Presentation on theme: "PHYSICIAN PRACTICE COMPLIANCE PROGRAMS"— Presentation transcript:
1PHYSICIAN PRACTICE COMPLIANCE PROGRAMS October 9, 20138:45 – 10:15 a.m.Marcia Brauchler, MPHCPC, CPC-H, CPC-I, CPHQDaryl Smith, FACMPEAll Rights Reserved.
2What brought us here? Marcia Brauchler MPH, CPC-I, CPHQ President, Physicians’ Ally, Inc.The payer contractPhysician Practice must maintain complianceHIPAA Training AssistanceHundreds of practices are struggling with this still
9Everyone in the practice knows where the written compliance policies and procedures are located.
10To the best of my knowledge, “compliance” was last addressed in my practice in this year:
11$1,215 37.5% of respondents said “0” or “no budget.” For my practice, “compliance” efforts should be allotted an annual budget of:37.5% of respondents said “0” or “no budget.”For the practices that gave a dollar amount, the annual average was:$1,215
12Disclaimer:This is not legal advice and represents only recommendations and observations in general compliance issues.We recommend you use this information to better examine your practices and to open a dialogue with your legal counsel.
13Objectives: 1: Describe the importance of a compliance program 2: Explain the basics of creating and maintaining a compliance program3: Review specific elements of a physician practice compliance plan
14Objective:Describe the importance of a compliance program
15What is Compliance? Practical definition: We should all follow the rules & regulationsBut how?15
16What is Compliance? … to conform, submit or adapt (as to a regulation) Compliance happens in every organization, as employers strive to comply with employment and labor law guidelines for safe workplaces and a responsible organization, including:… to conform, submit or adapt (as to a regulation)
17What is Health Care Compliance? Health care industry has to comply with the federal government’s expectations for participating in and receiving payment from its Medicaid and Medicare health insurance programs
18About the Office of Inspector General (OIG) Daniel R. LevinsonAs mandated by Inspector General Act (Public Law ), the mission of the OIG is to protect the integrity of Department of Health and Human Services (HHS) programs and the health and welfare of program beneficiariesOIG also plans, conducts and participates in a variety of interagency cooperative projects and undertakings relating to fraud and abuse with the Department of Justice (DOJ), the Centers for Medicare & Medicaid Services (CMS) and other governmental agencies18
19Why YOU should care about Compliance? Tangible benefitsAbide by applicable laws and regulationsReduce exposure to civil damages, criminal sanctions, and administrative remedies, such as program exclusionDemonstrate commitment to good corporate conductMay reduce or mitigate risks to your practice
20Why care about Compliance? Tangible benefits of complyingIdentify & prevent criminal and unethical conductProcedures for prompt, thorough investigations of alleged misconductInitiate immediate and appropriate corrective action20
21Why care about Compliance? Tangible benefits of complyingCentralized source of information on health care regulationsMethodology encouraging employees to report problemsImprove quality of patient care21
22Why care about Compliance? Intangible benefits of complyingGood investment in your practicePeace of mind that rules are being followed22
23Why care about Compliance? Intangible benefits of complyingDecrease the risk of whistleblowersClear and consistent message to employeesAn improved practice culture!23
24A Basic Compliance Program Good business for any workplaceShould include prevention and detection of criminal conduct andEnforcement of the rules24
25This all started with… HIPAA of 1996* Doubled Office of Inspector (OIG) auditors and investigatorsExpanded Federal Bureau of Investigation’s (FBI) ability to investigate health care fraudCreated Medicare Integrity Program (MIP)Federal government may enter into contracts with private entities to review and audit activities where Medicare provides coverageEstablished reward program to encourage Medicare beneficiaries to report questionable behavior* HIPAA = Health Insurance Portability and Accountability Act
26OIG Model Compliance Plan(s) “Voluntary” Guidance(s) for creating a Compliance Programs for:Individual and small group physician practices pThird party medical billing companiesHospitalsNursing homesEtc.
27I am aware of the OIG Individual and Small Group Voluntary Compliance Plan from 2000.
28“Mandatory” Compliance Programs Coming “Soon”… 2 PPACA provisions mandate compliance programs for Medicare and Medicaid providers§ 6401 applies to ALL Medicare and Medicaid providers§ 6402 applies to Medicare skilled nursing facilities & Medicaid nursing facilities ONLYPatient Protection and Affordable Care Act (PPACA)28
29I am aware that the Patient Protection and Affordable Care Act will require all Medicare and Medicaid providers to have mandatory compliance plans in the future.
30CMS Comment to Providers: Implementing a Compliance program is “not just a paper exercise”Must be able to demonstrate that they have a “systemic process for proactively and promptly fixing noncompliance issues”Must be effective
31Objective:Explain the basics of creating and maintaining a compliance program
32Start with a SnapshotOIG suggests at inception of a Compliance Program, a review “snapshot” of operations be done to judge later progress in reducing or eliminating potential areas of vulnerability
33Baseline Audit “How To” OIG Work Plan issuesAny previous audit findingsExisting policiesAre they appropriate? Followed? Missing?Analysis of current education & trainingAttestation & attendance forms?Government regulationsUpdates?Professional association insights into current issues/trendsProfessional liability carrier newsletter of potential risk areasInterview staffWrite-up & let them reviewMinutes of Board or Compliance Committee
37The 7 ElementsThe OIG believes any Compliance Plan has 7 basic elements…Written Policies and ProceduresDesignating a compliance officer or contactConduct appropriate training and educationEffective lines of communicationInternal MonitoringEnforcement of StandardsPrompt ResponseAnd an informal 8th…8. Ensure it is effective – Periodically reassess
38Compliance Plan - Element #1 Written Policies & ProceduresUp-to-dateUser friendlyReflect what is actually going on in the practice!Employee Handbook
39Compliance Plan - Element #2 Designate a compliance officer or contactGive them reporting authority to go ‘to the top’ when necessary
40Compliance Plan - Element #3 Conduct appropriate training and educationMake training part of the jobTest employee knowledgeEnsure compliance officer job education and training too!
41Compliance Plan - Element #4 Effective lines of communicationSolicit feedbackMaintain visibility with staff members
42Compliance Plan - Element #5 Internal MonitoringCreate an audit plan to audit:CodingContractsCare
43Compliance Plan - Element #6 Enforcement of StandardsEnforce disciplinary standards through well-publicized guidelines (i.e. your Sanctions Policy!)Act promptly when issue ariseTake corrective actionDocument it all!
44Compliance Plan - Element #7 Respond promptly to identified risks or compliance issuesConduct an investigationCreate a Corrective Action PlanTrain staff (if necessary)Tell the government (if determined necessary)Modify your program (if necessary)
45Make it “effective” (#8) Once the Plan is established, develop a process to evaluate it and measure its effectiveness
46Evaluating Effectiveness Ideas Possible Metrics of an effective Compliance Program:Staff knowledgePre & post testsQuizzesSkits/role playEducational sessions# hrs. logged on compliance# policies & procedures reviewed# charts audited
47Evaluating Effectiveness Ideas Possible Metrics of an effective Compliance Program:% of denials in claims# mtgs with compliance on agenda (Staff, RN, BoD, Compliance Cmte, finance, billing)# of CPCs on staff/MDs# of CHCs on staff/MDs# of networking contacts for compliance related questions/issues in contacts database
48Objective:Review specific elements of a physician practice compliance plan
50OIG – Billing risk areas for small practice (and 3rd party billing) Examples of necessary general coding & billing policies:UnbundlingUpcoding the level of service providedInappropriate balance billingEtc.
51OIG – 2013 Work Plan Issues: Noncompliance with assignment rules . . . Incident To services by non-physiciansPlace of Service coding errorsModifiers during global surgery period, etc.https://oig.hhs.gov/reports-and-publications/archives/workplan/2013/Work-Plan-2013.pdf
52COMPLIANCE HEAT MAP RISK ASSESSMENT Stark Anti-Kickback HIPAA ADA FCA 5StarkAnti-KickbackHIPAAADA4FCAMedical RecordsRISK3DEAOSHAHROverpayment2Anti-Trust112345PROBABILITY
53A NOTE ABOUT SLIDE FORMAT 1st Bullet = What is the regulation?2nd Bullet = Why should your practice care?3rd Bullet = Where do you get help to comply?
54HIPAAWhat? HIPAA is the Federal Standards for Privacy of Individually Identifiable Health Information and/or the Security Standards for the Protection of Electronic Protected Health Information (45 Code of Federal Regulations [CFR] Parts and 164.Why?Enforcement is increased due to ARRA. Maximum fine increased to $1.5 million per incident.Where?
55Medical Records - Documentation What?The way to defend yourselfWhy?Proving compliance with lawsWhere?
56Correct Coding What? Why? Where? Medicare National Correct Coding Initiative (NCCI) edits apply now under ACA [Section 1902(a)(42)(B)(i) to Medicaid agenciesWhy?Recovery Audit Contractor (RAC) ProgramAllows government to contract with 3rd parties to audit billing and coding practicesOctober 1, 2014—Transition from ICD-9 codes (13,000) to ICD-10 codes (65,000)Where?
57False Claims Act www.OIG.hhs.gov What? Prohibits the submission of false or fraudulent claims to the federal government 31 U.S.C. §§Why?Federal government’s #1 tool for fighting fraud and abuse. The OIG has returned over $30 billion to the federal government.Expected recoveries from 2012 alone = $6.9 billionPenalty is $5k-$10k & 3x damages to the federal programWhere?
58Overpayment Refunds What? Section 6402(a) of PPACA Requires providers to report and return an overpayment to the appropriate Medicaid state agency or Medicare contractor within 60 days of identificationWhy?False Claims Act liabilityWhere?(Proposed Rule)
59HR: Non-Discrimination What?Civil Rights Act of 1964 (Title VII)U.S. Equal Employment Opportunity Commission (EEOC) promotes equal opportunity in employmentRequired to investigate all employment discrimination chargesWhy?EEOC may file claims in federal courtSubstantial civil damagesLoss of reputationWhere?
60HR: Sexual Harassment What? Why? Where? Sexual harassment is a form of sex discrimination that violates Title VII of the Civil Rights Act of 1964Why?Penalties (via litigation)Lost wagesCompensatory damagesPunitive damagesWhere?Title VII of the Civil Rights Act of 1964 :Guidelines:
61HR: Family Medical Leave Act (FMLA) What? Family Medical Leave Act of 1993Applies to employers with 50 or more employeesProvides entitlement of up to 12 weeks of job-protected leave during any 12-month period for birth of a child, care of an immediate family member, employee’s own serious health condition, or an immediate family member is on active military duty.Why?Enforced by the Department of Labor, Wage and Hour DivisionCourt actions to compel complianceCivil actions filed by employeesWhere?FMLA:DOL Poster:
62HR: Fair Labor Standards Act (FLSA) What?Fair Labor Standards Act of 1938, as amended 29 U.S.C. 201Basic minimum wage and overtime payWhy?Enforced by Department of Labor, Wage and Hour DivisionCivil suits for back wages, liquidated damages, and expensesCivil money penalties (up to $100,000 each violation for some child labor violations)Criminal penalties including fines and imprisonmentProtection of employees filing complaintsWhere?
63HR: Americans with Disabilities Act (ADA) What?ADA Employment (Title I) [42 U.S.C. § ]Employers with 15 or more employees must provide qualified individuals with disabilities an equal opportunity to the full range of employment-related opportunities available to others.Prohibits discrimination in recruitment, hiring, promotions, training, pay, social activities and other employment privileges.Why?Enforcement through Department of JusticeWhere?Current text of ADA Law -Guide to Disability Rights Laws -ADA Q&A -
64OSHA Medical Practice What? Occupational Safety and Health Act of 1970 Safe and healthful workplacePrimary OSHA standards affecting physician practices:Bloodborne PathogensHazardous ChemicalsExit routesElectricalReporting occupational injuries and illness (state-law)OSHA PosterIonizing Radiation (only if you have it)Why?Enforced by OSHAPenalties of up to $63,000 per instance for willful violationsWhere?https://www.osha.gov/law-regs.html
65Anti-Kickback Statute What?Anti-Kickback Statute [42 U.S.C. § 1320a-7b(b)]Prohibits knowing & willful payment of remuneration to induce or reward patient referralsDon’t confuse with STARK rulesWhy?Enforced by the Office of the Inspector General (OIG)Civil penalties: <$50,000 per and administrative sanctions (i.e. exclusion)Criminal penalties—fines up to $25K each occurrence/prison sentence up to 5 yearsWhere?
66STARKWhat?Physician Self-Referral Law [42 U.S.C. § 1395nn]Prohibits physicians from referring patients to a health facility in which the physician has a financial interestOIG 3 QuestionsWhy?Enforced by OIG. Penalties include:Refunds, FCA liability, program exclusionCMP up to $15K per service; $100K per arrangementCivil assessments up to 3x the claimWhere?
67Self-Disclosure Protocol NEW!What?Section 6409(a) of PPACAWhy?A tool for your Compliance ProgramWhere?https://oig.hhs.gov/compliance/Self-Disclosure-Info/files/Provider-Self-Disclosure-Protocol.pdf
68Americans with Disabilities Act (ADA) What? ADA Employment (Title I) [42 U.S.C. § 12186(b)]Public accommodations (Title III)Prohibits discrimination, exclusion, segregation and unequal treatmentArchitectural standardsReasonable modifications to policies, practices, and proceduresExample: Service animalsEffective communication with people with hearing, vision, or speech disabilitiesExample: Interpreters for hearing impairedWhy?Enforcement through Department of JusticeWhere?
69DEA What? Title 21 CFR, Part 1300-1399 Drug Enforcement Administration (DEA)Provider must apply for DEA certificate to handle controlled substancesWhy?DEA Audits. Loss of DEA Certificate prevents prescribing appropriate medications.Where?
70FDAWhat?Approved drugs are found in the Food & Drug Administration (FDA) Orange BookOff-Label usePhysician must be well informedUse “firm scientific rationale” and “medical evidence”Maintain records of use and effectsOrder only FDA-approved drugsWhy?Can lead to a violation of the FCA, and a RAC audit.Where?
71Electronic Claims What? Administrative Simplification Compliance Act (ASCA) requires electronic filing of Medicare claimsAs of January 2014, all Medicare claims must be filed electronicallyEach provider must complete an Electronic Data Interchange (EDI) enrollment formWhy? Medicare will only pay on claims submitted electronically on claims after 1/1/2014.Where?
72Use of Non-Physician Providers What? Medicare billing options:NPPs own provider #NPP can use physician provider # in certain circumstances (“incident to”)Inpatient = Shared visitWhy?False Claims Act liability. Higher reimbursement rate.In 2012 and 2013 OIG Work Plans.Where?
73Medicare Incentive Programs What?Programs such as Meaningful Use, PQRS, eRx, ACOs, and others that offer additional bonus payments and/or penalties for meeting specific criteria. Must be able to document that criteria are actually met.Why?Receive incentivesAvoid penaltiesAvoid implication of False Claims or Fraud/AbuseWhere?Meaningful Use -PQRS and others -
74Patient Check-In What? Why? Where? Collecting Co-pays and Deductibles; Advance Beneficiary Notice (ABN)Financial Hardships; Professional CourtesiesWhy?False Claims Act & Anti-Kickback Statute. Penalties include jail time.Where?Not collecting co-pays, deductibles on a regular basis could constitute fraud.Professional Courtesy:Advanced Beneficiary Notice:
75Antitrust Laws What? Why? Where? Sherman Act (1890) outlaws or restricts business practices that are monopolistic or restrain interstate commerceClayton Act (1914) prohibits pricing discrimination among customers and prohibits business combinations the effect of which “substantially lessens competition”Why?Enforced Federal Trade Commission (FTC) and Department of Justice (DOJ)Injunction, civil penalties, or consumer redressWhere?
76Sunshine Act What? Why? Where? NEW! Physician Payment Sunshine Act Final Rule - ACA Section 1128GAnything over $10 or $100/yr per manufacturer or Group Purchasing Organization (GPO) must be reported by them.Why?Possible reputation and whistleblower risk to physicians and practicesNo legal ramifications for providers yetWhere?https://www.ama-assn.org/ama/pub/advocacy/topics/sunshine-act-and-physician-financial-transparency-reports.page
77Dismissing a Patient What? Why? Where? State law and risk management area.Legal and ethical compliance issues.Why?You must be careful when terminating patient relationships so that you do not discriminate or terminate in such a way as to violate your legal and ethical obligations to the patient.Where?Check with state medical board to ensure compliance with state-specific rulesMalpractice carrier.
78Informed Consents What? Basic principle of law and ethics Center for Medicare & Medicaid Services (CMS) Conditions of ParticipationWhy?Discussion and disclosure (Malpractice risk)Where?State lawMalpractice carrier
79Medicare Provider Exclusion Law What?Sections 1128 & 1156 of the Social Security ActOffice of Inspector General (OIG) maintains a list that identifies individuals found guilty of fraudulent billing, misrepresentation of credentials, etc.Why?Office of the Inspector General - can’t bill Medicare or MedicaidPrivate insurers are running the lists of providers as wellPractice policy should be to not employ or contract with individuals on the listWhere?for List of Excluded Individuals/Entities (LEIE)
80In-Office Labs What? Why? Where? Clinical Laboratory Improvements Amendments (CLIA) 42 CFR Part 493Certification required to receive federal funds for servicesWhy?False Claims Act implication. (enforced by the OIG)Criminal penalties and Civil Monetary Penalties. Program exclusion.Where?
81On-Call/Emergency Treatment What?Emergency Medical Treatment and Labor Act (EMTALA) 42 USC Sec. 1395ddImpacts hospitals w/ ED (mostly) and on-call physiciansOn-call lists must be current and signedPhysician must arrive within a reasonable amount of time (30-60 min)Why?Average of 400 investigations/yearCMP up to $50k per penaltyTermination from CMS (exclusion)Where?
82Collections for Bad Debt What?Fair and Accurate Credit Transactions Act (FACTA)Fair Debt Collection Act (FDCR)Collections of bad debt pose unique problems for health care providers and entitiesWhy?Enforced by the Federal Trade Commission (FTC)Where?
83Objectives: 1: Describe the importance of a Compliance program 2: Explain the basics of creating and maintaining a compliance program3: Review specific elements of a physician practice compliance plan
84Questions? Daryl Smith Marcia Brauchler Central Utah Clinic Marcia BrauchlerPhysicians’ Ally, Inc.