Recover Health Training Corporate Compliance Plan Code of Conduct Fraud & Abuse 1
The Course Objectives When you complete this course you will be able to: Understand Recover Health s reasons for implementing a Corporate Compliance Plan (CCP) and Code of Conduct. Know the seven essential components of the plan including: the structure of the program, training, communication, and monitoring systems. Understand how to report violations of the program. Know the definition of fraud and abuse and the consequences of fraudulent activities. Know when to talk to your supervisor, ask questions, and report any concerns. Understand your role in compliance. 2
Resources In addition to this training, each office has a manual titled: Corporate Compliance Plan, Fraud & Abuse Training. All information for this training comes from the manual and will be identified by page number at the bottom left hand corner of each slide. Resources for the Compliance Program: Branch Manager and Clinical Supervisor at the office level The Regional Director for the branch The Compliance Officer at the home office 3
Background In 1998 the OIG (Office of Inspector General) published Compliance Program Guidelines for Home Health Agencies. The OIG, and the industry, believes that a health care provider can use internal controls to more efficiently monitor adherence to regulations and requirements. The guidelines were developed in coordination with home health agencies and industry representatives. In formulating guidelines, the OIG worked closely with CMS and the Dept of Justice. The Recover Health Corporate Compliance Plan is based on the OIG Guidelines (Fed Reg / Vol 63, No. 152/Friday, Aug 7, 1998) 4
Excerpt from Mission Statement. We are committed to: Leading by example and creating a highly ethical environment, attracting staff who deal honestly in every transaction and respond honorably in every interaction. ** We are further committed to aligning with the OIG efforts to combat fraud and abuse. To that end, we have established a Compliance Program that promotes prevention, detection, and resolution and is based on the Program Guidance developed by the OIG for Home Health Agencies (Fed Register / Vol 63. No. 152 / Friday, August 7, 1998) ** A guiding principle of Recover Health s Mission Statement 5
Purpose of a Corporate Compliance Program (CCP) To establish the foundation, from which the Governing Body, management team and all staff conducts activities including daily operations, corporate functions, and all decision-making processes. To establish the framework that aligns our business activities with legal and ethical standards of practice for the industry. To serve as a testament for all of our employees, clients, and communities that we intend to conduct ourselves legally and ethically and provide services of the highest quality with the greatest integrity. *Recover Health Corporate Compliance Plan : pg 3 6
Reasons to Implement a Corporate Compliance Plan 1. Recover Health wants the staff, our communities, as well as the state & federal government to be confident that our business practices are executed legally. 2. Corporate Compliance Plans (CCPs) have become an industry standard to assure mechanisms are in place to avoid errors and discourage deliberate violations. 3. Internal monitoring systems provide a structure to identify business & operational practices that may not be acceptable. 4. Assures staff that they work for a company interested in their observations, eager to resolve problems, and committed to honesty. Encourages staff to ask questions. 5. Promotes early detection and prompt reporting and reduces the company s exposure to penalties in the event there is an infraction. 6. A CCP is a sincere effort to prevent conduct that is not acceptable and could affect Recover Health s reputation and good standing. *Recover Health Corporate Compliance Plan : pg 4 7
Recover Health s Compliance Plan Seven Essential Elements 1. Code of Conduct 2. Structure and Function of the Program 3. Training and Education 4. Lines of Communication & Anonymous Complaint Reporting 5. Systems to Monitor and Address Process or Practice that Creates Vulnerability for Non-Compliance and/or Fraudulent Activity 6. Systems to Respond to Allegations of Improper Conduct 7. Response to Detected Offenses *Recover Health Corporate Compliance Plan : pg 6 8
Why Seven Essential Elements? The OIG identified 7 activities that contribute to an effective Corporate Compliance Program The elements are based on the seven steps of the Federal Sentencing Guidelines (guidelines that detail the sanctions for offenders of Federal crimes such as fraud) Each of the seven activities promotes either prevention, detection, and/or resolution 9
The Code of Conduct What Is It? A commitment to compliance with Federal & State Standards with an emphasis on preventing fraud & abuse An expression of expectations for all Recover Health management and staff 10
1 st Essential Element: Code of Conduct = Four Guiding Principles COMMITMENT TO LEADERSHIP: I. Recover Health is committed to bringing leadership to home care and integrity to business in every community we serve and every way we operate. ¹ ACCOUNTABILITY FOR PRACTICES: II. All staff is accountable to ensure that all business practices are ethical and compliant with all requirements governing the industry². ¹Recover Health Compliance Plan : Code of Conduct pg 7 ²Recover Health Compliance Plan : Code of Conduct pg 7 11
1 st Essential Element: Code of Conduct = Four Guiding Principles COMMITMENT TO LEADERSHIP: III. Recover Health is committed to leading by example and creating a highly ethical environment, attracting staff who deal honestly in every transaction and respond honorably in every interaction³ IV. ACCOUNTABILITY FOR PRACTICE: All staff is responsible for conducting business with honesty, integrity and mutual respect ³Recover Health Compliance Plan : Code of Conduct pg 7 ⁴Recover Health Compliance Plan : Code of Conduct pg 7 12
2 ND Essential Element: Structure/Function Structure of Compliance Program Includes: Compliance Officer & Committee Governing Body & Ad Hoc Members Function of Committee: Identify areas of risk Review P&P that address risk Determine appropriate strategies to promote compliance Monitor investigations *Recover Health Corporate Compliance Plan : pg 10 11 13
3 rd Essential Element: Training Training Train the Trainer Branch Manager Responsible Leadership sets the tone for expectations and objectives within the agency. Train-the-Trainer creates a culture of knowledge and expertise for all stakeholders. All staff and independent contractors will have access to training and to the Compliance Plan. Timing of Training Upon hire Annually (Compliance Plan & Fraud & Abuse Training) *Recover Health Corporate Compliance Plan : pg 10 11 14
4 th Essential Element: Communication Systems Communication Channels for Fraud and Abuse Employees have multiple communication channels to report concerns or raise questions - without threat of retribution: Supervisor, Branch Manager, Regional Director, Compliance Officer, COO, President OR - Anonymous Report: (877-597-0807) Written Anonymous Report, page 42 of Compliance Plan, if written, include as much detailed info as possible: Office location Brief summary of concern Practice or process in question Individuals involved *Recover Health Corporate Compliance Plan : pg 12-13 15
5 th Essential Element: Systems to Respond Systems to Respond to Questions Brought Forward: Notification to Compliance Officer Governing Body will be apprised of any allegation of fraud and abuse Investigation led by Compliance Officer and may include: Identifying individuals/team to collect data Team submitting report to Compliance Committee Compliance Committee will be apprised of all activities and findings as they occur *Recover Health Corporate Compliance Plan : pg 14 16
6th Essential Element: Systems to Monitor Self-Monitoring Systems Include but are not limited to: Areas that may be problem prone are captured through: Chart Audits Incident Reports Client Grievance HHCAHPS Mock Surveys Management Reports Operational Reviews Staff Awareness *Recover Health Corporate Compliance Plan : pg 16 17
7th Essential Element: Response to Audits / Investigations Investigation and Remediation May Include Governing Body Oversight of the Following: Review of policy / process Correction Plans Disciplinary action which may include termination Legal counsel as indicated Return of wrongful payments Self-Reporting as Indicated *Recover Health Corporate Compliance Plan : pg 16 18
Definitions Fraud & Abuse Fraud: an intentional act of deception, misrepresentation or concealment in order to gain something of value (some benefit or payment for which no entitlement would otherwise exist. These acts may be committed either for the person s own benefit or for the benefit of some other party). Examples include: billing for services that were never provided deliberately misrepresenting services Abuse: excessive or improper use of services or actions that are inconsistent with acceptable business or medical practice. Refers to incidents that, although not fraudulent, may directly or indirectly cause financial loss. Examples include: providing medically unnecessary services billing for items or services that should not be paid for by Medicare *Recover Health Corporate Compliance Plan : pg 32 19
Some Risk Areas Identified by the OIG: Billing for services not rendered Duplicative billing Over-utilization and under-utilization Billing Medicare when client is not homebound False dating of amendments to nursing notes or Falsified plans of care or Forged beneficiary signatures on visit slips/logs that verify service were performed *Recover Health Corporate Compliance Plan : pg 34-39 20
Some Risk Areas Identified by the OIG: Duplication of services provided by assisted living facilities, hospitals, clinics, physicians, and other home health agencies; Need to look at the Service Agreement /client contract to determine services an Assisted Living Facility is contractually obligated to provide Intentional failure to return overpayments made by the Federal health care programs. *Recover Health Corporate Compliance Plan : pg 36 21
Some Risk Areas Identified by the OIG: Improper patient solicitation activities and high-pressure marketing of unnecessary services Home health agencies should not utilize prohibited or inappropriate conduct (e.g., offer free gifts or services to patients) to carry out their initiatives and activities designed to maximize business growth and patient retention. Any marketing information offered by home health agencies should be clear, correct, non-deceptive and fully informative. Services performed by home health agency personnel that constitute patient solicitation or activities duplicative of an institution s discharge planning responsibilities are not allowable. (we can coordinate care and transfer of our own clients or those referred) Incentives, inducements, or other illegal payments to actual or potential referral sources (physicians, hospitals, patients) that may violate the anti-kickback statute *Recover Health Corporate Compliance Plan : pg 34&35 22
IT IS NOT OKAY TO 1. Have a client sign timesheets before services are provided. The client must be able to review all services provided before signing 2. Work in a client's home when they are not there. All services are placed on hold if a client is hospitalized 3. Add days (not worked) to a timesheet even if it is okay with the family. All documentation must accurately represent services *Recover Health Corporate Compliance Plan : pg 37 23
IT IS NOT OKAY TO Make decisions because everyone else is doing it! 2010 study published 8/2/2012 ~ Medicare inappropriately paid $5M for home health care claims Home Health Agencies with questionable billing 4x the national average: Florida ~ 52% of total HHA s in state Texas ~ 45% of total HHA s in state Utah ~ 40% of total HHA s in state WI - 13%, IA & MN - 3% *Inappropriate and Questionable Billing by Medicare Home Health Agencies (OIE-04-11-00240) hhtp://oig.hhs.gov/oei/reports/oie-04-11-00240.asp 24
Consequences Fraud & Abuse Violations of: False Claims Act Anti-kickback Stark Law RESULT IN: Significant fines Civil monetary penalties Triple damages for each false claim Exclusion from Medicare / Medicaid Programs Imprisonment *Recover Health Corporate Compliance Plan : pg 20-22 25
Reporting Potential Fraud & Abuse Everyone has the right and responsibility to report possible fraud, or abuse. Report any concerns or questions to: Your supervisor or Your Regional Director or The Compliance Officer or The COO or The President OR: 1-877-597-0807 Remember: You may report anonymously. Retaliation is prohibited when you report a concern in good faith. 26
Not Sure? Ask!!!. It keeps us all accountable 27
Create a Culture of Open Communication All staff has access to all levels of the management team for any concern about questionable practices. and all levels of the management team will relay that to all staff 28
Access to the Compliance Plan All staff will have access to the Compliance Plan. The location of the Compliance Plan will be discussed at the time of training so staff is aware and has easy access. 29
Corporate Compliance Policies There are 12 policies that specifically address specific risk areas related to for preventing, monitoring and reporting potential areas of fraud and abuse including: 1. Board of Director Activities 2. Community Awareness 3. Conflict of Interest 4. Dually Eligible Clients 5. Exit Interviews 6. Free Items & Services: Clients 7. Free Items & Services: Referral Sources 8. Investigation & Corrective Action 9. Renting Space 10. Retention of Records 11. Searches Interviews 12. Utilization of Therapy 30
This completes the Corporate Compliance Fraud & Abuse Training. Your completion of this course acknowledges that you have: * reviewed the Code of Conduct * understand the guiding principles * understand the basics of fraud & abuse * agree to comply with all state, federal and local regulations, * and are accountable for all information contained within Your completion of the post-test constitutes your signature on this Acknowledgement Form. Please ask your supervisor for copy of the Acknowledgement Form. 31
Questions? Don t hesitate to ask questions about any part of the training. The next step is a post-test. 32