Eight Elements of Compliance and Operational Intersects Mathew D. Babcock Assistant Medicaid Inspector General Healthcare Financial Management Association of Northeastern New York First HFMA NENY Annual Institute December 17, 2013 Clifton Park, NY

Thank you For inviting the Office of the Medicaid Inspector General to speak today.

Today’s Agenda Introduction New York’s Medicaid Compliance Program Obligation Compliance Program Application to Operations Annual Certifications How Providers Can Use the Compliance Program Assessment Form (if we have time)

The Fine Print Personal opinions and ideas for collegial discussion These slides are not intended to provide legal advice; do not represent the opinion of OMIG; and shall not bind OMIG in any way Acknowledgement – ideas and some materials from many sources – we own the errors Assumption – you are here to learn what the right thing is, so we should try to help If you have a question, ask it – someone else probably wants to know the answer If you find these slides useful, please use them Compliance is a developing field, so expect changes

Introduction

OMIG’s MISSION STATEMENT Our mission is to enhance the integrity of the New York State Medicaid program by preventing and detecting fraudulent, abusive, and wasteful practices within the Medicaid program and recovering improperly expended Medicaid funds while promoting high-quality patient care.

We Have A Statewide Presence Regional Offices: Albany Buffalo Hauppauge New York City Rochester Syracuse White Plains

Recent Accomplishments: 2013 More than $144.6 million identified (actual cash recoveries: more than $310 million) (first nine months) Finalized and activated 20 audit protocols (posted on Web site – www.omig.ny.gov) (last updated: November 22, 2013)

2013-14 Work Plan For the second consecutive year, OMIG’s Work Plan is organized into Business Line Teams (BLTs): Managed Care Medical Services in an Educational Setting Home and Community Care Services Hospital and Outpatient Clinic Services

2013-14 Work Plan (Continued) BLTs (continued) Mental Health, Chemical Dependence, and Developmental Disabilities Services Pharmacy and Durable Medical Equipment Physicians, Dentists and Laboratories Residential Health Care Facilities Transportation

2013-14 OMIG Work Plan (Continued) New review types: inventory reviews (pharmacy billings, compare to drug inventories) Managed care Protocols: Audit protocols posted on the OMIG Web site, with new protocols under development Full Work Plan available at: http://www.omig.ny.gov/images/stories/ work_plan/2013_2014_workplan.pdf

OMIG’s Bureau of Compliance Mission Statement To educate, assist, and assess Medicaid program providers in meeting their obligation to establish and operate effective compliance plans that will prevent or in the alternative detect and address fraudulent, wasteful and abusive practices within the Medicaid program.

New York Is A Leader New York was the first state to require compliance programs. Created at the same time as OMIG in statute Federal government adopted this approach as part of the Affordable Care Act Compliance translates to the old adage: “An ounce of prevention is worth a pound of cure.”

New York's Medicaid Compliance PROGRAM obligation

Requirement for Compliance Programs Statutory and regulatory authority for the compliance program mandate? New York State Social Services Law (SSL) §363-d 18 New York Code of Rules and Regulations (NYCRR) Part 521

Who Must Have a Compliance Program? Persons… subject to Public Health Law Article 28 or 36; SSL §363-d subd. 4 and 18 NYCRR §521.1(a) subject to Mental Hygiene Law Article 16 or 31; or SSL §363-d subd. 4 and 18 NYCRR §521.1(b) Persons, providers or affiliates … for which Medicaid is a substantial portion of their business operations. SSL §363-d subd. 4 and 18 NYCRR §521.1(c)

Who Must Have a Compliance Program? (Continued) “Substantial portion of business operations” means any of the following: 18 NYCRR §521.2(b) “When a person, provider or affiliate …” “Claims or orders, or has claimed or has ordered or should be reasonably expected to claim or order at least $500,000 in any consecutive 12-month period from Medicaid; or” “Receives or has received, or should be reasonably expected to receive at least $500,000 in any consecutive 12-month period, directly or indirectly from Medicaid; or” “Submits or has submitted claims for care, services or supplies to Medicaid on behalf of another person or persons in the aggregate of at least $500,000 in any consecutive 12-month period.”

Elements of Mandatory Compliance Programs Compliance Programs shall include the following eight elements: SSL §363-d. sub 2 and 18 NYCRR § 521.3 (c) Element 1: Written Policies and Procedures - Code of Conduct/Ethics Element 2: Designation of Compliance Officer – Employee vested w/ responsibility Element 3: Training and Education Element 4: Communication Lines to the Compliance Officer/Function

Elements of Mandatory Compliance Programs (Continued) Element 5: Disciplinary Policies Element 6: Identification of Compliance Risk Areas and Non- Compliance Element 7: System of Responding to Compliance Issues Element 8: Policy of Non-Intimidation and Non-Retaliation

How to Build and Measure a Compliance Program for Effectiveness TONE FROM THE TOP Over time, are compliance gaps being closed? Assess the frequency of same audit issues/edits occurring. How are quality issues being addressed in the context of compliance? Are overpayments and underpayments being reported and recovered? Retest solutions previously identified to confirm relevance to the problem. M E A S U R BUI LD OUTCOMES Compliance connections to board, management & enterprise operations. Working Policies and Procedures. Systems identifying risk areas, errors, PoC and monitoring-#6. Implementation of corrections & improvement-#7. PROCESSES Compliance plan document-#1. Compliance Officer/Compliance Committees-#2. Training and education programs-#3. Communication lines to CO-#4. Disciplinary policies and procedures-#5. Non-retaliation/non-intimidation-#8. STRUCTURE

Compliance program Application to operations how your compliance program Can/should interact with the 7 areas in 18 NYCRR 521.3(a)

Preliminary Matters The 8 elements (above) provide the framework, the 7 areas (on the following slides) provide a context of how the 8 elements must be operationalized. The 7 areas do not mean that the compliance officer must run, oversee or operate these. There should be a compliance connection. Compliance connection could be: Compliance Officer on the team, committee, work group, etc. Reports routinely issued to Compliance Officer of identified issues and the result of Plans of Correction Reports available to Compliance Officer and management so that program integrity can be assessed independently Regular review by Compliance Officer of established control functions for the various operational areas Management of the issue by the Compliance Function Communication is key.

18 NYCRR § 521.3 Compliance Program Required Provider Duties Every required provider shall adopt and implement an effective compliance program. The compliance program may be a component of more comprehensive compliance activities by the required provider so long as the requirements of this Part are met. Required providers’ compliance programs shall be applicable to: billings; payments; medical necessity and quality of care; governance; mandatory reporting; credentialing; and other risk areas that are or should with due diligence be identified by the provider.

18 NYCRR § 521.3 Compliance Program Required Provider Duties (Continued) What are some examples you see for connections between your Compliance Program and… (1) billings Transportation in institution’s rates, but being separately billed.

18 NYCRR § 521.3 Compliance Program Required Provider Duties (Continued) What are some examples you see for connections between your Compliance Program and… (1) billings Audits of high risk coding and billing matters Review of claim denials and root cause analysis of reasons for denial Conduct a root cause analysis of billing errors and establish PoC Never events Review cost reports, rules for reimbursable costs & integrity of reports Unbundling Review billing staff training against errors and issues identified Transportation in institution’s rates, but being separately billed.

18 NYCRR § 521.3 Compliance Program Required Provider Duties (Continued) What are some examples you see for connections between your Compliance Program and… (2) payments

18 NYCRR § 521.3 Compliance Program Required Provider Duties (Continued) What are some examples you see for connections between your Compliance Program and… (2) payments Assess reason why payments are more/less than expected Program for Evaluating Payment Patterns Electronic Reports (PEPPER) Assess payment connection to billing issues and self disclosure obligation Assess performance against metrics for timeliness of resolution of payment inquiries

18 NYCRR § 521.3 Compliance Program Required Provider Duties (Continued) What are some examples you see for connections between your Compliance Program and… (3) medical necessity and quality of care

18 NYCRR § 521.3 Compliance Program Required Provider Duties (Continued) What are some examples you see for connections between your Compliance Program and… (3) medical necessity and quality of care Never events DOH survey results One-day stays Meaningful oversight systems for QI and medical necessity oversight

18 NYCRR § 521.3 Compliance Program Required Provider Duties (Continued) Peer-to-peer tracking and mentoring on outcomes, quality and resources Incident review and management Culture of institutional responsibility vs. individual culpability Identification and tracking of performance and relevance of quality indicators

18 NYCRR § 521.3 Compliance Program Required Provider Duties (Continued) What are some examples you see for connections between your Compliance Program and… (4) governance

18 NYCRR § 521.3 Compliance Program Required Provider Duties (Continued) What are some examples you see for connections between your Compliance Program and… (4) governance Tone from the top proves commitment to integrity by all associated with the provider Management-level compliance committee includes all major operations Board and management oversight on compliance program, its operations, reporting results, plans of correction, development of compliance metrics, and development of annual work plan

18 NYCRR § 521.3 Compliance Program Required Provider Duties (Continued) Reports to board and management include status report on work plan, management of risk areas, plans of correction, and retesting Meaningful conflict-of-interest disclosure and consideration process

18 NYCRR § 521.3 Compliance Program Required Provider Duties (Continued) What are some examples you see for connections between your Compliance Program and… (5) mandatory reporting

18 NYCRR § 521.3 Compliance Program Required Provider Duties (Continued) What are some examples you see for connections between your Compliance Program and… (5) mandatory reporting Overpayments and underpayments addressed consistently Affordable Care Act requirements tested and met Mandatory reporting includes payment issues, but also quality and clinical matters

18 NYCRR § 521.3 Compliance Program Required Provider Duties (Continued) What are some examples you see for connections between your Compliance Program and… (6) credentialing

18 NYCRR § 521.3 Compliance Program Required Provider Duties (Continued) What are some examples you see for connections between your Compliance Program and… (6) credentialing CMS recommends monthly excluded party checks Review of services provided against scope of practice of caregivers or list of services identified in the operational certificate Identify who must be credentialed against who is credentialed

18 NYCRR § 521.3 Compliance Program Required Provider Duties (Continued) What are some examples you see for connections between your Compliance Program and… (7) other risk areas that are or should with due diligence be identified by the provider

18 NYCRR § 521.3 Compliance Program Required Provider Duties (Continued) What are some examples you see for connections between your Compliance Program and… (7) other risk areas that are or should with due diligence be identified by the provider Risk management, quality, internal/external audit, etc., interaction Self assessment and addressing risks Self assessment and plans of correction or annual work plan OIG and OMIG annual work plans

18 NYCRR § 521.3 Compliance Program Required Provider Duties (Continued) Assess impact of changes to law/regulation, coding/billing rules Operational & organizational changes Identify performance against recognized benchmarks and react Verification of compliance programs by vendors, as applicable

Annual certification requirements

OMIG Webinar #18 http://bit.ly/1iQ57vY Certification Requirement for NYS Social Services Law §363-d and 18 NYCRR §521.3(b) Certification Requirement for federal Deficit Reduction Act of 2005

NYS Medicaid Provider Compliance Obligations Certification Requirement 18 NYCRR §521.3: (emphasis added) (b) Upon applying for enrollment in the medical assistance program, and during the month of December each year thereafter, a required provider shall certify to the department, using a form provided by the Office of the Medicaid Inspector General on its Web site, that a compliance program meeting the requirements of this Part is in place. ….

Federal Deficit Reduction Act of 2005 Obligations The DRA requires health care entities which receive or make $5 million* or more in Medicaid payments during a federal fiscal year (October 1 to September 30) to do the following: establish written policies and procedures informing and educating their employees, contractors and agents about federal and state false claims acts and whistleblower protections *DRA’s FAQs identify $5 million in direct Medicaid payments received from the State for providers or for MCOs $5 million in Medicaid payments made

Federal Deficit Reduction Act of 2005 Obligations (Continued) on or before January 1 of each year, required health care entities are required to certify: that it maintains the written policies that any employee handbook includes materials, required under the DRA mandate that the materials have been properly adopted and published by the health care entity, and that the materials have been disseminated to employees, contractors, and agents

Federal Deficit Reduction Act of 2005 Obligations (Continued) Oversight of the DRA certification process has been a requirement of OMIG since it first went into existence in 2007. OMIG has guidance on its Web site www.omig.ny.gov . See the Compliance tab and look for Certification.

How can providers use the compliance program assessment form?

Where Can I Find the Compliance Program Assessment Form on OMIG’s Web Site?

How Can Providers Use the Compliance Program Assessment Form? Be as thorough and complete as possible in the center column Inventory compliance program requirements Use in development of compliance work plans Self-Assessment Tool – feel free to make it your own Do not forget to certify in December 2013!! Use in training

How Can Providers Use the Compliance Program Assessment Form How Can Providers Use the Compliance Program Assessment Form? (Continued) Report card for communicating to constituencies Due diligence assessments of business partner’s/associate’s compliance programs Complete as requested during OMIG’s compliance program review process

Compliance Program Assessment Form

Questions?

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Matthew D. Babcock, FACHE Contact Information Matthew D. Babcock, FACHE Assistant Medicaid Inspector General – Bureau of Compliance New York State Office of the Medicaid Inspector General 800 North Pearl Street Albany, NY 12204 518-408-0401 compliance@omig.ny.gov