Barry County Community Mental Health Authority Compliance Annual Training Brenna Ellison LLMSW RAC Corporate Compliance Officer
Barry County
Community Mental
Health Authority
Compliance
Annual Training
Brenna Ellison LLMSW RAC Corporate Compliance Officer
Barry County Community Mental
Health Authority
Compliance Program
Barry Mental Health Authority is committed to the prevention & detection of fraud & abuse. In order to accomplish this, we have a Corporate Compliance Program and accompanying policies & procedures to provide guidance for doing business.
What is our Compliance Program?
A formal organizational support function that: Documents & monitors compliance with laws,
regulations, standards, policies & procedures
Facilitates positive change Ongoing Communication
Ongoing Education
Resulting in the identification, prevention & reduction of risk to the agency & staff
8 Elements of an Effective Program from the
Federal Sentencing Guidelines Oversight by Compliance Officer & Committee
Written Code of Conduct
Policies & Procedures
Communication
Education & Training
Auditing & Monitoring
Detecting Offenses & Corrective Action
Annual Risk Assessment
Benefits of a Effective Compliance/Ethics Program
Demonstrates commitment of legal & ethical behavior
Provides guidance to staff
Promotes ethical behavior
Improves quality, efficiency & consistency of service
Encourages staff to report their concerns
Provides prompt & thorough investigations of alleged misconduct
Initiates appropriate & decisive corrective action
Identifies & prevents criminal conduct
Ethical vs. Legal
Ethical – accepted principles of right & wrong that govern our behavior
Legal – rules & regulations which guide one’s actions
Why is this Important?
Identification and prosecution of health care fraud is a top priority for the Office of Inspector General and Department of Justice
Why is this Important?
Noncompliance has its costs, regardless of the reason, intentional or not, serious consequences can effect service providers, recipient of services, and organizations responsible for oversight.
Consequences are not always drastic when the choice is made not to comply or an individual makes an error in the process, but in some situations they are lost lives, lost jobs, fines, and/or imprisonment.
Fraud is: In general, the intentional deception or
misrepresentation by a person with the knowledge the deception could result in unauthorized benefit to him/herself or some other person. In other words:
It is intentionally attempting to deceive or execute a scheme to falsely obtain money or other benefit from a healthcare program &/or
Providing false information to someone or some entity that you know is false
Examples of Fraud
Knowingly billing for services not provided
Performing medically unnecessary services solely to obtain payments
Altering documentation or bills to obtain higher payment (upcoding)
Deliberate duplicate billing
Abuse is: Practices that are inconsistent with
sound fiscal, business or medical practices & result in an unnecessary cost to the payer, or in reimbursement for services that are not medically necessary or fail to meet professionally recognized standards for healthcare.
Examples of Abuse
Charges in excess for services & supplies
Submitting claims not in compliance with billing guidelines
Providing medically unnecessary services
Providing services that do not meet professionally recognized standards of care
Submitting bills to Medicare/Medicaid instead of the primary insurer
Abuse vs. Fraud: Understanding the Difference
Abuse results from practices that directly/indirectly result in unnecessary cost
Abusive billing practices may not result from “intent” or it may be impossible to prove that the intent to defraud existed
Abuse may develop into fraud if there is evidence of the subject knowingly & willfully conducting an abusive practice
Fraud requires evidence of intent to defraud (e.g. acts were committed knowingly, willfully & intentionally).
Civil and Criminal penalties
Waste
Improper practices that are inconsistent with sound fiscal, business, or clinical practices & result in unnecessary cost or reimbursement for services that are not medically necessary or fail to meet professionally recognized standards of care.
Examples of Waste
Healthcare spending that can be eliminated without reducing the quality of care, such as overuse and/or underuse or ineffective use of treatments or medication
Inefficiency in redundant testing, delays in treatment & making processes unnecessarily complex
False Claims
A false claim is prohibited by several different statutes. In general, a violation of the false claims law includes submitting or causing to be submitted a claim for payment when the claim is false or fraudulent. This includes using a false record to get the claim approved or paid.
Examples
Billing for services not provided
Billing for services greater than provided
Billing for services not documented
Billing for services not medically necessary
Billing for worthless services
Forging or altering documents
Misrepresenting information on documents
Lying about credentials
Such poor documentation habits that there is no evidence of ‘non-intent’
Michigan False Claims Act
The Michigan False Claims Act has been approved by the Federal Government. This approval allows Michigan to receive an additional 10% of recoveries from false claims. The reason for this is Michigan’s False Claims Act has tougher requirements than the Federal False Claims Act.
Medical Necessity Medical necessity is the underlying concept
under which payment decisions are made Medical necessity is established within the
Assessment Treatment Plans guide you on how to provide
medically necessary services Documentation of services allows the provider to
verify that the services provided to the consumer are medically necessary Tell me what you did for the consumer not just what
the consumer did
Medical necessity of the continuation of services is established within the periodic review
Quality of Care Providing the best quality of care to our clients
Assuring good quality services is an ethical obligation of providers
Enforcement priority for health care regulators
Adequate staffing to ensure health & safety
Medication errors
Following all licensing rules
Substandard or worthless services
$$$ - paybacks across all aspects of health care
What is a worthless service?
Deemed ineffective for a given condition based upon professionally recognized standards of care
Directly or indirectly results in unnecessary cost (did you get what you paid for and/or did you pay too much)?
Focus Areas Targeted by investigators and fraud
detection activities:
Quality of Care and Safety
Mental Health Provider Enrollment & Credentialing
Billing and Payments
Evaluation & Management Service Documentation
Residential Service Documentation
CLS Service Documentation
Questionable Billing for Outpatient Mental Health Services
Focus Areas Cont’d
Protected Health Information
Electronic Medical Record Safeguards
Security of Portable Devices
Program Integrity
Medicaid Managed Care Organizations Identify & Address Potential Fraud Incidents
Beneficiary Protections
Access to Services/Care
How Do We Reduce Risk?
Effective Compliance Program:
• Auditing & Monitoring
• Education & Training
• Documentation of Compliance Efforts
• Self Disclosure
• Communication
• Federal Exclusion Monitoring
Policies & Procedures
Compliance Plan – Code of Conduct
Code of Ethics
Ethical Billing Practices
Fraud Prevention and Detection
Claims Fraud and Abuse
Responding to a Government Investigation
Whistleblower’s Protection Act
A law that provides protection to employees who report a violation or suspected violation of state, local or federal law
Provides protection to employees who participate in hearings, investigations, legislative inquiries, or court actions & prescribes remedies & penalties
Whistleblower’s Protection Act
An employer shall not discharge, threaten, or otherwise discriminate against an employee because the employee reports or is about to report a violation
An employer shall post notices & use other appropriate means to keep employees informed of Whistleblower’s protections
We Believe Our Compliance Program
Enables you to do the
Right thing for the Right
Reason
Questions, Concerns or Suggestions
Talk to Brenna Ellison
269.948.8041 ext 142 or [email protected]
Talk to your Immediate Supervisor
Call the Hotline 800-218-8290
Who is Responsible for
Compliance?
Everyone
When in doubt
point it out!!
References Troklus, D; Waraner, G. (2006) Compliance 101, second
edition. Healthcare Compliance Association. Minneapolis MN.
HCProfessor. (2002) Compliance Training Handbook for the General Healthcare Staff. Opus Communications, Inc.
US Department of Health and Human Services, Office of Inspector General. (28 January 2014) 2014 Work Plan. http://www.oig.hhs.gov/reports-and-publicaitons/workplan/index.asp
Revised 2/2014