April 27, 2016 Development and Implementation of Corporate Compliance for FQHC’s Peak Performance Physicians, LLC Louisiana Primary Care Association T HE C OMPLIANCE I NSTITUTE 1 April 27, 2016
Compliance • Compliance does not get you into April 27, 2016 trouble; • It keeps you out of trouble. Peak Performance Physicians, LLC 2
LPCA Compliance Syllabus 1. Introduction to Compliance ‐‐ Power Point ‐‐ MARCH 30 a. OIG b. OCR April 27, 2016 2. Getting Started – APRIL 27 a. Compliance Officer – Role and Definitions b. Code of Conduct – Board Adoption c. Risk Assessment – “top five areas” d. Compliance Hotline Peak Performance Physicians, LLC 3. Conditions for Coverage – MAY 25 a. FQHC b. RHC 4. 340 b Plan – JUNE 29 5. Human Resources – JULY 27 a. Exclusions b. Licensure/Certifications c. Education 6. Financial Relationships ‐‐ AUG 31 a. Fraud and Abuse b. False Claims Act c. Stark Laws 7. Data Integrity – HIPAA ‐‐ SEPT 28 3 a. HIPAA I b. HIPAA HiTech
Presentation Goals Compliance Officer – Role and April 27, 2016 Definitions Code of Conduct – Board Peak Performance Physicians, LLC Adoption Risk Assessment – “top areas” Compliance Hotline 4
Compliance Institute • A cooperative between Peak Performance April 27, 2016 Physicians and Louisiana Primary Care Association Peak Performance Physicians, LLC • Our main goal: • To assist you in establishing an effective Compliance Plan at your facilities 5
Why Compliance Program? • Most all of the Compliance Books, Seminars, and other presentations always start with all the punishments…. April 27, 2016 • We think that compliance is doing what is right. Peak Performance Physicians, LLC • We further think that most all employees and employers want to a good job, and to do their jobs effectively and legally. 6
What is a Compliance Program? • A Compliance Program is an effective, practical and integrated management tool that establishes clear and defined goals and April 27, 2016 procedures designed to create a culture of compliance, reduce the occurrence of mistakes and prevent intentional violations of the applicable health care statutes and regulations. Peak Performance Physicians, LLC • An effective Compliance Program provides you and your employees with tools for acting ethically and for maintaining compliance with applicable laws and regulations. 7
Compliance Goals • Goal: to create a “Culture of Compliance” throughout the FQHC by showing a commitment from the top and enforcing April 27, 2016 compliance standards throughout the entity. • Benefit: by focusing attention on processes and reinforcing clinical standards through audits and training, Attendees can Peak Performance Physicians, LLC maintain and improve its high quality of care. • Benefit: by minimizing potential compliance errors; detecting and correcting any errors that do occur, Attendees will help keep such errors from becoming significant and crippling civil fines and penalties. 8
Key Elements for the Compliance Plan • Conducting internal monitoring and auditing; • Implementing compliance and practice standards; February 2016 • Designating a compliance officer or contact; • Conducting appropriate training and education; Peak Performance Physicians, LLC • Responding appropriately to detected offenses and developing corrective action; • Developing open lines of communication; and • Enforcing disciplinary standards through well ‐ publicized guidelines. http://oig.hhs.gov/authorities/docs/physician.pdf 9
Tools for Compliance • Utilizing the Compliance Officer and Compliance Committee as mechanisms for clarifying requirements and reporting potential April 27, 2016 misconduct; • Reviewing and understanding your written policies and procedures; Peak Performance Physicians, LLC • Maintaining effective lines of communication with management and other staff members; and • Participating in training and education opportunities. 10
Compliance Officer Duties/Responsibilities • The OIG recommends that every healthcare organization designate a Compliance Officer to carry out and enforce April 27, 2016 compliance activities. Peak Performance Physicians, LLC • The Compliance Officer should function as an independent and objective person that reviews and evaluates organizational compliance and privacy/confidentiality issues and concerns. ( The OIG prefers that the Compliance Officer answer to the Board and not to the CEO.) • The Compliance Officer’s main duties include coordination and communication of compliance plan; this involves 11 planning, implementing, and monitoring the program.
Compliance Officer Duties • Overseeing and monitoring the implementation of the compliance plan April 27, 2016 • Developing, coordinating, and participating in a multifaceted Peak Performance Physicians, LLC educational and training program • Regular reporting to the organization’s Governing Body, CEO and compliance committee on the progress of implementation; helping establish methods to improve the organization’s efficiency and quality of services; and reducing the organization’s vulnerability to fraud, abuse and waste 12
Compliance Officer Duties (cont’d) • Periodically revising the program in light of legal and organizational changes, as well as changes in the polices and April 27, 2016 procedures of government and private payor health plans Peak Performance Physicians, LLC • Developing, coordinating, and participating in a multifaceted educational and training program • Ensuring that independent contractors and agents who furnish medical services to the organization are aware of the requirements of the organization’s compliance program with respect to coding, billing and marketing. 13
Compliance Officer Duties (cont’d) • Coordinating personnel issues with the organization’s HR Department April 27, 2016 • Coordinating the organization’s financial management in organizing internal compliance review and monitoring Peak Performance Physicians, LLC activities, including annual or periodic reviews of departments or specific risk areas • Independently investigation and action on matters related to compliance, including the flexible design and coordination of internal investigations (e.g. responding to reports of problems or suspected violations) and any resulting corrective action with all providers, agents, and independent contractors if 14 appropriate
Compliance Officer Duties (cont’d) • Developing policies and programs that encourage managers and employees to report suspected fraud and other April 27, 2016 improprieties without fear of retaliation Peak Performance Physicians, LLC • Developing a process to screen all employees, physicians, independent contractors and suppliers to ensure that they have not been debarred or excluded from participation in the federal or state healthcare programs. 15
Compliance Officer • The Compliance Officer must have the authority to review all documents and other information relevant to compliance April 27, 2016 activities. Peak Performance Physicians, LLC 16
Sample Job Description • Forwarded to each of you before the presentation…. April 27, 2016 • This sample is very detailed, and smaller organizations may not have the resources to hire an officer with all of the Peak Performance Physicians, LLC qualifications and knowledge outlined in the job description. • Organizations can “bridge” these qualifications, by using the corporate attorney, or outside agents to help with establishing the Compliance Program 17
Code of Conduct • The central element of an effective Compliance Plan is the formal commitment to compliance embodied in the Code of Conduct, April 27, 2016 which should: • Include a statement of your ethical and compliance principles; • Include a summary of the broad ethical and legal standards under which the you and your administration, personnel and Medical Staff Peak Performance Physicians, LLC (“Personnel”) should operate; and • Reflect the your Mission, Vision and Values. • The Code of Conduct should be: • Reviewed thoroughly with each new employee upon hire during the orientation process and annually thereafter; • Followed by and reviewed by all Personnel; and • Updated periodically by the Compliance Department and your Board 18 of Directors.
Sample of Code of Conduct April 27, 2016 Peak Performance Physicians, LLC 19
Risk Assessment • A Risk Assessment is find compliance areas April 27, 2016 that may concern the organization the most. The initial Risk Assessment is based on the type of services provided by Peak Performance Physicians, LLC Attendees and the applicable Federal and State compliance statutes, regulations, rules and agency guidance (“the Regulatory Issues”) 20
Key Elements for the Compliance Plan • Conducting internal monitoring and auditing; • Implementing compliance and practice standards; February 2016 • Designating a compliance officer or contact; • Conducting appropriate training and education; Peak Performance Physicians, LLC • Responding appropriately to detected offenses and developing corrective action; • Developing open lines of communication; and • Enforcing disciplinary standards through well ‐ publicized guidelines. http://oig.hhs.gov/authorities/docs/physician.pdf 21
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