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Health Care Compliance Association Region VII Compliance Conference August 1, 2003.

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Presentation on theme: "Health Care Compliance Association Region VII Compliance Conference August 1, 2003."— Presentation transcript:

1 Health Care Compliance Association Region VII Compliance Conference August 1, 2003

2 Evaluating Your Compliance Program’s Effectiveness Lawrence A. Fogel, Partner Joseph M. Watt, Partner BKD, LLP Kansas City, MO

3 Criminal Fraud Convictions o Enforcement agencies continue to actively investigate and prosecute health care fraud cases o Criminal fraud convictions increased from 250 to 320 for the six month period ended March 31, 2003

4 What Role Do Boards Have? o Boards have fiduciary responsibilities for overseeing the corporate affairs of their organization o Boards need to have verbal & written communications with management to satisfy their oversight responsibilities o The OIG & AHLA co-authored the “Corporate Responsibility & Corporate Compliance Guidance” in April 2003

5 What Role Do Boards Have? o This guidance is designed to help boards better understand their oversight duties & responsibilities o Boards should be educated on this guidance & their fiduciary responsibilities o An effective compliance program is the centerpiece for boards to oversee the compliance activities of their organizations

6 Questions a CCO Should Be Prepared to Answer o How would you, as the CCO, answer the following question: o The Chairman of the Board asks you to evaluate your compliance program

7 Questions a CCO Should Be Prepared to Answer o How would you, as the CCO, answer the following question: o The CEO asks you if the compliance program is being followed

8 Questions a CCO Should Be Prepared to Answer o How would you, as the CCO, answer the following question: o A CCC member asks you if the compliance committee has achieved its goals

9 Questions a CCO Should Be Prepared to Answer o How would you, as the CCO, answer the following question: o A Federal Agent asks you to present documentation to show that your compliance program is effective

10 What You Will Learn Today o What areas of the compliance program should be evaluated? o How should the evaluation be conducted? o How can the evaluation be quantified? o How can the compliance program be improved?

11 Questions a CCP Should Address o What are the elements that distinguish an effective compliance program from an ineffective one? o How should the CCO & CCC identify & document the strengths & weaknesses in the compliance program?

12 Questions a CCP Should Address o What method or process has been established to evaluate the effectiveness of the compliance program? o What are the symptoms of an ailing compliance program? o What are the remedies to cure an ailing compliance program?

13 Symptoms of an Ailing Compliance Program o Compliance officer & committee o Compliance plan & code of conduct o Audits o Complaints o Policies o Education & training o Background checks

14 Questions a CCP Should Address o What method or process has been established to evaluate the effectiveness of the compliance program? o What are the symptoms of an ailing compliance program? o What are the remedies to cure an ailing compliance program?

15 Caution o Don’t make the mistake of thinking you already know what the problems are o You may not know what all the problems are or they may be bigger than you thought o Thinking about the problems does not solve them o Taking no action on addressing problems may indicate a lack of concern

16 Why Should Compliance Programs Be Reviewed Each Year? o The OIG recommends o An independent & objective review be conducted annually o Reviewer should be independent from line management o Annual reviews of the compliance plan & program are healthy & productive & show the organization is striving to improve its performance

17 What is a Compliance Program Assessment (CPA)? o The CPA is a management tool to measure the effectiveness of a compliance program o The CPA consists of 3 major phases o Phase 1-Compliance Retreat o Phase 2-Private Interviews o Phase 3-Documentation Review o A grade card is completed at the end of Phase 3

18 First Things First: The GAP Analysis o Before the three phases of the CPA are started, the compliance plan should be reviewed in detail o A GAP analysis of the plan & actual practices should be performed

19 First Things First: The GAP Analysis o GAPs can occur because of conflicting policies & differences between the plan’s requirements & actual practices o The compliance plan should be revised as necessary to eliminate all GAPs & to incorporate all significant legal & regulatory developments

20 Phase 1 Compliance Retreat o Each CCC member completes a scorecard evaluating the key elements of the CCP o The CCC members evaluate 20 elements

21 Phase 1 Compliance Retreat o These elements include, in part, the following o Were the CCC meetings productive? o Did the CCC meet as required? o Did the CCC meet its goals? o Were the plan & the code of conduct followed? o Was the compliance training effective? o Are policies & procedures clear & current? o Were audits conducted of risk areas? Were exceptions from audits properly resolved?

22 Phase 1 Compliance Retreat o Were disciplinary actions taken when necessary? o Were complaints processed according to the plan? o Were investigations of complaints conducted & resolved? o Were background checks conducted according to the plan? o Did the compliance program meet its objectives?

23 How Is the Scoring Done? o Each element is graded using a point scale of 1 to 10 o The scores are tabulated for each element & a composite score is calculated

24 How Is the Scoring Done? o Scores for each element may be compared to prior years o Composite scores may be compared to prior years

25 Other Benefits of the Retreat o A risk assessment can be performed by evaluating internal & external risks o A work plan can be developed to target exposure areas in the risk assessment o A brainstorming session can beneficial to identify opportunities to improve the compliance program

26 Phase II Private Interviews o Private interviews are usually conducted after the retreat o Interviews are scheduled in advance o CCC members & key players in the organization are interviewed

27 Phase II Private Interviews o Questions for the CCC members are different than the ones for the key players o Interviewees are asked a series of yes or no questions

28 Questions for CCC Members o Is the Board supportive of the compliance program? o Is senior management supportive of the compliance program?

29 Questions for CCC Members o Are the compliance meetings productive? o Has the organization followed its compliance program? o Was a risk assessment performed? o Were the risk areas audited? o Were compliance complaints received & resolved?

30 Questions for CCC Members o Was your compliance training satisfactory? o Were employees & other parties disciplined when necessary? o Are the policies & procedures clear & current? o Has your compliance program improved over the past 12 months?

31 Questions for Key Players o Do you know who the compliance officer is? o Does your organization have a compliance program? o Do you understand the purpose of the compliance program? o Have you read the plan & code of conduct? o Do you know how to report complaints?

32 Questions for Key Players o Is the process to report complaints effective? o Is your organization serious about compliance? o Has your compliance program improved over the past 12 months?

33 How is the Scoring Done? o Each positive response receives 1 point o Each negative response receives no points o The score is calculated by dividing the points earned by the total maximum points

34 Phase III Documentation Review & Grade Card o The final phase of the CPA is the review of key documentation & the completion of the grade card o The grade card is comprised of numeric & percentage scores for each of the seven major elements

35 The Seven Elements o General o Auditing & monitoring o Process to report complaints o Policies & procedures o Education & training o Background checks o Disciplinary actions

36 How is the Scoring Done? o The organization receives 1 point for each item on the grade card o The points that are earned are totaled & divided by the maximum points o A percentage grade is calculated for each element o A composite score is calculated as an overall grade for the compliance program

37 General o Included in this review: o Compliance committee minutes o Job descriptions o Committee composition o Compliance plan o Code of conduct o Other relevant documentation o A score is calculated on a maximum of 15 points

38 Auditing & Monitoring o Included in this review: o Was a risk assessment conducted? o Was a work plan prepared? o Was the work plan followed? o Was the OIG’s guidance along with other government agency’s guidance considered in the work plan? o Were internal & external audits conducted?

39 Auditing & Monitoring o The audits are reviewed along with the supporting documentation o A score is calculated on a maximum of 15 points

40 Process to Report Complaints o Included in this review: o Complaints received through the hotline & other reporting processes are reviewed

41 Process to Report Complaints o Documentation supporting the complaints is reviewed to determine if they were o Timely processed o Handled according to policy o Resolved in a proper manner o A maximum of 14 points can be earned

42 Policies & Procedures o Included in this review: o Are all policies & procedures in writing? o Are they current? o Do policies contain the model OIG language when appropriate?

43 Policies & Procedures o Are policies periodically reviewed? o Does a conflict of interest policy exist? o Does a gift & gratuity policy exist? o Does a record retention policy exist? o Does a business confidentiality policy exist? o Does a discount & waiver of coinsurance policy exist?

44 Policies & Procedures o Does a policy exist to provide free services? o Are the policies consistent if they appear in more than one document? o Are the policies followed? o A maximum score of 20 points can be earned

45 Education & Training o Included in this review: o Was the training documented? o Was the training coordinated & monitored? o Were new employees oriented on the compliance plan? o Was the orientation documented?

46 Education & Training o Did employees read the plan & the code, if required to do so? o Were employees given annual compliance training? o Were designated individuals given specialized training? o Was the training documented? o Was the training monitored?

47 Education & Training o Were employees given pre & post-tests? o Were employees surveyed on their educational needs? o Was the Board trained on compliance issues? o Was the medical staff trained on compliance issues? o A maximum of 15 points can be earned

48 Background Checks o Included in this review: o Focus on these issues to determine if background checks were properly conducted o Were background checks conducted in accordance with the compliance plan? o Were background checks conducted on all employees? o Was the OIG list of excluded providers & individuals checked?

49 Background Checks o Were felony background checks made? o Were background checks conducted on physicians? o Were they conducted on independent contractors & agency personnel? o Were reference checks conducted? o Was prior employment checked? o The score is based upon 10 total points

50 Disciplinary Actions o Policies & documentation relating to disciplinary actions are reviewed in this section o Sometimes it is difficult to distinguish between a compliance & non- compliance issue

51 Disciplinary Actions o Included in this review: o Does a disciplinary policy exist? o Has it been communicated to all employees? o Were employees disciplined when required by the policy? o Were compliance offenses defined? o Were employees evaluated on their compliance performance?

52 Disciplinary Actions o Were physicians subject to a disciplinary policy? o Has HR reported the disciplinary actions to the CCO? o A maximum of 10 points can be earned

53 Summary o There are many areas of a compliance program that should be evaluated o Documentation, communication & education are essential o When improvement is needed & corrective actions are taken, a clear message is sent that the organization is serious about compliance

54 Summary o Since the CPA is an annual process, an organization can compare results to measure improvement from year to year o The CPA can help an organization to objectively evaluate its compliance program to determine if it is effective

55 CPA o The CPA is an effective communication tool for the Board of Directors & management

56 Questions & Comments Thank you Lawrence A. Fogel, Partner 816 201-0218 Joseph M. Watt, Partner 816 201-0246


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