Compliance for Health Care Organizations

The Season For Compliance Is Upon Us Patrick V. Trotta, CPA

Overview of Presentation
Purpose of Corporate Compliance
Elements of a Corporate Compliance Program
Benefits derived from Corporate Compliance
Monitoring the effectiveness of Corporate Compliance Program

Purpose of Corporate Compliance
System designed to prevent, detect, and address financial improprieties and inadequate care
Identifies financial/care issues before they lead to government intervention
Uses internal controls to monitor adherence to applicable statutes, regulations and program requirements

Purpose of Corporate Compliance (cont.)
Fosters organizational culture that promotes commitment to Ethical and Effective behavior
Encourages employees and others to report potential problems
Minimize financial loss to the government, the taxpayers, and the nursing facility

Purpose of Corporate Compliance (cont.)
Enhance resident satisfaction and safety through delivery of improved quality of care
Improves the facility’s reputation for quality and integrity

Elements of a Corporate Compliance Program
Office of Inspector General (OIG) has determined 7 elements that are fundamental to an effective compliance program
Suggestions on how facilities can best establish internal controls and prevent fraudulent activities
OIG’s elements not mandatory or exclusive

OIG’s Seven Fundamental Elements
Policies, procedures, and standards of conduct
Designation of a compliance officer & compliance committee
Training & education

OIG’s Seven Fundamental Elements (cont.)
4. Effective lines of communication
5. Enforcement & discipline
6. Monitoring & audit of compliance system
7. Prompt response to detected offenses & corrective action plan

(1) Policies, Procedures, and Standards of Conduct
Written
Best practices
Interdisciplinary focus
Applies to employees, contractors, and vendors
Reviewed and updated

(2) Designation Compliance Officer & Compliance Committee
Responsible for developing, operating, and monitoring the compliance program
Should be autonomous
May have several different roles
Focus on financial and quality of care
Reports to ownership, governing body, and CEO

(3) Training & Education
Fundamental to Compliance Program
Begins with orientation and ongoing tracking
Appropriate to position
General to all employees

(4) Effective Lines of Communication
Between compliance officer and all employees
Reporting system to receive complaints and grievances
Hotline
Protect the anonymity of complaints and grievances

(5) Enforcement & Discipline
Condition of employment (excluded individuals/entities)
Compliance a factor in evaluation of job performance
Appropriate and timely action
Communication

(6) Monitoring & Audit of Compliance System
Periodic process to assess effectiveness of Compliance Program
Continuous quality improvement
Proactive process
Internal and external audits

(7) Prompt Response to Detected Offenses & Corrective Action Plan
Immediate investigation
Follow up on suspected noncompliance
Develop corrective action
Self disclosure

Benefits Derived From Corporate Compliance
Mandatory requirement for compliance programs by March, 2013
Different requirements depending upon facility type (e.g., large chain v. small provider)
Reduces exposure to civil damages and penalties, criminal sanctions, and administrative remedies

Benefits Derived From Corporate Compliance (cont.)
Survey results
Effective internal controls ensure compliance with government statutes and regulations and organizational standards
Ethical culture develops employee satisfaction and stable workforce

Benefits Derived From Corporate Compliance (cont.)
Ability to quickly react to operational compliance concerns and effectively allocate resources
Financial control
Billing and collection control and compliance

Monitoring The Effectiveness of Corporate Compliance Program
Compliance monitoring team
Identification of risk areas
Assessment steps

(1) Compliance Monitoring Team
Compliance officer
Compliance committee
Internal audit staff
Consultants
Lawyers
Independent auditors

(2) Identification of Risk Areas
Quality of care and residents rights
Employee screening
Vendor relationships
Billing and cost reporting

(2) Identification of Risk Areas (cont.)
Record keeping and documentation
Sufficient staffing
Comprehensive care plans
Medication management

Resident safety
Resident interactions
Staff screening
Submission of accurate claims
Proper case mix reporting
Therapy services
Screening for excluded individuals/entities
Restorative and personal care services

Anti-kickback statute
Free goods and services
Service contracts
Discounts
Hospices
Bed reservations
Other
Physician self referrals
Medicare Part D
HIPAA

(3) Assessment Steps
Base line assessment
Regular review of effectiveness
Mandated outside audit (??)

Final Thoughts & Questions Patrick V.Trotta, CPA Director, Elder Care Provider Services Glass Jacobson [email_address] (410) 356-1000 www.glassjacobson.com/ElderCare

Compliance for Health Care Organizations

by Glass Jacobson on Dec 05, 2011

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Compliance for Health Care Organizations — Presentation Transcript