What's in a Name (Chapter 1)

Question 1

What is the general meaning/emphasis of a compliance program?

Answer 1

Follow rules and regulations

Question 2

What is the general meaning/emphasis of an integrity program?

Answer 2

Values doing the right thing

Question 3

What are some of the compliance activities of an organization

Answer 3

EEOC
ERISA
OSHA
AAAASF
Labor Wage and Hour rules
Nuclear Regulatory Commission
JCAHO survey prep
Academic Research

Question 4

What is a Compliance Program?

Answer 4

Commits to the ethical way of doing the right thing:
Prevention, detection, collaboration and enforcement;
Policies, procedures and processes

Question 5

Who are the organizations/companies that need a Compliance Program?

Answer 5

Physician organizations;
Managed care organizations;
Ambulance or Transportation Suppliers
Third Party Billing Companies
Pharmaceutical Manufacturers
Hospital/Academic Medical Centers
Laboratories
Research Organizations
DME Distributions
Home Health Agencies/Hospices/Skilled Nursing Facility
Behavioral Health Organizations
Accountable Care Organizations (ACOs)
Ambulance Providers
Others

Question 6

Which organizations are responsible for enforcing rules and regulations under the Medicare and Medicaid laws outlined as part of the Social Security Act and administered by CMS

Answer 6

HHS Office of the Inspector General (OIG) and;
Justice Department

Question 7

What are the benefits of a Compliance Program for an organization?

Answer 7

Safeguards organization’s legal responsibility to abide laws and regulations (considered to be the first and foremost benefit).
Others benefits:
Good corporate conduct;
Identify and prevent criminal and unethical conduct;
Improve quality of care;
Centralize information on health care regulations;
Develop mechanism for reporting;
Develop procedure for investigation of alleged misconduct;
Initiate corrective action;
Reduce exposure to civil damages and penalties, criminal sanctions, and administrative remedies, such as program exclusion

Question 8

Five (5) reasons why Compliance Programs are essentials?

Answer 8

Paybacks to FI’s may result in audits
Probation and court-imposed programs
Government designed programs
Exclusion from governmental programs
Reduced threat of qui tam (whistleblower) lawsuits.

Question 9

OIG Top 10 Reasons for an Effective Compliance Program

Answer 9

Demonstrates commitment to honesty and responsibility
Reinforce employee’s sense of right and wrong
Fulfills legal duty to government and private payors
Cost effective vs. expense of defending against fraud
Provides accurate view of employee/contract behavior of FWA
Enhances quality of care to patients
Promptly corrects misconduct
May mitigate sanctions imposed by the government for violations
Voluntary preferred vs. OIG imposed program due to violation
May protect directors from personal liability

Question 10

Health Insurance Portability and Accountability Act of 1996 (HIPPA) specifcs

Answer 10

Makes it a criminal offense to submit claims based on incorrect codes or medically unnecessary services

Question 11

Balanced Budget Act of 1997 specifics

Answer 11

Three strikes you’re out clause - permanent expulsion if found guilty of fraud 3 times.

Question 12

Qui tam (whistleblower) specifics

Answer 12

Eligible for 15% to 25% of governments total award if DOJ assumes case.
Eligible for 25% to 30% of the total award if the DOJ declines case.
Rewarded even if they have not reported it internally .

Question 13

What is a Corporate Integrity Agreement (CIA)

Answer 13

Government imposed corrective action negotiated by an organization to avoid expensive litigation but admits no fault or liability.