Compliance 101
What should be in place to encourage workforce to report concerns?
Assure no retaliation policy is in place and a hot line number is clearly posted.
: The practice of using a billing code that provides a higher reimbursement rate than the billing code that actually reflects the service furnished is known as:
Upcoding
What is needed from the board in regards to a compliance program?
Vision and guidance
A _______ audit will provide a broad baseline risk assessment, a snapshot, or essentially a laundry list of all of the things you need to fix.
Retrospective Audit
The compliance committee functions include all :
Analyzing legal requirements and specific risk areas, regularly reviewing and assessing policies and procedures, monitoring internal systems related to standards, policies and procedures
Which law makes it a criminal offense to submit claims based on incorrect codes or medically unnecessary services?
HIPAA
Which of the following are examples of helpful prior experience a Chief Compliance Officer may have
Health care admin, Auditor, Attorney
Policy on disciple should include:
How the organization will handle non-compliance, address both failure to report and acts of non-compliance will be subject to discipline, outline of disciplinary procedures, including punishment should be appropriate to the offense
Which of the following is an aggravating factor to a culpability score in the Federal Sentencing Commission released "Chapter 8 Part B - Remedying Harm from Criminal Conduct, and Effective Compliance and Ethics Program?"
If the violation was a repeat offense;
Kalamazoo law firm is attempting to defend Poor Misunderstood Hospital. What documentation do they need to create a defense?
List of relevant documents reviewed and employees interviewed, changes made to P&P as well as recommended remedial actions, description of potential misconduct and the investigative process.
The book lists a few do's and don't of creating a Code of Conduct. What are some of the Do's?
Look at samples & Reflect your organization's spirit, tone, and culture.
In detecting a misconduct or wrongdoing, organization must respond appropriately. What is the first step a compliance officer should do?
Meet with legal counsel
The Health Care Compliance Association has prepared and published the Code of Ethics for Health Care Compliance Professionals. This document addresses three principals, which are broad standards of an aspiration and inspirational nature. They include:
Obligation to the Public, Obligation to the employing organization, and obligation to the profession.
Which areas does the OIG require training?
Reimbursement principles, proper confirm of diagnosis, how to handle alterations to medical records, duty to report misconduct.
According to the text, which of the following are "overlooked groups" when it comes to Standards of Conduct/Policies and Procedures? (Choose all that apply)
Suppliers Vendors Independent Contractors
Which law/act empowers the government to investigate and bring civil action in a fraud case?
The False Claims Act
A way to target potential deficiencies and areas of modification is to do the following___________
an internal assessment by interviewing employees by asking about risk, daily activities, processes/procedures.
Corporate Integrity Agreement (CIA)
government imposed compliance program
Concurrent Audit
identify and address potential problems as they arises.
Qui tam
is a whistleblower who brings the fraud to light.
An aggravating factor in FSG
is that the organization has had a repeated offense
The first logical step after having found a possible misconduct is to _________
meet with your in-house or external legal counsel.
OIG requires for written evaluations of audits to be presented how often.
no less than annually.
The timeframe for reporting misconduct to govt authority is no more than ________days.
60
The main focus of the Compliance Officer should be all of the following, except:
Administering discipline for those individuals that do not adhere to policies and procedures;
Dr. Johnson sends all his patient's to ACME DME company. ACME gives free DME equipment to Dr. Johnson for his family. What statute might they be violating?
Anti-kickback
Zenith Hospital is trying to determine what costs may be associated with starting a compliance program. Which of the following may be associated costs?
Staff salaries, Printing material cost, Reporting and computer costs
Hot Sauce Hospital got in hot water. The OIG found them guilty of misconduct. But not only were they guilty of misconduct, they compounded the problem. How did they do that?
There was a lengthy delay in their response and at the end of the day they failed to respond all together.
Dr. Kale is offered office space at no charge at a pharmaceutical company.
This is an example of an action that could be deemed as anti-kickback.
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
a criminal offense to submit claims based on incorrect codes or medically unnecessary services, and government has the power to exclude an organization from Medicare/caid and other govt programs.
False Claims Act (FCA)
empowers the govt to investigate and bring civil action in fraud cases. Implemented in Civil War to control price gouging.
Mr Timmonds of ACME healthcare is attempting to draft an audit agenda. Which of the following is important in this process?
Manage the scope of the audit, Review problem areas identified by OIG, Review existing policies.
Ms Jones has just set up the compliance program at her hospital. What is one of the programs first actionable items?
Performing a baseline audit
At rural hospital in the back woods of Kentucky, they are attempting to create a compliance course for their billing staff. Which of the following are necessary to include in the course?
The body of legal and regulatory knowledge guiding compliance activity, policies regarding patient confidentiality, activities most at risk with claim submission
The second step after determining misconduct is to _____
begin with a thorough investigation
List some OIG recommended trainings for all staff____
ethics, reimbursement principles, prohibitions on referrals, confirmation of diagnosis, claims submission for correct person, signatures, alterations, authorization for meds, proper documentation, duty to report misconduct
Effective compliance program
must be an ongoing process and commitment to an ethical way of conducting business
Length of CIAs
3-5 yrs with some lasting up to 8 yrs
What are the six steps to building a framework for effectiveness in compliance programs?
A. Identify risk B. Identify how org addresses risk C. Assess the "maturity" of the program D. Evaluate the extent the program is linked to measures of effectiveness E. Evaluate the measures of effectiveness and dynamic and continuously changing. F. Measure compliance program effectiveness against gov't/organizational goals..
To avoid lengthy and expensive litigation, an organization can negotiate a ____________with the govt admits no fault or liability but does submit to a govt plan for corrective action.
CIA
What is necessary in communication from the compliance program?
Caustic, creative, chilling
The best approach to auditing would be to:
Conduct a concurrent audit, correct upon finding and re-audit to assure compliance
Which law/act provides significant financial incentives for private citizens to come forward "qui tam?"
The False Claims Act
when an organization detects a problem, how do they respond?
Voluntary disclosure prior to 30 days but not more than 60 days to minimize fines
Non-retaliation/non-retribution
a policy for employees to know that they will not be punished for bringing issues forward.
What should be kept during a govt investigation?
detailed, written account of all activities, itemized inventory of all documents inspected or removed
If misconduct is found, what are the steps to disclose the violation to the government?
immediate referral to criminal or civil authorities, CAP, report to govt, and submission of overpayments.
In the event of an on site govt investigation, who should be notified and what other steps taken?
immediately notify the legal counsel and send all nonessential staff home
Some benefits of self disclosure are
less likely to have qui tam, damages could be reduced, may have the option of a self audit rather than govt audit.
The civil penalty for violating the false claim act is__________
not less than $5000 and not more than $10,000 plus treble damages sustained by govt, for each claim filed.
Before an govt investigation occurs, what should be reviewed carefully?
search warrant to ensure only identified documents are searched.
If an organization reports a violation promptly,
the culpability score may be mitigated.
If an upper level employee has participated in or was willfully ignorant of an offense,
the likelihood of culpability score will be increased.
What are the potential maximum penalties for False Claims violations?
$10,000 per violation and treble the overpayment
What are the steps in progressive discipline?
1) Supervision conference 2) Conference with higher authority 3) Written warning 4) Suspension without pay 5) Termination
How many hours does the CIA require of training?
1-3 hrs annual compliance education
A whistleblower can receive a % of the govt's total award
15-25% if DOJ assumes the case or 25-30% if DOJ declines
If there is a reason to believe the organization misconduct constituted a material violation of the civil law or the rules and regulations governing federally funded health care programs, then the organization must take steps to disclose the violation to the government. Per the OIG, such steps may include,
An immediate referral to criminal and/or civil enforcement authorities, A corrective action plan, A report to the Government, Submission of any overpayments if applicable
Audits should take into account the organization's compliance in relation to:
Areas of concerns previously identified by an outside agency, OIG Work Plan and OIG Fraud Alerts, Compliance Guidance for Third -Party Medicaid Billing Companies
There is no "one size fits all" compliance program. That said, what is necessary for a compliance program?
Commitment from the top and financial support
In the code of conduct, it is important to for enforcement and discipline to be____________________.
Fair, equitable, and fairly similar for everyone
What is progressive discipline?
It is discipline where penalties become increasingly more severe.
What are some of the points of disciplinary action?
Noncompliance will be punished. If you do something wrong, you may be fired. Failure to report noncompliance will be punished.
Dr. Cates has a patient that is need of a mobilized wheelchair. He refers his patient to his brother-in-law to get the new wheelchair. What law is being broken?
Stark Law
Ms. Jones the CEO for Samsonite Healthcare Systems is trying to put together a compliance team. What sorts of traits and experience should she look for in potential clients?
Strong people skills especially with unhappy people, High level of discretion, Training and Education background, Objective and Analytical
What are three measures of effectiveness for compliance programs?
Structure - Capacity of health care org to provide care Process - Performance measures Outcome -Observable, measurable results.
Guidance for assessing culpability score, the Federal Sentencing Guidelines uses 4 aggravating factors, which are:
Willfully ignorant of the offense, repeat violation, government investigation was hindered and tolerance of the violation was pervasive.
A code of conduct should be tailored to a specific hospital's needs. That said, which of the following may be important to include in the code of conduct?
Written plainly and concisely, consistent with hospital's policies and procedures (P&P)
OIG Top 10 reasons to implement a compliance program
demonstrates a strong commitment to honesty and responsible corporate relations, reinforces employees sense of right and wrong, fulfill legal duty to payers, cost effective, more accurate view of what is going on, quality of care to clients, provides procedures to promptly correct misconduct, mitigate any sanction imposed by government.
Office of Inspector General and Justice Department
is responsible for enforcing the rules and regulations under the Medicare and Medicaid laws outline as part of the SSA by CMS.
A mitigating factor for FSG
is that the organization cooperated with the govt investigators
Anti-kickback statute
law that prohibits any knowing and willful conduct involved in the solicitation , receipt, offer, or payment of any kind of remuneration in return for referring an individual or for recommending or arranging the purchase, lease, or ordering of an item or service that may be wholly or partially paid for by federal healthcare.
What are the 3 major objectives of a baseline audit?
Outlines the current operational standards, Identify real and potential weaknesses, Offers recommendations.
Retrospective Audit
not typically recommended but will provide a board baseline risk assessment or snapshot of what to fix
The compliance department at your hospital wants to find a few new ways to communicate compliance topics to the hospital. Which of the following answers encompasses the best ways your hospital can accomplish this?
All staff e-mails, In-house newsletter, company intranet page
Which law has a "3 strikes and you're out" clause requiring permanent expulsion for any health care organization found guilty for a 3rd time?
Balanced Budget Act
What sorts of things are included in a Code of Conduct?
Board of director's resolution supporting the compliance program ,Elaboration of the hospital's mission, Open door reporting mechanism, confidential, anonymous hotline, Description of compliance program, Narrative section i.e. Medicare compliance, conflict of interest, accepting of gifts and gratuities, Stark Law, quality of care, Specific areas of weakness (I would think you'd have to be super careful with this one.)
2010 FSG amendment changes includes way to further reduce culpability scores:
C&E program has responsibility- to report directly to board or appropriate subgroup, to detected offense before external discovery, prompt reporting, no one with OP responsibility participated in, condoned, or was willfully ignorant of the offense.
The OIG recommends that compliance officer considers the following techniques in regular review. Which one is the most significant?
Data collection and tracking
According to the text, the "lion's share of fraud and abuse offenses is attributed to":
Documentation and billing irregularities
When is progressive discipline not appropriate?
For blatant acts of fraud
Which of the following a tip for saving on future costs of compliance listed in the book?
Embed quality in existing process, Centralize common processes and controls, Emphasize training.
Beedy Hospital is trying to get their physicians involved in their compliance program. Which of the following is going to be useful in their efforts?
Emphasize clinical and fiscal improvements and provide a lot of data, build trust through partnership-like involvement and involve early, cultivate the early adopters and enthusiasts
Simple Hospital is small but Mr. Taylor, the chief compliance officer (CCO), feels that a compliance committee may be warranted. Which of the following is justification for the committee?
He wants a compliance committee to help promote the compliance program.
Which of the following is not one of the five points of disciplinary actions?
If you do something wrong, you may be fired.
The culpability score
calculation of the degree of blame or guilt used to determine fines, restitution, forfeiture, and probation.
According to the OIG, which of the following should a chief compliance officer do?
Oversee and monitor the compliance program, report to the board, revise program, develop educational and training material for the compliance program, ensure independent contractors are aware of compliance requirements, assist with internal audits, ensure appropriate background checks and independently investigate and act on matters.
Code of Conduct should contain:
Plainly written, at 8th grade reading level, including internal and external regulation
Code Red Hospital uncovers misconduct that is a material violation of civil laws governing federally funded healthcare. What must OIG require that they do?
Report it to the government and submit overpayment.
The OIG believes every effective compliance Program begins with a formal commitment to seven basic elements, based on and expanding upon the seven steps of the Federal Sentencing Guidelines. Which of the following is not one of the seven elements in the guidance for hospitals?
Terminating employees who have been investigated and found to have committed prior fraudulent acts
1984 Congress enacted Sentencing reform act which includes FSG
act designed to correct inequities in federal sentencing and give guidance for assessing fines and methods for calculation of culpability score.
Project Bad bundle
an effort by OIG to identify tests processed in groups but reported as processed individually and at the higher rate of reimbursement. also know as unbundling.
What are some of the functions in addition to aiding and supporting the compliance officer?
analyzing legal requirements & Risk areas, PP review, dev of code of conduct, monitor internal system related to PP, determine appro. strategy to promote compliance, develop a system to evaluate complaints
When developing policies and procedures, where do you start first?
areas of risk
72 Hour Window Rule
____stipulates that diagnostic tests provided on an outpatient basis within this timeframe must be billed as apart of the admission DRG.
DRG creep
___is the practice of billing using a code that provides a higher payment rate than the code that accurately reflects the service furnished to the patient.
What topics should be included into a basic compliance course?
legal and regulatory knowledge, organizations specific compliance policy, communication in/out of org, def violations and responses, confidentiality, claims submission, qualified to diagnose and procedure coding, documentation to determine claim submission, vendors held to same compliance standards, discipline.
A compliance officer or review can use such techniques as part of monitoring and reviewing compliance by
on site visits, interviews, questionnaires, review of documentation, review of financial reports, trend analysis, inclusion of compliance language in job descriptions and evaluations, exit interviews
A discipline policy should include several points such as noncompliance and failure to report will be punished along with_____________
outline of disciplinary actions, list of parties responsible for appropriate action, promise to be fair and consistent.
Stark Laws
physician referrals. law that state if a physician or family member has financial relationship with an entity that provides designated health services that the dr. may not make a referral for any health services that is reimbursable by Medicare, and the entity may not bill for the services as a result of the referral
Why compliance programs are essential
prevent paybacks, probation, government designed programs, exclusion, reduce threat of lawsuits from whistleblowers (qui tam).
compliance program
prevention, detection, collaboration, and enforcement
One example of high risk for physicians is
proper documentation of physician supervision of residents.
Benefits of compliance program addressed by OIG
safeguards the organizations' legal responsibility to abide by applicable laws and regulations.
While an investigation is occurring, what other steps should be taken?
take the necessary steps to immediately stop or modify the procedure that are the allege source of wrong doing.
Balanced Budget Act of 1997
three strikes and your out clause , requiring permanent expulsion if found guilty of fraud a third time.