Presentation to the Health Commission Office of Compliance and - PowerPoint PPT Presentation

Presentation to the Health Commission Office of Compliance and Privacy Affairs (OCPA) San Francisco Department of Public Health October 3, 2017

OCPA Overview 1. DPH Organizational Chart 2. DPH OCPA Roadmap 3. DPH Compliance Program 4. DPH Privacy Program 5. DPH Data Sharing/Governance Program 6. The Hard News: Whistleblowers, Hotline, Privacy Breaches, Disallowances 7. Accomplishments and Future Challenge 2

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OCPA Process/Roadmap Risk Compliance Our Service Governance Safeguards & Reinforce with Risk Policies & Corrective Training & Assessments Procedures Action Plans Communiques 4

DPH Compliance Why is it important? What is it?  Avoid harm to DPH 1. Policies and Procedures  Prevent illegal and unethical conduct 2. DPH Code of Conduct  Ensure compliance related to billing, 3. Risk Assessments documentation and delivery of service 4. Monitoring and Auditing  Prevent fraud, waste and abuse 5. Providing Guidance  Provide safe place to report suspected violations 5

DPH Privacy What is it? Why is it important? 1. Privacy Rule: Authorized?  Protect patient confidentiality Need to know? And  Protect against improper disclosures Minimum Necessary?  Avoid breaches and fines 2. HITECH: Is it shared securely?  Engineer data sharing to improve care 3. Are legal agreements in coordination and to better understand place? the populations we serve 6

DPH Data Sharing / Governance (established January 2016) What is it? Why is it important?  Ensure agreements contain proper legal 1. Legal agreements allowing sharing of PHI protections and are valid  Assures checks and balances are done 2. Registering and monitoring Data Sharing agreements before sharing (data security, privacy, business need) 3. Standardizing data sharing  Enables data sharing for our shared clients processes across City agencies Accomplishments: DPH Finalized 57 Data Sharing Agreements! 7

FY16-17 Findings

Whistleblower Program OCPA maintains a 24-7 toll-free Hotline to provide a safe place for employees to report suspected violations. The calls to the hotline may be made confidentially and anonymously. Below are some examples of types of complaints OCPA investigates.  Non-compliance with billing, coding, and documentation regulations  Suspected Healthcare Fraud, Abuse and Waste  Privacy breaches  Suspected violation of the DPH Code of Conduct or DPH policies  Conflict of Interest  Theft or Misuse of DPH and/or City resources 9

Whistleblower Complaints FY16-17 FY 16-17: WB Complaints Stats N = % Corrective Actions Complaints received: 74 100% Recoupment of funds 3 Complaints investigated and closed: 42 73% Counseling & Coaching Allegations were substantiated: 3 22 52% Education & Training 4 Findings (Substantiated) N = % Verbal/written warning 2 Conflict of Interest 3 14% Suspension 1 Code of Conduct 9 40% Change in practice Misuse of City Time / Resources 12 6 27% Improper Activity 4 18% Policy reinforced 18 Quality of Care 3 13% Separated from job 2 Healthcare Fraud, Waste & Abuse 3 13% 0 2 4 6 8 10 12 14 16 18 20 10

DPH Compliance Disallowances Losses (Recoupments) Top 3 reasons  Service did not meet medical necessity ZSFG  Incomplete documentation • Voluntary Repayments: $23K  Delay of service • External Audits: $3.72M Corrective Action  Provider education and training Behavioral Health Services  Implementing internal controls • Voluntary Repayments: $1.6M  Conducting internal reviews and • External Audits: $526K monitoring to ensure correction and compliance continues 11

DPH Privacy Breaches Top 3 reasons Penalties  Misplaced or Lost PHI DPH Assessed Penalties (estimated and actuals)  Improper Access or Snooping $1,400,000 $1,250,000  Unauthorized release or disclosure $1,200,000 $1,000,000 Corrective Action $875,000 $875,000 $825,000 $750,000 $800,000  Provider education and training $575,000 $550,000 $500,000 $600,000 $500,000  Privacy Pulse $400,000  Audit and monitoring $200,000  Establish internal controls $- FY0809 FY0910 FY1011 FY1112 FY1213 FY1314 FY1415 FY1516 FY1617  Disciplinary action 12

FY16-17 Accomplishments an and d Future Challenges

Accomplishments  Hired a full-time compliance and  Transitioned leadership privacy officer at LHH  Supported compliance/privacy  Passed DHCS Triennial audits for assistance and training requests outpatient Behavioral Health Services from DPH clinics and community and ZSFG Inpatient Psychiatry (73% partners drop in error rate)  Hired a full time Data Sharing Officer  Delivered annual web-based compliance/privacy trainings DPH-  Finalized 57 Data Sharing and wide Governance agreements with other City agencies and departments 14

Future Challenges  Timely and accurate submission of  Implementation of new electronic medical claims to avoid penalty health record  Optimize clinical documentation to  Increased cyberattacks and IT threats support quality healthcare and revenue cycle growth  Increased government scrutiny of privacy practices and breaches  Ensuring OCPA staff have the necessary tools, skills and knowledge to be effective in their jobs  Increased oversight by new regulators and government agencies  Bolster infrastructure to meet for medical claims program needs and objectives 15

Thank you! Questions?