CORPORATE COMPLIANCE

OIG PUBLISHES A _______ FOR EACH FISCAL YEAR

"WORK PLAN"

Coding compliance plan should include:

1. Code of conduct 2. Policies and procedures 3. Education & training 4. Communication 5. Auditing 6. Corrective action 7. Reporting

Under the______ Amendment of the US constitution, states have the primary responsibility for public health

10TH

Voluntary system of institutional review by an independent body created for the purpose of evaluating the work quality by using written criteria: ◦The Joint Commission ◦American Osteopathic Association/HFAP ◦DNV Healthcare, Inc

ACCREDIATION

Focused on penalties for fraud and abuse Mandated medical necessity screening prior to providing lab\radiology services

Balanced Budget Act

To be eligible for Medicare and Medicaid reimbursement, providers must demonstrate compliance with the Medicare _________________________, which is the process of certification

CONDITIONS OF PARTICIPATION AND CONDITIONS FOR COVERAGE

A health care facility that is accredited for Medicare participation purposes by one of the CMS-recognized accrediting organizations is "deemed" by CMS to have satisfied the Medicare CoPs.For such facilities, the State Survey Agency does not conduct a survey to certify or recertify the compliance of the facility with the applicable CoPs.

DEEMED STATUS

WHO IS THE LARGEST PURCHASER OF HEALTHCARE IN THE US?

DEPARTMENT OF HHS

In 2008 is the first new CMS-approved accreditation program in more than 40 years, First ever to integrate hospital accreditation with ISO 9001 Based out of Norway was started in the 1800 to certify ships

DNV HEALTHCARE INC,

______________ must ensure taxpayer money is spent wisely (i.e.is healthcare provided appropriate and actually provided)

Federal agencies

originally created in 1945 to conduct an objective review of services provided by osteopathic hospitals

HFAP

Agencies who detect, prosecute and prevent fraud and abuse:

HHS (OIG) Federal Department of Justice (via the Attorney General) (FBI) CMS (DEA) (IRS) State Attorney General

3 AGENCIES THAT PARTICIPATE IN Operation Restore Trust

HHS, OIG, CMS

Authorized the OIG to conduct investigations, audits and evaluations related to healthcare fraud & to have the OIG: Coordinate federal, state and local efforts targeting fraud Provide industry guidance concerning fraudulent healthcare practices Establish a national databank for reporting final adverse actions against healthcare providers Investigate fraud in private healthcare plans (current OIG policies preclude this) Identify & investigate Upcoding-assigning a code specifically for the purpose of obtaining a higher level of pmt (grouper) Unbundling-using multiple codes that describe individual components of a procedure rather than an appropriate single code that describes all portions of a procedure (NCCI)

HIPAA (1996)

Establish a national databank for reporting final adverse actions against healthcare providers Investigate fraud in private healthcare plans (current OIG policies preclude this)

HIPAA LEGISLATION

Since 1951, an independent, not-for-profit ACCREDITING ORGANIZATION accredits and certifies more than 19,000 health care organizations and programs in the United StatES

JOINT COMMISSION

LICENCESURE

Legal approval for a facility to operate or a person to practice (STATE REGULATORY AGENCIES)

FEDERAL FACILITIES DO ____ REQUIRE LICENSURE

NOT AKA VA

CERTIFICATION

Process by which government and non-government organizations evaluate educational programs, healthcare facilities and individuals as having met pre-determined standards

CORPORATE COMPLIANCE

Provide healthcare organizations with guidelines to enable them to develop comprehensive compliance programs that include policies and procedures

◦Certification of healthcare facilities is the responsibility?

STATE

UPCODING

assigning a code specifically for the purpose of obtaining a higher level of pmt (grouper)

LEGISLATION AGAINST FRAUD AND ABUSE STEM FROM...

civil False Claims act passed during the Civil War to prevent civil contractors from overbilling for services provided.

GOAL OF COMPLIANCE PROGRAMS

prevent accusations of make operations run more smoothly, improve service and contain costs .

UNBUNDLING

using multiple codes that describe individual components of a procedure rather than an appropriate single code that describes all portions of a procedure (