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

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

3. 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

4. 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

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

6. 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

7. 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

8. 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

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

10. 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?

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

12. 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

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

14. 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

15. 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

16. 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?

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

18. The Basics at AzCA
Fraud, Waste, and Abuse

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

20. 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

21. 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.

22. 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

23. 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.

24. Reporting Methods Anonymous Reporting
call the AzCA Fraud and Abuse Hotline at ext (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 ext (can call any time 24/7, provide requested information plus contact information)

25. 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

26. The False Claims Act
The False Claims Act (31 U.S.C ) 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.

27. 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.

28. 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.

29. 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

30. 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

31. 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

32. 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

33. 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.

34. Thank You!!!
Questions – Contact me at: Jacob Schmitt , x