Compliance Program Update Health Affairs Committee | March 21, 2018 - - PowerPoint PPT Presentation

Compliance Program Update

Health Affairs Committee | March 21, 2018

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COMPLIANCE PROGRAM UPDATE

• OIG Comments on Annual Report

– Received 1/31/18 – Requested additional information on one audit, clarification on hotline process and additional metrics from IRO – Submitted response 2/14/18

CIA Reporting Period 1: Follow-Up

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COMPLIANCE PROGRAM UPDATE

CIA Reporting Period 2

• July 1, 2017 – June 30, 2018
• Health Affairs Committee – CIA Compliance

Obligations

– Quarterly meetings to review and oversee UMHS’s compliance program and performance of the Chief Compliance Officer and the Compliance Committee – Submission (in Annual Report) of a description of documents and other materials reviewed during the Reporting Period in its oversight of the Compliance Program – Adoption of annual resolution summarizing its review and

• versight of UMHS’s compliance with Federal Health Care

programs and CIA obligations

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COMPLIANCE PROGRAM UPDATE

CIA Resolution Language

• “The Health Affairs Committee of the Board of Curators of the University of

Missouri has made a reasonable inquiry into the operations of the Compliance Program of MU Health (sometimes referred to as University of Missouri Health System or UMHS) including the performance of the Chief Compliance Officer and the Compliance Committee. Based on on its inquiry and review, the Health Affairs Committee has concluded that, to the best of its knowledge, UMHS has implemented an effective Compliance Program to meet Federal health care program requirements and the

• bligations of the Corporate Integrity Agreement.”

– Signed July 28, 2017 for Reporting Period 1

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Organized in accordance with the seven elements outlined by the DHHS OIG for effective compliance programs

• 1. Designate a compliance officer and compliance committees
• 2. Develop written compliance plans, policies, and standards of

conduct

• 3. Monitor and audit compliance risk areas
• 4. Develop open lines of communication
• 5. Implement education and training
• 6. Enforce disciplinary standards
• 7. Respond to detected deficiencies

Elements of the MU Health Compliance Program

COMPLIANCE PROGRAM UPDATE

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• Monitoring and auditing provides MU Health

with assurance that it is operating in accordance with rules, regulations and policy.

• The OCC works in conjunction with UM System

Internal Audit and MU Health leaders to develop an annual risk assessment. Work plans are informed by the risks identified and covers areas such as:

• Coding and billing
• Regulatory obligations
• Accreditation standards

COMPLIANCE PROGRAM UPDATE

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Jennifer May Chief Compliance Officer

• CIA, Compliance Program

Vacant (Recruiting) Director, Compliance

• Risk Assessment, Work Plan, Policies

Sean Rivera Information Security Officer

• HIPAA Security Risk Assessment,

Health Care Data Security Tina Overton Compliance Analyst

• Coding/Billing

Vacant (Recruiting) Compliance Analyst

• Regulatory

Sarah Sharp Compliance Analyst

• Conflicts of Interest

Shannyn Yalaoui Compliance Coordinator

• CED Liaison

Vacant (new) Compliance Analyst

• Training, Education &

Communications Joan Thoenen Compliance Analyst

• Hotline

Kristin Hahn-Cover Chief Quality Officer

• Risk Management, Regulatory

Accreditations Michele Kennett

• Assoc. Vice Chancellor
• Research Compliance

MU Health Executive Vice Chancellor for Health Affairs MU Health Care Chief Executive Officer

MU Chancellor UM System President UM System Board of Curators

Tina Adams-Salter System Privacy Officer

• HIPAA, OCR

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COMPLIANCE PROGRAM UPDATE

• Permanent CCO named
• Annual review of Policies
• Annual Mandatory Training due 5/31/18
• Claims Review recommendation due 4/1/18
• FY19 risk assessment and work plan development
• Disclosure Program

– CIA Reportable Events: FYTD - 5

• Exclusion Screening Vendor

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