1. Overview of Corporate Compliance
RRHIMA Educational Seminar
Lorri Lauzze, RHIT, CHC
March 22, 2017

2. Presentation Objectives
Learn about corporate compliance and how to identify risks for specific service lines 
Determine how and what risks to focus on with limited resources  
Gain valuable tips on implementing corrective actions for identified issues

3. Corporate Compliance
NY State Corporate Compliance programs must apply to the following:
Billing, Clinical Documentation and Coding
Payments
Medical Necessity
Quality of Care
Credentialing
Governance
Mandatory Reporting

4. Billing, Payments and Mandatory Reporting
Billing and Payments
Revenue cycle
Registration, Level of Care, Clinical Documentation, Coding, Charging, Billing, and Payments
Payments received through grants or programs where there are expectations outlined for that payment
Mandatory Reporting
Report, repay and explain all overpayments

5. Medical Necessity and Quality of Care
Clinical documentation must justify the need for care in relation to payment regulations
Example: ordering, performing, coding and billing for an EKG when medical record documentation by the physician fails to relate the need for such service
Quality of Care
Care provided does not meet expected standards of billed service
Example: Spanish speaking patient seen for a prescription refill; however the physician does not have an interpreter and therefore writes the script without discussing with the patient

6. Governance Conflicts of Interest
Code of Ethics/Employee Standards of Conduct
Code of conduct or code of ethics embodies compliance expectations

7. Credentialing
Credentialing of health care providers in relation to payment regulations
Appropriate licenses/credentials to perform and bill for services
Providers can become excluded from billing Medicare and Medicaid; therefore any services ordered and billed are in violation

8. Fraud, Waste, and Abuse Defined
An intentional act of deception or misrepresentation knowing that it could result in some unauthorized benefit or payment
Waste
Over-utilization of services and the misuse of health care resources
Abuse
Incidents that are improper, excessive, or inconsistent with accepted medical or business practices

9. Examples of Fraud, Waste, and Abuse
Billing for services that were not provided or misrepresenting the service to get paid
Retaining overpayments rather than making necessary claim adjustments or disclosures to payers
Misreporting the person rendering the service: always place the correct provider’s name in the “servicing provider” area

10. Examples of Fraud, Waste, and Abuse
Using another individual’s EMR sign on to document in the medical record; therefore, falsifying the author of the documentation
Deleting the existence of a patient’s visit from the scheduling and billing system
Backdating of any medical record entry

11. Examples of Fraud, Waste, and Abuse
Forging the signature of a provider
Cloning of EMR visit notes or falsifying documentation
Ordering and/or billing for services that are not medically necessary
Ordering and/or providing services by individuals not credentialed to do so

12. Stark Law: Physician Self-Referral
Prohibits physicians from making referrals to an entity, like a hospital, for the furnishing of designated health services (DHS)1 payable by Medicare if the physician (or an immediate family member of physician) has a financial relationship2 with the entity
DHS defined as 10 items/services the government considers to be susceptible to overutilization, such as: clinical laboratory services, inpatient and outpatient hospital services, diagnostic imaging, etc.
A financial relationship can be created through physician’s ownership or investment interest in the entity, or compensation arrangement with the entity

13. Stark Law
Example:
Can a physician refer her patients to an imaging center that her husband privately owns?
This may be a violation of the Stark Law. Contact compliance for any concerns
The Stark Law is very complex and should not be interpreted without the assistance of an attorney with relevant experience

14. Anti-Kickback Statute
Federal criminal law that prohibits offering, soliciting, paying, or receiving referrals for services that are paid by any federal health care program: Medicare and Medicaid
Both payer & receiver of kickback incentives are in violation
Kickback violations are professional misconduct
Example:
Can Doctor Jane offer a gift card to staff members in Doctor Doe’s office for every patient referred to Doctor Jane’s office?
This is a violation of Anti-Kickback Statute
Both doctor’s staff may be in violation

15. Government Agency Monitoring
OIG – Office of Inspector General
Mission is to protect the integrity of the Department of Health & Human Services programs as well as the health and welfare of program beneficiaries
OMIG – NY Office of the Medicaid Inspector General
Mission is to enhance the integrity of the NY State Medicaid program by preventing and detecting fraudulent, abusive and wasteful practices within the NY Medicaid program. Recovering improperly expended Medicaid funds while promoting high-quality patient care

16. Government Agency Monitoring
OMIG Compliance Bureau
Ensuring that providers who are required to have a compliance program have effective compliance programs. They assess the compliance plan and function of the program
MFCU – NY Medicaid Fraud Control Unit
The mission of State MFCUs, as established by Federal statute, is to investigate and prosecute Medicaid provider fraud and patient abuse and neglect under State law

17. Government Agency Monitoring
DOJ - United States Attorney’s Office for the Western District of New York
Is the principal Federal Law Enforcement Officer in the district and prosecutes all violations of Federal Criminal Law
FBI - Federal Bureau of Investigation
The FBI is the primary agency for exposing and investigating health care fraud, with jurisdiction over both federal and private insurance programs

18. Other Payer Monitoring
Excellus
Special Investigations and Fraud Unit
Audit providers
Report potential Fraud, Waste and Abuse identified to WNY U.S. Attorney’s office
MVP
Special Investigations Unit

19. What’s our Role in This? Departments/providers
Prevent fraud, waste and abuse by ensuring compliance with all federal, state and local laws
Corporate Compliance Departments
Support the system with preventing and identifying fraud, waste, and abuse to ensure compliance with all applicable federal, state and local laws

20. Risk Assessment for Service Line
In the Corporate Compliance profession, performing a risk assessment means to assess risk within a specific focused topic
How do you figure out what those specific topics are for your service line?

21. Risk Assessment for Service Line
Regulatory agency work plans
The Office of the Inspector General and the Office of the Medicaid Inspector General publish annual work plans and guidance conveying their planned audits
Evaluate your organizations risk in relation to those areas deemed a priority by the agencies who will be investigating you

22. Risk Assessment for Your Service Line
Regulatory agency enforcement actions
Research corporate integrity agreements and HHS OIG and Department of Justice websites for enforcement actions
Attend compliance conferences that include local and regional US Attorney’s office, MFCU, OMIG, OIG and third party payer fraud control units

23. Helpful Agency References
tal

24. Risk Assessment for Your Service Line
High volume billed services
High dollar services
Medicaid and Medicare payments
New services
New employees
Audience participation time
If you have to focus on 1 payer, do focus on Medicare and Medicaid. Government dollars
Educate the new doctor, don’t wait and audit to tell him he’s wrong and play I got you.
Audience, tell me some of the ways you identify risk?

25. Tips on Efficiently Evaluating Risk
Don’t spend time auditing what you already know is wrong, focus on corrective action
Look at data, it may be all you need to ascertain compliance
Figure out worst case scenario before diving in
What has been reported from internal sources as a concern, these could be the highest risk to your service line
Auditing: Dr.’s levels

26. Upon Identifying Non-Compliance
Contact corporate compliance function
Perform root cause analysis
Outline every contributing factor causing noncompliance (cannot proceed to corrective action without it)
Assess lack of controls
Front line, Department and Organization Level in addition to External Environment (regulations)
Why Do we keep having the same issue?

27. Root Cause Analysis Tools
Performing root cause analysis
PDCA
Fishbone
Cause and effect diagram
Lean Six Sigma
Google those when you need them!

28. Corrective Action Work with corporate compliance function
Cease non-compliance
Identify extent of non-compliance
Identify other areas of potential exposure
Claim adjustment to payer or payment to government agency

29. Monitoring
Monitoring applies to identifying reports and methods of periodic, efficient review that are effective indicators of compliance

30. Current Highest Risk Topic for Health Care Providers
The Whistleblower (Qui Tam)
Ensure your organization has a system to:
Respond to compliance issues as they are raised or identified in course of self-evaluations and audits
Implement procedures, policies and systems necessary to reduce the potential for recurrence of identified compliance problems
Correct compliance problems promptly, and thoroughly
Identify, and report compliance issues to proper government agencies (always working with Compliance Officer/Function)
Refund any overpayments

31. Current Highest Risk Topic for Health Care Providers
The Whistleblower (Qui Tam)
Ensure your organization has a policy of non-intimidation and non-retaliation in place to protect your organization and employees
N.Y. Labor Law §§ 740 and 741 (False Claims Act)

32. Questions & Open Discussion
Conclusion
Questions & Open Discussion