Compliance Training 2012 Compliance Training 2012 Training - - PDF document

Compliance Training 2012 Compliance Training 2012

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Training Objectives Training Objectives Training Objectives Training Objectives

• Understand the purpose of the

Understand the purpose of the Understand the purpose of the Understand the purpose of the Corporate Compliance Program. Corporate Compliance Program.

• Understand the role of the Corporate

Understand the role of the Corporate Compliance Department. Compliance Department.

• Understand your role in compliance.

Understand your role in compliance.

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What is Compliance What is Compliance What is Compliance What is Compliance

 Compliance can be described as conducting

Compliance can be described as conducting a business and oneself in an ethical, moral, a business and oneself in an ethical, moral, and legal manner. and legal manner.

 The SIH Compliance Program has an

The SIH Compliance Program has an emphasis on fraud and abuse in the emphasis on fraud and abuse in the emphasis on fraud and abuse in the emphasis on fraud and abuse in the Medicare and Medicaid programs, but also Medicare and Medicaid programs, but also includes other laws and regulations includes other laws and regulations includes other laws, and regulations. includes other laws, and regulations.

 It is doing the right thing and the RIGHT

It is doing the right thing and the RIGHT

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g g g g g g thing to do! thing to do!

Recovery Audit Contractor Recovery Audit Contractor y (RAC) (RAC)

 Hired by the federal government to identify improper

Hired by the federal government to identify improper payments and recover overpayments on Medicare payments and recover overpayments on Medicare claims States also hiring RACs to audit Medicaid claims States also hiring RACs to audit Medicaid

• claims. States also hiring RACs to audit Medicaid.
• claims. States also hiring RACs to audit Medicaid.

 Paid percentage of findings

Paid percentage of findings

 Request up to 278 medical records every 45 days for

Request up to 278 medical records every 45 days for retrospective reviews and 278 every 45 days for retrospective reviews and 278 every 45 days for t i f i ti t t t i f i ti t t prepayment reviews of inpatient stays prepayment reviews of inpatient stays

 Reviewing Medicare claims paid as far back as 3

Reviewing Medicare claims paid as far back as 3 g p g p

• years. Medicaid RACs will look back 5 years.
• years. Medicaid RACs will look back 5 years.

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Government Oversight Government Oversight

Congress

OIG

CMS

Surveys Courts Attorneys General

ZPIC PERM

Medi- Medi

DOJ

Attorneys General Health Boards Licensure Local Government Medicaid RAC

Medi

QIO

MIC

(Medicaid)

CERT

RAC

(Medicare)

DEA FDA

RAC OMIG MFCU QIO

Carrier

FI

MAC

IRS FBI VA DOT

Healthcare Provider

DOL

JCAHO &

HRSA FCC FTC EPA IRS OSHA

Treasury

SEC

• ther

accrediting agencies

HRSA FCC FTC

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Corporate Compliance Program Corporate Compliance Program Corporate Compliance Program Corporate Compliance Program

I t ll d l d I t ll d l d Internally developed Internally developed program that promotes program that promotes ethical and legal business ethical and legal business ethical and legal business ethical and legal business

• practices. It is designed
• practices. It is designed

to prevent, detect, correct to prevent, detect, correct p and, if necessary, report and, if necessary, report non non-

• compliant activity to

compliant activity to the appropriate Federal the appropriate Federal the appropriate Federal the appropriate Federal and State authorities. and State authorities.

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Compliance Compliance Program Program p g

 Helps our organization remain on the right

Helps our organization remain on the right path so we can path so we can path, so we can path, so we can

• live our mission and values

live our mission and values h ld t ti i th it h ld t ti i th it

• uphold our reputation in the community

uphold our reputation in the community

• care for patients

care for patients

 Help SIH maintain a moral and ethical

Help SIH maintain a moral and ethical culture culture culture. culture.

 Checks

Checks -

• n

n-

• Balance System

Balance System

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y

Code of Ethics and Conduct Code of Ethics and Conduct Code of Ethics and Conduct Code of Ethics and Conduct

Why have a Code of Ethics and Conduct? Why have a Code of Ethics and Conduct? – To uphold our mission values and ethics The core of To uphold our mission values and ethics The core of To uphold our mission, values, and ethics. The core of To uphold our mission, values, and ethics. The core of SIH/SIMS. SIH/SIMS. Who do they apply to? Who do they apply to? Who do they apply to? Who do they apply to? – Everyone! We should incorporate the Code of Ethics in our day Everyone! We should incorporate the Code of Ethics in our day to day operations. to day operations. What does the Code of Ethics cover? What does the Code of Ethics cover? – Things like treatment of patients, documentation, integrity and Things like treatment of patients, documentation, integrity and security of business records, patient and employee safety, security of business records, patient and employee safety,

• bligation to report compliance violations.
• bligation to report compliance violations.

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Where can you find the Code of Ethics? Where can you find the Code of Ethics? – The Intranet, SIH website, and the Compliance Program. The Intranet, SIH website, and the Compliance Program.

SIH Compliance Helpline SIH Compliance Helpline p p p p

You have questions . . . ’ll t ! we’ll get answers!

1 800 965 4583 1.800.965.4583

• r

618 529 2540 618.529.2540

The Helpline is available 24 hours a day, 7 days a week. The Helpline is available 24 hours a day, 7 days a week. All calls are confidential. SIH prohibits retaliation against anyone who in good f i h l i l i l i

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faith reports an actual or potential violation.

The Compliance Department O th W b

For more information about the Compliance

On the Web

For more information about the Compliance Department check out our new Intranet webpage!! To access, click on Departments at the top of the Intranet home page.

• Contact us (phone or email)
• Meet our staff
• Compliance Program

“E O ” l tt

• “Eye On” newsletters
• Report compliance issues (on-line Helpline)

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Compliance Committees Compliance Committees Compliance Committees Compliance Committees

• Corporate (includes Board members

Corporate (includes Board members Corporate (includes Board members Corporate (includes Board members & senior leaders) & senior leaders)

• Herrin Hospital

Herrin Hospital Herrin Hospital Herrin Hospital

• Memorial Hospital of Carbondale

Memorial Hospital of Carbondale

• St Joseph Memorial Hospital

St Joseph Memorial Hospital

• St. Joseph Memorial Hospital
• St. Joseph Memorial Hospital
• System Offices

System Offices

• SIMS

SIMS

• SIMS

SIMS These Committees advise and assist

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ese Co ttees ad se a d ass st the Compliance Officer.

Compliance Training Compliance Training Compliance Training Compliance Training

A significant element of the Corporate

A significant element of the Corporate Compliance Program is education. Compliance Program is education. g

ALL

ALL SIH workforce members receive SIH workforce members receive

ALL

ALL SIH workforce members receive SIH workforce members receive Compliance Training. Compliance Training.

Employees receive

Employees receive annual refresher training. annual refresher training.

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g

Compliance Department Compliance Department Compliance Department Compliance Department

• Risk assessment survey

Risk assessment survey Risk assessment survey Risk assessment survey

• Audit and monitor

Audit and monitor

• Research rules

Research rules

• Research rules

Research rules

• Review outside audit activity

Review outside audit activity

• Educate

Educate

• Educate

Educate

• Participate on multidisciplinary teams

Participate on multidisciplinary teams Interact with government and private/ third party Interact with government and private/ third party

• Interact with government and private/ third party

Interact with government and private/ third party auditors auditors

• Help maintain strong compliance program

Help maintain strong compliance program

• Help maintain strong compliance program

Help maintain strong compliance program

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Compliance Staff Compliance Staff

 Nurse Auditors

Nurse Auditors: RNs who compare the legal : RNs who compare the legal medical record ( medical record (ChartMaxx ChartMaxx) to charges on the ) to charges on the ti t’ t ti t’ t patient’s account patient’s account

 Janice Brewer (MHC) Janice Brewer (MHC) Linda Walkup (MHC) Linda Walkup (MHC)  Carolyn Johnson (HH) Carolyn Johnson (HH) Sarah Gill (SJ) Sarah Gill (SJ)  Carolyn Johnson (HH) Carolyn Johnson (HH) Sarah Gill (SJ) Sarah Gill (SJ)

 Internal Auditor

Internal Auditor, Jessica , Jessica Kranawetter Kranawetter, and , and Compliance Auditor Compliance Auditor Jenny Jenny Hertter Hertter perform audits perform audits Compliance Auditor Compliance Auditor, Jenny , Jenny Hertter Hertter, perform audits , perform audits and investigations, and research topics and and investigations, and research topics and answer questions in their areas of expertise answer questions in their areas of expertise Compliance Analyst Compliance Analyst, Jenny Baggett, researches , Jenny Baggett, researches new services and other issues and represents new services and other issues and represents

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new services and other issues, and represents new services and other issues, and represents Compliance at revenue cycle and other meetings Compliance at revenue cycle and other meetings

Compliance Staff Compliance Staff p

Clinical Compliance Auditors Clinical Compliance Auditors: Audit and investigate : Audit and investigate provider documentation coding and other issues provider documentation coding and other issues provider documentation, coding, and other issues provider documentation, coding, and other issues

Marybeth Roe (at CMA) Marybeth Roe (at CMA) Christy Williams (at LPC) Christy Williams (at LPC)

Government Audit Government Audit team responds to RAC audit team responds to RAC audit requests and findings, tracks/trends/reports, and requests and findings, tracks/trends/reports, and prepares appeals prepares appeals prepares appeals prepares appeals

Christi Roach, Coordinator Christi Roach, Coordinator Betheny Betheny Johnson, Asst Johnson, Asst

IT Auditor IT Auditor, Lisa , Lisa Cavitt Cavitt, collaborates with IT , collaborates with IT department, performs audits and investigations, department, performs audits and investigations, creates and runs reports and involved in system creates and runs reports and involved in system

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creates and runs reports, and involved in system creates and runs reports, and involved in system implementation/upgrades. implementation/upgrades.

Response to a Problem Response to a Problem Response to a Problem Response to a Problem

 Once an issue is discovered, it must be

Once an issue is discovered, it must be investigated. investigated. g

 Once investigated and confirmed, the

Once investigated and confirmed, the issue must be corrected and any issue must be corrected and any issue must be corrected and any issue must be corrected and any

• verpayment refunded (60 day limit).
• verpayment refunded (60 day limit).

 Once corrected, a follow

Once corrected, a follow-

• up review must

up review must be conducted. be conducted.

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Disciplinary Standards Disciplinary Standards Disciplinary Standards Disciplinary Standards

 C

t i ti l C t i ti l

 Create an organizational

Create an organizational culture that emphasizes culture that emphasizes thi l b h i thi l b h i ethical behavior. ethical behavior.

 See

See Improvement Improvement Counseling Counseling policy policy, , g p y p y, SY SY-

• HR

HR-

• 401.

401.

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Be familiar with Compliance Be familiar with Compliance Policies: Policies:

Protocol for Search Warrants (SY Protocol for Search Warrants (SY-

• LE

LE-

• 004)

004)

 Identify the agent in charge

Identify the agent in charge

 Identify the agent in charge.

Identify the agent in charge.

 Ask to see identification.

Ask to see identification.

 Request a delay until SIH’s General

Request a delay until SIH’s General Counsel or his designee can be present. Counsel or his designee can be present.

 Obtain a copy of the warrant.

Obtain a copy of the warrant.

 Request permission to copy medical

Request permission to copy medical

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 Request permission to copy medical

Request permission to copy medical records before releasing them. records before releasing them.

Identity Theft Red Flags (SY Identity Theft Red Flags (SY-

• CO

CO-

• 028)

028)

 Protect patient’s health and financial info and

Protect patient’s health and financial info and the integrity of the medical record by positively the integrity of the medical record by positively identifying the patient at registration and identifying the patient at registration and before care before care

 Report red flag (warning sign) to your

Report red flag (warning sign) to your immediate supervisor or the house supervisor, immediate supervisor or the house supervisor, p p p p who will review and, if necessary, will contact who will review and, if necessary, will contact

• ur Privacy Officer, Marcia Matthias, for
• ur Privacy Officer, Marcia Matthias, for

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further investigation. further investigation.

Gifts Gifts

Acceptable Acceptable-

•  N

i l l ift h f d fl N i l l ift h f d fl

 Nominal value gifts, such as food or flowers,

Nominal value gifts, such as food or flowers, preferably given to the entire department or unit. preferably given to the entire department or unit.

Not Acceptable Not Acceptable-

•  Cash or Gift Certificates

Cash or Gift Certificates

 Cash or Gift Certificates

Cash or Gift Certificates

Note: Government has strict limits on gifts to and from referral sources and vendors sources and vendors. Please refer to the following policies for more info: Business Gratuities, SIH system wide policy SY-CO-006 B i G t iti SIMS SM AD 012

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Business Gratuities, SIMS, SM-AD-012 Gifts from Patients, system wide policy SY-CO-008

False Claims Act False Claims Act (SY (SY-

• CO

CO-

• 019)

019)

 Federal law has existed since the Civil War.

Federal law has existed since the Civil War.

 Government tool for fighting fraudulent, abusive or

Government tool for fighting fraudulent, abusive or f l l i i l di th b itt d t th f l l i i l di th b itt d t th false claims, including those submitted to the false claims, including those submitted to the Medicare and Medicaid programs. Medicare and Medicaid programs.

 Illi

i h f l l i t titl d Illi i h f l l i t titl d

 Illinois has a false claims act entitled,

Illinois has a false claims act entitled, Whistleblower Reward and Protection Act Whistleblower Reward and Protection Act. It . It encourages employees with knowledge of encourages employees with knowledge of encourages employees with knowledge of encourages employees with knowledge of compliance issues to come forward. compliance issues to come forward.

 SIH has implemented a False Claims Act Policy to

SIH has implemented a False Claims Act Policy to

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 SIH has implemented a False Claims Act Policy to

SIH has implemented a False Claims Act Policy to raise awareness of importance of documentation. raise awareness of importance of documentation.

Examples of Compliance Failures Examples of Compliance Failures Examples of Compliance Failures Examples of Compliance Failures

• Behavioral therapist, $164K and 18 months in jail, fraud,

inflating amount of time spent with patients inflating amount of time spent with patients

• Medical corporation, $997K, fraud, billing for services not

provided (no reimbursement for what was being done, so coded as another service), physical therapy not done by qualified persons, billing for physician services when physician not in

• ffice, billing Medicare and VA for same services

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• Health care facility, $448K, False Claims Act, billing female

Lupron dose (pays better) even when male dose administered, failure to self disclose when facility discovered problem in 2009 failure to self disclose when facility discovered problem in 2009

• Doctor indicted for $8.1M conspiracy to commit healthcare

fraud, instructed CRNAs to document 31 minutes for all , endoscopies & colonoscopies when actual time was less

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Your Responsibility Your Responsibility Your Responsibility. . . Your Responsibility. . .

 Perform job duties in an ethical and compliant

Perform job duties in an ethical and compliant manner. manner.

 Adhere to all policies and procedures.

Adhere to all policies and procedures.

 Report potential violations of policies, Compliance

Report potential violations of policies, Compliance Program, or Code of Ethics. Program, or Code of Ethics.

 Cooperate with the Compliance Department

Cooperate with the Compliance Department during investigations and audits. during investigations and audits.

Ask questions & report your

Ask questions & report your W k W k

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• concerns. We want to know.
• concerns. We want to know.

IMPORTANT IMPORTANT IMPORTANT IMPORTANT

Compliance ultimately depends on each Compliance ultimately depends on each individual within the organization individual within the organization choosing to do the right thing, even when choosing to do the right thing, even when it is inconvenient or takes more time. it is inconvenient or takes more time.

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Questions? Questions? Questions? Questions?

Thank You!!

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Thank You!!