Debbie Troklus

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COMPLIANCE 101

• Debbie Troklus
• University of Louisville
• School of Medicine
• Greg Warner
• Mayo Clinic

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ExpectationsGoalsIssues
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Why Compliance Programs Are Essential

• Communicate Organizations Commitment
• Raise Awareness
• Mitigating Factor
• Avoid CIA
• Reduce Threat of Qui-Tams

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Compliance ProgramsHow Comprehensive Should They
Be?

• Medicare Billing Compliance
• Employment/Labor Law
• EMTALA
• Safety
• HIPAA
• Research
• Other Federal /or State Laws

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How to Prevent Qui Tam Suits

• Create an atmosphere that encourages compliance
• Set up a hotline
• Listen to employees

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A Compliance Program Provides

• Education
• Prevention
• Early Detection
• Collaboration
• Enforcement

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What Is a Compliance Program?

• Recommended by the Government
• Ethical and proper way to do business
• Commitment
• Encourage problems to be reported
• A process with constant monitoring

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Who Needs a Compliance Program?

• Physician Practices
• Hospitals
• Laboratories
• Teaching Institutions
• DME Distributors
• Home Health Agencies/ Hospices
• Others

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Organizational Steps to an Effective Compliance
Program
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Gain Support / Commitment

• Board
• Management
• Providers
• Staff

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Financial Support

• Development/Start-up
• Educational Materials
• Staffing
• Ongoing Operations

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Develop Code of Conduct

• Organizations ethical attitude
• Address weak areas
• Letter of endorsement
• Chain of command

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Identify Staffing Needs

• Appoint compliance officer
• Develop job descriptions for staff
• Supply vs. demand
• Oversight Committee
• Counsel

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Conduct Internal Assessment

• What is an assessment?
• Employee interviews
• Identify risk areas
• What is currently occurring?
• Who is responsible?
• What is the information flow?
• What are areas for concern?

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Develop Mission and Goals

• Achievable
• Measurable
• Communicate

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Plan Do Check Act
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Continuous Improvement
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Case Study (30 min)

• You are a new Compliance Officer and charged with
  implementing a compliance program over the next
  year. Develop a timeline for implementation
  along with an organizational chart.
• (Regional Health System 450 bed teaching
  hospital, two physician practices located within
  a 50 mile radius and one nursing home two blocks
  from the hospital)

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Tailoring Your Compliance Program
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3 Cs of Communication

• Clear
• Concise
• Creative

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Evaluating for Success

• Annual review of written program
• Continual review of policies and procedures
• Are policies being followed
• Continual review
• Awareness

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Measuring Effectiveness

• Structure
• Process
• Outcome

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Organizational Fit

• Code of conduct
• Mission, vision and objectives
• Culture drives program

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Advancing Your Program

• A compliance program is never finished it
  should always be a work in progress

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CHANGE
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Case Study (20 min)

• In 4 sentences provide the compliance mission
  statement for Regional Health System along with
  three achievable goals.

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Government Released Programs

• Laboratory Hospital
• Home Health DME
• Hospice Nursing Facilities
• Medicare Choice
• Physician Offices
• Third Party Billing

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Seven Essential Elements of a Compliance Plan

• Standards and Procedures
• Oversight
• Education and Training
• Monitoring and Auditing
• Reporting
• Enforcement and Discipline
• Response and Prevention

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Standards and Procedures

• Code of Conduct
• Keep It Simple
• Outline specific legal duty
• Attestation

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Oversight

• Compliance Officer
• Oversight Committee
• Other Committees
• Board

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Education and Training

• Communication Process
• Internal Vs. External
• Mandatory Vs. Voluntary
• Web Based Training
• Sanctions

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Monitoring and Auditing

• Program Effectiveness
• Internal Audits
• Compliance Reviews
• Outline Audit Procedures
• Staff Training

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Reporting and Investigation

• Hotline
• Policies and Procedures
• No Retribution for Reporting
• Privacy and confidentiality

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Enforcement and Discipline

• Sanctions for non-compliant behavior
• Consistency
• Stand firm
• OIG sanctions reviews

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Discipline Case Study

• How to integrate
• Code violations
• Necessary detail
• Alternatives

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Response and Prevention

• Internal Investigation
• Is it really a problem?
• How serious is it?
• Are their enough facts to investigate?
• Contact Counsel
• Interview
• Create Policy

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Relative Importance of Factors for Improving
Ethical ConductArthur Anderson n2800

• Consistency of Policies and Actions .56
• Ethical Behavior Rewarded .54
• Executive Leadership .52
• Unethical Behavior Punished .45
• Open Discussion of Ethics .43
• Formal Reporting Mechanism .32
• Familiarity with Ethics Code .08
• When employees see that a company takes ethics
  seriously, and policies are enforced, theyre
  more likely to behave ethically
• Success Magazine Jan 2000

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OIG Compliance Program Guidance

• Introduction
• Benefits of a Compliance program
• Application of Compliance Program Guidance
• Compliance Program Elements
• Seven Essential Elements
• Written Policies and Procedures
• Risk Areas

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Home Health and Hospice Guidance
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DME Guidance
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Third Party Billing OfficesMedicare Choice
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OIGs Physician Practice Guidance
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Debbie Troklusdctrok01_at_gwise.louisville.eduGreg
Warnergwarner_at_mayo.edu