Title: INTEGRATED%20CARE%20ALLIANCE,%20LLC%20Corporate%20Compliance%20Training
1INTEGRATED CARE ALLIANCE, LLCCorporate
Compliance Training
- Debra Schuchert, Compliance Officer
2INTEGRATED CARE ALLIANCE, LLCCorporate
Compliance Program
- It is the policy of Integrated Care
Alliance to comply with all laws governing its
operations and conduct business in keeping with
legal and ethical standards. It is also the
policy of Integrated Care Alliance to deal with
employees and customers using the highest
clinical and business ethics. - Integrated Care Alliance strives to maintain a
corporate culture which promotes the prevention,
detection, and resolution of possible violations
of laws and unethical conduct. - Integrated Care Alliance supports the government
in its goal to decrease financial loss from false
claims and has as its own goal, the reduction of
potential exposure to criminal penalties, civil
damages, and administrative actions. - Integrated Care Alliance believes that a
compliance program guides the Management Board,
President/CEO, managers, employees, and health
professionals in the efficient management and
operation of the company and in improving the
quality of its services.
3Corporate Compliance ProgramElements
- Integrated Care Alliance maintains written
standards, a Code of Conduct, a Risk Management
Plan and Compliance policies and procedures. - Integrated Care Alliance has a Compliance
Department consisting of staff responsible for
compliance efforts, Corporate Compliance
Committee, and affiliate Compliance officials.
The Corporate Compliance Committee conducts
quarterly meetings. - Integrated Care Alliance conducts education and
training programs for employees and maintains an - Ethics Hotline (866) 724-7544
- (24 hours a day, seven days a week)
- DWMHA Compliance Hot Line (313) 833-3502
- (24 hours a day, seven days a week)
- to foster an open atmosphere for employees to
report issues and concerns free from retaliation. - Integrated Care Alliance may use audits or other
evaluation techniques to monitor compliance with
identified risk area.
4Corporate Compliance ProgramElements
- Integrated Care Alliance maintains a system and
procedures to respond to allegations and detected
offenses. If it is determined that there is a
current deficiency or area of non-compliance, the
development of a corrective action plan is
completed to resolve the issue. - Integrated Care Alliance educates and trains its
employees on the requirements for the Compliance
Program, and the disciplinary policy for
employees who violate the compliance policies
and applicable laws. Disciplinary action may
include oral warnings, suspensions, and
termination of employment depending on the
circumstances and severity of the violation. - Integrated Care Alliance believes that compliance
with the law means not only following the law,
but also conducting business so the Company
deserves and receives recognition as good and
law-abiding corporate citizens. The goal is to
inspire confidence from clients, consumers,
employees, the community, and our government.
5Corporate Compliance policies
- CC-001 - Integrated Care Alliance Partners
Corporate Compliance Department - Ensure important
aspects of Compliance are monitored - CC-002 - Confidentiality
- Maintain confidentiality
of Integrated Care Alliance information
integrity of compliance program - CC-003 - Integrated Care Alliance Internal
Corporate Compliance Investigation - Respond to and
investigate possible violations of applicable
federal, state or local law and non-compliance
with - Integrated Care
Alliances Code of Conduct - CC-004 - Responding to a Governmental Inquiry or
Investigation - Guidelines for
responding to both federal and state government
investigations - CC-005 False Claims
- Compliant with federal /
state law and regulations related to the billing
payment of claims involving federal, state or
private programs - CC-006 Omnibus rules as related to
Anti-Kickback, Self Referral, and Stark Laws - Guidelines for Integrated
Care Alliance to comply with federal and state
anti-referral and anti-kickback laws and
regulations - CC-007 Compliance Record Storage Retention
- Guidelines for the retention of
documents related to the Compliance program
6Corporate Compliance Facts
- Possible penalties for NON-Compliance include the
following - Imprisonment , Fines, Termination
of Employment -
- Compliance is the responsibility
of - Compliance Officer , Federal Government, and
Employee -
- The following constitutes the filing
of a false claim knowingly and willfully
submit - Up-coding the level of
service provided - Improper documentation
practices - Double billing resulting
in duplicate payment - Failure to properly use coding modifiers
- Billing for items or services not rendered or
not provided as billed - Submit false information
- Failure to refund
credit balances
7What makes a claim FALSE ?
- Factually False Claims A factually false claim
means that the services on the bill did not
actually happen. This type of false claim can
take the form of billing for services not
provided ,billing for more expensive services
than those actually rendered (called up coding),
double-billing for services, or billing for
services that were medically unnecessary, even if
they were actually performed. - Legally False Claims A legally false claim
occurs when the circumstances of the services on
the claim or the claim itself create or reflect a
violation of an underlying law or regulation. For
example, claims for physician services rendered
pursuant to an arrangement that violate the Stark
Law (prohibiting self-referrals) or the
Anti-Kickback Statute are legally prohibited and
are thus false, if made knowingly. The
submission of the claim itself is evidence of the
providers implied certification that the claim
is valid, such that even if the provider (or
biller) has not affirmatively represented that
the claims are legally compliant, submitting
legally invalid claims is generally viewed as
knowing misrepresentation under the False Claims
Act (FCA). - Reverse False Claims A reverse false claim is
failure to return overpayments (made by the
Federal Government) within the 60 day time
frame imposed in 2010 by the Affordable Care Act
(ACA). The ACA added a requirement that all
overpayments be returned to the government within
sixty days of when the claim is identified, and
if not reported creates a False Claims Act
liability for failing to do so. The Centers of
Medicare and Medicaid Services (CMS) has issued
proposed rules on the subject. - Payment for a False Claim is a felony, punishable
by imprisonment for not more than 10 years, or by
a fine of not more than 50,000, or both. - False Claims Training form should be signed by
the MCPN staff and contracted Providers.
8Corporate Compliance Facts
- Who is liable under the False Claims Act?
- Any person or entity connected with the
submission of a false claim can be liable,
including - Providers
- Beneficiaries
- Health plans that do business with the
Federal government - Billing companies
- Contractors
- If a concern or question about compliance
arises, you should - Ask the Compliance Officer, Manager, or
notify Compliance Officer anonymously -
- Anti-Kickback Federal Penalties
- Criminal Penalties
- - Criminal Statue-felony charges (
5yrs and /or 25k Fine) - - Potential financial liability
under False Claim Act - Civil Money Penalties
- - Loss of Medicare Medicaid
provider status - - Civil Monetary penalties of 50K
per act, plus damages equal to 3x remuneration - involved.
9Corporate ComplianceFacts
- Compliance programs and claims may be
audited by Recovery Audit Contractors hired by
the Federal Government and State of Michigan
Contractors. -
A directive of the Affordable Care Act (ACA) is
a provision that requires states to expand their
Recovery Audit Contractor Programs (RACs) to
prevent provider fraud, waste, abuse and improper
payments, and to take administrative action to
recoup overpayments as may be necessary. The
Affordable Care Act requires the return of any
Federal Health-Care program overpayment no later
than 60 days after the overpayment is identified.
Medicare has been successfully conducting audits
and is now increasing the spread of these
recovery audits to Medicaid.
It is believed that the Affordable Care Act
requires the States to up their examinations of
Medicaid accounting , which could result in
recovering a total of nine to ten billion
dollars for the government.
10Corporate ComplianceFacts
- Things that should be reported
- Violations of law
- Inappropriate gifts, entertainment or gratuities
- Improper use of Authority property
- Violations of patient confidentiality
- Discrimination or harassment
- Stealing/Misuse of assets
- Embezzlement of funds
- Obstruction of Criminal or Internal
Investigations
11Office of Inspector General (OIG) Audits
- The OIG distributes an annual work plan that lays
out the areas that will be targeted during an
audit. In addition, to our annual onsite audits,
the following audits will be conducted according
to the OIG work plan -2015. - Audits
- OIG monthly Employee Exclusion Search
- Unallowable Room Board Charges
- Community Supports while consumer is in the
hospital - Skill Building
- Adult Foster Care Employee Training
- Adult Foster Care Reimbursement for Community
Living Support Services Personal Care - Supported Independent Living Providers
- Direct Care Wages
- Ability to Pay
- Claims Billing
- HIPAA Security
- Annual Compliance Training for Employees and VCE
Online Training course - Respite
12Office of Inspector General (OIG) Audits
- Audit Forms
- OIG Employee Exclusion Search - The employee
exclusion search must be performed on a monthly
basis. - Compliance Statement - Integrated Care Alliance
requires each provider to sign the Compliance
Statement as proof that the provider is
maintaining Compliance standards and trainings
within their organization. - Compliance Breach Notification on Protected
Health Information and Personal Record
Information Statement Integrated Care Alliance
requires each provider to sign the statement as
proof that the provider is maintaining policies
and procedures to safeguard Protected Health
Information (PHI) and Personal Record
Information (PRI). - Documentation Statements - Integrated Care
Alliance requires providers to have
documentation complete, accurate, and available
upon request for a provider or consumer audit.
If an onsite audit is conducted there is a 24
hour time frame to produce documentation if not
already available. A sampling of provider
services audit requires a 48 hour time frame to
produce documentation if not already available.
This does not apply to providers that have
started a new program, their documentation must
be present upon request.