division of health sciences office of institutional integrity protecting yourself and your practice
TRANSCRIPT
DIVISION OF HEALTH SCIENCES OFFICE OF
INSTITUTIONAL INTEGRITY
Protecting Yourself and Your Practice
WHAT IS HEALTHCARE COMPLIANCE?
Wide range of activities to help prevent, detect, and avoid fraud and abuse.
Follow institutional policy, state and federal laws & regulations
Monitor practice ethics and patient rights legislation
Effective training, communication, monitoring, enforcement and response
WHO IMPLEMENTS THE COMPLIANCE PROGRAM?
Office of Institutional Integrity
• Chief Institutional Integrity Officer- Kenneth DeVille, PhD, JD
• Executive Assistant- Lauren Perry
• Healthcare Regulatory Specialist- Michelle C. Evans, MPA
• Billing Compliance Manager- Brandy Styron, RHIA, CCS-P
• Billing Compliance Reviewers- Michele Lang, Kenya Dudley, Ashley Ross
• Administrative Support Associate- Pam Martin
Compliance Committees (BSOM, CAHS, SoDM, CoN)
Most important resource: Individual Employees!
TOP COMPLIANCE RISK AREAS
Documentation and Billing Integrity
Fraud and Abuse Laws
HIPAA Privacy
DOCUMENTATION AND BILLING
Accurate Coding and Billing are Critical
Fraudulent Billings Result in Stiff Penalties
Billing and Reimbursement Reviews Billing for services not performed (or underperformed) Ordering/billing for medically unnecessary
services Double billing, Upcoding/Downcoding If it’s not documented, it will not be
reimbursed
DOCUMENTATION AND BILLING
Teaching Physician Documentation RulesGenerally need evidence of physician presence during key portion of medical management with resident.
Electronic Medical Record Issues Sharing of passwords prohibited
Cutting and pasting is not recommended
Easy for internal reviewers and external auditors to track.
Assuming notes (History and Physical, progress notes, office visit, consults) instead of adding an addendum. (i.e. when adding a teaching statement, do not click “make me the author”)
NAVIGATING FRAUD AND ABUSE LAWS
FUNDAMENTAL POINTS Laws are very broad
Laws are complex and not intuitive
Laws apply to a wide variety of common financial relationships that are not obvious kickbacks or fraud
Penalties are serious
Enforcement is rising because of financial benefit to government.
Mistakes are not fraud, BUT lack of system to control mistakes or insufficient response to mistakes MAY BE
Defense is very expensive, even if successful.
FEDERAL FALSE CLAIMS ACT 31 U.S.C. §§ 3729-33
False Claims Act (FCA) prohibits anyone from “knowingly” submitting a false or fraudulent claim for payment to the government.
“Knowingly” means (i) actual knowledge; (ii) acts in deliberate ignorance of the truth or falsity of the information; or (iii) acts in reckless disregard of the truth or falsity of the information.
No proof of specific intent to defraud is required.
FEDERAL FALSE CLAIMS ACT
False Claims “can” result from actions such as:
Billing for services not rendered
“Upcoding”
“Double-billing”
Lack of medical necessity
Pattern of insufficient documentation
Violation of billing rules
False certification
FEDERAL FALSE CLAIMS ACTQUI TAM ACTIONS
The FCA allows a private person (a “qui tam relator”) to bring a civil action in the name of the United States.
Qui tam relators share in any money recovered
(including settlements). If government joins in action, relator is entitled to 15% to
25% of proceeds depending on relator’s contribution to case.
If government does not join in action, court may award relator not less than 25% and not more than 30% of proceeds.
FEDERAL FALSE CLAIMS ACT
Civil Penalties: Triple damages and penalties of $5,500 to $11,000 per false
claim for submission or causing submission of false claim.
Criminal Penalties: Felony conviction: 5-20 years in jail Misdemeanor conviction: 1 year in jail
FEDERAL ANTI-KICKBACK STATUTE (42 USC § 1320A-7B(B))
Prohibits offering, paying, soliciting or receiving anything of value to induce or reward referrals or generate Federal health care program business
FEDERAL ANTI-KICKBACK STATUTE
Statute makes it a crime (felony) to:
Knowingly and willfully
Solicit, offer, receive, or pay
Any remuneration (cash or in kind)
With intent to induce
Referrals of an individual for The furnishing of a service or item or procedure For which a federal healthcare program will pay.
FEDERAL ANTI-KICKBACK STATUTE
Examples of Kick-backs: Money, discounts, gifts, and credits
Criminal and civil liability for failure to comply
Criminal fines up to $25,000 and up to 5 yrs prison term per violation
Civil money penalties of $50,000 per violation Up to 3 times the amount of kickback Exclusion from federal health care programs *Possible violation of the False Claims Act
FEDERAL PROHIBITION ON PHYSICIAN SELF-REFERRAL
STARK LAW (42 USC § 1395NN)
Prohibits a physician from referring Medicare patients for designated health services to an entity with which the physician (or immediate family member) has a financial relationship, unless an exception applies
Prohibits the designated health services entity from submitting claims to Medicare for those services resulting from a prohibited referral
http://blog.tcs-inc.us/the-medsafe-compliance-corner/bid/54023/The-Stark-Law
PHYSICIAN SELF-REFERRAL STARK LAW
Only certain “designated health services” subject to Stark Law
Stark Safe Harbor/Exceptions
Civil liability for failure to comply Overpayment/refund obligation False Claims Act liability Civil monetary penalties and program exclusion for
knowing violations Potential $15,000 CMP for each service Civil assessment of up to three times the amount claimed
HIPAA PRIVACY RULE45 CFR PART 160
SUBPARTS A & E OF PARTS 164
Use and Disclosure of Protected Health Information (PHI)
Patient Rights regarding PHI
University Privacy Officer responsible for implementation and day-to-day administration
All privacy complaints should be directed to the University Privacy Officer
OFFICE OF INSTITUTIONAL INTEGRITYCODE OF CONDUCT
Standards for conduct at BSOM
Must read and sign attestation for Code of Conduct
Individual commitment to understanding and following the rules and ethical standards
Condition of employment
REPORTING INCIDENTS OF POTENTIALNON-COMPLIANCE TO THE
OFFICE OF INSTITUTIONAL INTEGRITY
Encouraged to use supervisors, administrators as the first line of reporting of any known incidents of noncompliance
Compliance HotlineAvailable 24 hours a day, 7 days a weekCan be anonymousToll free 1-866-515-4587E-mail [email protected]
No retaliation for good faith reporting of incidents of noncompliance
All good faith reports will be fully investigated
Confidentiality maintained to the fullest extent possiblePhysicians and staff have a professional duty to report potential
problems.
