Preventing Fraud and Abuse in Health Care

Preventing Fraud and Abuse in Health Care

Corporate Compliance what is it? Corporate Compliance is about the effort to fight healthcare fraud and abuse by making it a state and federal criminal offense

Fraud A lie or deception intended to gain something of value. The most frequent kind of fraud involving Medicare and Medicaid is when someone knowingly makes a false claim for payment.

What is Medicare and Medicaid Abuse? Actions that results in unnecessary costs Impossible to know whether the actions were intentional or not For example: incorrect diagnosis codes are used for filing a claim, resulting in overpayment for services

History In 2000, the US Department of Health and Human Services Office of Inspector General (OIG) issued guidelines to help health facilities fight fraud and abuse, particularly in relation to the Medicare and Medicaid programs. One of the guidelines stated that health facilities should have a compliance program

NYS Medicaid Facts New York State s Medicaid program (annually): Costs $46 billion Provides health care to over 4 million recipients through 60,000 active providers Enrolls 10,000 new providers Covers over 160 million eligibility verification and service authorization requests Processes 350 million claims and payments. Is the default state health insurance increasing efforts to include uninsured

More recently 2009 Every provider of medical assistance program items and services.shall adopt and implement an effective compliance program Social Services Law 363 d

Intent of Social Services Law 363 d Legislative Expectation: Providers will have EFFECTIVE Corporate Compliance Programs that will prevent and detect fraud and abuse. Providers need... to organize provider resources to: resolve payment discrepancies detect inaccurate billings, as quickly and efficiently as possible and to impose systemic checks and balances to prevent future recurrences.

Operating Principles The majority of Heath Care providers are honest Some providers have cut corners or looked the other way Criminals have infiltrated the Heath Care system Not everything bad is FRAUD Hussar, Robert, First Deputy State of New York, OMIG Mandatory Medicaid Compliance Programs

Corporate Compliance Program Designed to help ensure all staff know how to follow (comply with) the federal and state laws and regulations that apply to health facilities. Since many Department and Unit policies are linked to these very laws and regulations, corporate compliance is effective when it helps us DO WHAT OUR POLICIES SAY.

Corporate Compliance Program Details how staff should fulfill the requirements of federal, state and private health plans while providing quality care to clients/patients/residents.

Corporate Compliance OMIG The Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) is responsible for federal laws New York State Office of Medicaid Inspector General (OMIG) is responsible for state laws Both have zero tolerance toward fraud and abuse

Applicable Laws and Regulations Certain provisions of: the Federal False Claims Act (31 U.S.C 3729 3733, the Administrative Remedies for False Claims (31 U.S.C. 3801 3812) New York State laws (New York State Finance Law 187 194, New York State Social Service Law, New York Penal Law Art. 155; Art;175, Art;177 New York Labor Law ( 740, 741 ) Mental Health Law 18 part 521

Applicable Laws and Regulations The laws and regulations of Corporate Compliance: prohibit fraudulent conduct prohibit retaliating against staff who in good faith report such conduct relating to claims under Medicaid, Medicare and other government programs, and impose criminal and civil sanctions on any persons in violation.

Clinton County Corporate Compliance This presentation will help you: understand the eight essential elements of the Clinton County Corporate Compliance Plan (CCCCP) and explain its purpose cite five activities which evaluate patient/client/resident care identify three areas of illegal financial practices describe disciplinary actions for those responsible which may result when fraud and abuse are uncovered

Corporate Compliance your rights The CCCCP must include: training in corporate compliance information about your responsibilities in preventing and reporting fraud and abuse Clinton County s reporting procedures

Corporate Compliance Your Responsibilities You are held accountable under the CCCCP to: Follow the policies and procedures for the area you work in Report any misconduct or unethical practices you become aware of

Corporate Compliance Plan Eight Parts The eight main components of a CCCCP: 1. Written compliance policies and procedures 2. Identification of the Corporate Compliance Officer (CCO) and/or a CCO committee 3. Education and Training program for staff 4. Communication Plan for staff to make confidential reports about suspected or actual offenses

Corporate Compliance Plan Eight Parts continued 5. Enforcement and disciplinary actions 6. System for monitoring and evaluating compliance 7. System for responding to problems 8. Policy for non intimidation and non retaliation for good faith participation in the compliance program

1.Policies and Procedures Written Policies and Procedures: Define the framework that govern operations of the CCCCP Establish mechanisms to maintain and improve business practices and adherence to standards

County Code of Conduct All staff are expect to act in accordance with the highest level of professional and ethical standards in relation to the County s operations, documentation, coding, billing and day to day activities with an eye toward preventing fraud, waste and abuse. Clinton County Corporate Compliance Plan p. 19

Code of Conduct, cont Follows False Claims Act Verifies medical necessity for claims Prohibits participation in claims for services not provided Mandates staff to report knowledge or suspicion of fraud, waste or abuse Requires accurate reporting of expenses/finances Requires proper documentation including MD order

Medical Necessity Indicated Appropriate Efficacious Effective Efficient There is diagnosis to treat. There is a match between service and need. The service/intervention is shown to work based on best practice. The service/intervention is working. The intensity, frequency, duration is time and resource sensitive.

Code of Conduct, cont Do not sign off for another staff member Requires proper certification of staff Follows HIPAA regulations Assures no conflict of interest Does not accept bribes, gifts, gratuities intended to influence decisions or reward special attention or services Refuses kickback payments Follows nondiscrimination policy Refer to the Code of Conduct Policy for additional specifics pp 19 20

Policies and Procedures There are also policies procedures and protocols dealing with specific risks for Medicare and Medicaid fraud and abuse that are listed in the plan and interconnect units with the departmental and entire county plan. These include business associates agreements.

2. Compliance Officers The County Administrator is the County Corporate Compliance Officer. You should also know your Department s Corporate Compliance Officer ; your Department may also have Deputy Corporate Compliance Officers.

Compliance Officer Reports to the governing body Reviews documents relating to compliance Independently investigates and acts on matters relating to compliance and complaints and resulting corrective actions including independent contractors Develops audit programs to ensure compliance Advises and assists deputies in the implementation of the plan. Works with Compliance Committee to oversee the Plan

3. Education and Training Program Compliance training is provided to all new hires as part of departmental orientation and annually to all staff thereafter Overview of corporate compliance includes: Staff s rights and responsibilities Identification of potential risk areas Incident reporting process Disciplinary/corrective action

4. The Communication Plan Staff may report any action or activity that does not comply with corporate compliance regulations and policies and procedures.

Reporting may be done by: contacting the CCO through a telephone call or by submitting a written anonymous or signed letter Include the following information: The identified potential violation The date(s) the offence occurred, and The responsible party who participated in the activity

Reporting Is confidential Again, can be written, verbal, anonymous No one can be terminated from employment or punished (retaliated against) for reporting suspected misconduct. Secure places for you to drop a report may be located within your Department Also, a report can be made to your immediate supervisor, Department Head, or any of the compliance deputies.

5. Disciplinary and/or Corrective Actions After a report, the compliance officer/deputies will investigate and include recommendations for correction/disciplinary action in the summary If corrective action is appropriate, the compliance officer will develop a written action plan including tasks to be completed, deadlines, and person(s) responsible to carry out the plan The plan must be approved by management and may involve Personnel Department

5. Discipline and/or Corrective Actions cont d If disciplinary action is warranted, the nature, severity, and frequency of the violation will be considered before any discipline is administered Disciplinary actions may include: Verbal &/or written warning Financial penalties Suspension &/or Termination of employment or contract

6. Monitoring and Auditing The system for monitoring and auditing for corporate compliance at the Department/Unit Level may include but is not limited to: Regular review and revision of policies and procedures Supervisory oversight of client care including review of written documentation at discharge Field observations Committee and peer utilization reviews Activity log audits Patient satisfaction surveys Complaints State and fiscal audits QA,QI, and PAC Committee oversight Credentialing requirements Departmental governing board

7. System for Responding to Problems All staff are responsible to identify problems and explore possible root causes which may contribute to non compliance, and communicating the issue to supervisor, CCO or Department Head, who MUST respond The supervisor will oversee analysis of problem and development of new policies and procedures and/or additional training to address deficiency The supervisor, CCO or Department Head will monitor to ensure the preventive measure put in place has eliminated the non compliance using rapid cycle or another best practice improvement process

8. Non intimidation and Non retaliation The County ensures systems/policies are in place for nonintimidation and non retaliation for good faith participation in the compliance program including: Reporting potential issues Investigation of issues Self evaluations Audits Remedial Actions

Risk Management Risk management deals with the possibility that a loss or injury might occur. In risk management, risks are identified, evaluated, and remedied to make loss or injury less likely. The County and Departments address these risks by following policies and procedures to prevent fraud and abuse and to ensure quality care of clients.

Potential Risk Areas The Federal government identifies these areas where risk for non compliance is higher and where necessary corrective action is required: Unlawful billing practices including: Duplicate Billing submitting more than one claim for the same service Upcoding using a higher payment billing code rather than the code that reflects actual services provided Coding without proper supporting documentation

Potential Risk Areas continued False Claims include: (listed in the Federal Register/Vol.63.no.152.pg. 42414. August 7, 1998) Filing claims for services: not actually provided not medially necessary provided by unqualified or unlicensed clinical personnel False dating of addendums to nursing or therapist notes Untimely certification of Plans of Care Improper documentation of daily activity logs Inflated mileage vouchers Altered documentation in the clinical record after final approval Discounts and professional courtesy rates Falsifying plans of care Fraudulent time sheets

Potential Risk Areas continued Illegal referrals Kickbacks Receiving benefits for promoting services, it involves criminal law. Can be in the form of client referrals, gifts or gratuities, etc..

Importance of Documentation Documentation is an integral part of reimbursement It provides the data to validate coverage criteria and coding It justifies payment Proves/documents medical necessity

Corporate Compliance Corporate Compliance is doing the right thing and is everyone s responsibility.

References Hussar, Robert, First Deputy State of NY OMIG Mandatory Medicaid Compliance Programs, 2009 powerpoint Marland,Sandra, Inservice Educator, Homecare Unit, CCHD Corporate Compliance Plan, Best Corporate Compliance Practices, 2009. powerpoint Getting Paid for All Your Hard Work: The basics of reimbursement for healthcare products and services, 2002 by the Regulatory Affairs Professional Society (RAPS) Reprinted for the July 2002 issue of Regulatory Affairs focus with the permission of RAPS. www.raps.org Healthcare Compliance:Code of Conduct Handbook. Coastal Training Technologies Corp. Virginia Beach, VA. C.203 Ethics and Corporate Compliance in Health Care, Channing L. Bete Co.,Inc. 200 State Rd., South Deerfield, MA 01273 2000 Edition Houchen, Betsy, RN,JD. Committment to Compliance Beyond the OIG Guidelines An Implementation Program for Corporate Compliance in Home Health Care Agencies, Briggs Corp, Des Moines, IA, 1999 Jan 2010