Annual Compliance Training

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Annual Compliance Training

• Sweden De Matas
• Federal Compliance Officer
• Mental Health Division
• Updated November 2006

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Please read before proceeding!

• The following training is mandatory and required
  by all staff.
• Once completed, please print the test and
  certificate.
• Fill in the required information and send to
  Linda Waite at Mail Stop 45320.
• Keep a copy for your files.

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Why do we need a Compliance Program?

• The Health Insurance Portability and
  Accountability Act of 1996 gave the Department of
  Health and Human Services (DHHS) Office of
  Inspector General (OIG) and the U.S. Department
  of Justice more investigational funding and
  authority to increase penalties for health care
  fraud.
• Using these and other enforcement tools the
  government continues to investigate health care
  institutions across the country searching for
  violations of the False Claims Act and other
  Federal laws
• Example 2001 - 1.2 billion was recovered by the
  government as a result of cases pursued under the
  federal False Claims Act.

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What does a Compliance program do?

• Proactive practice that prevents fraudulent
  activities
• Protects from liability by assessing the
  organizations ability to operate within the
  rules, regulations and policies set by the
  government, insurance programs and payers.
• Facilities that are found guilty of violating
  federal criminal laws and have a compliance
  program may have reduced penalties of up to 70.
• Compliance monitors both fiscal and quality of
  care issues.

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Elements of a Compliance Program

• Established compliance standards and procedures
• Designation of a compliance officer and committee
• Effective communication
• Education and Training
• Auditing and Monitoring
• Consistent enforcement of standards
• Appropriate response to detected offenses

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Who is policing compliance?

• Department of Health and Human Services (DHHS) -
  OIG
• US Dept of Justice
• Federal Bureau of Investigation (FBI)
• Centers for Medicare and Medicaid Services (CMS)
• State Medicaid Fraud Units
• Office of Civil Rights

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Why should you care about compliance?

• Compliance affects every member of the
  organization.
• Compliance helps to increase confidence and
  communication.
• Provides a mechanism for informed decisions.

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• What is fraud and abuse?

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Fraud

• A deception deliberately practiced in order to
  secure unfair or unlawful gain.
• Knowingly and willfully executing or attempting
  to execute a scheme to defraud any health care
  benefit program or to obtain by means of false or
  fraudulent pretenses, representation or promises
  any of the money or property owned by or under
  the custody of any health care benefit program.

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Abuse

• to use wrongly or improperly
• may result, directly or indirectly, in
  unnecessary costs to programs, or
• improper payment for services that fail to meet
  professionally recognized standards of care
• services are medically unnecessary
• involves payment for items or services when there
  is no legal entitlement to that payment and the
  provider has not knowingly or intentionally
  misrepresented facts to obtain payment.

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• Medicare Medicaid Overview

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Medicaid

• Originated in 1965
• Provides healthcare coverage and services for low
  income and financially needy people
• Administered by states
• Jointly funded by both the federal and state
  government
• Program benefits and eligibility are defined by
  the state
• The Medicaid Fraud Control Unit (MFCU)
  investigates fraud and abuse issues

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Medicare

• Established in 1965 (Title XVIII of the SSA)
• Federally funded health insurance program for
  senior citizens age 65 and older as well as
  persons who have a long term disability or end
  stage renal disease
• Consists of 4 parts
• Part A institutional providers including
  inpatient care
• Part B services provided by suppliers
• Part C Managed care services that include Parts
  A B and also wellness and preventative health
  programs
• Part D Prescription drug benefit

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Administration Oversight

• Within the Department of Health and Human
  Services (HHS), the Center for Medicare
  Medicaid Services (CMS) provides operational
  direction as well as policy oversight
• The Office of the Inspector General (OIG) also
  within HHS is charged with investigations of
  suspected fraud and abuse.

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• The Deficit Reduction Act (DRA)

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The Deficit Reduction Act (DRA)

• Initiated in 2005
• Affects any employer who receives gt5 million per
  year in Medicaid payments
• Requires employers to provide information on
• The Federal False Claims Act
• Any Applicable State False Claims Act
• Whistleblower Rights Protection
• Fraud Abuse Policies

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The Federal False Claims Act

• Liability under this act pertains to anyone who
  knowingly presents or causes to be presented a
  false statement or fraudulent claim for payment
• The act does not require proof of a specific
  intent to defraud the government
• Penalties
• Criminal prosecution
• Exclusion
• Civil penalties of not less than 5,000 and not
  more than 11,000 per false claim, plus damages.

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Qui Tam Whistleblower

• Allows a person with actual knowledge of
  allegedly false claims to come forward to file a
  lawsuit on behalf of the U.S. government
• In 2004-2005, 1.1 billion was recovered through
  lawsuits initiated by whistleblowers
• Affords the person confidentiality and a
  financial award if the suit is successful
• No retaliation which can include employment
  reinstatement, back pay, etc.

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Federal Anti-kickback Statute

• The Social Security Act prohibits the offer,
  payment, solicitation, or receipt of any form of
  remuneration in return for the referral of
  Medicare or Medicaid patients.
• Violation is considered a felony, punishable by
  fines up to 25,000.00 per violation, plus
  imprisonment for up to five years.

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The Physician Self-Referral Law (Stark II)

• Prohibits physicians from making certain Medicare
  referrals to entities with which the physician or
  his family has a financial relationship.
• Sanctions include denial of payment, refund of
  payment, civil monetary penalties and exclusion
  from Medicare and Medicaid.

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Civil Monetary Penalties Act

• Pertains to providers who knew or had reason to
  know that an item or service was not provided as
  claimed.
• May result in civil monetary penalties of up to
  11,000.00 and exclusion.

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Applicable Policies and Rules

• Administrative Policy 8.02 (Client Abuse
  Reporting)
• Administrative Policy 9.01 (Incident Reporting)
• Administrative Policy 18.61 (Employee Grievance)
• Administrative Policy 18.62 (Allegations of
  Employee criminal activity)
• Administrative Policy 18.66 ( Discrimination
  Harassment Prevention)
• Administrative Policy 19.64 (Standards of Ethical
  Conduct)
• RCW 42.40 (Whistleblower)
• MHD Policy 4.11 (Exclusion)
• MHD Policy 4.08 (Reporting of Fraud Abuse)

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Examples of Healthcare Fraud

• Billing for services not provided
• Falsifying medical necessity
• Unbundling services
• Falsifying treatment plans or medical records
• Failing to report overpayments
• Duplicate billing
• Providing incentives to providers for referrals
• Billing for services provided by unlicensed
  individuals

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• Want to provide information but having second
  thoughts?

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Anonymous Hotline

• [phone] or [phone]
• The Compliance Hotline is a simple, risk free way
  for you to report activities that may involve
  violations of the Code of Ethic Conduct or even
  Criminal Conduct.
• The Hotline is a set of two telephone numbers
  established under the Compliance Program.
  Callers to the hotline can seek advice about
  their own situations and can report suspected
  violations by others.
• You can report violations of billing
  irregularities, coding that misrepresents
  services rendered, theft or embezzlement,
  conflicts of interest, self-referrals or
  kickbacks and any other conduct that may be a
  violation of law or ethics.
• You do not have to provide your name!

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Other Reporting Avenues
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(No Transcript)
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• How can you help?

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Get Involved!

• Learn how your job is critical to DSHS/MHD
  compliance efforts
• Double-check policies, ask questions
• Know the DSHS code of conduct
• It is better to ask questions, than leave things
  unresolved

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Have a Positive Outlook!

• Regard auditing and monitoring as opportunities
  for improvement.
• If an audit turns up a weakness, pro-actively
  examine how to improve it in the future.
• When new policies or procedures are posted, take
  the time to study them and incorporate them into
  your job.
• If you are confused - ask questions.
• Be flexible and know that changes are bound to
  occur.

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Contact Information

• Department of Social and Health Services
• Mental Health Division
• Sweden De Matas,
• Federal Compliance Officer
• P.O. Box 45320
• Olympia, WA 98504-5320
•  
• Phone [phone]
• Phone [phone]
•  
• Fax [phone]
• Resource www.cms.hhs.gov/MLNGenInfo/

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Last Step

• Thank you for completing this training and DONT
  FORGET to print the test and certificate.
  Complete the test, sign and date the certificate
  then send to the Compliance Officer at Mail Stop
  45320.

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Name __________________________________________I
nstructions Match the element with the
definition.
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Department of Social and Health Services Mental
Health Division
___________________________________ Print
Name ___________________________________ Sign
Name _____/_____/____ Date Training Completed
Compliance Training
P.O. Box 45320 Olympia, WA 98504-5320 Phone
[phone] Fax [phone]
Sweden De Matas, Federal Compliance Officer
Nov 06 to Nov 07