1.Cultural & Linguistic Competence. 2.Model of Care for Special Needs Patients. 3.Combating Medicare Fraud, Waste and Abuse. Revised January 2017

Transcription

1 Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs Patients 3.Combating Medicare Fraud, Waste and Abuse Revised January

2 This training presentation contains confidential and proprietary trade secrets of and copyrights belonging to RadNet Management, Inc., its subsidiaries, and/or affiliates (collectively, "RadNet"). This training presentation may only be used by a RadNet Center, RadNet's representatives or upon the express written permission of RadNet, and may not be reproduced in any media, either in whole or in part. Any reproduction of these documents, in whole or in part, or any use of these documents, other than as directed or agreed upon in writing by RadNet, is strictly prohibited and constitutes a violation of law. 2

3 Anyone who provides services to Medicare patients must complete annual compliance training. This three-part training series is required for us to be able to bill for services. Attestations must be completed annually for our payors stating this training has been completed by all RadNet employees and affiliates (contractual staff). 3

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5 Culture Culture is the learned and shared knowledge that specific groups use to generate their behavior and interpret their experience of the world. It is transmitted through social and institutional traditions to succeeding generations. Culture is a paradox: While many aspects remain the same, it is also constantly changing. beliefs practices communication languages thoughts rituals courtesies relationships roles values customs expected behaviors manners of interacting 5

6 Cultural Diversity The term Cultural Diversity is used to describe differences that distinguish one group or individual from another. nationality; ethnic or racial classification gender identity, self-identification physical and intellectual abilities socioeconomic status personal appearance religion, spirituality sexual orientation education level language gender age 6

7 Cultural Competence behaviors practices policies attitudes structures Cultural Competence requires that organizations have a clearly defined, congruent set of values and principles, p and demonstrate behaviors, attitudes, policies, structures, and practices that enable them to work effectively cross-culturally. 7

8 5 Elements of Cultural l Competence On an Individual Level 1. Acknowledge and value the cultural differences of others 2. Understand your own culture 3. Engage in a self-assessment of your acceptance level 4. Acquire cultural knowledge & skills 5. View people s behavior within a cultural context These five elements must be manifested at every level of an organization i and reflected in its attitudes, structures, policies, practices, and services in order to be a Culturally Competent Company. 8

9 Organizational & Personal Change Herein lies the challenge: Being a culturally competent organization requires changes in people s values, attitudes and/or habits of behavior. Start thinking about the intention of cultural diversity and the behavioral criteria needed to be accepting of everyone who comes to our centers for service. Take action by being aware of how you interact with our patients, visitors and referrers, and make every effort to give Everyone the Same Positive Experience. 9

10 Your Role If you are already accepting of all persons, no matter what their race, religion, age, gender, language, socioeconomic status, education level, religion, physical abilities, intellectual status, sexual orientation, gender identity, i self-identification ifi i or personal appearance, that s great. If you realize you have a bias toward someone who may be different than you, it s important that you understand you cannot allow that bias to affect how you deal with those persons in the workplace. 10

11 Things You Can Do 1. View the world through a cultural lens. Acknowledge that people with different cultural backgrounds have different needs. 2. Share your cultural experience with other employees. Understanding cultural differences leads to better acceptance. 3. Accept the diversity of others. Remove bias, prejudice, stereotyping, and discrimination from the workplace. Treat all patients and visitors equally. 4. Address racial, ethnic, linguistic, i and geographic disparities. iti Address the needs of each person in a professional manner, no matter what their cultural background or lifestyle may be. 5. Collaborate with others when you are unable to address the needs of a specific person. Get help if you are unable to provide what someone needs. 11

12 Be Culturally Competent As a Culturally Competent Company, we must all be capable of interacting gpositively with people p who do not: Look like Talk like Move like Think like Believe like Act like Live like..us 12

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14 The Centers for Medicare and Medicaid Services (CMS) created the Models of Care Plans to: Improve patient access to medical, mental health and social services, Improve access to affordable care, Improve coordination of health care, Assure cost-effective service delivery, And improve beneficiary health outcomes. 14

15 A Model of Care for Special Needs Patients is considered a vital component for ensuring the unique needs of each patient are identified and addressed. It is important that RadNet is able to provide services for patients who are unable to access care in the same way as someone without special needs. This includes, but is not limited i to, patients with severe medical conditions, physical needs, language needs, and gender needs or self-identification needs. 15

16 Special Needs Plans were also created by Congress under the Medicare Modernization Act as a way to focus on certain vulnerable groups of Medicare and Medicaid beneficiaries: The institutionalized, and Beneficiaries with severe or disabling chronic conditions. These beneficiaries are typically more challenging to treat. 16

17 While the American With Disabilities Act and RadNet s Special Accommodations Policy already address patients with physical mobility and communication impairments; And RadNet s Limited English Proficient Patients Policy addresses patients with English language limitations; The Centers for Medicare and Medicaid Services proposed regulations to ensure patients in LGBTQ communities have equal access to care. This includes establishing same-sex spouses being considered a person s representative, regardless of state law, for the purposes of exercising a patient s health care rights to ensure they receive equal care in medical facilities. 17

18 The Centers for Medicare and Medicaid Services also created an Oncology Care Model. Under this Special Needs Plan, physician practices are entering into payment arrangements that include financial and performance accountability for episodes of care surrounding chemotherapy administration to cancer patients. For those that are not already aware, RadNet is involved in an oncology practice on the west coast. CMS is also partnering with several commercial payers in this model. 18

19 Although RadNet does not coordinate an interdisciplinary care team (such as an HMO), our Company believes it is important to understand that: 1. All patients need to have equal access to care; and 2. Be treated in a professional and equal manner. 19

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21 Every year, billions of dollars are improperly spent because of health care fraud, waste and abuse. As someone who provides services for Medicare enrollees, your every action potentially affects the Medicare Program and Medicare Trust Fund. This training will help you understand, prevent, detect and correct fraud, waste and abuse. 21

22 Statutes, regulations and policies govern the Medicare, Medicaid and MediCal programs. RadNet must follow the guidelines of: 42 Code of Federal Regulations: Code of Federal Regulations: Section 50.3 of the Compliance Program Guidelines Among many other health care regulations 22

23 The centers for Medicare & Medicaid Services (CMS) requires RadNet to have an effective Compliance Program that: t Demonstrates RadNet s commitment to legal and ethical conduct; Provides guidance on how to handle compliance questions and concerns; and Provides guidance on how to identify and report compliance violations. 23

24 An effective compliance program is essential to prevent, detect and correct Medicare non-compliance, as well as fraud, waste and abuse. RadNet s Compliance Program includes the seven (7) Core Regulatory Requirements: Written Policies, Procedures and Standards of Conduct Compliance Officer & Committee with a High Level of Oversight Effective Training and Education Effective Lines of Communication Well-Publicized Disciplinary Standards and Prompt Response Routine Monitoring, Auditing & Identification of Compliance Risks Prompt response to Compliance Issues 24

25 As part of the Medicare Program, RadNet employees and affiliates must conduct themselves in an ethical and legal manner. It s about doing the right thing! Act fairly and honestly; Adhere to high ethical standards in all you do; Comply with all applicable laws, regulations and CMS requirements; and Report suspected violations. 25

26 RadNet s Code of Conduct states our Company s compliance expectations and the principles and values by which we operate our business. Related concepts include honor and moral codes. RadNet employees and affiliates are required to complete a Code of Conduct Policy Acknowledgement. The Code of Conduct includes seven (7) ethical standards. 26

27 1. I will perform my duties in good faith and to the best of my ability. I will act in the best interest of RadNet, and refrain from any illegal conduct. 2. I will not engage in any corrupt business intended to obtain favorable treatment by or additional business from any government entity, physician, patient, vendor or any other party in a position to benefit RadNet. 27

28 3. I will not pay any person or entity for the referral of patients, nor will I accept any payment for referrals. Referrals will be made solely l on the basis of what is best for the patient, without regard for the value or volume of business which any yperson or entity can provide to RadNet. 4. I will not participate in any false billing of patients, government entities or any other party. I will promptly report any suspicious billing practices to my supervisor or to the Corporate Compliance Officer. 28

29 5. I will not engage in any conduct which conflicts with the interests of RadNet without the express written consent of the RadNet Board of Directors. I will avoid even the appearance of impropriety and will report all apparent conflicts to the Corporate Compliance Officer. 29

30 6. I will not use RadNet confidential or proprietary information gathered during my employment with RadNet for my own personal benefit while I am employed at RadNet or at any time thereafter. I will not disclose confidential financial, medical or other information obtained from patients without their express written permission and in accordance with all applicable policies i and procedures of RadNet. 7. I will promptly report all suspected violations of this Code of Conduct by other RadNet employees or agents to the Corporate Compliance Officer. 30

31 RadNet is committed to conducting its business in a lawful and ethical manner. RadNet's employees and affiliated physicians are required to comply with all applicable laws, regulations, and policies affecting the operations of RadNet's business, including but not limited to rules relating to: Billing for items or services not actually provided; Improper coding practices; Providing medically unnecessary services; Failure to provide sufficient documentation; Improper reassignment of Medicare payments; Supervision of diagnostic services; Improper referral arrangements; Waivers of co-payments and deductibles; Improper patient inducements; Required payments to referral sources that violate the anti-kickback statute; Improper marketing activities; Contracts with suppliers, independent contractors, other medical practices, physician management companies, billing agents, etc. Joint ventures with other physicians, vendors, hospitals, and managed care organizations; and Other physician investments 31

32 Non-compliance is conduct that does not conform to the law, Federal health care program requirements or RadNet s business policies. i CMS has identified the Medicare high-risk areas: Advance Beneficiary Notices Conflicts of interest Claims processing Credentialing and provider networks Ethics Oversight and monitoring HIPAA Privacy Act Quality of care 32

33 Failure to follow Medicare Program requirements and CMS guidance can lead to serious consequences: Contract termination i / Loss of business and revenue Criminal penalties Exclusion from participation in all Federal health care programs Civil monetary penalties Those who engage g in non-compliant behavior may be subject to any of the following disciplinary standards: Mandatory retraining Disciplinary action Termination of employment or contract 33

34 Without programs to prevent, detect and correct non-compliance, we all risk: Harm to beneficiaries, such as: Delayed services Denial of benefits Difficulty in using providers of choice Other hurdles to care Less money for everyone, due to: Higher insurance copayments and premiums Lower benefits for individuals and employers Lower ratings Lower profits 34

35 Fraud is intentionally submitting false information to the government or a government contractor in order to get money or a benefit. Knowingly and willfully executing, or attempting to execute, a scheme to defraud any health care benefit program; Or to obtain any of the money or property owned by, or under the custody or control of, any health care benefit program by means of false or fraudulent pretenses, representations, or promises. 35

36 Knowingly billing for services not furnished or supplies not provided, including billing Medicare for appointments that the patient failed to keep. Knowingly altering claim forms, medical records, or receipts to receive a higher payment. The Health Care Fraud Statute makes it a criminal offense to knowingly and willfully execute a scheme to defraud a health care benefit program. Health care fraud is punishable by imprisonment for up to 10 years. It is also subject to criminal fines of up to $250,

37 Waste includes overusing services, or other practices that, directly or indirectly result in unnecessary costs to the Medicare Program. Waste is generally not considered to be caused by criminally negligent actions, but rather by the misuse of resources. Unlike fraud, the provider has not knowingly or intentionally misrepresented facts to obtain payment. 37

38 Examples of actions that may constitute Medicare waste include, but are not limited to: Conducting excessive office visits or writing excessive prescriptions. Administering and billing for contrast during a noncontrast ordered exam when it was not necessary for the diagnosis i of a specific condition. Ordering excessive diagnostic exams or laboratory tests. t 38

39 Abuse includes actions that may directly or indirectly result in unnecessary costs to the Medicare Program. Abuse involves payment for items or services when there is not legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment. 39

40 Examples of actions that may constitute Medicare abuse include, but are not limited to: Billing for unnecessary medical services. Charging excessively for services or supplies. Misusing codes on a claim, such as upcoding or unbundling codes. Billing for brand name drugs when generics are dispensed. 40

41 There are differences between fraud, waste and abuse. The primary difference is intent and knowledge. Fraud requires the person to have intent to obtain payment and the knowledge that their actions are wrong. Waste and Abuse may involve obtaining an improper payment or creating an unnecessary cost to the Medicare Program, but does not require the same intent and knowledge. 41

42 To detect fraud/waste/abuse, you need to know the law. The following slides provide information about: Civil False Claims Act, Health Care Fraud Statute, Criminal Fraud Anti-Kickback Statute Stark Statute Exclusion Health Insurance Portability and Accountability Act (HIPAA) If you d like more details on these specific laws, such as safe harbor provisions, i consult the applicable statute t t and regulations. 42

43 The Civil False Claims Act makes a person liable to pay damages to the Government if he or she knowingly: Conspires to violate the False Claims Act. Carries out other acts to obtain property from the Government by misrepresentation. i Knowingly conceals or improperly avoids or decreases an obligation to pay the Government. Makes or uses a false record or statement supporting a false claim. a false claim. Presents a false claim for payment or approval. 43

44 Any person who knowingly submits false claims to the Government is liable for three times the Government s damages caused by the violator, plus a penalty. The Civil Monetary Penalty may range from $5,500 to $11,000 for each false claim. A whistleblower is a person who exposes information or activity that is deemed illegal, dishonest, or violates professional or clinical standards. Persons who report false claims or bring legal actions to recover money paid on false claims are protected from retaliation. 44

45 The Health Care Fraud Statute states that Whoever knowingly and willingly executes, or attempts to execute, a scheme to defraud d any health care benefit program shall be: Fined Imprisoned not more than 10 years Or both Conviction under the statute does not require proof that the violator had knowledge of the law or specific intent to violate the law. 45

46 True story about someone violating the Health Care Fraud Statute. A Pennsylvania pharmacist submitted claims to Medicare for non-existent prescriptions and for drugs not dispensed. d He was found guilty of health care fraud. He received a 15-month prison sentence and $166,000 fine. 46

47 Persons who knowingly commit Criminal Fraud by making a false claim may be subject to: Criminal fines up to $250,000 Imprisonment for up to 20 years Or both If the violations resulted in death, the individual may be imprisoned for any term of years or for life. 47

48 The Anti-Kickback Statute prohibits knowingly and willfully soliciting, receiving, offering or paying remuneration (including any kickback, kb k bribe or rebate) for referrals for services that are paid, in whole or in part, under a Federal health care program (including the Medicare Program). Violations are punishable by: A fine of up to $25,000 Imprisonment for up to 5 years Or both 48

49 True story about someone violating the Anti-Kickback Statute. A radiologist who owned and served as medical director of a diagnostic testing center in New Jersey obtained nearly $2 million in payments from Medicare and Medicaid for diagnostic imaging procedures. He was found to have paid doctors for referring patients. He was guilty of violating the Anti-Kickback Statute. He was sentenced to 46 months in prison. 49

50 The Start Statute prohibits a physician from making referrals for certain designated d health services to an entity if the physician (or a member of his/her family): Has an ownership or investment interest; or A compensation arrangement (exceptions apply). Medicare claims tainted by an arrangement that does not comply with the Stark Statute are not payable. Penalties include: Up to a $15,000 fine for each service provided d Up to a $100,000 fine for entering into an unlawful arrangement or scheme 50

51 True story about someone violating the Stark Statute. A physician i routinely referred Medicare patients t to an oxygen supply company that he owned. He was found guilty of violating the Stark Statute. He had to pay the Government $203,000 to settle the allegations. 51

52 The Office of Inspector General (OIG) may impose Civil Monetary Penalties for a number of reasons, including: Arranging for services or items from an excluded individual or entity. Providing services or items while excluded. d Failing to grant OIG timely access to records. Knowing of an overpayment and failing to report and return it. Making false claims. Paying to influence referrals. 52

53 The penalties range from $10,000 to $50,000 depending on the specific violation. Violators are also subject to three times the amount: Claimed for each service or item; or Of remuneration offered, paid, solicited or received. Real life example of violating Civil Monetary Penalties law. A California pharmacy and its owner submitted claims to Medicare Part D for brand name prescription drugs that could not have been dispensed based on inventory records. He had to pay over $1.3 million to settle the allegations. 53

54 The Office of Inspector General (OIG) has authority to exclude individuals and entities from federally funded health care programs. They maintain a List of Excluded Individuals at org hhs gov on the internet. The U.S. General Services Administration also administers the Excluded Parties List System which contains debarment actions taken by Federal agencies at RadNet may not employ or do business with anyone or any company that is excluded. 54

55 The Health Insurance Portability and Accountability Act created greater access to health insurance and protection of health care data, and promoted standardization and efficiency in the health care industry. HIPAA safeguards help prevent unauthorized access to protected health care information. RadNet employees and affiliates with access to protected health information must comply with HIPAA. Violations may result in Civil Monetary Penalties. In come cases, Criminal Penalties may apply. 55

56 True story about someone violating HIPAA. A hospital employee was found guilty of obtaining i protected health information with intent to use it for personal gain. He was sentenced to 12 months and 1 day in prison. He was also terminated from employment. 56

57 FIRST: You must comply with all applicable statutory, regulatory and other Medicare requirements, including adopting and following RadNet s Compliance Program. SECOND: You have a duty to the Medicare Program to report any compliance concerns, as well as suspected or actual violations that you may be aware of. THIRD: You have a duty to follow RadNet s Code of Conduct that articulates our Company s commitment to standards of conduct and ethical rules of behavior. 57

58 Be familiar with laws, regulations and RadNet policies. i Conduct yourself in an ethical manner. Ensure data and billing are both accurate and timely. Verify all information provided to you, whether from a co-worker or a patient. Be on the lookout for suspicious activities and mistakes. 58

59 Everyone is required to report suspected instances of Fraud, Waste or Abuse. RadNet's Code of Conduct clearly l states this obligation. RadNet will not retaliate against you for making a good dfaith effort tin reporting. Do not be concerned about whether it is fraud, waste or abuse. Just report any concerns so we can evaluate the issue. Our goal is to fix problems before they become a bigger issue. 59

60 RadNet has 3 mechanisms in place for employees to report potential fraud, waste or abuse. If you suspect Fraud, Waste or Abuse, or have made an error that you need assistance with: 1. Talk to your supervisor or team leader 2. Call the Compliance Department 3. Call the Compliance Hotline if you wish to remain anonymous Compliance Department Compliance Hotline

61 If warranted, RadNet must report fraudulent activity to Government authorities, such as the Office of Inspector General, the Department of Justice, or the Centers for Medicare & Medicaid Services. The Self-Disclosure Protocol gives providers the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation. RadNet s Compliance & Quality Assurance Department will handle all such agency reporting to ensure proper documentation is gathered and provided. 61

62 Once fraud, waste or abuse has been detected, it must be promptly corrected. Correcting the problem ensures you are in compliance with government requirements and RadNet policies. Consult with Compliance Department staff to find out the process for corrective action plan development. Corrective actions will vary depending on the specific circumstances. 62

63 Corrective actions may include: Returning money that was improperly collected Adopting new document review requirements Providing educational materials to staff Revising gpolicies or procedures Sending warning letters Taking disciplinary action Terminating an employee or contractual relationship 63

64 ISSUE: Does the exam order look altered or possibly forged? Is the person receiving the service the actual beneficiary? (identity theft) Does the beneficiary s medical history support the services being requested? CORRECTIVE ACTION: Check orders for authenticity. Check photo ID during registration. Check history to ensure it matches the services requested. 64

65 ISSUE: Original orders are not scanned or documented in the RIS medical record. CORRECTIVE ACTION: All orders must be scanned and documented in the RIS medical record. 65

66 ISSUE: Verbal orders are not consistently documented in the RIS medical record. CORRECTIVE ACTION: Verbal orders must be documented in RIS and must include the following information. The names, titles and other identifying information for both parties to the call The authority of the person giving the verbal order The date and time of the call The specific order relayed The exam and clinical indication 66

67 ISSUE: The exam to be performed differs from the exam ordered where amended orders are not consistently obtained. CORRECTIVE ACTION: When an exam is going to be different from the one ordered, or an exam is going to be added on, an amended order must be obtained from the referring physician. All exams must be medically necessary. 67

68 ISSUE: Documentation of clinical indications in RIS are inconsistent with the order. This can occur when clinical information is obtained from the patient and the radiologist uses this in the report. CORRECTIVE ACTION: When information is obtained from the patient, it should be noted in the medical record (RIS) that the patient supplied the information. The Radiologist should dictate the ordered clinical indication i in the report. If the Radiologist i includes the information obtained from the patient, he or she should make mention that patient provided the information. 68

69 ISSUE: ABN not obtained when needed or is obtained when not necessary. ABNs not completed correctly or are incomplete. CORRECTIVE ACTION: RadNet ABN Training course provides instruction on completing the ABN form. Medicare coverage guidelines can help you understand when an ABN may be necessary. 69

70 If you have questions after reviewing this training module or need further assistance, please contact: Laura Foster, VP of Regulatory Affairs at Or your Regional Quality Assurance Specialist: West Coast: Carol Meena East Coast: April Dickerson

71 Please complete the corresponding Compliance Quiz to make sure you understand the information presented. 71