DIVISION OF HEALTH SCIENCES OFFICE OF INSTITUTIONAL INTEGRITY Protecting Yourself and Your Practice

WHAT IS HEALTHCARE COMPLIANCE? Wide range of activities to help prevent, detect, and avoid fraud and abuse.  Follow institutional policy, state and federal laws & regulations  Monitor practice ethics and patient rights legislation  Effective training, communication, monitoring, enforcement and response

WHO IMPLEMENTS THE COMPLIANCE PROGRAM? Office of Institutional Integrity Chief Institutional Integrity Officer- Kenneth DeVille, PhD, JD Executive Assistant- Lauren Perry Healthcare Regulatory Specialist- Michelle C. Evans, MPA Billing Compliance Manager- Brandy Styron, RHIA, CCS-P Billing Compliance Reviewers- Michele Lang, Kenya Dudley, Ashley Ross Administrative Support Associate- Pam Martin  Compliance Committees (BSOM, CAHS, SoDM, CoN)  Most important resource: Individual Employees!

TOP COMPLIANCE RISK AREAS  Documentation and Billing Integrity  Fraud and Abuse Laws  HIPAA Privacy

DOCUMENTATION AND BILLING  Accurate Coding and Billing are Critical  Fraudulent Billings Result in Stiff Penalties  Billing and Reimbursement Reviews  Billing for services not performed (or underperformed)  Ordering/billing for medically unnecessary services  Double billing, Upcoding/Downcoding  If it’s not documented, it will not be reimbursed

DOCUMENTATION AND BILLING  Teaching Physician Documentation Rules G enerally need evidence of physician presence during key portion of medical management with resident.  Electronic Medical Record Issues  Sharing of passwords prohibited  Cutting and pasting is not recommended  Easy for internal reviewers and external auditors to track.  Assuming notes (History and Physical, progress notes, office visit, consults) instead of adding an addendum. (i.e. when adding a teaching statement, do not click “make me the author”)

NAVIGATING FRAUD AND ABUSE LAWS FUNDAMENTAL POINTS  Laws are very broad  Laws are complex and not intuitive  Laws apply to a wide variety of common financial relationships that are not obvious kickbacks or fraud  Penalties are serious  Enforcement is rising because of financial benefit to government.  Mistakes are not fraud, BUT lack of system to control mistakes or insufficient response to mistakes MAY BE  Defense is very expensive, even if successful.

FEDERAL FALSE CLAIMS ACT 31 U.S.C. §§  False Claims Act (FCA) prohibits anyone from “knowingly” submitting a false or fraudulent claim for payment to the government.  “Knowingly” means (i) actual knowledge; (ii) acts in deliberate ignorance of the truth or falsity of the information; or (iii) acts in reckless disregard of the truth or falsity of the information.  No proof of specific intent to defraud is required.

FEDERAL FALSE CLAIMS ACT  False Claims “can” result from actions such as:  Billing for services not rendered  “Upcoding”  “Double-billing”  Lack of medical necessity  Pattern of insufficient documentation  Violation of billing rules  False certification

FEDERAL FALSE CLAIMS ACT QUI TAM ACTIONS  The FCA allows a private person (a “qui tam relator”) to bring a civil action in the name of the United States.  Qui tam relators share in any money recovered (including settlements).  If government joins in action, relator is entitled to 15% to 25% of proceeds depending on relator’s contribution to case.  If government does not join in action, court may award relator not less than 25% and not more than 30% of proceeds.

FEDERAL FALSE CLAIMS ACT  Civil Penalties:  Triple damages and penalties of $5,500 to $11,000 per false claim for submission or causing submission of false claim.  Criminal Penalties:  Felony conviction: 5-20 years in jail  Misdemeanor conviction: 1 year in jail

FEDERAL ANTI-KICKBACK STATUTE (42 USC § 1320A-7B(B)) Prohibits offering, paying, soliciting or receiving anything of value to induce or reward referrals or generate Federal health care program business

FEDERAL ANTI-KICKBACK STATUTE Statute makes it a crime (felony) to:  Knowingly and willfully  Solicit, offer, receive, or pay  Any remuneration (cash or in kind)  With intent to induce  Referrals of an individual for  The furnishing of a service or item or procedure  For which a federal healthcare program will pay.

FEDERAL ANTI-KICKBACK STATUTE  Examples of Kick-backs: Money, discounts, gifts, and credits  Criminal and civil liability for failure to comply  Criminal fines up to $25,000 and up to 5 yrs prison term per violation  Civil money penalties of $50,000 per violation  Up to 3 times the amount of kickback  Exclusion from federal health care programs  *Possible violation of the False Claims Act

FEDERAL PROHIBITION ON PHYSICIAN SELF-REFERRAL STARK LAW (42 USC § 1395NN)  Prohibits a physician from referring Medicare patients for designated health services to an entity with which the physician (or immediate family member) has a financial relationship, unless an exception applies  Prohibits the designated health services entity from submitting claims to Medicare for those services resulting from a prohibited referral

PHYSICIAN SELF-REFERRAL STARK LAW  Only certain “designated health services” subject to Stark Law  Stark Safe Harbor/Exceptions Civil liability for failure to comply  Overpayment/refund obligation  False Claims Act liability  Civil monetary penalties and program exclusion for knowing violations  Potential $15,000 CMP for each service  Civil assessment of up to three times the amount claimed

HIPAA PRIVACY RULE 45 CFR PART 160 SUBPARTS A & E OF PARTS 164  Use and Disclosure of Protected Health Information (PHI)  Patient Rights regarding PHI  University Privacy Officer responsible for implementation and day-to-day administration  All privacy complaints should be directed to the University Privacy Officer

OFFICE OF INSTITUTIONAL INTEGRITY CODE OF CONDUCT  Standards for conduct at BSOM  Must read and sign attestation for Code of Conduct  Individual commitment to understanding and following the rules and ethical standards  Condition of employment

REPORTING INCIDENTS OF POTENTIAL NON-COMPLIANCE TO THE OFFICE OF INSTITUTIONAL INTEGRITY  Encouraged to use supervisors, administrators as the first line of reporting of any known incidents of noncompliance  Compliance Hotline  Available 24 hours a day, 7 days a week  Can be anonymous  Toll free   No retaliation for good faith reporting of incidents of noncompliance All good faith reports will be fully investigated  Confidentiality maintained to the fullest extent possible  Physicians and staff have a professional duty to report potential problems.

DIVISION OF HEALTH SCIENCES OFFICE OF INSTITUTIONAL INTEGRITY