2. Corporate Compliance The federal Deficit Reduction Act and subsequentMedicaid Integrity Program requires that allhealth care entities that annually bill or pay out $5million or more in Medicaid establish a CorporateCompliance Program. A program is recommendedfor all health care entities.
3. Corporate Compliance The focus of our program is on ethics andintegrity in the workplace and compliance with federal and state laws related to fraud, false claims, theft or embezzlement, kickbacks, or other violations.
4. Corporate Compliance is… A working environment that encourages - Ethical and Proper Ways to Do Business Commitment Encourages Problems to be Reported Provides a Process with Constant Monitoring Processes which Prevent, Detect or Deter Non-Compliant Behavior
5. What are the Benefits of a Corporate Compliance Program? Increases awareness of compliance issues among Board, staff, vendors, and providers; Prevents and detects violations; Reduces potential liability; Enhances positive reputation by exercising due diligence.
6. The Guilford Center’s Corporate Compliance Program Includes: Corporate Compliance Officer; Corporate Compliance Committee; Policy and procedures; Corporate Compliance Plan (found by going to P:/ Drive, then the 2012 “Policies and Procedures” folder, and lastly the “Board and Director” folder); Training for all employees, supervisors and providers; Code of Ethics; Screening procedures for all employees, independent contractors and vendors to ensure they have not been sanctioned by a federal or state law enforcement, regulatory or licensing agency; On-going risk assessment of business functions; Anonymous whistle blower hotline.
7. It is the policy of The Guilford Center… To review and investigate all allegations of fraud and/or abuse, whether internal or external; To take corrective actions for any supported allegations after a thorough investigation; and To report confirmed misconduct to the appropriate parties and/or Agencies.
8. The Guilford Center Policies & Procedures Employment and/or Contracting with Excluded Parties Compliance Training Duty to Report County Compliance Hotline Non-Retaliation Responding to Reports of Non-Compliance Employee Consent to Search Voluntary Disclosure to Third Parties Responding to a Subpoena Responding to a Search Warrant Responding to Unannounced Visits by Government Officials/AuditorsB-6 Corporate Compliance Policy: Open Policy…
9. Laws and Regulations Several federal and North Carolina statutes serveas the basis for our requirements for compliance.The following slides will outline statutes relating tocompliance issues.As an employee of the Guilford Center it is yourresponsibility to report any behaviors thatmight constitute failure to comply.
10. North Carolina Laws Contracting for your own benefit; Misuse of confidential information; Gifts and favors; Secondary employment or private practice.
11. North Carolina General Statute Contracting for your own benefitNorth Carolina G.S. 14-234 This statute prohibitsmaking, or being in any manner concerned orinterested in making, a contract with the employer(the Guilford Center) for one’s own benefit. Thepenalty for violation of this general statute constitutesa misdemeanor.
12. North Carolina General Statute Misuse of confidential informationNorth Carolina G.S. 14-234.1 This general statuteapplies to employees of the state of North Carolinaand any of the state’s political subdivisions, whichincludes the Guilford Center.This statute prohibits using confidential information obtainedby virtue of a public office (employment) for personal gain, oraiding another to gain from using such information. Violation ofthis general statute constitutes a misdemeanor.
13. North Carolina General Statute Gifts and favors regulatedNorth Carolina G.S. 133-32 This statute states that employees who areresponsible for preparing plans, bid specifications or estimates for contracts, orawarding or administering agency contracts cannot give or receive gifts orfavors from contractors, subcontractors or suppliers who have contracts withlocal government agencies, or have performed under a contract within the pastyear or anticipates bidding on one. Violation (by giver or receiver) constitutes amisdemeanor.Guilford Center employees are prohibited from accepting gifts fromconsumers, providers or vendors, other than common courtesy itemssuch as coffee or snacks served during a training event.
14. Secondary Employment or Private Practice Employees of the Guilford Center are prohibited from secondary employment, including private practice, without obtaining prior approval of their supervisor and management. This approval includes completion of Form MHL 16. It is important that all such private practice endeavors be distinct from Agency time and premises that have been paid with public funds. Therefore, the Guilford Center prohibits any employee from engaging in private practice on agency property or during those hours that the employee is working (or on duty) for the agency.
15. What Federal Laws Address Fraud and Abuse? False Claims Act (FCA) Anti-Kickback Statute HIPAA Deficit Reduction Act Civil Monetary Penalties Act The False Claims Whistleblower Employee Protection Act
16. Civil and Administrative Statutes The False Claims Act (31 U.S.C. 3729-3733)This is the law most often used to bring a case against a health care provider for the submission of false claims. The False Claims Act prohibits knowingly presenting (or causing to be presented) a false or fraudulent claim for payment or approval.
17. The False Claims Act A false claim is a claim for payment forservices or supplies that were not provided specifically as presented or for which the provider is otherwise not entitled to payment.
18. False Claims Act Examples A claim… indicating a higher level of service than was actually provided for a service the provider knows is not reasonable and necessary for clinical services provided by an individual who does not meet the minimum education, experience or licensure requirements to provide the service for a service or supply that was never provided indicating the service was provided for a diagnosis code other than the true diagnosis code in order to obtain reimbursement for the service (which would not have been covered if the true diagnosis were submitted)
19. The False Claims Act Penalty for Unlawful ConductThe Penalty for violating the False Claims Act is aminimum of $5,500 up to a maximum of $11,000 foreach false claim submitted. In addition, theprovider could be found liable for damages of up tothree times the amount unlawfully claimed.
20. Anti –Kickback (U.S.C. 1320) Anti-Kickback It is a crime to knowingly and willfully solicit, receive, offer, or pay remuneration of any kind (money, goods or services) for the referral of an individual to another for the purpose of supplying services that are covered by a Federal Health care Program; or purchasing, leasing, ordering, or arranging for any good, facility, service, or item that is covered by a Federal health care program.
21. Anti-Kickback Penalty for Unlawful ConductThe penalty may include the imposition of a fine of up to $25,000, imprisonment of up to 5 years, or both. In addition, the provider can be excluded from participation in Federal health care programs.
22. Anti-Kickback ExampleProvider pays a referral fee and records the payment as salary or pays a higher than normal pay rate to compensate for the referrals.
23. Anti Kickback Statute Examples of Kick-Backs: Money Waiver of co-pays Discounts Gifts Credits Commissions
24. The Deficit Reduction Act Requires health care organizations who bill(providers) or pay out (LMEs) more than $5million annually in Medicaid to have an effectivecorporate compliance program in place as ofJanuary 1, 2007 as… A Condition of Payment
25. Civil Monetary Penalties Law (42 U.S.C. 1320) Not provided as indicated by the coding on the claim Not medically necessaryThis is a comprehensive statute that covers an array offraudulent and abusive activities and is very similar to the FalseClaims Act. This law prohibits a provider from presenting, orcausing to be presented, claims for services that the provider“knows, or should have known” were…
26. Civil Monetary Penalties Law Furnished by a licensed physician who obtained his/her license through misrepresentation of a material fact. Furnished by a physician who was not certified in the medical specialty that he/she claimed to be certified in or Furnished by a practitioner who was excluded from participation in the Federal Health Care Program to which the claim was submitted
27. Obstruction of a Criminal Investigation of Health Care Offenses (18 U.S.C. 1518) It is a crime to willfully prevent, obstruct, mislead,or delay the communication of records relating to a Federal health care offense to a criminalinvestigator. This law also applies to most types of health care plans.
28. Obstruction of a Criminal Investigation Penalty for Unlawful Conduct The penalty may include the imposition of a fine, imprisonment of up to 5 years, or both. Add exclusions and how you cannot do any role…
29. Your Responsibilities as Managers with The Guilford Center Include staff adherence to rules, regulations and overall compliance in your evaluations; Maintain awareness in order to detect violations and properly report them; Never retaliate against staff who report issues in good faith.
30. Your Responsibility as Employees of The Guilford Center Be certain you have read the compliance plan, policies and procedures related to your job and fully understand them. Ask questions about anything you are unsure of Perform your work with integrity If you learn of impropriety or suspect it, report it! Either by informing management or through the hotline. Be cooperative with investigations
31. How Do I Report Suspected Fraud and Abuse? Contact the Division of Medical Assistance by calling the DHHS Customer Service Center at 1-800-662-7030 (English or Spanish) or; Call the Medicaid fraud, waste and program abuse tip- line at 1-877-DMA-TIP1 (1-877-362-8471); or Call the Health Care Financing Administration Office of Inspector Generals Fraud Line at 1-800-HHS-TIPS; or Call the State Auditors Waste Line: 1-800-730-TIPS; or Complete and submit a Medicaid fraud and abuse confidential on .
32. Corporate Compliance Is In the News… The Affordable Care Act was enacted on March 23, 2010. CMS created the Center for Program Integrity on April 11, 2010. Governor Perdue signed Senate Bill 675, Prohibit Medicaid Fraud/Anti-Kickback law (Session Law 2010-185). The results of Program Integrity’s efforts can be seen everyday at the Office of Inspector General’s (OIG) website.OIG’s Most Wanted List: http://oig.hhs.gov/fraud/fugitives/index.asp In recent news, a Charlotte women was arrested for a $650,000 Medicaid fraud scheme. Click here to read the Press Release from the Department of Justice.