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Compliance Basics Presentation
- 1. Nick Merkin 11845 W Olympic Blvd., Suite 1250 Los Angeles, CA 90064 nmerkin@compliagent.com 310.996.8950 www.compliagent.com
- 2. Seven Elements of a Compliance Program WRITTEN COMPLIANCE POLICIES AND PROCEDURES DESIGNATED COMPLIANCE PROFESSIONALS EFFECTIVE TRAINING OF ALL STAFF EFFECTIVE COMMUNICATION PREVENTATIVE AUDITING AND MONITORING ENFORCEMENT OF STANDARDS PROMPT RESPONSE TO POTENTIAL COMPLIANCE VIOLATIONS
- 3. The Structure of our Programming...
- 4. Program Assessment and Development of a Tailored Compliance Plan…
- 5. Program Assessment and Development of a Tailored Compliance Plan Program Assessment • Conduct initial assessment of compliance programming already in place. • Identify areas for improvement and risk concern. • Presentation of findings through confidential memoranda and discussions with governing board and senior management. Compliance Plan • Development of strategic compliance plan narrowly-tailored to specific client’s business and regulatory needs. • Continuous monitoring and updating of compliance plan to reflect emerging risk areas and regulatory developments.
- 6. Education and Communication of Culture of Compliance…
- 7. Education and Communication of Standards Quarterly Compliance Survey • Issue Compliance Survey to key Facility employees to encourage reporting of actual or potential compliance violations • Investigation by Compliagent of any reported issues • Outcome of investigations are reported to the Facility’s Governing Board and monitored by Compliagent for effective resolution as indicated Participation in Policy Committee • Assist with the development of a monthly policy review agenda • Provide regulatory and clinical guidance for policy development Update to Compliance Plan • Annual review of the Compliance Plan (See Exhibit A) • Distribute Compliance Plan to facilities on an annual basis • All Facility employees receive a copy of the Compliance Plan Monthly Facility Updates • Monthly newsletter and additional guidance statements concerning regulatory issues as warranted • Quarterly distribution of Dashboard reporting Facility specific compliance metrics (See Exhibit B) • Issue policy updates from Policy Committee
- 8. Education and Communication of Standards (Continued) Ongoing Compliance Support and Guidance • Each Facility is assigned a designated consultant to provide ongoing support with the maintenance of the Compliance Program • Compliagent consultants are available to the facilities to provide guidance with regard to operational and clinical regulatory issues as needed Quarterly Training • Mandatory Annual Training: Compliance Program and HIPAA • Additional training topics are selected by Compliagent based upon client request, observed need, and regulatory enforcement priorities (See Exhibit C) • Trainings are conducted both on-site and via webinar • Compliagent provides training materials to Director of Staff Development for mandatory in-services to all staff
- 10. Risk Management Compliance Complaint Investigation • Develop investigation plan in coordination with Facility Compliance Officer • Investigation may include interviews of residents and/or employees, resident specific record review, or audit of multiple records • Investigational findings and recommendations are communicated to the Compliance Officer, Administrator and Governing Board (See Exhibit D) Hosting of Compliance Hotline • Hotline posters provided to each Facility • Compliance Hotline is a voicemail box that permits reporting 24/7 and allows callers to remain anonymous • Hotline calls are reported to the Compliance Officer and Administrator, unless a conflict of interest exists Risk Assessment • The Risk Assessment is revised annually base don regulatory enforcement priorities • Facilities complete the Risk Assessment on an annual basis • The Risk assessment using scoring based upon the response to determine the prioritization of risk management
- 11. Risk Management (Continued) Compliance Audits • Client selects the audit area for the Facility based on the information provided in the Risk Assessment • Audits include both operational and clinical topics (See Exhibit C) • Audit findings and recommendations are communicated to the Compliance Officer, Administrator and Governing Board Exclusion Screening • Monthly exclusion screening performed for all facility employees • Any negative results are communicated to Compliagent Consultants and the facilities • Compliagent consultants coordinate with the Facility’s administrator to address and resolve identified exclusions
- 13. Monitoring and Reporting Monitoring of Compliance Action Plan • Facility develops an action plan to address risk area identified in the OIG’s annual work plan • Any corrective actions resulting from hotline complaints or audits are also added to the action plan • Compliagent reviews the Facility’s action plan no less than quarterly to ensure effectiveness of the corrective actions Governing Board Reports • Compliagent will report all Compliance Program activity from the preceding quarter and provide updates on an ongoing activities • The Administrator reports on topics such as survey results, compliant surveys, QAPI activity, etc.
- 15. Maintenance and Validation Annual Compliance Program Assessment • Compliagent conducts an annual assessment to determine how effectively the Facility has implemented each of the OIG’s identified 7 elements of compliance • Results are communicated to the Compliance Officer and Governing Board Quarterly Compliance Program Dashboard • Compliagent issues a Facility specific dashboard quarterly to capture the Facility’s progress and areas for improvement • The information captured on the dashboard will vary but may include Risk Assessment scoring, Compliance Program Assessment scoring, hotline call volume, and quality measures Annual Risk Profile Evaluation Assessment • Compliagent has developed a tool for the categorization of risk to identify priority facilities • The data used includes survey deficiencies, quality measure data, staff turnover, star rating, etc. • Compliagent updates the used to calculate the risk profile on an annual basis
- 16. The Business Benefits of Independent Compliance Programming …
- 17. Access to Multiple Professionals With Varied Specialties Through a Single Point of Contact…
- 18. Single Point of Contact Access a network of qualified compliance professionals with different specializations through a “one-stop shop” approach… Even Larger Healthcare Organizations Need Help • May only have a handful of experienced compliance professionals with a narrow range of expertise on staff. Evaluating of Resources • Only enough room and resources for so many senior compliance personnel within one entity. We bring to bear a higher level of professional firepower to a compliance matter at a lower cost.
- 20. Lower Upfront Cost The initial investment in hiring qualified and experienced healthcare compliance professionals is high… Building Compliance Infrastructure On Your Own is Expensive • Hiring even a single compliance specialist and assistant may cost a healthcare organization hundreds of thousands of dollars a year. Outsourcing Saves You Money • Upfront expenditures involved in outsourcing an entity’s compliance function are much lower and involves a much smaller commitment to a scope of work that is narrowly defined and leanly priced in a detailed retention agreement. Even for organizations that are committed to building out a more extensive internal compliance department, it usually makes financial sense to begin with a combination of insourced and outsourced expertise.
- 21. Quicker Adaptation to Regulatory Changes…
- 22. Regulatory Adaptation Regulation Requirements are Going to Get Worse… Internal Change is Hard • Implementing organizational change internally can be cumbersome and a drain on resources. Outsourcing Makes it Easier • We focus specifically on the nuances of legal change and interpretation, are better suited than an internal corporate compliance department to monitor and react swiftly to changing laws and regulations. We a unique, multi-faceted perspective, gained from advising a variety of organizations, to develop “best practices” with an eye towards your business goals.
- 23. More Flexible Use of Compliance Resources…
- 24. Compliance Resources Compliance 101 We give you the ability to pick and choose from a menu of compliance options at any given time… Specialized Resourcing • We are able to tailor our resources based on an organization’s most recent compliance plan or risk assessment • Ex. HIPAA Training or Employee Screening Flexibility • We can follow new, strict budgets that will address any more pressing compliance needs as the organization grows • Resources are not locked-in to any particular need We have specialists in all these areas, so we can more nimbly address your evolving compliance concerns.
- 26. Third-Party Objectivity Third-Party Objectivity is Two-Fold… Internal • Difficult for employees to be completely objective about the strengths and, especially, the weaknesses in the organization • Fear of reprisal and fear of judgment is a high concern for employees External • Third-party conclusions may be viewed as more independent • Outsourced compliance specialist findings carry greater weight We’ve earned more credibility and success in reaching agreements and compromises with the government on behalf of their own clients.
- 27. We Guide Providers and Help Them Develop Self- Perpetuating, Scalable Infrastructure…
- 28. Improving the Bottom Line…
- 29. Nick Merkin 11845 W Olympic Blvd., Suite 1250 Los Angeles, CA 90064 nmerkin@compliagent.com 310.996.8950 www.compliagent.com Thank You. Questions?
Editor's Notes
- Hi. My name is Nick Merkin and I’m the CEO of Compliagent. And I’m going to tell you our story. And I’m also going to tell you about innovation. And how our work improves healthcare delivery and lowers costs. I’m also supposed to talk about some of the healthcare industry problems that we solve – and I will. But I’d rather talk about opportunities. Specifically, the opportunities afforded to us by robust healthcare compliance programming. And I know that sounds cliché. And it is. But I think that, sometimes, we are focused so much on solving problems that we miss the opportunities they create.
- Making the wrong choice in this content may cut deeply into profit margins. Even worse, a poor decision may result in an unacceptable level of regulatory risk and expose a healthcare provider to financial liability, criminal prosecution, and reputational harm. So how do we address all these problems… Here’s our basic structure… And I think in here lies much of our innovation… We’ve distilled compliance into a system and an infrastructure by studying hundeds of past and current CIAs, statutes, regulations, and guidance statements, and hundreds of conversations with healthcare managers. We’ve also looked at it thorough the lens of our own years of collective experience in the healthcare regulatory industry. And that includes 7 JDs, a former healthcare facility administrator with over a decade of experience, three really knowledgeable former directors of nursing, a physician, and people with certifications with HIPAA and HITrust data security, as well as human resources specialists, a former hospital executive, and MBAs. And that includes, not joking, the former starting guard for Providence’s women’s basketball team and a former NCAA Division One triple jumper and long jumper. We’re tall people in our office.
- So, I don’t have enough time to due it justice, but let me take you through an outline of what we do. We start off with a compliance program initial assessment – What we call a “gap analysis.” Leading to the Development of a tailored Compliance Program. Simple enough.
- Education & Communication of Standards Quarterly Compliance Survey Update to Compliance Plan Participation in Policy Committee Monthly newsletter and additional guidance statements concerning regulatory issues as warranted Dashboard reporting Facility specific compliance metrics Issue policy updates from Rockport Policy Committee Quarterly Training
- Ongoing Compliance Support and Guidance Each Facility is assigned a designated TCI consultant to provide ongoing support with the maintenance of the Compliance Program Hosting of Compliance Hotline Compliance Complaint Investigation Annual Risk Assessment Compliance Audits Monthly Exclusion Screening
- Monitoring of Compliance Action Plan Facility develops an action plan to address risk area identified in the OIG’s annual work plan Any corrective actions resulting from hotline complaints or audits are also added to the action plan TCI consultants review the Facility’s action plan no less than quarterly to ensure effectiveness of the corrective actions Governing Board Reports TCI consultants will report all Compliance Program activity from the preceding quarter and provide updates on an ongoing activities The Administrator reports on topics such as survey results, compliant surveys, QAPI activity, etc.
- Annual Compliance Program Assessment TCI consultants conduct an annual assessment to determine how effectively the Facility has implemented each of the OIG’s identified 7 elements of compliance Results are communicated to the Compliance Officer and Governing Board Quarterly Compliance Program Dashboard TCI issues a Facility specific dashboard quarterly to capture the Facility’s progress and areas for improvement The information captured on the dashboard will vary but may include Risk Assessment scoring, Compliance Program Assessment scoring, hotline call volume, and quality measures Annual Risk Profile Evaluation TCI has developed a tool for the categorization of risk to identify priority facilities The data used includes survey deficiencies, quality measure data, staff turnover, star rating, etc. TCI updates the used to calculate the risk profile on an annual basis
- Outsourcing Facilitates Access to Multiple Qualified Compliance Professionals With Varied Specializations Through a Single Point of Contact. Another related advantage to an outsourced compliance model is the ability to access a network of qualified compliance professionals with different specializations through a “one-stop shop” approach. By necessity, even larger healthcare organizations may only have a handful of experienced compliance professionals with a narrow range of expertise on staff. After all, there is only enough room and resources for so many senior compliance personnel within one entity. We bring to bear a higher level of professional firepower to a compliance matter at a lower cost.
- Outsourcing Requires a Lower Initial Investment. The initial investment in hiring qualified and experienced healthcare compliance professionals is high. At bottom, when incorporating all the expenses involved in building compliance infrastructure on your own, the hiring of even a single compliance specialist and assistant may cost a healthcare organization hundreds of thousands of dollars a year. In contrast, the upfront expenditures involved in outsourcing an entity’s compliance function is much lower and involves a much smaller commitment to a scope of work that is narrowly defined and leanly priced in a detailed retention agreement. Even for organizations that are committed to building out their own more extensive internal compliance departments in the future, it usually makes financial sense to begin with a combination of insourced and outsourced expertise.
- Outsourcing Requires a Lower Initial Investment. The initial investment in hiring qualified and experienced healthcare compliance professionals is high. At bottom, when incorporating all the expenses involved in building compliance infrastructure on your own, the hiring of even a single compliance specialist and assistant may cost a healthcare organization hundreds of thousands of dollars a year. In contrast, the upfront expenditures involved in outsourcing an entity’s compliance function is much lower and involves a much smaller commitment to a scope of work that is narrowly defined and leanly priced in a detailed retention agreement. Even for organizations that are committed to building out their own more extensive internal compliance departments in the future, it usually makes financial sense to begin with a combination of insourced and outsourced expertise.
- Outsourcing Promotes Quicker Adaptation to Regulatory Changes Like we’ve discussed, the last few years have seen exponential expansion in the regulatory requirements governing healthcare providers. It’s gonna get worse. Implementing organizational change internally can be cumbersome and a drain on resources. We focus specifically on the nuances of legal change and interpretation, are better suited than an internal corporate compliance department to monitor and react swiftly to changing laws and regulations. In addition, we have a unique vantage point to watch how regulatory change manifests in a variety of organizations and to use that perspective to develop “best practices” with an eye towards your business goals.
- An Outsourced Model Promotes a More Flexible Use of Compliance Resources In contrast to the “all or nothing” approach of building out internal compliance infrastructure, we give you the ability to pick and choose from a menu of compliance options at any given time. For example, based on an organization’s most recent compliance plan and risk assessment, an entity may decide that in a particular quarter or year, resources should be focused on HIPAA training or on more effective employee screening. We can then simply be tasked (on a strict budget) to facilitate those goals. In contrast, a healthcare organization that has already invested significant internal resources in, for example, revamping its reimbursement control structure by hiring a dedicated compliance specialist with expertise solely in this function, may lack the flexibility to address these more pressing compliance needs as they arise and the organization grows. We have specialists in all these areas, so we can more nimbly address your evolving compliance concerns.
- Third-Party Objectivity A final benefit to an outsourced compliance model is the objectivity brought to the compliance function when a third-party firm is retained. These benefits are twofold and have both an internal and external component. Internally, it can be difficult for employees to be completely objective about the strengths and (especially the) weaknesses of their own organizations and departments. It is human nature to protect one’s “turf.” As a result, employees may be reticent to point out deficiencies in their own areas of responsibility or to acknowledge weaknesses to superiors. Even legitimate criticism of other departments or functions within an organization can be difficult because of the fear of reprisal or the concern that one’s feedback may be taken as political or self-serving in nature. We can mitigate many of these concerns as the professionals involved have fewer such pressures to temper their analyses. Moreover, externally, the work and conclusions reached by a third-party compliance specialist may be viewed as more independent and carry greater weight with enforcement agencies than those reached by internal employees. We’re more familiar with the governmental agencies and even the enforcement officials – we sit in meetings with them in Sacramento and all over CA all the time -- in their areas of expertise and we’ve earned more credibility and success in reaching agreements and compromises with the government on behalf of their own clients.
- The point is to develop a Infrastructure with you … To make compliance a business function, part of your strategic planning process, and part of your quality assurance plan. And here’s the real innovation. We don’t take the “memo only approach.” When I was a lawyer, my healthcare provider clients asked me for help. I gave them CYA memos and effectively said, “here, do it yourself.” That model is dead. Or at least it’s dead in our office and in our healthcare provider clients organizations. We want to make your internal compliance programming self-perpetuating. We want to empower you by working with you. Our guidance is continuous, educational programming is continuous, our monitoring, our reporting, your strategic planning working hand in hand with you to fine tune and tailor your programs. Were always there.
- So I promised I’d get to the “opportunities” part… Healthcare compliance is a challenge. It’s a business challenge. It costs money. And it’s also a healthcare delivery challenge. Here’s the secret though – flash the college health spreadsheet – that’s a compliance dashboard we use for one of our clients – it ties right into their business cycle financial programming. what I’ve learned doing compliance is that a rigorous and effective compliance program will ALWAYS lead to cost savings. Compliance RED FLAGS are always business RED FLAGS and profitability RED FLAGS. Compliance is the canary in the coal mine. Just to give you one example – when we look at a compliance data point like “Number of admissions from your top admitting physicians over the course of a year,” which is a self-referral issue and a compliance issue, that’s also a revenue issue. When we compare your organizations number of excluded individuals identified over the course of 36 months and the ratio of that to the national average, that a compliance issue, but it’s also a HR metric and it’s a recruiting and strategic planning issue for you. When present to your facility’s governing board about the number and composition by of your hotline grievance calls, that’s a compliance issue – but that’s also a revenue issue. And if you’re not paying attention to these metrics, you’re losing out on the bottom line. I’m going to even go sar far as to issue you a challenge. I can guarantee you that solid compliance infrastructure will save you money – real money – not prevention money – I don’t mean “we avoided a potential enforcement action against you by training your Privacy Officer money…” I mean revenue cycle issues that you’re missing and that compliance analytics will spot for you. That’s a promise.