the gentiva compliance program

The Gentiva Compliance Program

© Gentiva Health Services, 2002 2

Introduction

Corporate criminal liabilityFederal sentencing guidelinesCompliance program protectionBackgroundRequirementsEffect of programHIPPA IntroductionClosing comments/questions

Corporate criminal liabilityFederal sentencing guidelinesCompliance program protectionBackgroundRequirementsEffect of programHIPPA IntroductionClosing comments/questions

© Gentiva Health Services, 2002 3

Corporate Criminal Liability

A corporation is liable for any act committed by an employee which has the actual or intended effect of benefiting the company

The act must be within the scope of the employee’s actual or apparent authority

A corporation is liable for any act committed by an employee which has the actual or intended effect of benefiting the company

The act must be within the scope of the employee’s actual or apparent authority

© Gentiva Health Services, 2002 4

Department of Justice/CMS

New audit approach focusing on fraud and abuse issues

Operation restore trust

Auditor focus: recovering funds

New emphasis on closing down agencies

New audit approach focusing on fraud and abuse issues

Operation restore trust

Auditor focus: recovering funds

New emphasis on closing down agencies

OIG permitted to refer cases directly to DOJ

FBI involvement/ health care fraud teams

Health care #3 national priority

Increased criminal prosecution

OIG permitted to refer cases directly to DOJ

FBI involvement/ health care fraud teams

Health care #3 national priority

Increased criminal prosecution

© Gentiva Health Services, 2002 5

Federal Sentencing Guidelines

© Gentiva Health Services, 2002 6

Sentencing Guidelines

Comprehensive crime control act of 1984 enacted guidelines for individuals

Proposed guidelines for sentencing organizations became law in November 1991

Philosophy : carrot and stick approach

Just punishment

Adequate deterrence

Comprehensive crime control act of 1984 enacted guidelines for individuals

Proposed guidelines for sentencing organizations became law in November 1991

Philosophy : carrot and stick approach

Just punishment

Adequate deterrence

© Gentiva Health Services, 2002 7

Purpose

Incentives for organizations to maintain internal mechanisms Preventing

Detecting

Reporting criminal conduct

Standard requirements

Customized to each organization

Each step is valued towards demonstrating effectiveness of program

Incentives for organizations to maintain internal mechanisms Preventing

Detecting

Reporting criminal conduct

Standard requirements

Customized to each organization

Each step is valued towards demonstrating effectiveness of program

© Gentiva Health Services, 2002 8

Mitigating Factors

Compliance program

An effective compliance program to prevent and detect violations of the law, within the meaning set out in the guidelines, is the only mitigating element that can be implemented by a corporation prior to the criminal acts that give rise to prosecution

Compliance program

An effective compliance program to prevent and detect violations of the law, within the meaning set out in the guidelines, is the only mitigating element that can be implemented by a corporation prior to the criminal acts that give rise to prosecution

© Gentiva Health Services, 2002 9

Compliance Program

0

20

40

60

80

100

$ M

illi

on

s

With a Program Without a Program

© Gentiva Health Services, 2002 10

Compliance Standards

Medicare fraud and abuse laws

Federal false claims act Anti-kickback act Stark I & II (III?) Conditions of Participation Wedge audits Licensure Labor/ wage and hour Anti-trust

– Etc.

Medicare fraud and abuse laws

Federal false claims act Anti-kickback act Stark I & II (III?) Conditions of Participation Wedge audits Licensure Labor/ wage and hour Anti-trust

– Etc.

© Gentiva Health Services, 2002 11

Program Oversight

C O M P L IA N C E P R O G R A M S TR U C TU R EG en tiva H ea lth S ervices

B oard o f D irec to rsA u d it C om m ittee

C h ie f C om p lian ce O ffice r

F in an ce /R e im b u rsem en t

C h ie f F in an c ia l O ffice r

O p era tin g D irec to rs

C h ie f O p era tin g O ffice r

P res id en t/C E O

© Gentiva Health Services, 2002 12

Employee Training

Compliance policies must be distributed to all employees

Mandatory compliance training: VP’s, Branch Directors, Field Staff

Additional training through in-services, flyers, memorandum, bulletins, newsletters, Gentiva University, etc.

Compliance testingManagers training series

© Gentiva Health Services, 2002 13

Delegation of Authority

Monitoring of employees with respect to compliance standards

Employee screenings (in accordance with applicable laws)

Performance evaluation including adherence to compliance standards

© Gentiva Health Services, 2002 14

Enforcement & Discipline

Penalty matches offense

Range of sanctions

“Due process”

Self-disclosure (mitigating factor)

Management responsible for misconduct of subordinates

See progressive disciplinary policy

© Gentiva Health Services, 2002 15

Response & Corrective Action

Who’s involved?

What happened?

Who follows up?

Plan of action

Legal counsel?

Notify authorities

Corrective action

Preventive measures

© Gentiva Health Services, 2002 16

Effect of Program

Reduced risks and exposures

Reduce corporate liabilities

Enhances image with intermediaries

Public image

Increase quality

Increase profitability

Reduced risks and exposures

Reduce corporate liabilities

Enhances image with intermediaries

Public image

Increase quality

Increase profitability

© Gentiva Health Services, 2002 17

COMPLIANCE

QUALITY

Compliance IS Quality in ACTION

Compliance Circle

© Gentiva Health Services, 2002 18

Closing Comments/Questions

Additional Questions

1-631-501-7390 – Chris Anderson

Chris.Anderson@Gentiva.com

Additional Questions

1-631-501-7390 – Chris Anderson

Chris.Anderson@Gentiva.com