Introduction to the Compliance & Ethics Program General Compliance - 2013 1
What is Corporate Compliance? Refers to measures a company takes to help ensure it follows all local, state and federal laws. Compliance Program focus: quality of care resident rights billing and cost reporting employee screening financial relationships with vendors and physician and accuracy and confidentiality of medical information. prevent fraud and abuse of federal health care programs LTC is the most regulated business in the USA challenging to keep up! Regulating Agencies Centers for Medicaid and Medicare Services, Occupational Safety and Health Administration, Food and Drug Administration, Privacy Office of the Department of Health and Human Services Investigating or auditing agencies Office of Inspector General, Medicaid Integrity Program, Program Safeguard Contractors, Fiscal Intermediaries, Department of Justice, Federal Bureau of Investigations General Compliance - 2013 2
A Compliance Program The Affordable Care Act mandated compliance programs in nursing homes for 2013. The facility has had a compliance and ethics program for several years. The program represents the Nursing Home s commitment to compliance with all billing and claims submissions, as well as other laws and regulations that govern long-term care. General Compliance - 2013 3
How is compliance assured? Under the Compliance and Ethics Program, there are several measures in place to assure compliance, such as: Hiring of qualified persons that have not been found guilty of committing fraud or abuse Providing training regarding roles and expectations Establishing mechanism for reporting of concerns or issues Developing policies and procedures that address compliance issues and standards General Compliance - 2013 4
How is compliance assured? Conducting audits and monitoring activities to detect and prevent issues Conducting investigations and inquiries Holding all accountable for their job performance Not condoning retaliation for good-faith reporting of potential compliance issues Promoting a culture of compliance and ethical behavior Committing to doing the right thing all of the time General Compliance - 2013 5
Your Role in the Program The facility and its employees have an important role in protecting Medicare and Medicaid funds. Both the Medicare and Medicaid programs are in financial trouble, partly because of fraud and abuse of the programs. We all have a role to play to prevent and identify wrong-doing so that these programs will be there when we need them. Additionally, we are committed to assuring that the quality of care and services provided by the facility remain at a high level. General Compliance - 2013 6
Compliance Education Education is a basic part of the program. General Compliance Training is conducted at the time of hire and annually. Participation is mandatory. Additional compliance training may be conducted as necessary. Also mandatory. Summaries of several important laws are provided in the Standards of Conduct for your reference. General Compliance - 2013 7
Reporting of Potential Compliance Issues Under the Compliance Program, all employees, contractors and individuals affiliated with the facility are required to report actual or potential violations of policy or law. General Compliance - 2013 8
Reporting Issues An issue can be reported by contacting the following: Direct supervisor Manager/director Compliance Officer Compliance hot line This is not a chain of command. Issues can be reported to anyone on the list. HR issues are to be addressed directly with the HR manager. The hot line can register a concern with HR but then that issue will be forwarded to the facility HR manager for review. General Compliance - 2013 9
Examples of Reportable Issues Quality of care or quality of life issues (avoidable pressure sores, not enough staffing) Residents Rights (Trust Fund issues) Privacy and Confidentiality issues (HIPAA) Inappropriate Billing (services not provided or substandard) Improper compensation of vendors or physicians (kickbacks, bribes, improper gifts to physicians) Unsafe environment (Life Safety) Not returning an identified overpayment General Compliance - 2013 10
Compliance Hot Line 866-895 4519 Available 24/7 Anonymity (as allowed by law) Caller can call back for follow-up or to add additional information to original report Calls are confidential/need-to-know basis General Compliance - 2013 11
Standards of Conduct Communicate general information about the program, the institution s commitment to compliance, employee roles, and some areas of law and risk. Consider it a guide to conduct Not a substitute for policies and procedures It is a reference, so keep it handy! General Compliance - 2013 12
Standards of Conduct Key Points All employees are required to conduct themselves based on the standards. Adherence is required and failure to do so will result in disciplinary action. If you have any questions about what is in the Standards of Conduct (SoC), contact the facility Administrator or the hot line. You have a duty to report any issues or questions. No tolerance for retaliation for good faith reporting report any retaliation to the Compliance Officer or the hot line. Specific information on these topics is in the SoC. General Compliance - 2013 13
Reporting Issues If in doubt or it sounds funny trust your instincts and talk to someone! Approach supervisors and managers or Contact the Compliance Officer or Compliance hot line number (866-895-4519) Retaliation not tolerated - report retaliation to HR or Compliance Officer or via hot line General Compliance - 2013 14
Important Information Your Compliance Officer is the Administrator. The hot line number is located on the Standards of Conduct and is also posted in the facility. Keep the Standards of Conduct handy. General Compliance - 2013 15