MEDICAID, MEDICARE & THIRD-PARTY BILLER COMPLIANCE TRAINING
ANNUAL COMPLIANCE TRAINING Navigation Tips You must have your PC’s sound on and close out all other programs from your PC. The navigation bar at the bottom of the slide will guide you through the training. When you finish the training course, you must complete and submit a certification/Acknowledgement Form in Module 5.
ANNUAL COMPLIANCE TRAINING Navigation Tips You must have your PC’s sound on and close out all other programs from your PC. The navigation bar at the bottom of the slide will guide you through the training. When you finish the training course, you must complete and submit a certification/Acknowledgement Form in Module 5. EXIT
PREPARATION Coordinate with your supervisor to have your phone covered/forwarded so you won’t be interrupted. Schedule approximately 1 hour to complete the training. The training is narrated so headphones may help you focus and avoid distracting your co-workers. Have a pen and paper handy. If you have questions, write them down and at the end of the training, call or the Compliance Officer. You must complete this entire mandatory training program before completing the Acknowledgement Form. ANNUAL COMPLIANCE TRAINING
PREPARATION Coordinate with your supervisor to have your phone covered/forwarded so you won’t be interrupted. Schedule approximately 1 hour to complete the training. The training is narrated so headphones may help you focus and avoid distracting your co-workers. Have a pen and paper handy. If you have questions, write them down and at the end of the training, call or the Compliance Officer. You must complete this entire mandatory training program before completing the Acknowledgement Form. ANNUAL COMPLIANCE TRAINING EXIT
COMPLIANCE OFFICE STAFF Compliance Officer – Jill Chaffee (715) Compliance Analyst – Attorney Jim Sherman ANNUAL COMPLIANCE TRAINING
COMPLIANCE OFFICE STAFF Compliance Officer – Jill Chaffee (715) Compliance Analyst – Attorney Jim Sherman ANNUAL COMPLIANCE TRAINING EXIT
TRAINING MODULES ANNUAL COMPLIANCE TRAINING 1.What is Compliance? 2.County’s Compliance Program 3.False Claims Act 4.Integrity Agreement 5.Certification
TRAINING MODULES ANNUAL COMPLIANCE TRAINING 1.What is Compliance? 2.County’s Compliance Program 3.False Claims Act 4.Integrity Agreement 5.Certification EXIT
MODULE 1 WHAT IS COMPLIANCE? ANNUAL COMPLIANCE TRAINING
MODULE 1 WHAT IS COMPLIANCE? ANNUAL COMPLIANCE TRAINING EXIT
WHAT IS COMPLIANCE? Knowing and following Federal, State and County laws, regulations, rules, guidelines, policies and procedures that apply to our jobs. Think about the agencies that regulate or oversee your activities. Compliance is throughout all departments, divisions, programs that provide Mental Health Services. Includes contractors, their employees and subcontractors. ANNUAL COMPLIANCE TRAINING
WHAT IS COMPLIANCE? Knowing and following Federal, State and County laws, regulations, rules, guidelines, policies and procedures that apply to our jobs. Think about the agencies that regulate or oversee your activities. Compliance is throughout all departments, divisions, programs that provide Mental Health Services. Includes contractors, their employees and subcontractors. ANNUAL COMPLIANCE TRAINING EXIT
OVERVIEW OF THE HEALTH CARE INDUSTRY Healthcare is Under Increased Scrutiny from Federal & State Governments. Estimated 10% of 1 Trillion spent on healthcare fraud/waste or abuse Federal and State healthcare programs facing financial difficulty Government Response Healthcare is enforcement priority Government personnel added and coordinated efforts (e.g. FBI, DOJ, OIG) New/tougher laws & regulations enacted including the Patient Protection & Affordable care Act of 2010 (the “Healthcare Reform Act”). The Act contains numerous provisions relating to healthcare fraud/waste/abuse, program integrity and new enforcement measures and resources. Also requires all healthcare providers participating in federal programs to establish and maintain a compliance program as a condition of their continued participation. ANNUAL COMPLIANCE TRAINING
OVERVIEW OF THE HEALTH CARE INDUSTRY Healthcare is Under Increased Scrutiny from Federal & State Governments. Estimated 10% of 1 Trillion spent on healthcare fraud/waste or abuse Federal and State healthcare programs facing financial difficulty Government Response Healthcare is enforcement priority Government personnel added and coordinated efforts (e.g. FBI, DOJ, OIG) New/tougher laws & regulations enacted including the Patient Protection & Affordable care Act of 2010 (the “Healthcare Reform Act”). The Act contains numerous provisions relating to healthcare fraud/waste/abuse, program integrity and new enforcement measures and resources. Also requires all healthcare providers participating in federal programs to establish and maintain a compliance program as a condition of their continued participation. ANNUAL COMPLIANCE TRAINING EXIT
HEALTHCARE FRAUD & ABUSE FRAUD False statements of representation of facts to obtain payment/benefit to which not otherwise entitled. Committed for one’s own benefit or on behalf of another. Must establish acts were performed knowingly, willfully and intentionally. Civil fraud violations have a lower standard of proof. Usually involve sanctions and financial penalties. ABUSE Practices that directly or indirectly result in unnecessary increased costs to clients. Medically unnecessary over- utilization. Not in conformance with industry standards. Fees that are unreasonable or unfair. Restrictive of patient choice. ANNUAL COMPLIANCE TRAINING
HEALTHCARE FRAUD & ABUSE FRAUD False statements of representation of facts to obtain payment/benefit to which not otherwise entitled. Committed for one’s own benefit or on behalf of another. Must establish acts were performed knowingly, willfully and intentionally. Civil fraud violations have a lower standard of proof. Usually involve sanctions and financial penalties. ABUSE Practices that directly or indirectly result in unnecessary increased costs to clients. Medically unnecessary over- utilization. Not in conformance with industry standards. Fees that are unreasonable or unfair. Restrictive of patient choice. ANNUAL COMPLIANCE TRAINING EXIT
RELEVANCE OF COMPLIANCE PROGRAMS Government believes the best way to protect public healthcare dollars is to prevent fraud/abuse. Educating individuals on the laws, regulations and organization’s standards that apply to them in the workplace. Encouraging individuals to ask questions or voice their concerns to the compliance officer. ANNUAL COMPLIANCE TRAINING
RELEVANCE OF COMPLIANCE PROGRAMS Government believes the best way to protect public healthcare dollars is to prevent fraud/abuse. Educating individuals on the laws, regulations and organization’s standards that apply to them in the workplace. Encouraging individuals to ask questions or voice their concerns to the compliance officer. ANNUAL COMPLIANCE TRAINING EXIT
WHY ARE COMPLIANCE PROGRAMS IMPORTANT? Promote open communication and problem resolution. Maintain Federal, State, County and industry standards to comply with increased government regulations. Demonstrate organization’s commitment to comply with all legal and ethical responsibilities. Keep pace with trend in the health care industry. ANNUAL COMPLIANCE TRAINING
WHY ARE COMPLIANCE PROGRAMS IMPORTANT? Promote open communication and problem resolution. Maintain Federal, State, County and industry standards to comply with increased government regulations. Demonstrate organization’s commitment to comply with all legal and ethical responsibilities. Keep pace with trend in the health care industry. ANNUAL COMPLIANCE TRAINING EXIT
ELEMENTS OF A COMPLIANCE PROGRAM ANNUAL COMPLIANCE TRAINING Compliance Program Compliance Officer & Committee Training & Education Policies & Procedures Monitoring & Auditing Communication & Anonymous Disclosure Corrective Action Code of Conduct Ethics Employees & Contractors
ELEMENTS OF A COMPLIANCE PROGRAM ANNUAL COMPLIANCE TRAINING Compliance Program Compliance Officer & Committee Training & Education Policies & Procedures Monitoring & Auditing Communication & Anonymous Disclosure Corrective Action Code of Conduct Ethics Employees & Contractors EXIT
MODULE 2 CHIPPEWA COUNTY’S COMPLIANCE PROGRAM ANNUAL COMPLIANCE TRAINING
MODULE 2 CHIPPEWA COUNTY’S COMPLIANCE PROGRAM ANNUAL COMPLIANCE TRAINING EXIT
CHIPPEWA COUNTY’S COMPLIANCE PROGRAM Required by Title 42 CFR Section 7 Specific Requirements 1.Standards & Procedures 2.Compliance Officer and Committee 3.Training and Education 4.Communication 5.Enforcement 6.Internal Monitoring/Auditing 7.Prompt response/corrective action ANNUAL COMPLIANCE TRAINING
CHIPPEWA COUNTY’S COMPLIANCE PROGRAM Required by Title 42 CFR Section 7 Specific Requirements 1.Standards & Procedures 2.Compliance Officer and Committee 3.Training and Education 4.Communication 5.Enforcement 6.Internal Monitoring/Auditing 7.Prompt response/corrective action ANNUAL COMPLIANCE TRAINING EXIT
COMPLIANCE REQUIREMENT #1: Standards & Procedures Mission Statement Code of Conduct Code of Ethics (For County employees only) View by clicking on the appropriate link below: Code of Conduct for Employees (section only) Code of Conduct for Employees (section only) ANNUAL COMPLIANCE TRAINING
COMPLIANCE REQUIREMENT #1: Standards & Procedures Mission Statement Code of Conduct Code of Ethics (For County employees only) View by clicking on the appropriate link below: Code of Conduct for Employees (section only) Code of Conduct for Employees (section only) ANNUAL COMPLIANCE TRAINING EXIT
COMPLIANCE REQUIREMENT #1: Standards & Procedures Mission Statement: Chippewa County Human Services Department will comply with applicable laws, regulations, rules or guidelines governing the provision of mental health services. All employees and contractors, who provide and receive payment for mental health services, are expected to conduct themselves honestly, fairly and with a high degree of integrity. Accordingly, the County has implemented a Compliance Program to ensure, to the extent reasonably possible, that all employees invoke a high degree of business honesty and integrity required of health care professionals and providers. In addition, this program has been instituted as a means of preventing fraud, abuse and false billings to any third-party payer. Strict adherence to the Compliance Program is expected of all mental health employees and contractors. ANNUAL COMPLIANCE TRAINING
COMPLIANCE REQUIREMENT #1: Standards & Procedures Mission Statement: Chippewa County Human Services Department will comply with applicable laws, regulations, rules or guidelines governing the provision of mental health services. All employees and contractors, who provide and receive payment for mental health services, are expected to conduct themselves honestly, fairly and with a high degree of integrity. Accordingly, the County has implemented a Compliance Program to ensure, to the extent reasonably possible, that all employees invoke a high degree of business honesty and integrity required of health care professionals and providers. In addition, this program has been instituted as a means of preventing fraud, abuse and false billings to any third-party payer. Strict adherence to the Compliance Program is expected of all mental health employees and contractors. ANNUAL COMPLIANCE TRAINING EXIT
COMPLIANCE REQUIREMENT #1: Standards & Procedures Conduct Standards The County is committed to full compliance with all applicable laws, regulations, rules and guidelines that apply to its mental health operations and services. Employee and contractor conduct is at the core of this commitment. County employees and contractors must adhere to: The Code of Conduct and the Compliance Program County employees must also adhere to the county’s Code of Ethics. ANNUAL COMPLIANCE TRAINING
COMPLIANCE REQUIREMENT #1: Standards & Procedures Conduct Standards The County is committed to full compliance with all applicable laws, regulations, rules and guidelines that apply to its mental health operations and services. Employee and contractor conduct is at the core of this commitment. County employees and contractors must adhere to: The Code of Conduct and the Compliance Program County employees must also adhere to the county’s Code of Ethics. ANNUAL COMPLIANCE TRAINING EXIT
COMPLIANCE REQUIREMENT #1: Standards & Procedures Code of Conduct County’s behavior expectations County’s commitment to its employees and contractors and to promote compliance with all applicable laws, etc. Familiarize staff with the basic legal principles of ethical standards of behavior expected in the provision, documentation, coding or billing of mental health services. Code of Ethics Established by the Leadership Committee Applies to all county employees ANNUAL COMPLIANCE TRAINING
COMPLIANCE REQUIREMENT #1: Standards & Procedures Code of Conduct County’s behavior expectations County’s commitment to its employees and contractors and to promote compliance with all applicable laws, etc. Familiarize staff with the basic legal principles of ethical standards of behavior expected in the provision, documentation, coding or billing of mental health services. Code of Ethics Established by the Leadership Committee Applies to all county employees ANNUAL COMPLIANCE TRAINING EXIT
COMPLIANCE REQUIREMENT #1: Standards & Procedures Certification All employees and contractors must sign the Acknowledgement and Agreement Form and submit it to the Compliance Officer. Form and instructions are in Module 5. ANNUAL COMPLIANCE TRAINING
COMPLIANCE REQUIREMENT #1: Standards & Procedures Certification All employees and contractors must sign the Acknowledgement and Agreement Form and submit it to the Compliance Officer. Form and instructions are in Module 5. ANNUAL COMPLIANCE TRAINING EXIT
COMPLIANCE REQUIREMENT #1: Standards & Procedures Documenting Compliance Activities Protects integrity of the compliance process and confirms the effectiveness of the Complicate Program. Must document, at a minimum: Trainings Investigations Anonymous Reporting Self-disclosure Modifications to the Compliance Program Results of the County’s auditing/monitoring efforts ANNUAL COMPLIANCE TRAINING
COMPLIANCE REQUIREMENT #1: Standards & Procedures Documenting Compliance Activities Protects integrity of the compliance process and confirms the effectiveness of the Complicate Program. Must document, at a minimum: Trainings Investigations Anonymous Reporting Self-disclosure Modifications to the Compliance Program Results of the County’s auditing/monitoring efforts ANNUAL COMPLIANCE TRAINING EXIT
COMPLIANCE REQUIREMENT #2: Compliance Officer and Committee Compliance Officer Responsibilities Oversight of the Compliance Program Establish and maintain the Code of Conduct & Policies and Procedures Chair the Compliance Committee Ensure an ongoing training/education program Establish auditing/monitoring procedures Compliance investigations Promote awareness and understanding of the positive, ethical and moral practices consistent with the mission and values of the county and those required by applicable laws, regulations, rules or guidelines. Report findings to the Agency Director. ANNUAL COMPLIANCE TRAINING
COMPLIANCE REQUIREMENT #2: Compliance Officer and Committee Compliance Officer Responsibilities Oversight of the Compliance Program Establish and maintain the Code of Conduct & Policies and Procedures Chair the Compliance Committee Ensure an ongoing training/education program Establish auditing/monitoring procedures Compliance investigations Promote awareness and understanding of the positive, ethical and moral practices consistent with the mission and values of the county and those required by applicable laws, regulations, rules or guidelines. Report findings to the Agency Director. ANNUAL COMPLIANCE TRAINING EXIT
COMPLIANCE REQUIREMENT #2: Compliance Officer The Compliance Officer has the full authority to stop any work process that may be the cause of, or is contributing to non-compliance, until the process has been reviewed and/or corrected, if needed. ANNUAL COMPLIANCE TRAINING
COMPLIANCE REQUIREMENT #2: Compliance Officer The Compliance Officer has the full authority to stop any work process that may be the cause of, or is contributing to non-compliance, until the process has been reviewed and/or corrected, if needed. ANNUAL COMPLIANCE TRAINING EXIT
COMPLIANCE REQUIREMENT #2: Compliance Officer & Committee Compliance Committee Responsibilities include: Organizational Support Promote awareness of the Compliance Program Advise the Compliance Officer Implement the Compliance Program Monitor/assess effectiveness of compliance with applicable laws, etc. Address areas of concern or risk ANNUAL COMPLIANCE TRAINING
COMPLIANCE REQUIREMENT #2: Compliance Officer & Committee Compliance Committee Responsibilities include: Organizational Support Promote awareness of the Compliance Program Advise the Compliance Officer Implement the Compliance Program Monitor/assess effectiveness of compliance with applicable laws, etc. Address areas of concern or risk ANNUAL COMPLIANCE TRAINING EXIT
Employee & Contractor Roles & Responsibilities in Compliance Help the county operate a successful Compliance Program Comply with the Code of Conduct & Code of Ethics Adhere to the Compliance Program and all applicable laws, rules, regulations, guidelines, policies and procedures Report a violation or suspected violation. ANNUAL COMPLIANCE TRAINING
Employee & Contractor Roles & Responsibilities in Compliance Help the county operate a successful Compliance Program Comply with the Code of Conduct & Code of Ethics Adhere to the Compliance Program and all applicable laws, rules, regulations, guidelines, policies and procedures Report a violation or suspected violation. ANNUAL COMPLIANCE TRAINING EXIT
COMPLIANCE REQUIREMENT #3: Training & Education All county employees and contractors, including contractor’s employees and subcontractors, must be trained and retrained to keep abreast of changes in Federal, State and County laws, rules regulation, policies and procedures. ANNUAL COMPLIANCE TRAINING
COMPLIANCE REQUIREMENT #3: Training & Education All county employees and contractors, including contractor’s employees and subcontractors, must be trained and retrained to keep abreast of changes in Federal, State and County laws, rules regulation, policies and procedures. ANNUAL COMPLIANCE TRAINING EXIT
COMPLIANCE REQUIREMENT #3: Training & Education Timelines: Within 30 days of hire or contract effective date Annually General Compliance Training Mandatory for all employees & contractors who: Provide mental health services Work in any mental health program or paid with MH $$ Are responsible for the billing, claiming, accounting or cost reporting of mental health services ANNUAL COMPLIANCE TRAINING
COMPLIANCE REQUIREMENT #3: Training & Education Timelines: Within 30 days of hire or contract effective date Annually General Compliance Training Mandatory for all employees & contractors who: Provide mental health services Work in any mental health program or paid with MH $$ Are responsible for the billing, claiming, accounting or cost reporting of mental health services ANNUAL COMPLIANCE TRAINING EXIT
COMPLIANCE REQUIREMENT #4: Communication Maintain open lines of communication Annual trainings Post the Code of Ethics and Code of Conduct Post information regarding options for reporting compliance violations or concerns anonymously Non-retaliation Policy ANNUAL COMPLIANCE TRAINING
COMPLIANCE REQUIREMENT #4: Communication Maintain open lines of communication Annual trainings Post the Code of Ethics and Code of Conduct Post information regarding options for reporting compliance violations or concerns anonymously Non-retaliation Policy ANNUAL COMPLIANCE TRAINING EXIT
COMPLIANCE REQUIREMENT #4: Communication Reporting Violations Employees and contractors are EXPECTED To report any activity that may violate the Compliance Program’s mission, standards and any applicable law, regulation, rule or guideline. ANNUAL COMPLIANCE TRAINING
COMPLIANCE REQUIREMENT #4: Communication Reporting Violations Employees and contractors are EXPECTED To report any activity that may violate the Compliance Program’s mission, standards and any applicable law, regulation, rule or guideline. ANNUAL COMPLIANCE TRAINING EXIT
COMPLIANCE REQUIREMENT #4: Communication Non-Retaliation Policy Chippewa County prohibits retaliation against any person making a report. Any employee engaging in any form of retaliation will be subject to disciplinary action. For a contractor engaging in any form of retaliation, termination of their contract may result. ANNUAL COMPLIANCE TRAINING
COMPLIANCE REQUIREMENT #4: Communication Non-Retaliation Policy Chippewa County prohibits retaliation against any person making a report. Any employee engaging in any form of retaliation will be subject to disciplinary action. For a contractor engaging in any form of retaliation, termination of their contract may result. ANNUAL COMPLIANCE TRAINING EXIT
COMPLIANCE REQUIREMENT #4: Communication Disclosure Program Reporting Methods Anonymously: Mail: Jill Chaffee, Compliance Officer 711 N Bridge St Chippewa Falls, WI Direct to the Compliance Officer Phone (715) ANNUAL COMPLIANCE TRAINING
COMPLIANCE REQUIREMENT #4: Communication Disclosure Program Reporting Methods Anonymously: Mail: Jill Chaffee, Compliance Officer 711 N Bridge St Chippewa Falls, WI Direct to the Compliance Officer Phone (715) ANNUAL COMPLIANCE TRAINING EXIT
Anonymous Reporting Scenario Steve White has falsified documentation. He documented and billed for services for days he wasn’t even at work. His supervisor lets him get away with it. Someone needs to look into this. Q) Does this report contain sufficient information to begin an effective investigation? ANNUAL COMPLIANCE TRAINING
Anonymous Reporting Scenario Steve White has falsified documentation. He documented and billed for services for days he wasn’t even at work. His supervisor lets him get away with it. Someone needs to look into this. Q) Does this report contain sufficient information to begin an effective investigation? ANNUAL COMPLIANCE TRAINING EXIT
Anonymous Reporting Scenario Steve White has falsified documentation. He documented and billed for services for days he wasn’t even at work. His supervisor lets him get away with it. Someone needs to look into this. A) No - the information provided lacks the detailed need to effectively investigate the concern: Who? What? Where? When? Why? How? ANNUAL COMPLIANCE TRAINING
Anonymous Reporting Scenario Steve White has falsified documentation. He documented and billed for services for days he wasn’t even at work. His supervisor lets him get away with it. Someone needs to look into this. A) No - the information provided lacks the detailed need to effectively investigate the concern: Who? What? Where? When? Why? How? ANNUAL COMPLIANCE TRAINING EXIT
Anonymous Reporting Scenario Steve White, an LCSW who works for the ABC Clinic on Plaza Street, has falsified documentation. He documented and billed for services for 11/20, 12/7 & 8 which are days he wasn’t even at work. I mentioned my concern to Ron Wood, his supervisor, but Ron said that he’s too busy to keep track of everyone and besides, he trusts Steve. Q) Does the anonymous report contain sufficient information to begin an effective investigation? ANNUAL COMPLIANCE TRAINING
Anonymous Reporting Scenario Steve White, an LCSW who works for the ABC Clinic on Plaza Street, has falsified documentation. He documented and billed for services for 11/20, 12/7 & 8 which are days he wasn’t even at work. I mentioned my concern to Ron Wood, his supervisor, but Ron said that he’s too busy to keep track of everyone and besides, he trusts Steve. Q) Does the anonymous report contain sufficient information to begin an effective investigation? ANNUAL COMPLIANCE TRAINING EXIT
Anonymous Reporting Scenario Steve White, an LCSW who works for the ABC Clinic on Plaza Street, has falsified documentation. He documented and billed for services for 11/20, 12/7 & 8 which are days he wasn’t even at work. I mentioned my concern to Ron Wood, his supervisor, but Ron said that he’s too busy to keep track of everyone and besides, he trusts Steve. A) Yes, it provides answers to Who? What? Where? When? Why? How? ANNUAL COMPLIANCE TRAINING
Anonymous Reporting Scenario Steve White, an LCSW who works for the ABC Clinic on Plaza Street, has falsified documentation. He documented and billed for services for 11/20, 12/7 & 8 which are days he wasn’t even at work. I mentioned my concern to Ron Wood, his supervisor, but Ron said that he’s too busy to keep track of everyone and besides, he trusts Steve. A) Yes, it provides answers to Who? What? Where? When? Why? How? ANNUAL COMPLIANCE TRAINING EXIT
Code of Conduct Question: You have a compliance concern and/or believe that a fraudulent activity is occurring. What should you do? Select the best answer below: A.Don’t report and see if the fraudulent activity stops. B.Report your concerns to your supervisor or department head. C.Immediately report your concerns to the Compliance Officer. D.Any of the above. ANNUAL COMPLIANCE TRAINING
Code of Conduct Question: You have a compliance concern and/or believe that a fraudulent activity is occurring. What should you do? Select the best answer below: A.Don’t report and see if the fraudulent activity stops. B.Report your concerns to your supervisor or department head. C.Immediately report your concerns to the Compliance Officer. D.Any of the above. ANNUAL COMPLIANCE TRAINING EXIT
COMPLIANCE REQUIREMENT #5: Enforcement Fair, reasonable but enforced Communicate enforcement & discipline standards Prohibits prejudice, bias or other non-standard conduct Employee subject to appropriate disciplinary action by his/her department head County Personnel Rules and progressive discipline used: Oral, Written, Suspension w/o pay, Salary Reduction, Demotion, Dismissal ANNUAL COMPLIANCE TRAINING
COMPLIANCE REQUIREMENT #5: Enforcement Fair, reasonable but enforced Communicate enforcement & discipline standards Prohibits prejudice, bias or other non-standard conduct Employee subject to appropriate disciplinary action by his/her department head County Personnel Rules and progressive discipline used: Oral, Written, Suspension w/o pay, Salary Reduction, Demotion, Dismissal ANNUAL COMPLIANCE TRAINING EXIT
COMPLIANCE REQUIREMENT #6: Internal Monitoring & Auditing Reviews conducted to measure compliance with: Billing and Coding Exclusion List Compliance Education Medical Reviews Operating Licenses Clinical Staff Licensure Correction Documentation Report findings to Compliance Officer, Compliance Committee and Director, as required. ANNUAL COMPLIANCE TRAINING
COMPLIANCE REQUIREMENT #6: Internal Monitoring & Auditing Reviews conducted to measure compliance with: Billing and Coding Exclusion List Compliance Education Medical Reviews Operating Licenses Clinical Staff Licensure Correction Documentation Report findings to Compliance Officer, Compliance Committee and Director, as required. Internal Compliance Review and Monitoring Internal Compliance Review and Monitoring ANNUAL COMPLIANCE TRAINING EXIT
COMPLIANCE REQUIREMENT #6: Internal Monitoring & Auditing Background & Sanction Screening Licensing boards and National Practitioner Databanks Ensures that the county does not hire or contract with an individual or entity that is suspended or excluded from Federal healthcare programs. County's Sanction Screening Policy to identify suspended or excluded persons: Screen all prospective employees, contractors and volunteers/interns against the exclusion list prior to hire/contract/engaging their services and bi-annually thereafter. Exclusions lists: HHS OIG List of Excluded Individuals/Entities (LEIE) ANNUAL COMPLIANCE TRAINING
COMPLIANCE REQUIREMENT #6: Internal Monitoring & Auditing Background & Sanction Screening Licensing boards and National Practitioner Databanks Ensures that the county does not hire or contract with an individual or entity that is suspended or excluded from Federal healthcare programs. County's Sanction Screening Policy to identify suspended or excluded persons: Screen all prospective employees, contractors and volunteers/interns against the exclusion list prior to hire/contract/engaging their services and bi-annually thereafter. Exclusions lists: HHS OIG List of Excluded Individuals/Entities (LEIE) ANNUAL COMPLIANCE TRAINING EXIT
COMPLIANCE REQUIREMENT #6: Internal Monitoring & Auditing Other areas monitored/audited: Disclosure Program Billing Committee decisions Business Office functions/processes Modifications/updates to EHR system Cost Reports ANNUAL COMPLIANCE TRAINING
COMPLIANCE REQUIREMENT #6: Internal Monitoring & Auditing Other areas monitored/audited: Disclosure Program Billing Committee decisions Business Office functions/processes Modifications/updates to EHR system Cost Reports ANNUAL COMPLIANCE TRAINING EXIT
COMPLIANCE REQUIREMENT #7: Response & Corrective Action Prompt Investigation Corrective Action Follow-up Further Action Prompt Refund of Overpayments ANNUAL COMPLIANCE TRAINING
COMPLIANCE REQUIREMENT #7: Response & Corrective Action Prompt Investigation Corrective Action Follow-up Further Action Prompt Refund of Overpayments ANNUAL COMPLIANCE TRAINING EXIT
COMPLIANCE PROGRAM REVIEW Q)The purpose of the County’s Code of Conduct is to: A.Promote the county’s commitment to compliance. B.State the county’s behavior expectations, legal standards and ethical requirements. C.Address all county mental health employees, volunteers and contractors (including contractor’s staff). D.All of the above. ANNUAL COMPLIANCE TRAINING
COMPLIANCE PROGRAM REVIEW Q)The purpose of the County’s Code of Conduct is to: A.Promote the county’s commitment to compliance. B.State the county’s behavior expectations, legal standards and ethical requirements. C.Address all county mental health employees, volunteers and contractors (including contractor’s staff). D.All of the above. ANNUAL COMPLIANCE TRAINING EXIT
COMPLIANCE PROGRAM REVIEW Q)The purpose of the County’s Code of Conduct is to: A.Promote the county’s commitment to compliance. B.State the county’s behavior expectations, legal standards and ethical requirements. C.Address all county mental health employees, volunteers and contractors (including contractor’s staff). D.All of the above. ANNUAL COMPLIANCE TRAINING
COMPLIANCE PROGRAM REVIEW Q)The purpose of the County’s Code of Conduct is to: A.Promote the county’s commitment to compliance. B.State the county’s behavior expectations, legal standards and ethical requirements. C.Address all county mental health employees, volunteers and contractors (including contractor’s staff). D.All of the above. ANNUAL COMPLIANCE TRAINING EXIT
COMPLIANCE PROGRAM REVIEW Q)What is the role of the Compliance Committee? A)To assist and advise the Compliance Officer. B)To assist in the development or review of compliance related policy and procedures. C)To rule on appropriate discipline for compliance violation issues. D)To assist in the implementation of the Compliance Program. E)All of the above. F)A, B & D only. ANNUAL COMPLIANCE TRAINING
COMPLIANCE PROGRAM REVIEW Q)What is the role of the Compliance Committee? A)To assist and advise the Compliance Officer. B)To assist in the development or review of compliance related policy and procedures. C)To rule on appropriate discipline for compliance violation issues. D)To assist in the implementation of the Compliance Program. E)All of the above. F)A, B & D only. ANNUAL COMPLIANCE TRAINING EXIT
COMPLIANCE PROGRAM REVIEW Q)What is the role of the Compliance Committee? A)To assist and advise the Compliance Officer. B)To assist in the development or review of compliance related policy and procedures. C)To rule on appropriate discipline for compliance violation issues. D)To assist in the implementation of the Compliance Program. E)All of the above. F)A, B & D only. ANNUAL COMPLIANCE TRAINING
COMPLIANCE PROGRAM REVIEW Q)What is the role of the Compliance Committee? A)To assist and advise the Compliance Officer. B)To assist in the development or review of compliance related policy and procedures. C)To rule on appropriate discipline for compliance violation issues. D)To assist in the implementation of the Compliance Program. E)All of the above. F)A, B & D only. ANNUAL COMPLIANCE TRAINING EXIT
COMPLIANCE PROGRAM REVIEW Q)We have the right to report breaches without fear of retaliation? TRUE Or FALSE ANNUAL COMPLIANCE TRAINING
COMPLIANCE PROGRAM REVIEW Q)We have the right to report breaches without fear of retaliation? TRUE Or FALSE ANNUAL COMPLIANCE TRAINING EXIT
COMPLIANCE PROGRAM REVIEW Q)We have the right to report breaches without fear of retaliation? TRUE Or FALSE ANNUAL COMPLIANCE TRAINING
COMPLIANCE PROGRAM REVIEW Q)We have the right to report breaches without fear of retaliation? TRUE Or FALSE ANNUAL COMPLIANCE TRAINING EXIT
COMPLIANCE PROGRAM REVIEW Q)For county employees, discipline for a violation of a compliance issue falls outside the normal disciplinary process? TRUE Or FALSE ANNUAL COMPLIANCE TRAINING
COMPLIANCE PROGRAM REVIEW Q)For county employees, discipline for a violation of a compliance issue falls outside the normal disciplinary process? TRUE Or FALSE ANNUAL COMPLIANCE TRAINING EXIT
COMPLIANCE PROGRAM REVIEW Q)For county employees, discipline for a violation of a compliance issue falls outside the normal disciplinary process? TRUE Or FALSE ANNUAL COMPLIANCE TRAINING
COMPLIANCE PROGRAM REVIEW Q)For county employees, discipline for a violation of a compliance issue falls outside the normal disciplinary process? TRUE Or FALSE ANNUAL COMPLIANCE TRAINING EXIT
MODULE 3 False Claims Act ANNUAL COMPLIANCE TRAINING
MODULE 3 False Claims Act ANNUAL COMPLIANCE TRAINING EXIT
FALSE CLAIMS ACT Accuracy is critical in our billing/claim documents because the specific intent to defraud is NOT required under the Federal and State False Claims Act. ANNUAL COMPLIANCE TRAINING
FALSE CLAIMS ACT Accuracy is critical in our billing/claim documents because the specific intent to defraud is NOT required under the Federal and State False Claims Act. ANNUAL COMPLIANCE TRAINING EXIT
Federal Civil False Claims 31 U.S.C. SECTION 3729(A) Any person who knowingly presents, or causes to be presented to the Federal Government a false claim, is liable to the U.S. Government for a civil penalty, for EACH claim of not less than $5,000 and not more than $10,000, plus three times the amount of the damages. For Example: Erroneous billings of 120 claims for $12,000 could result in a penalty of over $1.2 million. ANNUAL COMPLIANCE TRAINING
Federal Civil False Claims 31 U.S.C. SECTION 3729(A) Any person who knowingly presents, or causes to be presented to the Federal Government a false claim, is liable to the U.S. Government for a civil penalty, for EACH claim of not less than $5,000 and not more than $10,000, plus three times the amount of the damages. For Example: Erroneous billings of 120 claims for $12,000 could result in a penalty of over $1.2 million. ANNUAL COMPLIANCE TRAINING EXIT
Federal False Claims Act 31 U.S.C. SECTION 3730 Includes provisions that allow a private citizen (relator) to file suit alleging false claims on behalf of the relator and the government. This is known as: “Qui Tam Action” ANNUAL COMPLIANCE TRAINING
Federal False Claims Act 31 U.S.C. SECTION 3730 Includes provisions that allow a private citizen (relator) to file suit alleging false claims on behalf of the relator and the government. This is known as: “Qui Tam Action” ANNUAL COMPLIANCE TRAINING EXIT
Federal Whistleblower Protection 31 U.S.C. SECTION 3730(h) Provides protection to employees against discharge, demotion suspension, threats, harassment or discrimination by the employer, for cooperating with or stating a False Claims Act investigation. ANNUAL COMPLIANCE TRAINING
Federal Whistleblower Protection 31 U.S.C. SECTION 3730(h) Provides protection to employees against discharge, demotion suspension, threats, harassment or discrimination by the employer, for cooperating with or stating a False Claims Act investigation. ANNUAL COMPLIANCE TRAINING EXIT
Federal Criminal False Claims 18 U.S.C. SECTION 1035 Criminalizes false or fictitious statements involving a Federal health care benefit program. PENALTIES up to 5 years in prison, and/or $25,000 fine. ANNUAL COMPLIANCE TRAINING
Federal Criminal False Claims 18 U.S.C. SECTION 1035 Criminalizes false or fictitious statements involving a Federal health care benefit program. PENALTIES up to 5 years in prison, and/or $25,000 fine. ANNUAL COMPLIANCE TRAINING EXIT
Wisconsin False Claims Act 2007 Wisconsin Act 20 Section of Wisconsin Statutes applies to claims made to any officer, employee or agency of this state.. ANNUAL COMPLIANCE TRAINING
Wisconsin False Claims Act 2007 Wisconsin Act 20 Section of Wisconsin Statutes applies to claims made to any officer, employee or agency of this state.. ANNUAL COMPLIANCE TRAINING EXIT
Wisconsin False Claims Act The federal Deficit Reduction Act of 2005 provided states with a financial incentive to pursue more civil fraud cases against Medical Assistance providers. WI Act 20: Establishes civil liability for individuals or entities that submit false or fraudulent claims to the Medical Assistance program; Requires civil penalties of three times the amount of damages sustained by the State, and assessments of at least $5,000 but no more than $10,000 for each violation; and. ANNUAL COMPLIANCE TRAINING
Wisconsin False Claims Act The federal Deficit Reduction Act of 2005 provided states with a financial incentive to pursue more civil fraud cases against Medical Assistance providers. WI Act 20: Establishes civil liability for individuals or entities that submit false or fraudulent claims to the Medical Assistance program; Requires civil penalties of three times the amount of damages sustained by the State, and assessments of at least $5,000 but no more than $10,000 for each violation; and. ANNUAL COMPLIANCE TRAINING EXIT
Wisconsin False Claims Act The Wisconsin False Claims Act also includes provisions that allow a private citizen to bring a civil action for violation of this article as a “qui tam plaintiff” The Act rewards individuals who bring a case to civil court on the State’s behalf against another person or entity for making a false or fraudulent claim for Medical Assistance, including rewards of at least 15% but not more than 30% of any proceeds of the action or settlement of the claim.. ANNUAL COMPLIANCE TRAINING
Wisconsin False Claims Act The Wisconsin False Claims Act also includes provisions that allow a private citizen to bring a civil action for violation of this article as a “qui tam plaintiff” The Act rewards individuals who bring a case to civil court on the State’s behalf against another person or entity for making a false or fraudulent claim for Medical Assistance, including rewards of at least 15% but not more than 30% of any proceeds of the action or settlement of the claim.. ANNUAL COMPLIANCE TRAINING EXIT
Wisconsin Whistleblower Protections An employer may not discharge, discipline, retaliate against or otherwise discriminate against an employee because the employee has exercised certain rights, filed a complaint, or testified or assisted in an enforcement action relating to a violation of the state’s labor laws. Government workers are also protected if they exercise their free speech rights by publicly disclosing information about believed violations of any state or federal law; mismanagement or abuse of authority in state government; a substantial waste of public funds; or a danger to public health or safety. In addition, workers may sue their employer in circuit court for damages, court costs and attorney fees. Citations: Sections 46.90, 50.07, , , and , Wisconsin Statutes. ANNUAL COMPLIANCE TRAINING
Wisconsin Whistleblower Protections An employer may not discharge, discipline, retaliate against or otherwise discriminate against an employee because the employee has exercised certain rights, filed a complaint, or testified or assisted in an enforcement action relating to a violation of the state’s labor laws. Government workers are also protected if they exercise their free speech rights by publicly disclosing information about believed violations of any state or federal law; mismanagement or abuse of authority in state government; a substantial waste of public funds; or a danger to public health or safety. In addition, workers may sue their employer in circuit court for damages, court costs and attorney fees. Citations: Sections 46.90, 50.07, , , and , Wisconsin Statutes. ANNUAL COMPLIANCE TRAINING EXIT
Recent Cases/Convictions Related to Healthcare Fraud MILWAUKEE - September 29, 2009, a Milwaukee business owner entered a plea of guilty to one count of felony Medical Assistance Fraud. The charge is against Quality Life Care Management, a Medicaid funded business entity that was expected to help Medicaid recipients obtain the services they need. According to the Criminal Complaint filed by the Department of Justice, the company’s owner billed the Medicaid program for more hours than were actually worked by company employees. Company payroll records show that between June 2005 and November 2005, Medicaid was billed for 5,617 more hours than were actually worked causing $141, in overpayments by the program. The business owner was sentenced to 12 months in the House of Corrections and ordered to repay $141, in the Medicaid program and $14,474 in court obligations. This was investigated by the WI DOJ. ANNUAL COMPLIANCE TRAINING
Recent Cases/Convictions Related to Healthcare Fraud MILWAUKEE - September 29, 2009, a Milwaukee business owner entered a plea of guilty to one count of felony Medical Assistance Fraud. The charge is against Quality Life Care Management, a Medicaid funded business entity that was expected to help Medicaid recipients obtain the services they need. According to the Criminal Complaint filed by the Department of Justice, the company’s owner billed the Medicaid program for more hours than were actually worked by company employees. Company payroll records show that between June 2005 and November 2005, Medicaid was billed for 5,617 more hours than were actually worked causing $141, in overpayments by the program. The business owner was sentenced to 12 months in the House of Corrections and ordered to repay $141, in the Medicaid program and $14,474 in court obligations. This was investigated by the WI DOJ. ANNUAL COMPLIANCE TRAINING EXIT
Recent Cases/Convictions Related to Healthcare Fraud Whistle-blower case on hospice fraud settled for $25 million JS Online: Milwaukee - March 1, 2012 One of the nation's largest providers of hospice care has agreed to pay $25 million to settle a Medicare fraud case initiated after a former company nurse in Milwaukee filed a whistle- blower suit. It was the second such settlement in six years for the healthcare organization which paid the federal government $12.5 million in 2006 after another Wisconsin-based employee sued. “The whistle blowers don't do too badly, either. Under the False Claims Act, they are entitled to a cut of the recovery and will share about $4.6 million.” ANNUAL COMPLIANCE TRAINING
Recent Cases/Convictions Related to Healthcare Fraud Whistle-blower case on hospice fraud settled for $25 million JS Online: Milwaukee - March 1, 2012 One of the nation's largest providers of hospice care has agreed to pay $25 million to settle a Medicare fraud case initiated after a former company nurse in Milwaukee filed a whistle- blower suit. It was the second such settlement in six years for the healthcare organization which paid the federal government $12.5 million in 2006 after another Wisconsin-based employee sued. “The whistle blowers don't do too badly, either. Under the False Claims Act, they are entitled to a cut of the recovery and will share about $4.6 million.” ANNUAL COMPLIANCE TRAINING EXIT
Summary Legal authority for government investigations comes from: Federal False Claims Act Federal Criminal False Claims Provisions WI Act 20: False Claims Act Intent is NOT necessary for false claims liability. Penalties can be: Civil monetary penalties Criminal prosecution and prison time Both Federal and Wisconsin laws contain whistleblower protections ANNUAL COMPLIANCE TRAINING
Summary Legal authority for government investigations comes from: Federal False Claims Act Federal Criminal False Claims Provisions WI Act 20: False Claims Act Intent is NOT necessary for false claims liability. Penalties can be: Civil monetary penalties Criminal prosecution and prison time Both Federal and Wisconsin laws contain whistleblower protections ANNUAL COMPLIANCE TRAINING EXIT
MODULE 4 Integrity Agreements in·teg·ri·ty 1. adherence to moral and ethical principles; soundness of moral character; honesty. 2. the state of being whole, entire, or undiminished: to preserve the integrity of the empire. 3. a sound, unimpaired, or perfect condition: the integrity of a ship's hullsound ANNUAL COMPLIANCE TRAINING
MODULE 4 Integrity Agreements in·teg·ri·ty 1. adherence to moral and ethical principles; soundness of moral character; honesty. 2. the state of being whole, entire, or undiminished: to preserve the integrity of the empire. 3. a sound, unimpaired, or perfect condition: the integrity of a ship's hullsound ANNUAL COMPLIANCE TRAINING EXIT
What is an Integrity Agreement? Negotiated compliance obligations between the U.S. Office of Inspector General (OIG) and health care providers. Provider consents to these obligations as part of the civil settlement. In exchange, the OIG agrees not to exclude that provider from participation in Federal health care programs (Medicare and Medicaid). OIG has permissive exclusion authority under the False Claims Act or Civil Monetary Penalties Law. Typical term is 5 years. These compliance measures seek to ensure the integrity of Federal health care program claims submitted by the provider. ANNUAL COMPLIANCE TRAINING
What is an Integrity Agreement? Negotiated compliance obligations between the U.S. Office of Inspector General (OIG) and health care providers. Provider consents to these obligations as part of the civil settlement. In exchange, the OIG agrees not to exclude that provider from participation in Federal health care programs (Medicare and Medicaid). OIG has permissive exclusion authority under the False Claims Act or Civil Monetary Penalties Law. Typical term is 5 years. These compliance measures seek to ensure the integrity of Federal health care program claims submitted by the provider. ANNUAL COMPLIANCE TRAINING EXIT
Integrity Agreements are a result of a Medicare or Medicaid fraud investigation when problems are discovered: Examples of problems: Non-covered services Incorrect units of service Services were not provided Documentation is missing Results: Repayment of erroneous billings Payment of penalties and attorney fees Implement of an Integrity Agreement (5 years) ANNUAL COMPLIANCE TRAINING
Integrity Agreements are a result of a Medicare or Medicaid fraud investigation when problems are discovered: Examples of problems: Non-covered services Incorrect units of service Services were not provided Documentation is missing Results: Repayment of erroneous billings Payment of penalties and attorney fees Implement of an Integrity Agreement (5 years) ANNUAL COMPLIANCE TRAINING EXIT
Q)If Chippewa County is ever subject to an Integrity Agreement, once it concludes, the county can never be subject to another in the future? TRUE Of FALSE ANNUAL COMPLIANCE TRAINING
Q)If Chippewa County is ever subject to an Integrity Agreement, once it concludes, the county can never be subject to another in the future? TRUE Of FALSE ANNUAL COMPLIANCE TRAINING EXIT
Q)If Chippewa County is ever subject to an Integrity Agreement, once it concludes, the county can never be subject to another in the future? TRUE Of FALSE ANNUAL COMPLIANCE TRAINING
Q)If Chippewa County is ever subject to an Integrity Agreement, once it concludes, the county can never be subject to another in the future? TRUE Of FALSE ANNUAL COMPLIANCE TRAINING EXIT
Q)Chippewa County could be excluded from participating in Federal Healthcare Program for failing to meet documentation & Billing Standards during a Federal or State Review? TRUE Of FALSE ANNUAL COMPLIANCE TRAINING
Q)Chippewa County could be excluded from participating in Federal Healthcare Program for failing to meet documentation & Billing Standards during a Federal or State Review? TRUE Of FALSE ANNUAL COMPLIANCE TRAINING EXIT
Q)Chippewa County could be excluded from participating in Federal Healthcare Program for failing to meet documentation & Billing Standards during a Federal or State Review? TRUE Of FALSE ANNUAL COMPLIANCE TRAINING
Q)Chippewa County could be excluded from participating in Federal Healthcare Program for failing to meet documentation & Billing Standards during a Federal or State Review? TRUE Of FALSE ANNUAL COMPLIANCE TRAINING EXIT
MODULE 5 Certification ANNUAL COMPLIANCE TRAINING
MODULE 5 Certification ANNUAL COMPLIANCE TRAINING EXIT
Certification Instructions Click here to access the Acknowledgement Form.here Print, complete and sign the form. Keep a copy for your records. Send the original, signed form to the Compliance Officer: County employees use interoffice mail; Contractors mail to: Jill Chaffee, Compliance Officer 711 N. Bridge St Chippewa Falls, WI ANNUAL COMPLIANCE TRAINING
Certification Instructions Click here to access the Acknowledgement Form.here Print, complete and sign the form. Keep a copy for your records. Send the original, signed form to the Compliance Officer: County employees use interoffice mail; Contractors mail to: Jill Chaffee, Compliance Officer 711 N. Bridge St Chippewa Falls, WI ANNUAL COMPLIANCE TRAINING EXIT
If you have any questions, please contact the Compliance Office: (715) , Jill Chaffee Thank you! ANNUAL COMPLIANCE TRAINING