Corporate Compliance

Annual Update 2012

The federal Deficit Reduction Act and subsequent Medicaid Integrity Program requires that all health care entities that annually bill or pay out $5 million or more in Medicaid establish a Corporate Compliance Program. A program is recommended for all health care entities.

Corporate Compliance

Corporate Compliance

The focus of our program is on ethics and integrity in the workplace and compliance with

federal and state laws related to fraud, false claims, theft or embezzlement, kickbacks, or

other violations.

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

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.

What are the Benefits of a Corporate Compliance Program?

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.

The Guilford Center’s Corporate Compliance Program Includes:

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.

It is the policy of The Guilford Center…

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/Auditors

B-6 Corporate Compliance Policy: Open Policy…

The Guilford Center Policies & Procedures

Several federal and North Carolina statutes serve as the basis for our requirements for compliance. The following slides will outline statutes relating to compliance issues.

As an employee of the Guilford Center it is your responsibility to report any behaviors that might constitute failure to comply.

Laws and Regulations

Contracting for your own

benefit;

Misuse of confidential information;

Gifts and favors;

Secondary employment or private practice.

North Carolina Laws

Contracting for your own benefit

North Carolina G.S. 14-234 This statute prohibits making, or being in any manner concerned or interested in making, a contract with the employer (the Guilford Center) for one’s own benefit. The penalty for violation of this general statute constitutes a misdemeanor.

North Carolina General Statute

Misuse of confidential information

North Carolina G.S. 14-234.1 This general statute applies to employees of the state of North Carolina and any of the state’s political subdivisions, which includes the Guilford Center.

This statute prohibits using confidential information obtained by virtue of a public office (employment) for personal gain, or aiding another to gain from using such information. Violation of this general statute constitutes a misdemeanor.

North Carolina General Statute

Gifts and favors regulated

North Carolina G.S. 133-32 This statute states that employees who are responsible for preparing plans, bid specifications or estimates for contracts, or awarding or administering agency contracts cannot give or receive gifts or favors from contractors, subcontractors or suppliers who have contracts with local government agencies, or have performed under a contract within the past year or anticipates bidding on one. Violation (by giver or receiver) constitutes a misdemeanor.

Guilford Center employees are prohibited from accepting gifts from consumers, providers or vendors, other than common courtesy items such as coffee or snacks served during a training event.

North Carolina General Statute

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.

Secondary Employment or Private Practice

False Claims Act (FCA)

Anti-Kickback Statute

HIPAA

Deficit Reduction Act

Civil Monetary Penalties Act

The False Claims Whistleblower Employee Protection Act

What Federal Laws Address Fraud and Abuse?

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.

Civil and Administrative Statutes

A false claim is a claim for payment for

services or supplies that were not provided specifically as presented or for which the

provider is otherwise not entitled to payment.

The False Claims Act

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)

False Claims Act Examples

The Penalty for violating the False Claims Act is a minimum of $5,500 up to a maximum of $11,000 for each false claim submitted. In addition, the provider could be found liable for damages of up to three times the amount unlawfully claimed.

The False Claims Act Penalty for Unlawful Conduct

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.

Anti –Kickback(U.S.C. 1320)

Penalty for Unlawful Conduct

The 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.

Anti-Kickback

Example

Provider pays a referral fee and records the payment as salary or pays a higher than normal pay rate to compensate for the referrals.

Anti-Kickback

Examples of Kick-Backs:

Money Waiver of co-pays Discounts Gifts Credits Commissions

Anti Kickback Statute

Requires health care organizations who bill

(providers) or pay out (LMEs) more than $5 million annually in Medicaid to have an effective corporate compliance program in place as of January 1, 2007 as…

A Condition of Payment

The Deficit Reduction Act

Not provided as indicated by the coding on the claim Not medically necessary

This is a comprehensive statute that covers an array of fraudulent and abusive activities and is very similar to the False Claims Act. This law prohibits a provider from presenting, or causing to be presented, claims for services that the provider “knows, or should have known” were…

Civil Monetary Penalties Law(42 U.S.C. 1320)

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

Civil Monetary Penalties Law

It is a crime to willfully prevent, obstruct, mislead, or delay the communication of records relating to a

Federal health care offense to a criminal investigator. This law also applies to most types of

health care plans.

Obstruction of a Criminal Investigation of Health Care Offenses

(18 U.S.C. 1518)

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…

Obstruction of a Criminal Investigation

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.

Your Responsibilities as Managers with 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

Your Responsibility as Employees of The Guilford Center

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 General's Fraud Line at 1-800-HHS-TIPS; or

Call the State Auditor's Waste Line: 1-800-730-TIPS; or Complete and submit a Medicaid fraud and abuse confident

ial online complaint form.

How Do I Report Suspected Fraud and Abuse?

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.

Corporate Compliance Is In the News…