Development and Implementation of Corporate Compliance for FQHCs - - PowerPoint PPT Presentation

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Development and Implementation of Corporate Compliance for FQHCs - - PowerPoint PPT Presentation

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April 27, 2016 Development and Implementation of Corporate Compliance for FQHCs 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

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Development and Implementation of Corporate Compliance for FQHC’s

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Louisiana Primary Care Association THE COMPLIANCE INSTITUTE

April 27, 2016

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Compliance

  • Compliance does not get you into

trouble;

  • It keeps you out of trouble.

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LPCA Compliance Syllabus

1. Introduction to Compliance ‐‐ Power Point ‐‐ MARCH 30

a. OIG b. OCR

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

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

a. HIPAA I b. HIPAA HiTech

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Presentation Goals

 Compliance Officer – Role and Definitions  Code of Conduct – Board Adoption  Risk Assessment – “top areas”  Compliance Hotline

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Compliance Institute

  • A cooperative between Peak Performance

Physicians and Louisiana Primary Care Association

  • Our main goal:
  • To assist you in establishing an

effective Compliance Plan at your facilities

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Why Compliance Program?

  • Most all of the Compliance Books, Seminars, and other

presentations always start with all the punishments….

  • We think that compliance is doing what is right.
  • We further think that most all employees and employers want

to a good job, and to do their jobs effectively and legally.

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What is a Compliance Program?

  • A Compliance Program is an effective, practical and integrated

management tool that establishes clear and defined goals and procedures designed to create a culture of compliance, reduce the occurrence of mistakes and prevent intentional violations

  • f the applicable health care statutes and regulations.
  • An effective Compliance Program provides you and your

employees with tools for acting ethically and for maintaining compliance with applicable laws and regulations.

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Compliance Goals

  • Goal: to create a “Culture of Compliance” throughout the

FQHC by showing a commitment from the top and enforcing compliance standards throughout the entity.

  • Benefit: by focusing attention on processes and reinforcing

clinical standards through audits and training, Attendees can 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.

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Key Elements for the Compliance Plan

  • Conducting internal monitoring and auditing;
  • Implementing compliance and practice standards;
  • Designating a compliance officer or contact;
  • Conducting appropriate training and education;
  • 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

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Tools for Compliance

  • Utilizing the Compliance Officer and Compliance Committee as

mechanisms for clarifying requirements and reporting potential misconduct;

  • Reviewing and understanding your written policies and

procedures;

  • Maintaining effective lines of communication with management

and other staff members; and

  • Participating in training and education opportunities.

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Compliance Officer Duties/Responsibilities

  • The OIG recommends that every healthcare organization

designate a Compliance Officer to carry out and enforce compliance activities.

  • The Compliance Officer should function as an independent

and objective person that reviews and evaluates

  • rganizational 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 planning, implementing, and monitoring the program.

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Compliance Officer Duties

  • Overseeing and monitoring the implementation of the

compliance plan

  • Developing, coordinating, and participating in a multifaceted

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

  • rganization’s efficiency and quality of services; and reducing

the organization’s vulnerability to fraud, abuse and waste

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Compliance Officer Duties (cont’d)

  • Periodically revising the program in light of legal and
  • rganizational changes, as well as changes in the polices and

procedures of government and private payor health plans

  • 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.

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Compliance Officer Duties (cont’d)

  • Coordinating personnel issues with the organization’s HR

Department

  • Coordinating the organization’s financial management in
  • rganizing internal compliance review and monitoring

activities, including annual or periodic reviews of departments

  • r 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

  • r suspected violations) and any resulting corrective action

with all providers, agents, and independent contractors if appropriate

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Compliance Officer Duties (cont’d)

  • Developing policies and programs that encourage managers

and employees to report suspected fraud and other improprieties without fear of retaliation

  • 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.

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Compliance Officer

  • The Compliance Officer must have the authority to review all

documents and other information relevant to compliance activities.

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Sample Job Description

  • Forwarded to each of you before the presentation….
  • This sample is very detailed, and smaller organizations may

not have the resources to hire an officer with all of the 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

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Code of Conduct

  • The central element of an effective Compliance Plan is the formal

commitment to compliance embodied in the Code of Conduct, 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 (“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
  • rientation process and annually thereafter;
  • Followed by and reviewed by all Personnel; and
  • Updated periodically by the Compliance Department and your Board
  • f Directors.

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Sample of Code of Conduct

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Risk Assessment

  • A Risk Assessment is find compliance areas

that may concern the organization the

  • most. The initial Risk Assessment is based
  • n the type of services provided by

Attendees and the applicable Federal and State compliance statutes, regulations, rules and agency guidance (“the Regulatory Issues”)

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Key Elements for the Compliance Plan

  • Conducting internal monitoring and auditing;
  • Implementing compliance and practice standards;
  • Designating a compliance officer or contact;
  • Conducting appropriate training and education;
  • 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

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Risk Assessment

  • Our Team has considered the following areas as the Highest

Risk Areas for an Organization.

– CfC – Compliance with Conditions for Coverage to Qualify as an FQHC – 340b ‐‐ Compliance with the requirements to participate in the 340b program – Human Resources ‐‐ Compliance with requirements for FQHC personnel – Financial Relationships – Compliance with Federal and State healthcare fraud and abuse statutes – Data integrity – compliance with Federal and State requirements to maintain the confidentiality of patient medical records and financial information – Medical Record Chart Data Integrity – insuring that the Medical Record fully documents the care given, and supports both the Diagnoses and Level of Service Billing.

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Risk Assessment: Questionnaires

  • Develop questionnaires relative to each of the Risk Areas that

have been defined by the Compliance Officer/Committee.

  • The questionnaires are intended to gain a better

understanding of Organization’s current compliance efforts and operations and how each address the Regulatory Issues.

  • The questionnaires will become the Framework for the GAP

analysis, and will allow the Compliance Officer/Committee to establish an Implementation Plan.

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Risk Assessment (cont.)

  • What will you need to do to complete the risk

assessment?

– Select who will answer the questionnaires and how they will be answered;

  • Identify the individual(s) who will answer the

questionnaires (Note: the answering of the questionnaires may be outsourced to another individual

  • r entity)
  • The individual(s) or entity should coordinate with the

individual(s) and/or departments having information relevant to the questions.

– Coordinate the completion of the Questionnaires with Compliance Officer

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Compliance Hotline

  • Establish Compliance Hotline
  • It is confidential
  • Check it frequently
  • Keep a log of calls (report to Compliance Committee)
  • Investigate all calls
  • Frequently the hotline is used to report personnel problems;

discuss issues with Human Resources

  • Do Not Discourage the use of the Compliance Hotline

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Compliance Hotline

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Regulatory / Guidance / Enforcement

  • Office of the Inspector General – OIG
  • http://oig.hhs.gov/
  • Health Resources and Services Administration – HRSA
  • http://www.hrsa.gov/index.html
  • Office of Civil Rights ‐‐ OCR
  • http://www.hhs.gov/ocr/index.html

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Next Steps

  • Appoint Compliance Officer
  • Establish a Coding Hotline
  • Review Compliance Guidance
  • Review Compliance Plan
  • Review Areas of Greatest Risk
  • Perform GAP Analysis
  • Establish a “Code of Conduct”

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April 27, 2016 Peak Performance Physicians, LLC

29 Bill Carbrey, MHA, CMC info@peakphys.com 305 205 7525