Compliance for Health Care Organizations


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The Season for Compliance is upon. The Office of the Inspector General has mandated elder care facilities institute this 7 part compliance program. Are you ready?

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  • Compliance for Health Care Organizations

    1. 1. The Season For Compliance Is Upon Us Patrick V. Trotta, CPA
    2. 2. Overview of Presentation <ul><li>Purpose of Corporate Compliance </li></ul><ul><li>Elements of a Corporate Compliance Program </li></ul><ul><li>Benefits derived from Corporate Compliance </li></ul><ul><li>Monitoring the effectiveness of Corporate Compliance Program </li></ul>
    3. 3. Purpose of Corporate Compliance <ul><li>System designed to prevent, detect, and address financial improprieties and inadequate care </li></ul><ul><li>Identifies financial/care issues before they lead to government intervention </li></ul><ul><li>Uses internal controls to monitor adherence to applicable statutes, regulations and program requirements </li></ul>
    4. 4. Purpose of Corporate Compliance (cont.) <ul><li>Fosters organizational culture that promotes commitment to Ethical and Effective behavior </li></ul><ul><li>Encourages employees and others to report potential problems </li></ul><ul><li>Minimize financial loss to the government, the taxpayers, and the nursing facility </li></ul>
    5. 5. Purpose of Corporate Compliance (cont.) <ul><li>Enhance resident satisfaction and safety through delivery of improved quality of care </li></ul><ul><li>Improves the facility’s reputation for quality and integrity </li></ul>
    6. 6. Elements of a Corporate Compliance Program <ul><li>Office of Inspector General (OIG) has determined 7 elements that are fundamental to an effective compliance program </li></ul><ul><li>Suggestions on how facilities can best establish internal controls and prevent fraudulent activities </li></ul><ul><li>OIG’s elements not mandatory or exclusive </li></ul>
    7. 7. OIG’s Seven Fundamental Elements <ul><li>Policies, procedures, and standards of conduct </li></ul><ul><li>Designation of a compliance officer & compliance committee </li></ul><ul><li>Training & education </li></ul>
    8. 8. OIG’s Seven Fundamental Elements (cont.) <ul><li>4. Effective lines of communication </li></ul><ul><li>5. Enforcement & discipline </li></ul><ul><li>6. Monitoring & audit of compliance system </li></ul><ul><li>7. Prompt response to detected offenses & corrective action plan </li></ul>
    9. 9. (1) Policies, Procedures, and Standards of Conduct <ul><li>Written </li></ul><ul><li>Best practices </li></ul><ul><li>Interdisciplinary focus </li></ul><ul><li>Applies to employees, contractors, and vendors </li></ul><ul><li>Reviewed and updated </li></ul>
    10. 10. (2) Designation Compliance Officer & Compliance Committee <ul><li>Responsible for developing, operating, and monitoring the compliance program </li></ul><ul><li>Should be autonomous </li></ul><ul><li>May have several different roles </li></ul><ul><li>Focus on financial and quality of care </li></ul><ul><li>Reports to ownership, governing body, and CEO </li></ul>
    11. 11. (3) Training & Education <ul><li>Fundamental to Compliance Program </li></ul><ul><li>Begins with orientation and ongoing tracking </li></ul><ul><li>Appropriate to position </li></ul><ul><li>General to all employees </li></ul>
    12. 12. (4) Effective Lines of Communication <ul><li>Between compliance officer and all employees </li></ul><ul><li>Reporting system to receive complaints and grievances </li></ul><ul><li>Hotline </li></ul><ul><li>Protect the anonymity of complaints and grievances </li></ul>
    13. 13. (5) Enforcement & Discipline <ul><li>Condition of employment (excluded individuals/entities) </li></ul><ul><li>Compliance a factor in evaluation of job performance </li></ul><ul><li>Appropriate and timely action </li></ul><ul><li>Communication </li></ul>
    14. 14. (6) Monitoring & Audit of Compliance System <ul><li>Periodic process to assess effectiveness of Compliance Program </li></ul><ul><li>Continuous quality improvement </li></ul><ul><li>Proactive process </li></ul><ul><li>Internal and external audits </li></ul>
    15. 15. (7) Prompt Response to Detected Offenses & Corrective Action Plan <ul><li>Immediate investigation </li></ul><ul><li>Follow up on suspected noncompliance </li></ul><ul><li>Develop corrective action </li></ul><ul><li>Self disclosure </li></ul>
    16. 16. Benefits Derived From Corporate Compliance <ul><li>Mandatory requirement for compliance programs by March, 2013 </li></ul><ul><li>Different requirements depending upon facility type (e.g., large chain v. small provider) </li></ul><ul><li>Reduces exposure to civil damages and penalties, criminal sanctions, and administrative remedies </li></ul>
    17. 17. Benefits Derived From Corporate Compliance (cont.) <ul><li>Survey results </li></ul><ul><li>Effective internal controls ensure compliance with government statutes and regulations and organizational standards </li></ul><ul><li>Ethical culture develops employee satisfaction and stable workforce </li></ul>
    18. 18. Benefits Derived From Corporate Compliance (cont.) <ul><li>Ability to quickly react to operational compliance concerns and effectively allocate resources </li></ul><ul><li>Financial control </li></ul><ul><li>Billing and collection control and compliance </li></ul>
    19. 19. Monitoring The Effectiveness of Corporate Compliance Program <ul><li>Compliance monitoring team </li></ul><ul><li>Identification of risk areas </li></ul><ul><li>Assessment steps </li></ul>
    20. 20. (1) Compliance Monitoring Team <ul><li>Compliance officer </li></ul><ul><li>Compliance committee </li></ul><ul><li>Internal audit staff </li></ul><ul><li>Consultants </li></ul><ul><li>Lawyers </li></ul><ul><li>Independent auditors </li></ul>
    21. 21. (2) Identification of Risk Areas <ul><li>Quality of care and residents rights </li></ul><ul><li>Employee screening </li></ul><ul><li>Vendor relationships </li></ul><ul><li>Billing and cost reporting </li></ul>
    22. 22. (2) Identification of Risk Areas (cont.) <ul><li>Record keeping and documentation </li></ul><ul><li>Sufficient staffing </li></ul><ul><li>Comprehensive care plans </li></ul><ul><li>Medication management </li></ul>
    23. 23. (2) Identification of Risk Areas (cont.) <ul><li>Resident safety </li></ul><ul><ul><li>Resident interactions </li></ul></ul><ul><ul><li>Staff screening </li></ul></ul><ul><li>Submission of accurate claims </li></ul><ul><ul><li>Proper case mix reporting </li></ul></ul><ul><ul><li>Therapy services </li></ul></ul><ul><ul><li>Screening for excluded individuals/entities </li></ul></ul><ul><ul><li>Restorative and personal care services </li></ul></ul>
    24. 24. (2) Identification of Risk Areas (cont.) <ul><li>Anti-kickback statute </li></ul><ul><ul><li>Free goods and services </li></ul></ul><ul><ul><li>Service contracts </li></ul></ul><ul><ul><li>Discounts </li></ul></ul><ul><ul><li>Hospices </li></ul></ul><ul><ul><li>Bed reservations </li></ul></ul><ul><li>Other </li></ul><ul><ul><li>Physician self referrals </li></ul></ul><ul><ul><li>Medicare Part D </li></ul></ul><ul><ul><li>HIPAA </li></ul></ul>
    25. 25. (3) Assessment Steps <ul><li>Base line assessment </li></ul><ul><li>Regular review of effectiveness </li></ul><ul><li>Mandated outside audit (??) </li></ul>
    26. 26. Final Thoughts & Questions Patrick V.Trotta, CPA Director, Elder Care Provider Services Glass Jacobson [email_address] (410) 356-1000