2. Risk Management: why and how to protect your health center
Presented by:
Steve Smith, MBA, FACMPE, CHFP, Managing Consultant

3. AGENDA What is a compliance program and why is it important?
Specific areas for heightened risk
Define elements of compliance programs and how they are applied
Risk evaluation and improvement
Questions

4. What is a compliance program?
“…to encourage the development and use of internal controls to monitor adherence to statutes, regulations, and program requirements.”
Policies and Procedures
Measuring Effectiveness
Training
Lines of Communication
Internal Auditing
Enforcement and Prompt Response

5. Why are compliance programs important
Risk mitigation
Economic
Reputational
Criminal
Increased staff communication
Direct or anonymous notifications
Improved patient care
Satisfaction scores
Complaints
Improved financial results

6. OIG Compliance Work Plans
“Set forth various projects including OIG audits and evaluations that are underway or planned to be addressed during the fiscal year…” OIG website
How is the work plan developed
Mandatory requirements for OIG reviews (laws, regulations)
Congress, HHS management, or Office of Management and Budget
Top management and performance challenges facing HHS
Work performed by other oversight organizations (GAO)
Management’s actions to implement OIG recommendations from previous reviews
Potential for positive impact

7. Areas of heightened risk
Medicare Fraud
More than 300 people accused of reimbursement fraud in 2016
Documentation of medical necessity and complexity
Privacy, Security and Technology
Cybersecurity policies and procedures
Risk assessments, policies and training
340B Drug Discount Program
Documentation of participation and purchasing
Potential removal from program
Physician Compensation
Fair market value
Internal controls

8. Consequences of noncompliance
Criminal or civil fraud liability
False Claims Act imposes damage of three times the amount of the fraud & civil monetary damages
Exclusion from participating in federal healthcare programs
Corporate Integrity Agreements
Damage to reputation

9. Elements of compliance programs
Seven elements as defined by OIG
Written compliance policies, procedures and standards of conduct
Designate a compliance officer and a compliance committee
Conduct effective training and education on policies, procedures and standards of conduct
Develop lines of communication to facilitate communication with staff and allow anonymous reporting
Conduct internal monitoring and auditing through periodic self-audits
Enforce standards for employees through well-publicized disciplinary guidelines
Respond promptly to detected offenses and develop corrective action plans

10. Elements of compliance programs
Living, breathing document
If it has dust on it, it isn’t effective
Annual plan includes measureable goals and objectives
Driven by internal analysis and/or OIG guidance
Policies and procedures must be well-publicized
Documentation of training and receipt of information retained either electronically or in personnel files
Documentation of compliance committee meeting minutes and compliance officer reports
Board involvement
Self and/or external audits

11. Effective compliance officers will…
Conduct regular corporate compliance committee meetings
Investigate all complaints
Resolve all complaints
Effectively maintain the compliance hotline
Determine if training was adequate
Determine all scheduled audits were conducted and results are documented
Resolve all audit exceptions

12. Effective compliance committees will…
Hold regularly scheduled, meaningful meetings
Document all topics discussed and actions taken during meetings
Assign and complete “homework” assignments
Function according to committee stated goals
Hold organization accountable for compliance program success

13. Effective compliance programs will…
Maintain compliance plan and code of conduct
Clear and user friendly?
Distributed to all employees and other affected persons?
Practical and realistic?
Followed in daily operations?
Develop a compliance work plan annually
How were risks assessed?
Were baseline and follow-up audits conducted?
Were outside auditors used?
Were OIG priorities considered?
What were (and what was done with) the findings?

14. Effective compliance programs will…
Establish compliance policies and procedures
Were departmental policies and procedures reviewed?
Are all policies and procedures current?
Can policies and procedures be understood and is there sufficient detail?
Do all employees have current job descriptions? Are they complete and accurate?
Provide training and education
How effective was the training?
Was all necessary training received?
Were non-employees trained on compliance?
Was the training documented?

15. Effective compliance programs will…
Establish disciplinary actions
Were all employees disciplined appropriately based on severity of the offense?
Was discipline applied consistently? According to policy?
Were hospital policies sufficient to address compliance violations?
Was discipline documented and retained?
Establish process to receive complaints
Was a hotline established?
Were all calls documented and investigated?
Were anonymous complaints filed?

16. Effective compliance programs will…
Respond to violations
Were offenses identified during the year?
Were they handled appropriately, documented and retained?
Were they self reported?
Were monies repaid?
Were policies and procedures revised as necessary?
Was education and training conducted, documented and retained as a result?

17. compliance program self assessment
Compliance Program Effectiveness Questionnaire issued to Board, senior management, and compliance committee
Process owned by Corporate Compliance Officer
Based on the OIG’s seven elements of an effective compliance program
Simple “Yes” or “No” answers
Calculate response rates and determine areas of greatest need
Questions with large numbers of absent responses indicates lack of knowledge about the compliance program
Areas of greatest need should be considered in compliance program annual work plan and education

18. conclusion
Does your organization have a corporate compliance program and when was it last updated?
Did you organization do what it said it would do in the compliance program?
How well did the organization and program perform?
What areas can be improved?
When was the program last reviewed by an outside party?

19. Helpful compliance Program links
OIG Compliance Education Materials
OIG Resource Guide
OIG “Operating an Effective Compliance Program”
OIG Work Plan

21. Steve Smith, MBA, FACMPE, CHFP Managing Consultant //sbsmith@bkd
Steve Smith, MBA, FACMPE, CHFP Managing Consultant //