Chapter 2 Flashcards
The code of Conduct
-demonstrates the organization’s ethical attitude and its enterprise wide emphasis on compliance
-will need to be tailored to the organization’s culture, business and corporate identity
-provides a process for proper decision making
-managers are encouraged to refer to the code of conduct whenever possible, even including elements or standards into performance reviews
Who must agree and abide by the Code of Conduct
-everyone from the board to volunteers must receive, read, understand and agree
-CIA’s require all employees to attest on an annual basis
Code of Conduct: Content Checklist
-Reflects cultures and values
-written plainly - suggested 8th grade reading level
-translated into other languages as appropriate
-Mentions organizational policies without completely restating them
-Is consistent with company policies and procedures
Code of Conduct and Employees
-all must receive, read and understand
-training should be provided specific to the code
-should attest to it in writing annually
-must be enforced failing and consistently through appropriate discipline
-should understand that noncompliance will bring about discipline
Code of Conduct Purpose
-Represent culture of organization
-summarize specific guidelines to follow
-allow employees to know what’s required of them
-provide process for proper decision making
-confirm employees put standards into everyday practice
-elevate corporate performance in basic business relationships
-confirms the organization upholds and supports proper compliance conduct
Compliance Policies and Procedures
-are specific and address identified areas of risk
-should be integrated into existing policies
-Only thing worse that not having a policy is having a policy and not following it
-make sure they are realistic and measurable
OIG work plan
-released in the fall of each year
-highlights those areas the government will give close attention to in the coming months
-be sure to target those areas and address them in the policy and procedures
What areas do Compliance related policies and procedures exist for?
-Auditing and monitoring
-compliance record retention
-self-disclosure
-regular sanction checks
-specific areas of risk
-Non-retaliation
-Stark/anti-kickback
-HIPAA Privacy and Security
-others
Upcoding
-using a billing code that provides a higher reimbursement rate than the billing code that actually reflects the service furnished
-HIPAA added an additional civil monetary penalty to the OIG sanction authorities for upcoding violations
DRG Creep
practice of billing using a DGR code that provides a higher payment rate than the DRG code that accurately reflects the service furnished to the patient
Civil Monetary Penalties Law (CMPL)
regulations which apply to any claim for an item or service that was not provided as claimed or that was knowingly submitted as false and which provides guidelines for the levying of fines for such offences
Teaching physicians
-effective July 1996 and revised November 2002
-outlines documentation regulations for services provided by residents and teaching physicians
Non-retaliation policy
-should be developed and communicated
-if employees are afraid to bring issues forward a compliance program could not be effective
Government comes knocking
develop policies so that your staff knows what to do if presented with a subpoena, search warrant or if questioned by a government investigator
-cannot tell them what they must do but can tell them what their rights are
Anti-Kickback Statute
-prohibits any knowing and willful conduct involving the solicitation, receipt, offer, or payment of any kind of remuneration in return for referring an individual or for recommending or arranging the purchase, lease or ordering of an item or service that may be wholly or partially paid for under a federal health care program.
-is a criminal statute
Anti-Kickback Statue Penalties
-hefty fines
-imprisonment
-any reimbursement secured under an illegal referral may be considered a false claim
Examples of Anti-kickback Violations
-offering office space at no charge or less than fair market value to physicians
-cut-rate support services such as dictation or secretarial services
-computer equipment provided at no charge by a pharmaceutical company
Safe harbors
Explicit regulatory exceptions to otherwise legally prohibited conduct. Federal safe harbor regulations specify certain joint ventures and other arrangements concerning hospitals and/or physicians which do not violate Medicare fraud and abuse laws
Stark Law
-Self-referral statute
-a physician or an immediate family member has a financial relationship with an entity that provides designated health services (DHS) that the physician may not make a referral for any DHS that is reimbursable by Medicare, and the entity that provides the services may not bill Medicare for the services provided as a result of the prohibited referral
-is a civil act and penalties are substantial
Compliance Officers Duties
-implementation, administration day to day oversight of program
-reporting to the governing body
-revising program as appropriate
-develop, coordinate and participate in the education and training
-ensure independent contractors and agents are aware of the program requirements
-ensure background checks are done
-assist with auditing and monitoring activities
-independently investigating and acting on matters related to compliance
Who is the focal point of the Compliance program
the compliance officer
The Health Care Compliance Association’s three principles
-Obligation to the public-should embrace the spirit and the letter of the law
-Obligation to the employing organization
-obligation to the profession
What different perspectives does the OIG believe will benefit the committee
-operations
-finance
-audit
-human resources
-utilization review
-social work
-discharge planning
-medicine
-coding and legal
-employees and managers of key operating units
Compliance committee functions
-participating in the identification and prioritization of risk
-regularly reviewing and assessing compliance policies and procedures
-assisting with the development of standards of conduct and policies and procedures
-conducting an annual review of the Compliance Plan document
-determining the appropriate strategy to promote compliance
-developing a system to solicit, evaluate, and respond to complaints and problems
What are the first and possibly most important lines of defense for a compliance program?
Education and training
How does the OIG suggest training
2 separate types
-1 a general session on compliance for all employees
-2 coving more specific information for appropriate personnel
General Compliance Training would at least include?
-elements of your compliance program
-your organization’s Code of Conduct
-The reporting system
-Individual accountability for reporting suspected non-compliance
-Non-retaliation policy
-who the compliance officer is
-explanation of fraud, waste and abuse
How many educational hours does the OIG recommend annually for basic training?
There is no definite timeframe however 1-3 hours is required in many CIAs
