1. COMPLIANCE PROGRAM

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

3. 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?

4. 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.

5. 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.

6. 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.

7. 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).

8. 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.

9. 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.

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

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

12. Elements of the Compliance Program
People
Communication
Structure

13. People Corporate Compliance Officer Compliance Committee
UCP employees, contractors, business associates

14. Communication Compliance Hotline Compliance Email Direct Contact
Compliance Newsletter, etc.

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

16. Additional Departmental Duties
Investigating and Reporting
Enforcement and Discipline
Response and Prevention

17. Questions ?

18. Final Items
Training Acknowledgement form
Handouts