1. The Basics of Corporate Compliance
Doing the Right Thing

2. Objectives: Understanding Corporate Compliance HIPAA’s Impact
How this effects our jobs

3. Healthcare Abuse & Fraud
Healthcare Abuse and Fraud is costing our government billions of dollars.
Unethical doctors, hospitals, or
other organizations have improperly
billed for services,thus escalating healthcare costs for the rest of us.

4. Healthcare Fraud
To combat escalating costs, three governmental agencies are enforcing
healthcare regulations.

5. Three Governmental Agencies
Federal Trade Commission
Department of Justice
Office of the Attorney General

6. Federal Trade Commission
FTC ensures that doctors can no longer be treated to expensive dinners at lavish hotels or attend
sporting events at the drug company’s expense.
To avoid anti-kickback laws, FTC enforces that drug companies document their time and training. (Kickback is defined as the return of a sum of money or objects already received, typically as the results of pressure, coercion, or secret agreement…The American Heritage Dictionary- 4th ed)

7. Department of Justice (DOJ)
DOJ investigates fraud in nonprofit agencies.
Major reimbursement claim systems are being scrutinized and monitored by the DOJ.
DOJ looks at due diligence, is it done to validate credentials or licenses? If there are too many non-credentialed employees, the facility doesn’t meet contract guidelines.

8. Office of the Attorney General
Office of the Attorney General investigates outpatient psychiatric services
Mental health services in nursing facilities
Improper billing of psychiatric services:
Individual psychotherapy
Psychological Testing
Group Therapy

9. Medicare Help

10. Program Integrity The office of Program Integrity was developed to:
Play a key role in getting providers in compliance with Medicare, by identifying errors and problems.
Ask providers for refunds, if it finds the government overpaid.
Work with insurance carriers directly and indirectly to help providers comply with Medicare.
The office of the Attorney General and the Office of Program Integrity investigates and makes referrals to the DOJ.

11. Fraud, Waste, Abuse
“Analysis suggests that 10 to 12 percent of healthcare expenditures is waste, fraud, and abuse…”
Fried of Shaw, Pittman, a healthcare law firm.

12. For Prosecution of Healthcare Fraud and Abuse
Laws, Acts and Statutes
For Prosecution of Healthcare Fraud and Abuse

13. False Claims Act
Act was reserved for intentional fraudulent conduct, i.e., where the provider knowingly submitted a false claim.

14. Examples of Fraudulent Behavior
Documenting a contact that did not occur!!
Documenting longer contact instead of actual time
(ie 1 hour instead of 45 minute contact)
Documenting intentionally wrong person, place, time
Including time for non-allowable activities into documentation
Don’t

15. Stark Self-Referral Law
Prohibits physicians from making self-referrals

16. Anti-Kickback Statute
Prohibits providers from offering patients anything of value
Waiving co-payment or deductibles for referrals
Inflating charges to beneficiaries in order to cover the amount of the waiver

17. Christus Health Affiliates Story

18. HIPAA- Health Insurance Portability and Accountability Act 1996
A New Law Added
HIPAA- Health Insurance Portability and Accountability Act
1996

19. HIPAA: Health Insurance Portability and Accountability Act
HIPAA is a multi-faceted law meant to
streamline the healthcare system in a high technology age.
HIPAA is federal regulation that covers
all healthcare providers and their associates.

20. HIPAA establishes:
Consistent standards for uniform transmission of electronic health care claims.
Standards for securing storage of data.
Most importantly, increases Privacy and Security.

21. HIPAA’s “PHI” “PHI”- Protected Health Information
All individually identifiable health information transmitted or maintained by a covered entity, regardless of form is now protected.

22. HIPAA: Health Insurance Portability and Accountability Act- Four Parts
The Accountability portion of the act
created Healthcare crimes:
1. Healthcare Fraud
“Accepting benefits or payment for benefits under false or fraudulent pretenses, representations, or promises.”
2. Healthcare Theft or Embezzlement
”Knowingly and willfully taking any money or other assets of a healthcare program for the use of any person other than the rightful owner.”

23. HIPAA HealthCare Crimes
3. Healthcare False Statements
“to make false representations in connection with the delivery of, or payment for, any healthcare benefit or make any material false, fictitious, or fraudulent statements.”

24. HIPAA Healthcare Crimes
4. Obstruction of Criminal Healthcare Offense Investigations
“To obstruct in any way the criminal investigation of a healthcare offense whether by failing to produce subpoenaed records or by inducing others to not communicate with criminal investigators.”

25. How does this affect us? Hill Country MHMR is a governmental
agency. As the local authority for mentally ill and mentally retarded people in 19 counties, we accept money from the state and federal government.
How we do business is closely scrutinized.

26. To Ensure Compliance with all Federal and State Regulations
We need to follow our Corporate Compliance Plan

27. Corporate Compliance Plan
The Office of the Attorney General
established the Compliance Program
Guidance Guidelines to assist providers
in preventing the submission of erroneous claims or engaging in unlawful conduct involving Federal healthcare programs.

28. Components of an Effective Compliance Program
Conducting internal monitoring and auditing;
Implementing compliance and practice
standards;
Designating a compliance officer or contact;
Conducting appropriate training and education;
Developing open lines of communication;
Enforcing disciplinary standards through well publicized guidelines.

29. Statement of Policy and Open Communication
HCMHMR Board and Management are committed to providing avenues which ethical issues may be raised, reviewed, and resolved openly and honestly.
There is an Open Door Policy where employees are free to express their concerns and to exchange ideas without fear of reprisal.

30. Corporate Compliance Officer and Compliance Committee
A Corporate Compliance Officer (CCO) has been named to ensure state and federal regulations are followed.
The CCO is responsible for oversight and corrective action

31. Gifts and Favors
“An occasional lunch or dinner or gift of limited value.”
“Monetary gifts or favors in attempt to gain influence or advantage”
“Any gift limited in value and consistent with common business courtesies.”
Giving monetary gifts is never acceptable.

32. Compliance/Monitoring and Auditing
We are committed to complying with all federal and state laws and regulations.
Documentation will follow state and federal guidelines and will be done in a timely manner.
All direct care staff will document according to the TAC guidelines, “after each contact.”
We will conduct audits and other risk evaluations to monitor compliance as stated in our agency policy and procedure manual.

33. Compliance/Monitoring and Auditing
All staff will be trained in their specialty area.
HCMHMR will maintain processes to detect Medicaid/Medicare or other third party compliance offenses.
We will initiative corrective action plans.
Reporting to the appropriate regulatory authorities.
Address consequences when employees or contract providers fail to comply.

34. Accounting and Reporting
Each employee and contract provider will ensure the integrity of the Center by accurately and truthfully recording all corporate information, accounting and operational data through strict adherence to established accounting and business procedures.

35. Corporate Resources
Each employee and contract provider is expected to use corporate resources economically and safeguard corporate assets at all times.

36. HIPAA Privacy Rule: Written Consent
The Privacy Rule requires written consent by a patient before covered entities may use or disclose the patient’s protected health information.
Please,
Release my heart…

37. HIPAA Privacy Rule: Minimum Necessary Standard
The Minimum Necessary Standard requires that covered entities make “reasonable” efforts to limit access to
PHI based upon the minimum information necessary to perform a particular role.

38. HIPAA Privacy Rule: Right to Request Restrictions
Patients have the right to request their healthcare providers communicate to them by “alternative means” or at “alternative locations.”
Patients have a right to be “de-listed”.
Their name doesn’t have to be on a “patient list.”

39. Hill Country Community MHMR Center
Corporate Code & Media
Hill Country Community MHMR Center

40. Electronic Media
All electronic communications systems, including , internet access, and voice mail are the property of HCMHMR and are to be used primarily for business purposes.

41. Electronic Media Con’t
As all electronic communication systems and messages generated are the property of HCMHMR, they are subject to review at any time.
Use HIPAA guidelines to protect the confidentiality, integrity and availability of electronic protected health information.

42. Controlled Substances Focus
The illegal use/abuse or possession of alcohol or any controlled substance in the workplace is unacceptable and will not be tolerated.
These acts are illegal and jeopardize the safety of employees, contract providers and consumers.
It reduces productivity, reliability and trustworthiness.

43. Reporting Misconduct

44. Reporting Misconduct
Bring to your supervisor any violation of this Corporate Code of Conduct.
Supervisors will suggest an appropriate action.

45. Reporting Misconduct
Reporting will remain confidential unless obliged by professional code of conduct, state or federal law.
No employee or contractor will be punished or subjected to reprisal because of good faith reporting.

46. Whistleblower Protection
Whistleblower protection is provided by federal acts and related statutes that shield employees from retaliation for reporting illegal acts of employers.
An employer can’t rightfully retaliate in any way, such as discharging, demoting, suspending, or harassing the whistleblower.
If an employer retaliates anyway, whistleblower protection might entitle employee to file a charge with a government agency, sue the employer, or both.

47. Hill Country’s Corporate Compliance Officer
Joe Lovelace

48. Consequences for not following Cooperate Compliance
TERMINATION of employment
Referral to Appropriate Authority:
Local Police and/or State Police
State and/or Federal Attorney General
FBI
Possible Jail Time and/or Fines

49. Conclusion
Always Do the Right Thing and you’ll be in compliance with HCCMHMRC policies!