D E B R A S C H U C H E R T, C O M P L I A N C E O F F I C E R

Transcription

1 D E B R A S C H U C H E R T, C O M P L I A N C E O F F I C E R

2 INTEGRATED CARE ALLIANCE, LLC CORPORATE COMPLIANCE PROGRAM It is the policy of Integrated Care Alliance to comply with all laws governing its operations and conduct business in keeping with legal and ethical standards. It is also the policy of Integrated Care Alliance to deal with employees and customers using the highest clinical and business ethics. Integrated Care Alliance strives to maintain a corporate culture which promotes the prevention, detection, and resolution of possible violations of laws and unethical conduct. Integrated Care Alliance supports the government in its goal to decrease financial loss from false claims and has as its own goal, the reduction of potential exposure to criminal penalties, civil damages, and administrative actions. Integrated Care Alliance believes that a compliance program guides the Management Board, President/CEO, managers, employees, and health professionals in the efficient management and operation of the company and in improving the quality of its services.

3 CORPORATE COMPLIANCE PROGRAM ELEMENTS Integrated Care Alliance maintains written standards, a Code of Conduct, a Risk Management Plan and Compliance policies and procedures. Integrated Care Alliance has a Compliance Department consisting of staff responsible for compliance efforts, Corporate Compliance Committee, and affiliate Compliance officials. The Corporate Compliance Committee conducts quarterly meetings. Integrated Care Alliance conducts education and training programs for employees and maintains an ICA Ethics Hotline (866) (24 hours a day, seven days a week) DWMHA Compliance Hot Line (313) (24 hours a day, seven days a week) to foster an open atmosphere for employees to report issues and concerns free from retaliation. Integrated Care Alliance may use audits or other evaluation techniques to monitor compliance.

4 CORPORATE COMPLIANCE PROGRAM ELEMENTS Integrated Care Alliance maintains a system and procedures to respond to allegations and detected offenses. If it is determined that there is a current deficiency or area of noncompliance, the development of a corrective action plan is completed to resolve the issue. Integrated Care Alliance educates and trains its employees on the requirements for the Compliance Program, and the disciplinary policy for employees who violate the compliance policies and applicable laws. Disciplinary action may include oral warnings, suspensions, and termination of employment depending on the circumstances and severity of the violation. Integrated Care Alliance believes that compliance with the law means not only following the law, but also conducting business so the Company deserves and receives recognition as good and law-abiding corporate citizens. The goal is to inspire confidence from clients, consumers, employees, the community, and our government.

5 CORPORATE COMPLIANCE POLICIES CC Integrated Care Alliance Partners Corporate Compliance Department Ensure important aspects of Compliance are monitored CC Confidentiality Maintain confidentiality of Integrated Care Alliance information & integrity of compliance program CC Integrated Care Alliance Internal Corporate Compliance Investigation Respond to and investigate possible violations of applicable federal, state or local law and non-compliance with ICA s Code of Conduct. Revised Identify specific time frame of 24 hours for initiation of investigation and days for results. Revised Identified that there would not be any form of reprimand or retaliation to an employee for initiating an issue/investigation. CC Responding to a Governmental Inquiry or Investigation Guidelines for responding to both federal and state government investigations Revised Identify specific time frame of 24 hours for initiation of investigation and days for results. Revised Identified that there would not be any form of reprimand or retaliation to an employee for initiating an issue/investigation CC-005 False Claims Compliant with federal / state law and regulations related to the billing & payment of claims involving federal, state or private programs CC-006 Omnibus rules as related to Anti-Kickback, Self Referral, and Stark Laws Guidelines for Integrated Care Alliance to comply with federal and state anti-referral and anti-kickback laws and regulations CC-007 Compliance Record Storage Retention Guidelines for the retention of documents related to the Compliance program

6 CORPORATE COMPLIANCE FACTS Possible penalties for NON-Compliance include the following: Imprisonment, Fines, & Termination of Employment Compliance is the responsibility of EVERYONE, including the Compliance Officer, Federal Government, and Employee The following constitutes the filing of a false claim Individual KNOWINGLY and WILLFULLY submits a claim. Up-coding the level of service provided Improper documentation practices Double billing resulting in duplicate payment Failure to properly use coding modifiers Billing for items or services not rendered or not provided as billed Submit false information Failure to refund credit balances

7 WHAT MAKES A CLAIM FALSE? Factually False Claims : A factually false claim means that the services on the bill did not actually happen. This type of false claim can take the form of billing for services not provided, billing for more expensive services than those actually rendered (called up coding), double-billing for services, or billing for services that were medically unnecessary, even if they were actually performed. Legally False Claims: A legally false claim occurs when the circumstances of the services on the claim or the claim itself create or reflect a violation of an underlying law or regulation. For example, claims for physician services rendered pursuant to an arrangement that violate the Stark Law (prohibiting self-referrals) or the Anti-Kickback Statute are legally prohibited and are thus false, if made knowingly. The submission of the claim itself is evidence of the provider s implied certification that the claim is valid, such that even if the provider (or biller) has not affirmatively represented that the claims are legally compliant, submitting legally invalid claims is generally viewed as knowing misrepresentation under the False Claims Act (FCA). Reverse False Claims: A reverse false claim is failure to return overpayments (made by the Federal Government) within the 60 day time frame imposed in 2010 by the Affordable Care Act (ACA). The ACA added a requirement that all overpayments be returned to the government within sixty days of when the claim is identified, and if not reported creates a False Claims Act liability for failing to do so. The Centers of Medicare and Medicaid Services (CMS) has issued proposed rules on the subject. Payment for a False Claim: Is a felony, punishable by imprisonment for not more than 10 years, or by a fine of not more than $50,000, or both. When adequate evidence of violations exists, OIG staff work closely with prosecutors from the Department of Justice (DOJ) to develop and pursue false claims cases against individuals and entities that defraud the Government. False Claims Training form should be signed by the MCPN staff and contracted Providers. (Attachment)

8 FALSE CLAIMS ACT (FCA) Under the False Claims Act there is Whistleblower protection from employer retaliation. Protects steps taken to remedy the misconduct through methods such as internal reporting to a supervisor or company Compliance department, and refusal to participate in the misconduct that leads to false claims, whether or not steps are clearly in furtherance if a potential whistleblower action. Protects individuals from employment retaliation when associated others made efforts to stop FCA violations. This language is intended to deter and penalize indirect retaliation by, for example firing a spouse or child of the person who blew the whistle. Protects not just employees but also contractors, agents, & physicians from discrimination by health care providers that employ them as independent contractors, and government subcontractors from discrimination or other retaliation by government prime contractors.

9 WHISTLEBLOWERS PROTECTION ACT 469 The Whistleblowers Protection Act 469 is an act which provides protection to employees who report a violation or suspected violation of state, local or federal law; to provide protection to employees who participate in hearings, investigations, legislative inquiries or court actions; and to prescribe remedies and penalties. An Employer can not discharge, threaten, or otherwise discriminate against an employee reporting a violation of law, regulation, or rule prohibited. Clear and convincing evidence is required as a civil action in circuit court for injunctive relief or actual damages. A person who violates this act shall be liable for a civil fine. A court, in rendering a judgment in an action brought pursuant to this act, shall order, reinstatement of the employee, the payment of back wages, full reinstatement of fringe benefits and seniority rights, actual damages, or any combination of these remedies. This act should not be construed to require an employer to compensate an employee for participation in an investigation, hearing or inquiry, held by a public body.

10 CORPORATE COMPLIANCE FACTS Who is liable under the False Claims Act? Any person or entity connected with the submission of a false claim can be liable, including; Providers, Beneficiaries, Billing Companies, Contractors, and Health Plans that do business with the Federal Government. If a concern or question about compliance arises, you should: Notify the Compliance Officer or Manager. This can also be done anonymously. Anti-Kickback Federal Penalties: Anti Kickback Statue Penalties ( 5yrs. and /or $25k Fine or both) Criminal Fraud Penalties: If convicted,the individual shall be fined, imprisoned, or both. If violations resulted in death, the individual may be imprisoned for any term of years or for life or both. Civil Money Penalties: - Loss of Medicare & Medicaid provider status - Civil Monetary penalties of $50K per act, plus damages equal to 3x remuneration involved. - Civil money penalty for each claim is between $5, $10, Stark Statute- Physician Self-Referral Law: Up to $ for entering into an arrangement or scheme. Up to $15,000 for each service.

11 CORPORATE COMPLIANCE FACTS Compliance programs and claims may be audited by a Recovery Audit Contractor (RAC) hired by the Federal Government and State of Michigan Contractors. A directive of the Affordable Care Act (ACA) is a provision that requires states to expand their Recovery Audit Contractor Programs (RAC) to prevent provider fraud, waste, abuse and improper payments, and to take administrative action to recoup overpayments as may be necessary. The Affordable Care Act requires the return of any Federal Health-Care program overpayment no later than 60 days after the overpayment is identified. Medicare has been successfully conducting audits and is now increasing the spread of these recovery audits to Medicaid. It is believed that the Affordable Care Act requires the States to up their examinations of Medicaid accounting, which could result in recovering a total of nine to ten billion dollars for the government.

12 CORPORATE COMPLIANCE FACTS Things that should be reported: Violations of law Inappropriate gifts, entertainment or gratuities Improper use of Authority property Violations of patient confidentiality Discrimination or harassment Stealing/Misuse of assets Embezzlement of funds Obstruction of Criminal or Internal Investigations A culture of compliance within an organization Prevents noncompliance, Detects noncompliance & Corrects noncompliance. Prevent- Operate within your organization s ethical expectations. Detect & Report- If you detect potential noncompliance report it. Correct- Correct noncompliance to protect beneficiaries and to save money.

13 OFFICE OF INSPECTOR GENERAL (OIG) AUDITS The OIG distributes an annual work plan that lays out the areas that will be targeted during an audit. In addition, to our annual onsite audits, the following audits will be conducted according to the OIG work plan Audits: OIG monthly Employee Exclusion Search Unallowable Room & Board Charges Community Supports while consumer is in the hospital Skill Building Adult Foster Care Employee Training Adult Foster Care Reimbursement for Community Living Support Services & Personal Care Supported Independent Living Providers Direct Care Wages Ability to Pay Claims & Billing HIPAA Security Annual Compliance Training for Employees and VCE Online Training course Respite

14 OFFICE OF INSPECTOR GENERAL (OIG) AUDITS Audit Forms: OIG Employee Exclusion Search - The employee exclusion search must be performed on a monthly basis by all contracted providers and ICA. The ICA Website has OIG Monthly Exclusions /Monthly Reinstatement files that can be opened in Excel to assist providers in the OIG search. In addition, OIG website links are available for providers to complete OIG required searches. LEIE- Database and Current Monthly Supplements list.asp Supplement Archive archive.asp Online Searchable Database Conduct individual and multiple searches on this OIG website. Compliance Statement - Integrated Care Alliance requires each provider to sign the Compliance Statement as proof that the provider is maintaining Compliance standards and trainings within their organization. Compliance & Breach Notification on Protected Health Information and Personal Record Information Statement Integrated Care Alliance requires each provider to sign the statement as proof that the provider is maintaining policies and procedures to safeguard Protected Health Information (PHI) and Personal Record Information (PRI). Documentation Statements - Integrated Care Alliance requires providers to have documentation complete, accurate, and available upon request for a provider or consumer audit. If an onsite audit is conducted there is a 24 hour time frame to produce documentation if not already available. A sampling of provider services audit requires a 48 hour time frame to produce documentation if not already available. This does not apply to providers that have started a new program, their documentation must be present upon request.

15 FRAUD WASTE AND ABUSE OIG investigates allegations of fraud, waste, and abuse in all of the Department s programs. This includes billing for services not rendered, medically unnecessary, misrepresented services, receipt of kickbacks, illegal payments made to providers, and patient harm. Specific case types include health care fraud schemes related to home health agencies, personal care, and home and community based services. These schemes are established for the sole purpose of stealing Medicare/Medicaid dollars. Those who participate in these schemes may face heavy fines, jail time and exclusion from participating in Federal health care programs. Fraud: Fraud requires the person to have an intent to obtain payment and the knowledge that their actions are wrong. Waste: Overutilization of services, or other practices that, directly or indirectly, result in unnecessary cost to the Medicare/Medicaid program. Waste is generally not considered to be caused by criminally negligent actions, but rather the misuse of resources. Abuse: Includes actions that may, directly or indirectly, result in unnecessary costs to the Medicare /Medicaid 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. There are differences between fraud, waste and abuse. One of the primary differences is intent and knowledge. Fraud requires the person to have an intent to obtain payment and the knowledge that their actions are wrong. Waste and abuse may involve obtaining an improper payment, but does not require the same intent and knowledge.

16 HIPAA Health Insurance Portability and Accountability Act of 1996 (P.L ) Created greater access to health care insurance, protection of privacy of health care data, and promoted standardization and efficiency in the health care industry. Safeguards to prevent unauthorized access to protected health care information. As individuals that have access to protected health care information, you are responsible for adhering to HIPAA.

17 ETHICS Always Do the Right Thing! As a part of the Medicare/Medicaid program, it is important that you conduct yourself in an ethical and legal manner. It s about doing the right thing!!! Act Fairly & Honestly Comply with the letter and spirit of the law Adhere to high ethical standards in all that you do Report suspected violations