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