City and County of San Francisco San Francisco Department of Public Health Office of Compliance and Privacy Affairs ANNUAL COMPLIANCE TRAINING NOTE: This training must be completed before June 30 th of each fiscal year Revision date 3-01-16 Compliance Hotline: 1-855-729-6040 toll-free 1
DPH Compliance is: Doing things right in areas of: Billing Coding Medical records & documentation Ethics & Integrity Grants & Research Healthcare Fraud, Abuse & Waste Day-to-day job duties 2
Important to note: 1. The DEADLINE to complete this course is: June 30 th of each fiscal year. 2. Failure to complete this training and submit the annual attestation by the imposed deadline may result in being non-compliant with the DPH Code of Conduct. 3. Staff who do not complete this training prior to the deadline will not be allowed to provide or bill for services. 4. Training directors are responsible for ensuring that their interns/fellows complete this course before they start providing clinical services. 5. DO NOT share the post-test answer key with your colleagues. Employees caught sharing the answer key will be in direct violation of the DPH Code of Conduct. This could result in disciplinary action. 6. Print your certificate of completion and give it to your program director for record-keeping. 7. Program directors are responsible for collecting and maintaining the certification of completion for each staff member within their program. You will be asked to produce such records in the event of a compliance audit. 3
Welcome to the SFDPH Annual Compliance Training GOALS: After you complete this course, you will: I. Recall DPH s commitment to doing things right II. Describe the DPH Code of Conduct III. Understand the consequences of violations. IV. Know how to report potential violations of the DPH Code of Conduct V. Understand the non-retaliation policy 4
Things You Should Know About DPH Compliance: 1. Mission: To ensure integrity in DPH business and clinical operations. 2. Service: We can help you (or your office) resolve your billing or related documentation/systems issues. 3. Hotline: If you uncover issues or violations, immediately call the DPH Compliance Hotline at 1-855- 729-6040 toll-free, 24 hours/day, 7 days/week. The call may be made confidentially and anonymously. 4. Website: The DPH Compliance website has useful information, such as the DPH Compliance Plan, the DPH Code of Conduct, and training materials. Find it at: https://www.sfdph.org/dph/comupg/knowlcol/policies/byunit.asp and scroll down to Compliance 5
Things You Should Know About DPH Compliance (cont.): 5. The Office of Compliance and Privacy Affairs provides education and training, with the goal of preventing problems before they occur. 6. The Office of the Inspector General (OIG) or Department of Justice (DOJ) may contact an employee about compliance-related matters. If so, notify your supervisor and your Compliance Officer immediately. Compliance is everyone s responsibility. It s all about Doing it Right! 6
Code of Conduct 7
DPH Code of Conduct The DPH Code of Conduct is an important part of the Compliance Program. DPH employees, contractors, interns, volunteers, and agents who do business with or on behalf of DPH are expected to follow this code. It describes our commitment to fully comply with all applicable local, state, and federal standards and regulations. In addition to the DPH Code of Conduct, various disciplines may have their own professional code of conduct that staff, contractors, interns, and others who do business with or on behalf of DPH are expected to follow. 8
DPH Code of Conduct You are expected to: 1) Follow all Departmental policies. 2) Do your work honestly, ethically, and responsibly. 3) Know the laws and rules related to your job. 4) Abide by acceptable billing, claiming and purchasing practices. 5) Respect the privacy and confidentiality of our clients, providers and consumers. 6) Avoid activities that may be dishonest, false, misleading, considered workplace harassment or considered conflict of interest. 7) Refrain from misusing local, state, federal, or research funds. 8) Comply with the provisions of the City s Administrative Code with regard to contracting, purchasing, or payment transactions. 9) Report Compliance issues. 9
Compliance Issues Conflict of Interest Use of City Resources Healthcare Waste Healthcare Abuse Healthcare Fraud 10
Conflict of Interest 1. Exploiting one s professional or official capacity for personal benefit. Example: An employee is asked to review RFPs to select a new vendor and doesn t tell anyone his sister-in-law owns one of the companies being reviewed. 2. Having direct supervision of, or responsibility for, the performance evaluations, pay, or benefits of any close relative or friend. Example: A manager directly supervises her niece. 3. Requiring subordinates to perform duties during work hours that is not consistent with the duties or responsibilities of the department. Example: A supervisor asks his employee to sell raffle tickets for his son s school fundraiser during work hours. 11
Conflict of Interest - Accepting Gifts Accepting gifts or other improper invitations is prohibited in exchange for influence in conducting business with patients, payers, vendors, contractors, and other business associates. Examples: A manager accepts a gift certificate from a vendor. A City consultant gives your team gifts he says are just company freebies. They include tickets, free restaurant vouchers, and other items The program coordinator of a SFDPH program has been asked to attend an annual appreciation dinner to receive an award on behalf of the City. The employees $50 dinner ticket is provided free 12
Conflict of Interest - Accepting Gifts Exceptions to the gift rules: Gifts, other than cash with an aggregate value of $25 or less per occasion; and Gifts such as food and drink, without regard to value, to be shared in the office See Statement of Incompatible Activities, V. Prohibition on Gifts for Assistance with City Services in the HR section of Polices & Procedures: https://www.sfdph.org/dph/comupg/knowlcol/policies/bycategory.asp#cor 13
Conflict of Interest Additional Employment The DPH employee working additional job(s) must: 1. Complete a Request for Approval of Additional Employment Form every year. The form can be obtained here: http://dphnet.in.sfdph.net/node/167 2. Obtain approval in advance from her/his department and then the Department of Human Resources (DHR). 3. This applies to all DPH employees whether part-time or full time. 14
Use of City Resources Use of City resources for personal, political, employee organization or other non-city business is strictly prohibited. City resources include, but are not limited to, facilities, equipment, devices, telephones, computers, copier, fax machine, email, internet access, supplies and any time for which you are receiving compensation from the City. Source: The CCSF Employee Handbook http://www.sfdhr.org/index.aspx?page=30 15
Use of City Resources Examples of inappropriate use of City Resources A City employee uses a City car for business but on his way back he does a few personal shopping errands. A City employee stays in her office during her lunch break and uses her office computer to look at sports events, play games, view videos, and sometimes gamble. 16
Healthcare Waste is: Overutilization of services, careless or needless spending of funds, or other practices that, directly or indirectly, result in unnecessary costs to the health care system. It is not generally considered to be caused by criminally negligent actions, but by the misuse of resources. Examples of Healthcare Waste: Same activities being performed in different ways by different people. Making copies of multiple forms with same information. Incorrect billing based on medical necessity. 17
Healthcare Abuse is: Actions that may, directly or indirectly, result in unnecessary costs to the Medicare or Medicaid program or the improper payment for services that fail to meet professionally recognized standards of care or that are medically unnecessary. Examples of Healthcare Abuse: Improper payment for services. Payment for services that fail to meet professionally recognized standards of care. Using City resources (e.g., city van, office supplies, etc.) for personal use. The difference between Fraud and Abuse is that Fraud is intentional. 18
Healthcare Fraud is: Knowingly and willfully executing, or attempting to execute a scheme or artifice to defraud any health care benefit program or to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program. Examples of Healthcare Fraud: Double billing for the same service or equipment Upcoding (incorrectly assigning codes to generate higher reimbursement) Unbundling services (charging separately for items that should be consolidated) 19
You play a vital role Comply with the laws, regulations, standards, and DPH policies that apply to you. Report non-compliance, fraud, abuse and waste. Understand the scope of practice of your professional license, certificate, registration, or license-waiver, including any restrictions determined by your job description and DPH policies and procedures. Avoid any actions or activities that may present as a conflict of interest, or promptly disclose those actions or activities and seek guidance and resolution from your supervisor and/or your Compliance Officer. Do not engage in any acts or activities that may constitute workplace misconduct (e.g., excessive tardiness, dishonesty) harassment (e.g., unwanted intimidation, offensive jokes) conflict of interest (e.g., engaging in non-work related activity, dual-relationships with clients) 20
Violations & Penalties False Claims Act (FCA) Whistleblower Non-Retaliation Exclusion List 21
What happens if there is a Compliance Violation? 1) Potential compliance violations will be thoroughly investigated by the DPH Office of Compliance and Privacy Affairs. 2) Once an investigation is completed, Administration will take appropriate actions to resolve the violation and prevent recurrence. 3) Actions could include employment discipline (up through termination), criminal charges, and/or civil penalties (fines). 22
False Claims Acts (FCA) Committing Fraud and Abuse related to reimbursements could lead to financial and criminal prosecution. The Federal government and the State of California have laws that make it illegal to lie or cheat the government by billing for services inappropriately. These laws are the main tools used by the government to take action against hospitals, doctors, clinics, etc., that bill for services inappropriately. The laws also authorizes what is known as qui tam actions, commonly referred to as whistleblower actions. The FCA protects a whistleblower from employer retaliation. 23
FCA Violations: Penalties that may be incurred Criminal Prosecution and other monetary penalties for submitting false claims. Exclusion from federal and state healthcare programs (inability to bill Medicare, Medi-Cal, and other publicprivate grant funded projects). Civil Penalties of not less than $5,500 and not more than $11,000 per claim, plus three times the amount of the damages the government sustains. 24
FCA Violations Real World: In 2013, in New Orleans, La., Jerayr Rostamian, of Northridge, Calif., was sentenced to 40 months in prison, three years of supervised release and fined $250,000. Rostamian pleaded guilty to structuring monetary transactions to avoid reporting requirements. Med-Tech Technologies, Inc., a company owned by Rostamian, was sentenced to five years of probation and ordered to pay $3,722,480 in restitution to Medicare and Medicaid. In 2013, the Chief Financial Officer of a hospital in California was sentenced to 8 months of home confinement and ordered to pay $10.6 million in restitution after pleading guilty to charges of conspiracy to pay kickbacks for patient referrals and other related crimes. In 2014, in Washington DC., the Diagnostic Imaging Group (DIG) has agreed to pay a total of $15.5 million to resolve allegations that its diagnostic testing facility falsely billed federal and state health care programs for tests that were not performed or not medically necessary and for paying kickbacks to physicians. 25
DPH Compliance & Hiring: Program Integrity Exclusion List Monitoring The Office of Inspector General monitors and lists individuals and business entities that should be excluded from providing goods or services that will be billed to government health care programs. DPH receives federal funding for administrative operations as well as direct patient care. Therefore, DPH must ensure that no agent, employee, contracted staff member, or intern is on this Exclusion List. https://exclusions.oig.hhs.gov/ The exclusion applies to all positions in the workplace, not just those who submit claims. It also applies to all administrative and management services furnished by the excluded person. DPH Office of Compliance and Privacy Affairs conducts monthly monitoring on all employees, contracted staff, interns and agents to ensure persons are not on the state or federal exclusion lists. 26
What could exclude you from providing services Program Exclusion (42 U.S.C. Section 1320a-7) and W&IC 14043..6 and 14123 Being convicted of program-related crimes, crimes relating to patient abuse or neglect, and other convictions relating to health care fraud and/or obstruction of an investigation are grounds for suspension/exclusion from providing services at the Department of Public Health. Medi-Cal law mandates an entity or provider of health care services be excluded from participation in the Medi-Cal program when the individual or entity has: Been convicted of a felony; Been convicted of a misdemeanor involving fraud, abuse of the Medi-Cal program or any patient, or otherwise substantially related to the qualifications, functions, or duties of a provider of service; Been suspended from the federal Medicare or Medicaid programs for any reason; Lost or surrendered a license, certificate, or approval to provide health care; Breached a contractual agreement with the Department that explicitly specifies inclusion on this list as a consequence of the breach. 27
DPH Non-Retaliation Policy Department of Public Health employees, contractors, interns, volunteers, and other agents: Have a duty and responsibility to report misconduct, including actual or potential violations of laws, regulations, policies, procedures, or this organization s standards/code of conduct, as a potential compliance issue and Are protected from any form of discrimination, harassment or retaliation within the organization. This means you can NEVER be punished for fulfilling this duty. 28
If you know or suspect a violation, immediately call the Compliance Hotline: 1-855-729-6040 toll-free Calls to the Hotline may be made confidentially and anonymously (24 hours, 7 days a week) ALWAYS REMEMBER SFDPH has a Non-Retaliation policy Call the Compliance Hotline immediately to report violations related to: DPH Code of Conduct or Compliance Program Medi-Cal, Medicare, and other program regulations Conflict of Interest Falsification of documents Possible fraud or abuse Charting or billing concerns 29
Supervisors and managers are expected to: 1. Promote and support compliance with all applicable laws, regulations, standards, departmental policies, and the code of conduct 2. Post, disseminate, and communicate regularly with staff about any changes to DPH policy, billing, coding and documentation standards, workplace conduct, professional ethics, etc. 3. Stay current on regulatory agency updates and changes, and ensure that subordinates have a clear understanding of those affecting their duties and responsibilities 4. Schedule regular compliance training for staff, new hires, volunteers, and interns 5. Identify potential risk areas specific to your unit and notify your Compliance Officer 6. Ensure staff do not engage in activity outside the scope of their practice 30
Supervisors and managers are expected to: 7. Maintain an open-door policy that encourages employees to raise problems and concerns 8. Enforce the DPH s non-retaliation policy 9. Receive and resolve issues identified by employees and implement necessary corrective or remedial actions 10. Assist the Compliance Officer, as deemed necessary, in implementing any necessary changes or remedial actions based on findings from auditing and monitoring activities 11. Avoid actions that may present as a conflict of interest, or promptly disclose those actions and seek guidance and resolution from your supervisor and/or Compliance Officer 12. Understand and comply with the state professional licensure board standards regarding the legal scope of practice of that role and any restrictions determined by your (and subordinate staff) job description, including DPH policies and procedures 31
DPH Compliance Program Policies 1. Compliance Policy: Operations of a Compliance Program https://www.sfdph.org/dph/files/policiesprocedures/com6_compliancepolicy.pdf 2. Compliance Program: Mission, Elements, and Responsibilities https://www.sfdph.org/dph/files/policiesprocedures/com7_complianceprogrammission.pdf 3. Compliance Program: Code of Conduct https://www.sfdph.org/dph/files/policiesprocedures/com8_compliancecodeofconduct.pdf 32
Attention Clinical Setting Staff and all Supervisors/Managers PLEASE CONTINUE TO NEXT PAGE for additional, mandatory training. All other staff, CONGRATULATIONS! You have completed the SFDPH Annual Compliance Training Instructions: 1. Read and electronically sign the Compliance Program Annual Code of Conduct 2. Take the Compliance Program Annual Quiz (100% of questions must be answered correctly) and save your Certificate of Completion 3. Email the Certificate of Completion to your program director for filing Program Directors, please note, you must keep these completed Certificates on file (can be electronically filed) for seven (7) years for all employees under your supervision, even if they have since left your supervision. Should any breach or incident need to be investigated, you may be asked to present these forms. 33
Clinical Documentation Compliance P D O C U M E N T A T I O N P R O V I D E R P R O T E C T I O N Medical records are legal documents that are the property of DPH and under the custodian of the site s Health Information Services or Medical Records Department. Medical record entries must be legible, signed, and dated. Clinical staff are responsible for documenting the clinical course of the patient/client, using appropriate CPT, HCPCS and/or E&M codes. Medical record documentation should include pertinent facts, findings and observations about an individual s health history, past and present illnesses, exams, tests, treatment and outcomes. It should chronologically document the care provided to the patient/client and also provide documentation of each patient s/client s condition and treatment. Medical record documentation must support the medical necessity of tests and services. Each entry into the medical record must be able to stand alone and support the test and/or service being reported. All documentation must be completed in a timely manner (See Departmental Policy). If it s not documented, it didn t happen. 34
Billing Compliance (Fraud & Abuse) False Billing is a SERIOUS offense. Never bill for services not rendered. Never change coding without the consent of the clinician who performed the service. The best practice is to have the clinician change the coding and resubmit the encounter form for processing. Always report exact time it took you to deliver service (i.e., 11 minutes face-toface, 2 mins documentation. Total time: 13 mins. DO NOT ROUND UP VALUE TO 15 mins). Always bill all other payor sources before billing Medi-Cal (exception: Victims Of Crime). Services are not billable if performed outside of an individual s scope of practice. Medicare and Medi-Cal rules prohibit knowingly and willfully making or causing to be made any false statement or representation of a material fact in an application for benefits or payment. State & Federal law state that it is unlawful to conceal or fail to disclose the occurrence of an event affecting a health care provider s right to payment with the intent to secure payment that is not due. Examples of false billing & claims include, but are not limited to: Billing inappropriate or inaccurate costs on cost reports. Billing for a length of stay beyond what is medically necessary. Billing for services for items that are not medically necessary. Billing excessive charges. 35
Research Integrity Anyone who receives local, state, and federal funds and grants to conduct research must comply with all applicable regulations imposed upon the recipients of those funds. These regulations generally prohibit misconduct in science, which includes intentional fabrication, falsification, or plagiarism in proposing, conducting, or reporting research. Honest errors or differences in interpretations of data are not considered violations. DPH is committed to ensuring that individuals engaged in research comply with high standards of ethical behavior and integrity, and conduct research in accordance with DPH policies, institutional Review Board procedures, and requirements of all local, state, federal and private sponsors. 36
Additional Resources: Ethical Principles and Code of Conduct by Profession American Medical Association: https://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics.page? American Nurses Association: http://nursingworld.org/mainmenucategories/ethicsstandards/codeofethicsfornurses American Pharmacist Association: https://www.pharmacist.com/code-ethics American Psychological Association: https://www.apa.org/ethics/code/index.aspx American Psychiatric Association: http://www.psychiatry.org/psychiatrists/practice/ethics American Association for Marriage and Family Therapy: https://aamft.org/imis15/content/legal_ethics/code_of_ethics.aspx 37 The National Association of Social Workers: https://www.socialworkers.org/pubs/code/code.asp
Clinical Setting Staff and all Supervisors/Managers CONGRATULATIONS You have completed the SFDPH Annual Compliance Training Instructions: 1. Read and electronically sign the Compliance Program Annual Code of Conduct 2. Take the Compliance Program Annual Quiz (100% of questions must be answered correctly) and save your Certificate of Completion 3. Email the Certificate of Completion to your program director for filing Program Directors, please note, you must keep these completed forms on file (can be electronically filed) for seven (7) years for all employees under your supervision, even if they have since left your supervision. Should any breach or incident need to be investigated, you may be asked to present these forms. 38