1. Corporate Compliance Board Training 2018
01/17
Ensure tomorrow...
Comply today
Allegan County Community Mental Health Services
Corporate Compliance Board Training 2018
2018

2. The Goals of this Presentation is for You to Know:
The essentials of a Corporate Compliance Program;
What constitutes fraud, waste and abuse (FWA);
3. Board Members role in
Corporate Compliance.
2018

3. Essentials of Corporate Compliance
Part I
Essentials of Corporate Compliance

4. What is Corporate Compliance?
Simply put, corporate compliance is the process for ensuring that ACCMHS follows the laws, regulations, standards, and code of conduct that apply to us.
2018

5. A Corporate Compliance Program…
is a system which designed to detect and prevent violations of law by the agents, employees, officers and directors.
2018

6. A Corporate Compliance Program
01/17
A Corporate Compliance Program
Is required by law for entities receiving over 5 million dollars in Federal funding;
Reduces the risk of unlawful or improper conduct;
Establishes an effective method to assess and manage risks;
Reduces the potential for liability and financial loss;
Establishes Board and employee training to increase awareness and decrease the possibility to breach the law.
Ensures the federal and state dollars received are used to provide services to those in need.
2018

7. The Seven Elements of an Effective Compliance Program
OIG* Compliance Program Guidelines and ACA:*
Implement a written Compliance Program, Policies, and Plan.
Designate a Compliance Officer and Compliance Committee.
Conduct effective training and education.
Maintain effective communication.
Perform internal monitoring and auditing.
Enforce standards through well-publicized disciplinary guidelines.
Respond promptly to detected offenses.
*Office of Inspector General
*Affordable Care Act
2018

8. What Typically Are Our Greatest Ongoing Risks?
Fraud Waste and Abuse
Privacy/Confidentiality
Security of Information
Code of Conduct (Doing the right things all the time)
2018

9. Ongoing Assessment of Risks
A Risk Management Program is a sub-part of the Compliance Program and must be in accordance with the MDHHS Contract and CARF Standards.
RISK MANAGEMENT is a logical and systematic method of identifying, analyzing, prioritizing, treating, and monitoring the risks involved in any organizations activities or processes.
2018

10. Who Has Responsibility for the Effectiveness of the Compliance Program?
Everyone!!!!!!
ACCMHS:
Board
Management Team
Consumers
Supervisors
Staff
Providers
2018

11. Who has Responsibility for the Overall Management of the ACCMHS Compliance Program?
The Compliance Director/Officer:
Serves as the focal point for all Agency compliance activities and must be high-level staff with direct access to the Executive Director and the ACCMHS Board.
2018

12. Responsibilities for Carrying Out the Compliance Program
Corporate Compliance Committee
Compliance Director/Officer (Phil Brouwer)
Reimbursement Coordinator (Lynn Yetman)
Privacy Officer* (Kim Bectel)
Security Officer* (Jason Wilkey)
*Required by the Health Insurance Portability and Accountability Act (HIPAA)
Ad Hoc Members
Executive Director
Finance Director
Clinical Director
Human Resources Manager
Recipient Rights Officer
2018

13. Compliance Committee Functions
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Compliance Committee Functions
Use of audits and monitoring techniques to identify compliance issues.
Review and investigate allegations of waste, fraud, abuse, and other compliance infractions.
Take corrective action, including recommending staff discipline, claims paybacks/adjustments, changes to address systemic problems and preventative measures.
Train ACCMHS Board, staff, and providers in the culture of compliance.
2018

14. Reporting of Potential Compliance Issues
Everyone has an obligation to make a good faith effort to report any activity that appears to violate compliance practices.
2018

15. Anyone May Report Potential Compliance Issues by:
Notifying their supervisor,
Contacting the ACCMHS Compliance Director/Officer,
Contacting any member of the ACCMHS
Corporate Compliance Committee.
If preferred, potential compliance issues may be reported to the Lakeshore Regional Entity (LRE)/PIHP.
No retribution to anyone who reports in good faith.

16. Whistleblower’s Protection Act
A law that provides protection to employees who report a violation or suspected violation of state, local, or federal law.
Provides protection to employees who participate in hearings, investigations, legislative inquiries, or court actions; and prescribes remedies and penalties.
An employer shall not discharge, threaten, or otherwise discriminate against an employee because the employee reports or is about to report a violation.
An employer shall post notices and use other appropriate means to keep employees informed of Whistleblowers’ protections.
2018

17. Part II
Fraud, Waste and Abuse

18. What is Fraud?
Per 42 CFR (Code of Federal Regulations): Fraud is an intentional deception or misrepresentation made by someone with knowledge that the deception will result in benefit or financial gain.
2018

19. Potential Fraud Examples
Billing for services that were never provided.
Reporting inaccurate start/stop times for services which knowingly result in increased payment.
Falsifying treatment plans or medical records to knowingly maximize payments.
Billing for a service without documentation – “if it’s not documented, it didn’t happen.”
2018

20. Federal False Claims Act (FCA)
Anyone who violates the FCA is liable for a civil penalty of $5,500 to $11,000 per claim, plus three times the amount paid.
A person violating the FCA can be liable for the costs of a civil action brought to recover any penalties or damages.
Violators can be excluded from participating in Medicare, Medicaid, and other government programs.
(In significant cases, an individual can serve a prison term)
2018

21. The Federal False Claims Act Applies When an Organization or Person:
Knowingly presents the government with a false claim for payment;
Knowingly makes a false statement to get a fraudulent claim paid;
Conspires to defraud the government by getting a false claim paid by the government;
Knowingly makes a false record or statement to conceal, avoid, or decrease an obligation to pay the Government; and/or
“Causes” a false claim to be submitted.
2018

22. What is Abuse?
Abuse describes incidents or practices inconsistent with accepted and sound medical, behavioral health business, or fiscal practices.
The difference between fraud and abuse boils down to the person’s intent. Both activities have the same effect: they consume valuable Medicaid/Medicare resources
2017

23. Potential Abuse Examples
-Billing for services that were not medically necessary.
-Misusing codes on a claim, i.e. ‘upcoding.’
-Patterns of errors due to lack of awareness, due diligence, monitoring, etc. on the part of staff and administration.
2018

24. What is Waste?
Waste includes any practice that results in an unnecessary consumption of federally-funded financial or clinical resources.
2018

25. Potential Waste Examples
Attending a conference that is not relative to an
individual’s position.
Creating or purchasing an expensive software program in which a less expensive and equally good program already exist.
Excessive use of office supplies.
Scheduling consumer contacts in the community without considering scheduling according to proximity within the county to minimize staff time and mileage reimbursement.
2018

26. Medicare/Medicaid Oversight
“HEAT” (Health Care Fraud Prevention and Enforcement Action Team) is the primary oversight group that began in It is an interagency effort (OIG, Dept. of Justice and the Center for Medicare and Medicaid [CMS]) specifically focused on combating health care fraud.
 For every $1.00 the federal government spent on combatting healthcare fraud and abuse, the government recovered $4.00 in 2017.
2018

27. OVERSIGHT (cont.)
The federal government recovered $2.6 billion dollars due to fraud in the 2017 fiscal year.
The HHS Office of the Inspector General (OIG) carried out 788 criminal actions and 818 civil actions against individuals and entities involved in Medicare and Medicaid fraud schemes. The actions included false claims lawsuits, civil monetary penalty settlements, and administrative recoveries associated with provider self-disclosure issues.
Additionally, HHS-OIG excluded over 3,200 providers and entities from participating and billing Medicare, Medicaid, and other federal healthcare programs.
2018

28. Board Members and Corporate Compliance
Part III
Board Members and Corporate Compliance

29. ACCMHS Board Oversight Responsibility
01/17
ACCMHS Board Oversight Responsibility
Duty of care. Board members:
Act in “good faith” – void of conflict of interest and decisions made with “reasonable inquiry”
Act with level of care that an ordinarily prudent person would exercise in their decision-making
Act in a manner that they reasonably believe is in the best interest of the organization
Ensure that ACCMHS has implemented and maintains an “effective” compliance program.
Must be “active” and knowledgeable about the Compliance Program
2018

30. Board Oversight (Cont.)
Maintain code of conduct/ethical behavior in all decision-making;
Review compliance reports provided to the Board.
Receive ongoing training on Corporate Compliance and learn about our Corporate Compliance Program;
Comply with ACCMHS Board policies and By-Laws;
Assist ACCMHS in assuring the highest standard of care for the residents of Allegan County.
2018

31. Reporting Potential Compliance Issues
To contact ACCMHS Compliance Director/Officer:
Office Phone: , ext. 2762
Cell Phone:
In writing (either anonymously or with your name): interoffice mail addressed to Compliance Director/Officer at CSB. The Corporate Compliance Suspected Violation form is preferred, but any other format is also acceptable.
Lakeshore Regional Entity PIHP

32. QUESTIONS