We’re not in Kansas

anymore!

Healthcare has changed and we need

courage, knowledge

and a big heart to survive the change!

How did we get here Toto?MEDICARE BBA Balanced Budget Act 1997

DRG’s, Perspective Payment System, APC’s HIPAA – Health Information Portability &

Accountability Act - 2001 MMA - Medicare Modernization Act 2003

Created Stark, Sarbanes Oxley (SOX), Anti-kickback, Physician Referral guidelines, Medicare Fraud & Abuse

DRA – Deficit Reduction Act 2005 Created Medicaid Integrity Program (MIP) Dramatically Increased Resources of CMS

& HHS-OIG to Fight Medicaid Fraud Funding - $560M over 5 Years

How did we get here Toto?Medicare Contract Reform (MCR)

POA’s – Present on Admission Indicators HAC’s – Hospital Acquired Infections RAC’s – Recovery Audit Contractors MAC’s – Medicare Administrative Contractors

MS-DRG’s – from 500+ to 745 Adds Severity Levels DRG w/ no cc/mcc – $2500 DRG w/cc - $3500 DRG w/cc & mcc - $5000

How did we get here Toto? In Georgia –

2003 - Medicaid ACS conversion from EDS 2006 - 3 New Medicaid CMO’s for pregnant

women and children 2009 – SHBP Plan Changes - CAHABA Part A – MAC on May 4th

- Reimbursement cuts – 5% 2010 – Change Medicaid Payer from ACS to

EDS

How did we get here Toto? In Georgia –

2003 - Medicaid ACS conversion from EDS 2006 - 3 New Medicaid CMO’s for pregnant

women and children 2009 – SHBP Plan Changes - CAHABA Part A – MAC on May 4th

- Reimbursement cuts – 5% 2010 – Change Medicaid Payer from ACS to

EDS

The Bad WitchCMS REGULATORY

COMPLIANCE - OIG

MEDICARE LOST AN ASTONISHING $23 BILLION IN 1996 due to corporate fraud, waste, and error, according to former Secretary of Health and Human Services Donna Shalala.

OIG Core PrinciplesHHS OIG guidelines - Core principles 1) implement written policies, procedures,

and standards of conduct; 2) designate a compliance officer; 3) conduct effective training; 4) develop effective lines of

communication;

OIG Core PrinciplesHHS OIG guidelines - Core principles 5) enforce standards through well-

publicized disciplinary guidelines; 6) conduct internal monitoring and

auditing; and 7) respond promptly to detected offenses,

developing corrective action and reporting to the government.

IMPLEMENT FRAUD PREVENTION POLICIES

Written policies, procedures, and standards of conduct address specific risk areas such as:

1. patient rights, 2. billing and cost reporting, 3. employee screening, 4. kickbacks, 5. inducements, and self-referrals.

IMPLEMENT FRAUD PREVENTION POLICIES

According to the guideline, these policies and procedures should ensure: 1) Complete and accurate medical record documentation, and compliance should be required and used as an evaluative tool during employee performance appraisals.

2) Furthermore, the guideline requires creation of a code of conduct that is easy to read and details the health-care facility's expectations and general principles as applicable to employees.

DESIGNATE COMPLIANCE OFFICER

The second HHS OIG guideline requires "designation of a compliance officer and compliance committee charged with the responsibility for developing, operating, and monitoring the compliance program, and who reports directly to the owners, governing body, and/or CEO."

The compliance officer has the authority to review all documents and information pertinent to compliance activities.

TRAIN EMPLOYEES The HHS OIG guidelines consider the

"development and implementation of regular, effective education and training programs for all affected employees" a critical element of compliance.

TRAIN EMPLOYEES The HHS OIG also encourages specific

program topics, including: 1) compliance with Medicare requirements;2) appropriate and sufficient

documentation for clinical and financial records;

3) patients rights; and 4) the duty to report misconduct.

The HHS OIG's emphasis on both general and specific training underscores its importance in an effective compliance program.

COMMUNICATE EFFECTIVELY

Communication is the backbone of an internal control system.

COMMUNICATE Anonymously-Whistle Blower Hotline

The HHS OIG guidelines require "the creation and maintenance of an effective line of communication between the compliance officer and all employees, including a process, such as a hotline or other reporting system, to receive complaints, and the adoption of procedures to protect the anonymity of complainants and to protect whistle blowers from retaliation."

HIRE THE RIGHT EMPLOYEES

The fifth HHS guideline states the necessity of "the development of policies and procedures addressing the non-employment or retention of excluded individuals or entities and the enforcement of appropriate disciplinary action against employees or contractor who have violated corporate or compliance policies and procedures, applicable statutes, regulations, or federal, state, or private payer health-care program requirements."

HIRE THE RIGHT EMPLOYEES

The HHS OIG guidelines also require written standards of conduct to include procedures for handling disciplinary problems and the names of those who will be responsible for enforcing the discipline

AUDIT COMPLIANCE The HHS OIG guidelines specify "the use of audits and/or other risk

evaluation techniques to monitor compliance, identify problem areas, and assist in the reduction of identified problems."

AUDIT COMPLIANCE These guidelines also state that an internal

control program should include an ongoing evaluation process with periodic reviews to determine the effectiveness of the compliance program and to ensure that program goals are being met.

This review process can include such practices as testing employees for knowledge of requirements, site visits, examination of complaint logs, trend analysis, and employee surveys.

AUDIT COMPLIANCE EMPLOYEE QUESTIONNAIRE • Annually • And at termination

DO YOUR EMPLOYEES KNOW?• HAVE YOU OR ARE YOU AWARE OF

VIOLATIONS?• HIPAA PRIVACY & SECURITY• FRAUD & ABUSE• REPORTING HOTLINE

RESPOND TO DETECTED OFFENSES AND IMPLEMENT CORRECTIVE MEASURES

The final HHS OIG guideline stresses the need for diligence in discovering violations and swift action once violations are detected

RESPOND TO DETECTED OFFENSES AND IMPLEMENT CORRECTIVE MEASURES

According to the guideline, "Violations of a facility's compliance program policies threaten the facility's reputation as a reliable, honest, and trustworthy health-care provider."

If the facility detects but does not act on problems, it risks criminal prosecution and possible exclusion from the Medicare system.

RESPOND TO DETECTED OFFENSES AND IMPLEMENT CORRECTIVE MEASURES

Health-care providers should investigate these areas of concern and take corrective measures within 60 days after uncovering credible evidence of a violation. These measures include:

1) returning any overpayment;

2) sending a report to the government;

3) referring violators to criminal or civil law enforcement officials.

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