COMPLIANCE PROGRAM

Agenda  Initial Scenarios  Review of General Compliance Information  Review UCP’s Compliance Program  Questions and Discussion

Pre Test  1.You can round up time when billing for services ( e.g. 51 min = 60 min).  2. A Supervisor or Director can write notes for services performed by staff members they supervise.  3. Documentation is needed for every service that is billed?

What is a False Claim?  A request for payment for a service or a item that is not reasonable or necessary for the diagnosis or treatment of the consumer.

Examples of False Claims  Billing for services that did not occur.  Inflating time spent providing services.  Upcoding  Billing for services performed by unqualified staff.  Improper billing and coding for services.

Filing of a False Claim  Misconduct that is related to the submission of claims to Federal health care programs (Medicare, Medicaid) can be grounds for a civil suit, criminal prosecution or administrative remedies under the False Claims Act (FCA).  This applies to any person or entity that knowingly presents a fraudulent or false claim to the government for approval or payment.

Civil Law Suits  Can be filed under the FCA by the federal government and by private individuals.  Private individuals filing FCA civil suits are known as Qui Tam relators or whistleblowers (usually employees or former employees who learn about the fraudulent activities while carrying out their job responsibilities).

Penalties Related to the FCA  Exclusion - Individuals and Agencies  Monetary Penalties - maximum penalty is $10,000 per claim but can be greater for certain offenses. – These are usually dealt with through a settlement agreement.  Assessment in lieu of damages – usually three times the amount claimed for each item or service in question.

Penalties Continued  Termination or non-renewal of provider/participation agreement.  Intermediate Sanctions – non-payment, governmental take over of the agency, etc.  Filing of criminal charges = jail time in addition to the civil fines and penalties.

Other Areas of Fraud  Anti Kickback Laws  Stark Law - Prohibition against Physician Self Referrals

What has UCP done about this? Appointment of a Compliance Officer and Creation of a Corporate Compliance Program

Elements of the Compliance Program  People  Communication  Structure

People  Corporate Compliance Officer  Compliance Committee  UCP employees, contractors, business associates

Communication  Compliance Hotline  Compliance  Direct Contact  Compliance Newsletter, etc.

Structure  Establishment of UCP Code of Ethics and Business Conduct  Development of Compliance Policies and Procedures  Training/Education  Internal Auditing and Monitoring

Additional Departmental Duties  Investigating and Reporting  Enforcement and Discipline  Response and Prevention

Questions ?

Final Items  Training Acknowledgement form  Handouts