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The Modern Day
Compliance Program
Bridging the Gap Between Integrity and Performance




HEALTH CARE COMPLIANCE ASSOCIATION - WEB CONFERENCE
Time/Date: 1pm EST | 10am PST | September 27, 2012
Presenters: Craig B. Garner and Andrew A. Woodward




                                                      1
The Modern Day Compliance Program
                            Bridging the Gap Between Integrity and Performance




Why Establish a Compliance Program?




                                                                         2
The Modern Day Compliance Program
   Bridging the Gap Between Integrity and Performance




                                                3
The Modern Day Compliance Program
                                                               Bridging the Gap Between Integrity and Performance




Yesterday
• Demonstrate a commitment to honest and responsible conduct.


• Increase the likelihood of preventing, identifying and correcting unlawful and
  unethical behavior at an early stage.


• Encourage employees to report potential problems to allow for appropriate internal
  inquiry and corrective action.


• Minimize any financial loss to government and taxpayers through early detection
  and reporting, as well as any corresponding financial loss to the provider.




                                                                                                            4
The Modern Day Compliance Program
                                                             Bridging the Gap Between Integrity and Performance




Today
• The Affordable Care Act requires all health care providers to implement formal
  health care compliance programs as a condition of enrollment in Medicare,
  Medicaid and the Children’s Health Insurance Program (CHIP).


• This compliance program must contain certain core principles established by the
  Federal Government.


• OIG recommends seven elements from the 2010 U.S. Federal Sentencing
  Guidelines Manual as the basis for these core elements.




                                                                                                          5
The Modern Day Compliance Program
                                                              Bridging the Gap Between Integrity and Performance




Elements from U.S. Federal Sentencing Guidelines
• Implementing clear standards and procedures to prevent and detect violations

• Securing appropriate oversight by designated Compliance Officer

• Employing due diligence in hiring and assigning personnel

• Communication compliance standards and procedures and providing training to
  employees at all levels

• Incorporating procedures for monitoring and auditing, including periodic evaluation
  of program effectiveness

• Maintaining consistent disciplinary mechanisms

• Designing a process to investigate and remediate after detecting a violation



                                                                                                           6
The Modern Day Compliance Program
                                                               Bridging the Gap Between Integrity and Performance




Tomorrow
VALUE BASED PURCHASING (VBP) PROGRAM
•   Hospitals:    Beginning October 2012, hospitals face a 1% reduction overall in
    Medicare payments under the Inpatient Prospective Payment System (IPPS),
    designed to calculate performance bonuses. By 2015, hospitals showing poor
    performance may also face additional reductions.


•   Physicians: Beginning in 2015, the value-based payment modifier applicable to
    Medicare Fee for Service applies to all groups of 25 or more eligible professionals
    (including physicians, practitioners and therapists), followed by a complete phase-
    in by 2017.




                                                                                                            7
The Modern Day Compliance Program
                         Bridging the Gap Between Integrity and Performance




Integrity Meets Performance




                                                                      8
The Modern Day Compliance Program
                                                             Bridging the Gap Between Integrity and Performance




Fraud and Abuse Laws after Medicare
•The Social Security Amendments
•Medicare-Medicaid Anti-Fraud and Abuse Amendments
•Omnibus Reconciliation Act
•Civil Monetary Penalties Law
•Medicare and Medicaid Patient and Program Protection Act
•Ethics in Patient Referral Act
•Omnibus Budget Reconciliation Act
•The Health Insurance Portability and Accountability Act (HIPAA)
•The Balanced Budget Act
•The Deficit Reduction Act
•The Fraud Enforcement and Recovery Act
•The Patient Protection and Affordable Care Act

                                                                                                          9
The Modern Day Compliance Program
                                                          Bridging the Gap Between Integrity and Performance




Core Elements of a Compliance Program
•Compliance Officer
•Compliance Committee
•Code of Conduct
•Written Policies and Procedures
•Training and Education
•Communicating Compliance Issues

The OIG recognizes that physician practices differ from hospitals, and financial
limitations may impede the scope of certain physician compliance programs.




                                                                                                     10
The Modern Day Compliance Program
                                                       Bridging the Gap Between Integrity and Performance




Hospital VBP Program
The VBP Program is based on a hospital’s total performance score (TPS), which
includes, in part, 12 Clinical Process of Care measures (70% of the TPS) in the
following categories:

•Acute Myocardial Infarction
•Heart Failure
•Pneumonia
•Surgical Care Improvement Project




                                                                                                  11
The Modern Day Compliance Program
                                                         Bridging the Gap Between Integrity and Performance




Hospital VBP Program (continued)
The TPS also includes 8 Patient Experience of Care dimensions (30% of TPS) from
the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
survey:

•communication with doctors
•communication with nurses
•responsiveness of hospital staff
•pain management
•communication about medication
•cleanliness and quietness
•discharge information
•overall rating



                                                                                                    12
The Modern Day Compliance Program
                                                              Bridging the Gap Between Integrity and Performance




Physician Value Modifier Scoring
For groups with 25 or more physicians, CMS recommends that the following outcome
measures be used in the calculation:



•30-day post discharge visits
•All cause readmissions
•Composite of acute prevention quality indicators (pneumonia, UTI, dehydration)
•Composite of chronic prevention quality indicators (COPD, heart failure, diabetes)

https://www.surveymonkey.com/s/garnerhealth




                                                                                                         13
The Modern Day Compliance Program
                                   Bridging the Gap Between Integrity and Performance




Physician Value Modifier Amount
Combine each quality measure
into a quality composite and
each cost measure into a cost
composite using the following
domains:




                                                                              14
The Modern Day Compliance Program
                                Bridging the Gap Between Integrity and Performance




Bridging the Gap Part 1: Financial Alerts




                                                                           15
The Modern Day Compliance Program
                                                             Bridging the Gap Between Integrity and Performance




Alerts Dashboard
Augment financial reports with custom “alerts” designed to identify anomalies in
accounts receivable and payable each month. The dashboard tracks select
accounts, calculates an average value based on actual census, and generates
automatic notifications each time any tracked item falls outside the appropriate
range.




                                                                                                        16
The Modern Day Compliance Program
                                                            Bridging the Gap Between Integrity and Performance




Alerts Dashboard
A central dashboard monitors all alerts from one location. Hospital or physician
management can isolate billing codes from where the alerts are generated, identify
the reason for the anomaly and address existing concerns.




                                                                                                       17
The Modern Day Compliance Program
                                                                Bridging the Gap Between Integrity and Performance




Charge Description Master
                                   Track hospital CDMs against regional
                                   averages as well as historical averages to
                                   confirm charges fall within accepted levels.

                                   http://www.oshpd.ca.gov/chargemaster/
                                   http://www.hospitalcompare.hhs.gov/


Alerts occur when charges fall outside the expected range.
                                                                                    Alert Triggered




                                                                                                           18
The Modern Day Compliance Program
                          Bridging the Gap Between Integrity and Performance




   Bridging the Gap Part 2:
Tracing an Excluded Individual




                                                                     19
The Modern Day Compliance Program
                                                         Bridging the Gap Between Integrity and Performance




Tracing Hospital Employees/Vendors
Track all officers, employees and vendors against the OIG’s List of Excluded
Individuals and Entities (LEIE)   http://oig.hhs.gov/exclusions/index.asp




                                                                                                    20
The Modern Day Compliance Program
                                                               Bridging the Gap Between Integrity and Performance




Tracing Hospital Employees/Vendors (continued)
Upon identification of an excluded entity, a report will calculate all charges
attributed thereto. It may also identify areas for further investigation to determine
the scope of any financial impact.

If appropriate, provider can self
disclose any overpayment.




                                                                                                          21
The Modern Day Compliance Program
                                                                 Bridging the Gap Between Integrity and Performance




Tracing Hospital Employees/Vendors (continued)
•Calculate   financial impact of clinical services or products attributed to an
excluded employee or vendor through a direct model.
•Calculate financial impact of clinical services or products attributed only in part to
an excluded employee or vendor through a pro-rated model.
•Hybrid model appropriate based upon available billing and data records.




                                                                                                            22
The Modern Day Compliance Program
                                                               Bridging the Gap Between Integrity and Performance




Benefits of an Active Compliance Program
By taking a proactive approach to identify any early warnings for billing anomalies or
excluded employees/vendors, providers:

•Demonstrate a commitment to honest and responsible corporate conduct.
•Increase the likelihood of preventing, identifying, and correcting unlawful                       and
unethical behavior at an early stage.
•Encourage employees to report potential problems to allow for appropriate internal
inquiry and corrective action.
•Minimize   any financial loss to government and taxpayers through early detection
and reporting, as well as any corresponding financial loss to the provider.
•Enjoy increased bonuses under the VBP programs.



                                                                                                          23
The Modern Day Compliance Program
                                                               Bridging the Gap Between Integrity and Performance




Form Over Substance
Follow HCAHPS Quality Assurance Guidelines v.7.0


•Hospitals must continuously collect and submit HCAHPS data in accordance with the
current HCAHPS Quality Assurance Guidelines and the quarterly data submission
deadlines.
•To   participate in the collection of HCAHPS data, a hospital must either (1) contract
with an approved HCAHPS survey vendor or (2) self-administer the survey, provided
the hospital attends HCAHPS training and meets Minimum Survey Requirements.
•Four   approved methods of administering the CAHPS Hospital Survey: (1) mail; (2)
telephone; (3) mixed (mail followed by telephone); and (4) active interactive voice
response.



                                                                                                          24
The Modern Day Compliance Program
                       Bridging the Gap Between Integrity and Performance




RACs, MACs, MICs and ZPICs




                                                                  25
The Modern Day Compliance Program
                                                             Bridging the Gap Between Integrity and Performance




RACs
•Recovery    Audit Contractor (RAC) Program:           This began as a three-year
demonstration using RACs to detect and correct improper payments within Medicare.


•The   original goal of the demonstration program
was to determine whether the use of RACs would
be a cost-effective way to maintain the integrity of
Medicare by ensuring that provider payments
were correct.




                                                                                                        26
The Modern Day Compliance Program
                                                           Bridging the Gap Between Integrity and Performance




MACs
•Medicare Administrative Contractors (MACs): Groups that process Part A and Part B
claims. MACs oversee claim completion and accuracy.


•Due to the scope of their jurisdiction, CMS believes
MACs will be able to review discrepancies between
the two sets of claims, revise payments and/or
increase denials.




                                                                                                      27
The Modern Day Compliance Program
                                                              Bridging the Gap Between Integrity and Performance




MICs
Medicaid Integrity Contractors (MICs): MICs
review Medicaid claims in search of
inappropriate payments or fraud. MICs also
audit    Medicaid      claims  and     identify
overpayments and areas of high risk for
payment errors or fraud. Some possible targets
include the following:

•Services provided after the death of a beneficiary

•Duplicate claims

•Unbundling of services

•Outpatient claims with service dates that overlap dates of an inpatient stay

                                                                                                         28
The Modern Day Compliance Program
                                                            Bridging the Gap Between Integrity and Performance




ZPICs
Zone Program Integrity Contractors (ZPICs): Formerly known as Program
Safeguard Contractors (PSCs), ZPICs serve the same jurisdictions as Medicare
Administrative Contractors. ZPICs conduct investigations, aid law enforcement and
execute audits of Medicare advantage plans.

The ZPIC data analysis program is designed to identify provider billing practices
and services that pose the greatest financial risk to Medicare. The data analysis
program seeks to:

•Identify high risk areas of potential error
so that they may be closely monitored.


•Establisha baseline so contractors can
recognize unusual trends, utilization
changes or outright schemes designed to
maximize reimbursement unlawfully.

                                                                                                       29
The Modern Day Compliance Program
                        Bridging the Gap Between Integrity and Performance




Additional Considerations




                                                                   30
The Modern Day Compliance Program
                                                              Bridging the Gap Between Integrity and Performance




HITECH and Data Breaches
Under HITECH, any covered entity that maintains “unsecured” protected health
information (PHI) and discovers a breach of such information must notify each
individual whose PHI “has been, or is reasonably believed by the covered entity to
have been, accessed, acquired or disclosed as a result of such breach.”

PHI must be made “unusable, unreadable or indecipherable” through encryption.

•What to do upon discovering a breach?
•What are the notice requirements?
•What fines may be assessed for a security breach?




                                                                                                         31
The Modern Day Compliance Program
                                                              Bridging the Gap Between Integrity and Performance




Self Disclosure and Overpayments
OIG: Hospitals who wish to voluntarily disclose self-discovered evidence of potential
fraud to the OIG may do so under the Provider Self-Disclosure Protocol (SDP).

CMS: The Medicare voluntary self-referral disclosure protocol includes a process to
enable providers of services and suppliers to self-disclose actual or potential
violations of the physician self-referral statute.

FISCAL INTERMEDIARY: Should a hospital identify an overpayment, sending a
check to Medicare for the appropriate amount may prevent offsets or delays of future
claim payments.




                                                                                                         32
The Modern Day Compliance Program
                                                                Bridging the Gap Between Integrity and Performance




Fair Market Value
“Fair market value” refers to the value in “arm’s-length” transactions, consistent with
the general market value.

Areas of Concern:
•Physician employment
•Physician practice acquisition
•Joint venture arrangements
•Call coverage and other personal service agreements
•Management services agreements
•Co-management arrangements




                                                                                                           33
The Modern Day Compliance Program
                                                              Bridging the Gap Between Integrity and Performance




Enrollment Improvements and Screening
•Enrollment is processed faster (two-thirds reduction in time)
•Enrollment is user-friendly (available online)
•Enrollment is more reliable (consisting of one system for all enrollees and including
up to date information)
•Fraudulent providers and suppliers are subjected to extensive, risk-based screening
through the new Automated Provider Screening (APS) system (implemented
December 31, 2011)
•Medical identities checked against Compromised Numbers database
•Addresses checked against valid location databases
•Revocations, exclusions and felony convictions all checked by new system




                                                                                                         34
The Modern Day Compliance Program
                                                            Bridging the Gap Between Integrity and Performance




About the OIG




OIG website http://oig.hhs.gov/
The Data Bank (National Practitioner Data Bank and Healthcare Integrity and
Protection Data Bank) http://www.npdb-hipdb.hrsa.gov
HEAT (Stop Medicare Fraud) http://www.stopmedicarefraud.gov/
HHS website http://www.hhs.gov/




                                                                                                       35
The Modern Day Compliance Program
                                                                                 Bridging the Gap Between Integrity and Performance




Craig B. Garner
Craig is an attorney and health care consultant, specializing in issues
pertaining to modern American health care and the ways it should be managed
in its current climate of reform. Craig is also an adjunct professor of law at
Pepperdine University School of Law, where he teaches courses on hospital
law and the Affordable Care Act.

Between 2002 and 2011, Craig was the Chief Executive Officer of Coast Plaza
Hospital. He was responsible for administration and oversight of this general
acute care hospital providing services to the City of Norwalk and surrounding
communities in Southeast Los Angeles County.

Additional information can be found at www.craiggarner.com/about.




                                                                                                                            36
The Modern Day Compliance Program
                                                                                     Bridging the Gap Between Integrity and Performance




Andrew A. Woodward
Andrew Woodward is a financial and strategic consultant for health care
and other business entities, focusing on financial efficiency, integrity and
growth opportunity. In addition to working with companies on a day-to-day
basis, Andrew has restructured entire financial tracking and accountability
systems for acute care hospitals, improving the institutions’ internal visibility,
decreasing and identifying instances of undercharges and overcharges, and
maximizing overall profitability. Andrew has more than 10 years of
experience in venture funding and strategic partnership development. A co-
Founder and Partner at Propel Funding Accelerators in Los Angeles, CA,
Andrew works with start-ups and small businesses in the areas of financing,
operational build-out and corporate strategy. Andrew has been a director at
Garner Health since the company ’ s inception. Andrew believes that
entrepreneurial thinking is critical to the long-term success of health care
institutions, and his expertise in designing systems to increase efficiency
while maintaining integrity makes sound strategic improvements in the
health care institutions with which he works. Andrew is a graduate of
Babson College in Wellesley, MA.             For more information, contact
andrew@garnerhealth.com.




                                                                                                                                37
Thank You
Craig B. Garner and Andrew A. Woodward




                                         38

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The Modern Day Health Care Compliance Program

  • 1. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance HEALTH CARE COMPLIANCE ASSOCIATION - WEB CONFERENCE Time/Date: 1pm EST | 10am PST | September 27, 2012 Presenters: Craig B. Garner and Andrew A. Woodward 1
  • 2. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance Why Establish a Compliance Program? 2
  • 3. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance 3
  • 4. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance Yesterday • Demonstrate a commitment to honest and responsible conduct. • Increase the likelihood of preventing, identifying and correcting unlawful and unethical behavior at an early stage. • Encourage employees to report potential problems to allow for appropriate internal inquiry and corrective action. • Minimize any financial loss to government and taxpayers through early detection and reporting, as well as any corresponding financial loss to the provider. 4
  • 5. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance Today • The Affordable Care Act requires all health care providers to implement formal health care compliance programs as a condition of enrollment in Medicare, Medicaid and the Children’s Health Insurance Program (CHIP). • This compliance program must contain certain core principles established by the Federal Government. • OIG recommends seven elements from the 2010 U.S. Federal Sentencing Guidelines Manual as the basis for these core elements. 5
  • 6. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance Elements from U.S. Federal Sentencing Guidelines • Implementing clear standards and procedures to prevent and detect violations • Securing appropriate oversight by designated Compliance Officer • Employing due diligence in hiring and assigning personnel • Communication compliance standards and procedures and providing training to employees at all levels • Incorporating procedures for monitoring and auditing, including periodic evaluation of program effectiveness • Maintaining consistent disciplinary mechanisms • Designing a process to investigate and remediate after detecting a violation 6
  • 7. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance Tomorrow VALUE BASED PURCHASING (VBP) PROGRAM • Hospitals: Beginning October 2012, hospitals face a 1% reduction overall in Medicare payments under the Inpatient Prospective Payment System (IPPS), designed to calculate performance bonuses. By 2015, hospitals showing poor performance may also face additional reductions. • Physicians: Beginning in 2015, the value-based payment modifier applicable to Medicare Fee for Service applies to all groups of 25 or more eligible professionals (including physicians, practitioners and therapists), followed by a complete phase- in by 2017. 7
  • 8. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance Integrity Meets Performance 8
  • 9. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance Fraud and Abuse Laws after Medicare •The Social Security Amendments •Medicare-Medicaid Anti-Fraud and Abuse Amendments •Omnibus Reconciliation Act •Civil Monetary Penalties Law •Medicare and Medicaid Patient and Program Protection Act •Ethics in Patient Referral Act •Omnibus Budget Reconciliation Act •The Health Insurance Portability and Accountability Act (HIPAA) •The Balanced Budget Act •The Deficit Reduction Act •The Fraud Enforcement and Recovery Act •The Patient Protection and Affordable Care Act 9
  • 10. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance Core Elements of a Compliance Program •Compliance Officer •Compliance Committee •Code of Conduct •Written Policies and Procedures •Training and Education •Communicating Compliance Issues The OIG recognizes that physician practices differ from hospitals, and financial limitations may impede the scope of certain physician compliance programs. 10
  • 11. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance Hospital VBP Program The VBP Program is based on a hospital’s total performance score (TPS), which includes, in part, 12 Clinical Process of Care measures (70% of the TPS) in the following categories: •Acute Myocardial Infarction •Heart Failure •Pneumonia •Surgical Care Improvement Project 11
  • 12. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance Hospital VBP Program (continued) The TPS also includes 8 Patient Experience of Care dimensions (30% of TPS) from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey: •communication with doctors •communication with nurses •responsiveness of hospital staff •pain management •communication about medication •cleanliness and quietness •discharge information •overall rating 12
  • 13. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance Physician Value Modifier Scoring For groups with 25 or more physicians, CMS recommends that the following outcome measures be used in the calculation: •30-day post discharge visits •All cause readmissions •Composite of acute prevention quality indicators (pneumonia, UTI, dehydration) •Composite of chronic prevention quality indicators (COPD, heart failure, diabetes) https://www.surveymonkey.com/s/garnerhealth 13
  • 14. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance Physician Value Modifier Amount Combine each quality measure into a quality composite and each cost measure into a cost composite using the following domains: 14
  • 15. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance Bridging the Gap Part 1: Financial Alerts 15
  • 16. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance Alerts Dashboard Augment financial reports with custom “alerts” designed to identify anomalies in accounts receivable and payable each month. The dashboard tracks select accounts, calculates an average value based on actual census, and generates automatic notifications each time any tracked item falls outside the appropriate range. 16
  • 17. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance Alerts Dashboard A central dashboard monitors all alerts from one location. Hospital or physician management can isolate billing codes from where the alerts are generated, identify the reason for the anomaly and address existing concerns. 17
  • 18. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance Charge Description Master Track hospital CDMs against regional averages as well as historical averages to confirm charges fall within accepted levels. http://www.oshpd.ca.gov/chargemaster/ http://www.hospitalcompare.hhs.gov/ Alerts occur when charges fall outside the expected range. Alert Triggered 18
  • 19. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance Bridging the Gap Part 2: Tracing an Excluded Individual 19
  • 20. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance Tracing Hospital Employees/Vendors Track all officers, employees and vendors against the OIG’s List of Excluded Individuals and Entities (LEIE) http://oig.hhs.gov/exclusions/index.asp 20
  • 21. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance Tracing Hospital Employees/Vendors (continued) Upon identification of an excluded entity, a report will calculate all charges attributed thereto. It may also identify areas for further investigation to determine the scope of any financial impact. If appropriate, provider can self disclose any overpayment. 21
  • 22. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance Tracing Hospital Employees/Vendors (continued) •Calculate financial impact of clinical services or products attributed to an excluded employee or vendor through a direct model. •Calculate financial impact of clinical services or products attributed only in part to an excluded employee or vendor through a pro-rated model. •Hybrid model appropriate based upon available billing and data records. 22
  • 23. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance Benefits of an Active Compliance Program By taking a proactive approach to identify any early warnings for billing anomalies or excluded employees/vendors, providers: •Demonstrate a commitment to honest and responsible corporate conduct. •Increase the likelihood of preventing, identifying, and correcting unlawful and unethical behavior at an early stage. •Encourage employees to report potential problems to allow for appropriate internal inquiry and corrective action. •Minimize any financial loss to government and taxpayers through early detection and reporting, as well as any corresponding financial loss to the provider. •Enjoy increased bonuses under the VBP programs. 23
  • 24. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance Form Over Substance Follow HCAHPS Quality Assurance Guidelines v.7.0 •Hospitals must continuously collect and submit HCAHPS data in accordance with the current HCAHPS Quality Assurance Guidelines and the quarterly data submission deadlines. •To participate in the collection of HCAHPS data, a hospital must either (1) contract with an approved HCAHPS survey vendor or (2) self-administer the survey, provided the hospital attends HCAHPS training and meets Minimum Survey Requirements. •Four approved methods of administering the CAHPS Hospital Survey: (1) mail; (2) telephone; (3) mixed (mail followed by telephone); and (4) active interactive voice response. 24
  • 25. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance RACs, MACs, MICs and ZPICs 25
  • 26. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance RACs •Recovery Audit Contractor (RAC) Program: This began as a three-year demonstration using RACs to detect and correct improper payments within Medicare. •The original goal of the demonstration program was to determine whether the use of RACs would be a cost-effective way to maintain the integrity of Medicare by ensuring that provider payments were correct. 26
  • 27. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance MACs •Medicare Administrative Contractors (MACs): Groups that process Part A and Part B claims. MACs oversee claim completion and accuracy. •Due to the scope of their jurisdiction, CMS believes MACs will be able to review discrepancies between the two sets of claims, revise payments and/or increase denials. 27
  • 28. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance MICs Medicaid Integrity Contractors (MICs): MICs review Medicaid claims in search of inappropriate payments or fraud. MICs also audit Medicaid claims and identify overpayments and areas of high risk for payment errors or fraud. Some possible targets include the following: •Services provided after the death of a beneficiary •Duplicate claims •Unbundling of services •Outpatient claims with service dates that overlap dates of an inpatient stay 28
  • 29. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance ZPICs Zone Program Integrity Contractors (ZPICs): Formerly known as Program Safeguard Contractors (PSCs), ZPICs serve the same jurisdictions as Medicare Administrative Contractors. ZPICs conduct investigations, aid law enforcement and execute audits of Medicare advantage plans. The ZPIC data analysis program is designed to identify provider billing practices and services that pose the greatest financial risk to Medicare. The data analysis program seeks to: •Identify high risk areas of potential error so that they may be closely monitored. •Establisha baseline so contractors can recognize unusual trends, utilization changes or outright schemes designed to maximize reimbursement unlawfully. 29
  • 30. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance Additional Considerations 30
  • 31. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance HITECH and Data Breaches Under HITECH, any covered entity that maintains “unsecured” protected health information (PHI) and discovers a breach of such information must notify each individual whose PHI “has been, or is reasonably believed by the covered entity to have been, accessed, acquired or disclosed as a result of such breach.” PHI must be made “unusable, unreadable or indecipherable” through encryption. •What to do upon discovering a breach? •What are the notice requirements? •What fines may be assessed for a security breach? 31
  • 32. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance Self Disclosure and Overpayments OIG: Hospitals who wish to voluntarily disclose self-discovered evidence of potential fraud to the OIG may do so under the Provider Self-Disclosure Protocol (SDP). CMS: The Medicare voluntary self-referral disclosure protocol includes a process to enable providers of services and suppliers to self-disclose actual or potential violations of the physician self-referral statute. FISCAL INTERMEDIARY: Should a hospital identify an overpayment, sending a check to Medicare for the appropriate amount may prevent offsets or delays of future claim payments. 32
  • 33. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance Fair Market Value “Fair market value” refers to the value in “arm’s-length” transactions, consistent with the general market value. Areas of Concern: •Physician employment •Physician practice acquisition •Joint venture arrangements •Call coverage and other personal service agreements •Management services agreements •Co-management arrangements 33
  • 34. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance Enrollment Improvements and Screening •Enrollment is processed faster (two-thirds reduction in time) •Enrollment is user-friendly (available online) •Enrollment is more reliable (consisting of one system for all enrollees and including up to date information) •Fraudulent providers and suppliers are subjected to extensive, risk-based screening through the new Automated Provider Screening (APS) system (implemented December 31, 2011) •Medical identities checked against Compromised Numbers database •Addresses checked against valid location databases •Revocations, exclusions and felony convictions all checked by new system 34
  • 35. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance About the OIG OIG website http://oig.hhs.gov/ The Data Bank (National Practitioner Data Bank and Healthcare Integrity and Protection Data Bank) http://www.npdb-hipdb.hrsa.gov HEAT (Stop Medicare Fraud) http://www.stopmedicarefraud.gov/ HHS website http://www.hhs.gov/ 35
  • 36. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance Craig B. Garner Craig is an attorney and health care consultant, specializing in issues pertaining to modern American health care and the ways it should be managed in its current climate of reform. Craig is also an adjunct professor of law at Pepperdine University School of Law, where he teaches courses on hospital law and the Affordable Care Act. Between 2002 and 2011, Craig was the Chief Executive Officer of Coast Plaza Hospital. He was responsible for administration and oversight of this general acute care hospital providing services to the City of Norwalk and surrounding communities in Southeast Los Angeles County. Additional information can be found at www.craiggarner.com/about. 36
  • 37. The Modern Day Compliance Program Bridging the Gap Between Integrity and Performance Andrew A. Woodward Andrew Woodward is a financial and strategic consultant for health care and other business entities, focusing on financial efficiency, integrity and growth opportunity. In addition to working with companies on a day-to-day basis, Andrew has restructured entire financial tracking and accountability systems for acute care hospitals, improving the institutions’ internal visibility, decreasing and identifying instances of undercharges and overcharges, and maximizing overall profitability. Andrew has more than 10 years of experience in venture funding and strategic partnership development. A co- Founder and Partner at Propel Funding Accelerators in Los Angeles, CA, Andrew works with start-ups and small businesses in the areas of financing, operational build-out and corporate strategy. Andrew has been a director at Garner Health since the company ’ s inception. Andrew believes that entrepreneurial thinking is critical to the long-term success of health care institutions, and his expertise in designing systems to increase efficiency while maintaining integrity makes sound strategic improvements in the health care institutions with which he works. Andrew is a graduate of Babson College in Wellesley, MA. For more information, contact andrew@garnerhealth.com. 37
  • 38. Thank You Craig B. Garner and Andrew A. Woodward 38