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 This is a sample overview presentation for Corporate Compliance requiring agency individualization.  As a home health agency, you may wish to add specifics regarding CoPs and clinical documentation.  Feel free to adjust and modify as needed.  Please delete this slide.

 Compliance efforts should support a corporate culture that promotes prevention, detection, and resolution of instances of conduct not conforming with Federal and State Law or ethical and business practices. Federal Register 62:9436 March 1997 Introduction……….

 This Corporation is committed to promoting strong business ethics, monitoring compliance with applicable rules, regulations, and law. Having a strong compliance program with solid internal quality control mechanisms assists this Corporation to maintain its commitment as a firm of integrity and assists to prevent unethical conduct.

 Continually improving the quality of services and products provided as well as consistent environmental structure that encourages employees to report potential problems  Having procedures in place for prompt investigation of areas of concern.

 Describe the mission of a Corporate Compliance Program  Identify what is the Office of the Inspector General (OIG) and its focus  Identify potential areas of vulnerability  Identify how this Corporation looks to minimize Corporate Compliance risk

 List some of this Corporation’s responsibilities to its clients  Identify what the employee should do if they suspect violation of Federal Law or ethical business conduct.  Identify required elements of a compliance program and its input on personnel.

The OIG has identified the following seven critical elements of an effective compliance plan: 1 Written policies and procedures 2. Designation of a Corporate Compliance Officer 3. Ongoing education and training 4. Effective lines of communication

5. Enforcement of Standards 6. Auditing and Monitoring 7. Investigation and corrective action

Providing easy to understand explicit guidelines for Compliance for all employees to follow  Ensure that employees understand what is expected of them in the conduct of their job

 Ensure that objective quality standards are defined for each department.  Ensure that those quality standards are measurable and metrics are routinely deployed

 Ensure employees are using Compliance Standards in their daily work activity  Enhance corporate performance in basic business relationships  Ensure the business culture at the Corporation supports ethical, quality oriented and honorable conduct.  Develop and maintain trust in the healthcare community of firms using services and products of this Corporation.

 Provide a process for decision making when the business standards DO NOT provide a clear answer to an issue or dilemma.

 By providing a written Standard of Conduct for distribution to all employees upon hiring By training on Compliance Standards with Policies and Procedures to employees of the Corporation.

 By providing ease of access to the Corporate Compliance Officer  By providing a hotline to report areas of potential non-compliance

 By monitoring and enforcement through the Compliance Officer and Compliance Committee  By review and update of the Corporate Compliance Program annually and as needed  By participation of all levels of management in the Compliance program

To provide efficient, cost effective systems and support services in accordance with the highest quality and ethical standards.

 Coding  Billing  Accounting

Write a statement about services provided and adherence to regulation. Below is a sample : This Corporation provides Coding and Billing services to many Clients nationwide. Compliance guidelines for Billing companies and Coding conventions for Coding companies have been developed by regulatory bodies and are followed by this firm.

 Upcoding – placing patient in a higher case mix category than is warranted.  Downcoding – coding patients at a lower level than is appropriate  Sequencing – arranging Diagnosis in proper order from Primary reason for Home Health to lessor conditions that may impact on HH Care and ADLs.

 Correctly assigning primary and primary secondary diagnoses  Correctly applying therapy diagnosis  Diagnosis with wound, ulcer, or surgical detail support  Assuring all diagnoses have adequate documentation supportive detail

 Charting entries consistent with Dx coding  Evidence of homebound status in charting  Following specific state regulation

 Evidence of genuine medical necessity face to face  Assessment or reassessment of patients  Time points  Charting/Documentation consistent with original Plan of Treatment or change in condition

 Failure to return credit balances made by Federal Government  Billing for services not Medically Necessary  Billing for services for a non-homebound patient  Routine waiver of co-payments  Billing for services without a Physician’s Order

 Billing for services without proper clinical documentation  Overcharging for services or supplies  Billing for services before physician orders are signed  Duplicate billing  Inappropriate Coding  Improper application of CBSA codes

 Which of the following is a reason the government might investigate a billing company for potential fraud and abuse? A. Unfavorable analysis of billing patterns B. Billing two different payors for the full invoice C. Patient or client complaint D. All of the above

 Provide Management Reports to insure  There are physician orders for services rendered  There are signed Physician Orders

 Adherence to current ICD-9-CM coding convention to  Prevent upcoding or downcoding  Monitor for proper sequencing  Monitor accuracy of OASIS integrated assessment  Notification of potential non-reimbursable visits based on 485 (Medical POC) review

 Code to the highest level of specificity with documentation to support the coding decisions  Provide reliable response to documentation and coverage questions  Provide a tool that assures validation of visits made.  Release only “clean” claims

A. Have a Strong Corporate Compliance Program  Policies and Procedures  Code of conduct  Confidential Disclosure Program  Training and Education  Screening  Internal audits Clinical, Coding, Billing Departments for Compliance  Seeking Data, Data, Data!  Disciplinary guidelines

B.Have a Corporate Compliance Officer  Upper level position with direct access to the CEO  CCO experienced and credentialed to execute the Corporate Compliance plan  Employees know how to contact the Corporate Compliance Officer

C. Legal Review  Corporate Counsel review of all Client Contracts  Corporate Counsel review of Joint Ventures  Corporate Counsel availability to Corporate Compliance Officer

 You have the option to speak with your Supervisor or contact the Corporate Compliance Officer  If you are uncomfortable with this direct approach you may complete a Compliance Concern Form (located_________) or call the Compliance Help Line at________________.

 The identity of all callers is treated as confidential!  The information provided will not be disclosed or discussed with anyone other than those who have legitimate need to know in order to perform their duties.  If, because of the nature of the complaint or issue, it becomes necessary to provide your name, that fact and other options will be discussed prior to disclosure.

 All information is expected to be truthful and accurate.  This Corporation does not condone the making of false or malicious reports.  This Corporation will not tolerate any retaliatory actions taken against any employee for providing truthful and accurate information.

1.DUTY TO REPORT  Employees have the duty to report all suspect or questionable conduct. 2.HOW TO REPORT  Employees should notify their immediate supervisor of any suspected impropriety. Once notified, the supervisor must immediately notify the compliance officer. 3.Employees may notify the Corporate Compliance Officer directly in person or by phone or

 “Bobby doesn’t like me.”  “My Supervisor isn’t fair.”  “My manager overworks me.”  “I’m not happy.” Although these are important concerns, the company has other problem solving procedures for employees with issues of this nature.  Oh my!

The Fundamentals of a Compliance Program may be expressed as the four E’s: - Educate - Encourage - Enable - Enforce

 Gain competitive advantage through greater credibility and assurance to employees and client partners. What does this mean?  Enhance reimbursement and operating margins by focusing on personnel improvement and education in documentation, coding, billing and operational efficiencies

 Decrease the potential of negative audits through documentation of procedures and reviews that minimize problems before coding and claims submission. What does this mean?

 Improve organizational structure to distribute legal and corporate policy changes throughout the organization.  Reduce liability exposure by demonstrating commitment to implementing a comprehensive and effective compliance program.

 Knowing you are a part of a team committed to quality control and ethical conduct in the business world.  Your comments?