Chief Compliance Officer COMPLIANCE PROGRAM Jacob Schmitt, MPA Chief Compliance Officer & Director of Quality February 2017 www.ArizonasChildren.org

Today, we will…. Review AzCA’s Compliance Program through DHHS expectations. Identify AzCA’s measures. Note areas of concern. Review Basic FWA Information. Summary

7 Elements Of An Effective Compliance Program US Dept. of Health and Human Services Office of the Inspector General 7 Elements Of An Effective Compliance Program

Element #1 ELEMENT AzCA’s Measures Does the agency have written policies and procedures and standards of conduct? Compliance Plan reviewed annually Organizational Code of Ethics updated 2016 Standards of Conduct

Element #1 – Written P&Ps and Standards of Conduct Compliance Plan Organizational Ethics National Assoc. of Social Workers Code of Ethics

Element #2 Element AzCA’s Measure Does the agency have a designated Compliance Officer, Compliance Committee, and governing body? Chief Compliance Officer (CCO) - Jacob Compliance Committee CCO provides information directly to the Board CCO employed by AzCA

Element #2 – Compliance Officer, Compliance Comm., Governing Body Board receipt of compliance reports on a semi-annual basis. Program Committee and Audit Committee also receive updates

Does the agency have an effective training and education program? Element #3 Element AzCA’s Measure Does the agency have an effective training and education program? Employees receive training upon hire and annually Training includes information on: Reporting, Qui tam actions, Whistleblower protections, and Disciplinary action

Element #3 – Training & Education Program Training for board members Annual training/record-keeping Annual Compliance week with information distributed to staff

Element #4 Does the agency have effective lines of communication? AzCA’s Measure Element Effective communication between CCO and others System in place to receive and respond to reports Emphasizes non-retaliation and non-retribution Reporting available 24/7 Does the agency have effective lines of communication?

Element #4 – Effective Lines of Communication Regularly scheduled meetings (audit, program, compliance) Annual training and messaging informs staff of reporting options

Element #5 Element AzCA’s Measure Does the agency utilize enforcement of well-publicized disciplinary standards? Policy outlines training requirements and that disciplinary action can be taken

Element #5 – Enforcement of Disciplinary Standards Widely publicized Tracking process needs to be developed to capture data elements

Element #6 Element AzCA’s Measure Does the agency have an effective system for monitoring, auditing and identifying compliance risks? Ongoing Data Validation Auditing Access to relevant staff, information and records Process for OIG and exclusion lists in place

Element #6 – System for Monitoring, Auditing and Identifying FWA Monitoring and auditing work plan CCO reporting Follow-up of corrective actions Implementing creation and review of data reports to be proactive

Element #7 Element AzCA’s Measure Reasonable inquiry into all reported compliance/FWA issues Procedures for referring to other agencies Does the agency have procedures and systems in place for promptly responding to compliance issues?

Element #7 – Prompt Response to Compliance Issues Timeline developed for investigation process CAP monitoring Documentation and tracking

The Basics at AzCA Fraud, Waste, and Abuse

Fraud, Waste, Abuse (FWA) Outline Define and identify FWA Reporting requirements Reporting methods Roles in the investigation Reporting protections Investigation results

Define and Identify FWA Fraud - Elements of Fraud: The act (evidence of wrongdoing). Knowledge and intent (willfully intended to commit act – generally evidenced by a pattern of wrongdoing). Benefit – (some type of measurable benefit obtained from the act by the person committing the act). EXAMPLE – Up-Coding – assigning a code that pays more than the correct code

Define and Identify FWA Waste - the over-utilization of services, or other practices that, directly or indirectly, result in unnecessary costs to the affected governmental or private funding program. Misuse of resources EXAMPLE – Over-production – duplicate or redundant information on forms.

Define and Identify FWA Abuse – (Behavioral Health Programs) Practices inconsistent with sound fiscal business or medical practices that result in unnecessary costs to the funder (AHCCCS, State of AZ, CMS) Abuse – (Child Welfare Programs) Practices inconsistent with sound fiscal business or child welfare practices that result in unnecessary costs to the funder (State of AZ, grantors, etc.) EXAMPLES – Claims for services not medically necessary; refusing access to medical records

Reporting Requirements AzCA’s Code of Ethics outlines each employee's responsibility to understand, detect, and report potential fraud, waste, and abuse occurrences. Training stresses that compliance with these ethical requirements is a condition of employment and that failure to comply may result in disciplinary action.

Reporting Methods Anonymous Reporting call the AzCA Fraud and Abuse Hotline at 1-800-947-7611 ext. 1600 (can call any time 24/7 and provide requested information) fill out report form and send to Chief Compliance Officer via inner office or US mail (Arizona’s Children Association, 711 E. Missouri Ave., Ste. 200, Phoenix, AZ 85014) Identified Reporting call the AzCA Fraud and Abuse Hotline at 1-800-947-7611 ext. 1600 (can call any time 24/7, provide requested information plus contact information) email: jschmitt@arizonaschildren.org

Reporting Protections Whistle-blower protections outlined in the Whistleblower Protection Act (31 U.S.C. 3730(h) ) Any AzCA employee who reports under the False Claims Act (known as a “Whistle Blower”) is protected from discrimination such as: termination demotion suspension threats harassment Whistle Blowers subjected to retaliation or discrimination are entitled to all necessary and appropriate relief and correction, such as job reinstatement, back pay, and legal fees. AzCA does NOT tolerate retaliation or retribution

The False Claims Act The False Claims Act (31 U.S.C. 3729-3733) states that a person who knowingly submits a false or fraudulent claim to Medicare, Medicaid, or other federal healthcare program is liable to the federal government. Under this act… A person can be held accountable for knowingly: Filing false claims, Using a false record or statement to obtain payment, Using a false record or statement to decrease an obligation of payment, or Otherwise conspiring to defraud.

The False Claims Act A person or entity can be liable for civil penalties under the False Claims Act Fines can be between $5,500 and $11,000 per claim PLUS 3 times the amount of damages that the government sustained In health care cases, the amount of damages sustained is considered to be the amount paid for each claim that is determined to be false.

Qui Tam Actions A Qui Tam Action is a process where an individual can request to file a lawsuit on behalf of the federal government If the government doesn’t act within a prescribed timeframe or choose to join in the lawsuit, the individual can proceed alone. If the government takes the case, the individual filing the suit receives between 15 and 25% of the amount recovered. If the government doesn’t take the case, the individual filing the suit can receive between 25 and 30% of the amount recovered.

Reporting Methods Report Form see AzCA’s Suspected Fraud & Abuse Report Intake Form on the data directory in the Forms on ‘data’ drive, Fraud&Abuse folder complete the form by hand or online and send to Jacob Schmitt using the above contact information

Reporting Protections Whistle-blower protections – Any AzCA employee who reports under the False Claims Act (known as a “Whistle Blower”) is protected from discrimination such as: termination demotion suspension threats harassment Whistle Blowers subjected to retaliation or discrimination are entitled to all necessary and appropriate relief and correction, such as job reinstatement, back pay, and legal fees. AzCA does NOT tolerate retaliation or retribution

Roles in the Investigation Chief Compliance Officer – lead, investigate, report and respond Compliance Committee – advise, assist, inform, plan and correct Reporter – (when known) – participate, inform AzCA Staff – maintain confidentiality, provide information

Investigation Results Coordination/Reporting to Other Agencies Once the investigation is complete – CCO shares the results with the Compliance Committee Disciplinary action, if warranted, is issued and recorded CAPs are created, implemented and monitored

Summary AzCA meets the 7 elements of a quality corporate compliance program/plan Information on Fraud, Waste and Abuse is presented to staff and board members annually Understanding your role in FWA reporting is key to a successful Corporate Compliance Program.

Thank You!!! Questions – Contact me at: Jacob Schmitt 602-234-3733, x. 2233 JSchmitt@arizonaschildren.org