICER AND COMPLIANCE COMMITTEE 20 10
11 incumbent upon a health system s corporate officers and managers to provide ethical leadership to the organization and to assure that adequate systems are in place to facilitate ethical and legal conduct Per OIG Guidance 21 OIG RECOMMENDS Every nursing home provider should designate a compliance officer to serve as the focal point for compliance activities. Appropriate authority is critical to the success of the program, necessitating the appointment of a high level official with direct access to the nursing facility s president or CEO, governing body, all other senior management, and legal counsel 22 11
12 KEY RESPONSIBILITIES Oversee and monitor the implementation Reporting on a regular basis to the nursing facility s governing body, CEO, and compliance committee Periodically revise the compliance program due to changes in law etc. Develop and coordinate multi faceted educational and training programs Ensuring independent contractors and agents are aware of resident s rights as well as facility compliance program Coordinate personnel issues with HR and ensure HHS OIG s list of excluded individuals and entities have been checked ( or ) Coordinating internal compliance review and monitoring activities, including annual or periodic reviews of departments Investigate any report or allegation concerning possible unethical and improper activity and MONITOR corrective action Participating with facility s counsel in the appropriate reporting of self discovered violations of program requirements Continue momentum of the compliance program after initial years 23 COMPLIANCE COMMITTEE Analyzing the legal requirements with which the nursing facility must comply, and specific risk areas; Assessing existing policies and procedures that address these risk areas for possible incorporation into the compliance program; Working with appropriate departments to develop standards of conduct and policies and procedures to promote compliance with legal and ethical requirements; Recommending and monitoring, in conjunction with the relevant departments, the development of internal systems and controls to carry out the organization s policies; Determining the appropriate strategies and approaches to promote compliance with program requirements and detection of any potential violations, such as through hotlines and other fraud reporting mechanisms; Developing a system to solicit, evaluate, and respond to complaints and problems; and Monitoring internal and external audits and investigations for the purpose of identifying deficiencies, and implementing corrective action
13 THOUGHTS ON RESPONSIBILITIES Vendor management Business Associate Agreements Sanction screening 25 WHAT NEXT? Look at responsibilities of current designated compliance officer Identify a team Develop communication chart 26 13
14 CONDUCTING EFFECTIVE TRAINING AND EDUCATION 27 TRAINING RECOMMENDATIONS Compliance o Operation and importance o o Consequences Role of employee Specific Training on Issues o o o o Risk areas Medicare participation requirements Documentation Medical and financial Marketing practices Continuing Education on Compliance Issues 28 14
15 HHS/DOJ HEALTH CARE FRAUD PREVENTION AND ENFORCEMENT ACTION TEAM'S ("HEAT") Training Regularly review and update training programs. Try different approaches. Use real life examples. Make training completion a job requirement. Test employees understanding of training topics. Maintain documentation to show which employees received training. Train the Board. Train yourself and your compliance staff. Attend conferences and webinars, subscribe to publications and OIG s list, monitor OIG s website, and network with peers to stay up to date and get ideas. compliancetraining/files/operatinganeffectivecomplianceprogramfinalbr508.pdf 29 WHAT NEXT? Determine training needed Code of Conduct roll out Use of monthly staff meetings Provider training 30 15
16 DEVELOPING EFFECTIVE LINES OF COMMUNICATION 31 COMMUNICATION Access to Compliance Officer Open lines of Communication Open door policy Hotlines Less formal communication techniques Anonymous basis Who do they trust? 32 16
17 MEANINGFUL AND OPEN COMMUNICATION Requirement that employees report conduct that a reasonable person would, in good faith, believe to be erroneous or fraudulent Creation of a user friendly process Provisions in the standards and procedures that state that a failure to report is a violation Development of simple and readily accessible procedure to process reports 33 HHS/DOJ HEALTH CARE FRAUD PREVENTION AND ENFORCEMENT ACTION TEAM'S ("HEAT") Lines of Communication Have open lines of communication between you and employees. Maintain an anonymous hotline to report issues to you. Enforce a non retaliation policy for employees who report potential problems. Establish a direct line of communication between you and the Board. Use surveys or other tools to get feedback on training and on the compliance program. Use newsletters or internal websites to maintain visibility with employees. Regularly meet with the Board and brief them on the compliance program. compliancetraining/files/operatinganeffectivecomplianceprogramfinalbr508.pdf 34 17
18 WHAT NEXT? Evaluate lines of communication Look at employee exit interviews Look at application forms for questions What type of screening is done? 35 CONDUCTING INTERNAL MONITORING AND AUDITING 36 18
19 PER GUIDANCE What When o Standards & procedures o Day to day operations o Claims development, billing and cost reports, and relationships with third parties o At least annually How o Random or o On risk areas 37 WHAT DOES THE OIG EXPECT? Periodic audits could include the following: On site visits to all facilities owned and/or operated by the nursing home owner; Testing the billing and claims reimbursement staff on its knowledge of applicable program requirements and claims and billing criteria; Unannounced mock surveys and audits; Examination of the organization s complaint logs and investigative files; Legal assessment of all contractual relationships with contractors, consultants and potential referral sources; Reevaluation of deficiencies cited in past surveys for State requirements and Medicare participation requirements; 38 19
20 WHAT DOES THE OIG EXPECT? (CONT.) Periodic audits could include the following: Checking personnel records to determine whether individuals who previously have been reprimanded for compliance issues are now conforming to facility policies; Questionnaires developed to solicit impressions employees and staff concerning adherence to the code of conduct and policies and procedures, as well as their work loads and ability to address the residents activities of daily living; Validation of qualifications of nursing facility physicians and other staff, including verification of applicable State license renewals; Trend analysis, or longitudinal studies, that uncover deviations in specific areas over a given period; and Analyzing past survey reports for patterns of deficiencies to determine if the proposed corrective plan of action identified and corrected the underlying problem 39 In addition, the audits and reviews should inquire as to compliance with specific rules and policies that have been the focus of particular attention on the part of the intermediaries or carriers, law enforcement as evidenced by OIG Special Fraud Alerts, OIG audits and evaluations, and law enforcement s initiatives
21 HHS/DOJ HEALTH CARE FRAUD PREVENTION AND ENFORCEMENT ACTION TEAM'S ("HEAT") Internal Auditing Perform proactive reviews in coding, contracts & quality of care. Create an audit plan and re evaluate it regularly. Identify your organization s risk areas. Use your networking and compliance resources to get ideas and see what others are doing. Don t only focus on the money also evaluate what caused the problem. Create corrective action plans to fix the problem. Refer to sampling techniques in OIG s Self Disclosure Protocol and in CIAs to get ideas. compliancetraining/files/operatinganeffectivecomplianceprogramfinalbr508.pdf 41 NEXT STEPS Develop policy on audit & monitoring Baseline review 42 21
22 ENFORCING STANDARDS THROUGH WELL-PUBLICIZED DISCIPLINARY GUIDELINES 43 OIG EXPECTATIONS Disciplinary Policy and Enforcement An effective compliance program should include disciplinary policies that set out the consequences of violating the nursing facility s standards of conduct, policies, and procedures. Intentional noncompliance should subject transgressors to significant sanctions. Federal Register / Vol. 65, No. 52 / Thursday March 16, 2000/ Notices II.G 44 22
23 AT A MINIMUM Ensure that violations of the practice s compliance policies will result in consistent and appropriate sanctions including termination Also must be flexible Also include action for those who fail to detect or report violations Exit interviews Application 45 INCLUSION IN IN-HOUSE MANUALS Warnings (oral), Reprimands (written), Probation, Demotion, Temporary suspension, Termination, Restitution of damages, Referral for criminal prosecution. Include in house training and procedure manuals is sufficient to meet well publicized standard 46 23
24 HHS/DOJ HEALTH CARE FRAUD PREVENTION AND ENFORCEMENT ACTION TEAM'S ("HEAT") Enforcement of Policies and Procedures and prompt response Delegate/empower teams closest to the issues to perform reviews, but be careful of possible conflicts or personal relationships that may interfere with getting an objective review. Act promptly, and take appropriate corrective action. Create a system or process to track resolution of complaints. Enforce your policies consistently through appropriate disciplinary action compliancetraining/files/operatinganeffectivecomplianceprogramfinalbr508.pdf 47 RESPONDING PROMPTLY TO DETECTED OFFENSES AND DEVELOPING CORRECTIVE ACTION 48 24
25 OIG EXPECTATIONS Compliance officer or other management officials immediately investigate the allegations to determine whether a material violation of applicable law or the requirements of the compliance program has occurred Take decisive steps to correct the problem Corrective Action plan Overpayment returned Federal Register / Vol. 65, No. 52 / Thursday March 16, 2000/ Notices II.H 49 CORRECTIVE ACTION Corrective action is a key measurement of program/process effectiveness Reviews, audits, etc. without follow up is meaningless Corrective action that is ineffective must be addressed Staff who can not carry out compliance directives, after repeated education and training, then those staff must be held accountable, which may lead to termination 50 25
26 WHAT NEXT? Investigation policy/procedure Corrective Action Plan Monitoring 51 ASSESSING EFFECTIVENESS OF COMPLIANCE PROGRAM 52 26
27 OIG RECOMMENDATION Evaluate each individual element of compliance program to assess the effectiveness of the program Day to day operations integration Assess whoever fills the integral roles of compliance officer and compliance committee 53 HHS/DOJ HEALTH CARE FRAUD PREVENTION AND ENFORCEMENT ACTION TEAM'S ("HEAT") Measuring Effectiveness Develop compliance program with benchmarks and measurable goals. Set up a system to measure how well you are meeting those goals. Involve the Board in creating the program and regularly update the Board regarding compliance risks, audits, and investigations. If one or more goals are not met, investigate why and how to improve in the future. Assess whether the compliance program has sufficient funding and support. compliancetraining/files/operatinganeffectivecomplianceprogramfinalbr508.pdf 54 27
28 EXAMPLE POLICIES AND PROCEDURES Do employees experience recurring pitfalls because the guidance on certain issues is not adequately covered in company policies? Do employees flagrantly disobey an organization s standards of conduct because they observe no sincere buy in from senior management? Do employees have trouble understanding policies and procedures because they are written in legalese or at difficult reading levels? Does an organization routinely experience systematic billing failures because of poor instructions to employees on how to implement written policies and practices? 55 EXAMPLE - CULTURE Does a compliance officer have sufficient professional experience working with billing, clinical records, documentation, and auditing principles to perform assigned responsibilities fully? Has a compliance officer or compliance committee been unsuccessful in fulfilling their duties because of inadequate funding, staff, and authority necessary to carry out their jobs? Did the addition of the compliance officer function to a key management position with other significant duties compromise the goals of the compliance program? 56 28
29 QUESTIONS? Lori Laubach, CHC, Principal
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