0. Shasta County Health and Human Services Agency
General Compliance Training
REMEMBER TO CUE VIDEO PRIOR TO PRESENTATION
HANDOUT-QUIZ
As people who work in the field of health care, it is important that you be knowledgeable about the Medicare and Medicaid fraud and abuse laws. These laws are broad and can affect all of us who work in the health care field including those who work in billing, who provide direct client care, who work as administrative support, and those who supervise.
Violating the fraud and abuse laws can result in criminal penalties; civil fines; exclusion from
the Federal health care programs, which include Medicare and Medicaid; and even loss
of your medical license by your State medical board.
Welcome

1. Our Goals Today To help you feel comfortable with asking questions.
To inform you of whom to contact to ask questions
To let you know that you are responsible to disclose
To share with you that you have a safe and confidential place to disclose
When you leave today we would like you to know who to call when you have questions, understand your responsibilities as they relate to disclosure, know that there is a safe and confidential toll free disclosure line.

2. Purpose of the Training
Promote a workplace culture of ethics and compliance
Increase understanding of:
State and Federal Healthcare Laws
Shasta County’s policies
Employee Responsibilities
Promote compliance with federal health care program requirements
The purpose of the General Compliance Training is to promote an organization wide culture of ethical behavior and attitude, to help you understand the state and federal laws and regulations that we all need to comply with, to help you understand Shasta county’s policies and – very importantly – what your responsibilities are.
Ask Audience: What defines an ethical culture? Examples:
Integrity
Honesty
Respect for fellow colleagues and clients
Understanding and abiding by the organization’s ethical standards (code of conduct) and laws and regulations
Asking questions

3. Deficit Reduction Act - DRA
The ABC’s—Education Requirements:
The Federal False Claims Act
Administrative remedies for false claims and statements
Any state laws pertaining to civil or criminal penalties for false claims and statements
The whistleblower protections under such laws
Handout—Summary Review of Medicaid Integrity Program
The DRA was signed into law in 2006
The DRA imposes mandatory compliance obligations on any entity that receives annual Medicaid payments of at least $5 million under a state Medicaid plan.
These entities must establish written policies with information about(on slide):
The Federal False Claims Act;
Administrative remedies, such as internal auditing and systems control, for false claims and statements.
State laws regarding civil or criminal penalties for false claims and Statements;
whistleblower protections

4. Health care fraud is a serious problem…
The Government spends almost a trillion dollars each year on the Medicare and Medicaid programs.
Although there is no precise measure of health care fraud, experts estimate that fraudulent billings to the programs are in the range of 3–10 percent.
That means that fraud, waste, and abuse cost taxpayers $30 billion to $100 billion dollars
each year.
Fraud:
drain the taxpayers’ money,
Puts beneficiaries’ health and welfare at risk by exposing them to unnecessary services and taking money away from needed patient care.
When the Federal Government recovers money from fraud cases, it returns the money
to the Medicare Trust Fund to pay for legitimate patient care.

5. Abuse includes excessively or improperly using government resources
Fraud includes obtaining a benefit through intentional misrepresentation or concealment of material facts
Waste includes incurring unnecessary costs as a result of deficient management, practices, or controls
Abuse includes excessively or improperly using government resources
Fraud includes the obtaining of something of value through intentional misrepresentation or concealment of material facts.
Waste includes incurring unnecessary costs as a result of deficient management, practices, systems or controls
Abuse includes any practice that is not consistent with the goals of providing patients
with services that
are medically necessary,
(2) meet professionally recognized standards,
(3) are fairly priced.
Abuse also involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly misrepresented the facts to obtain payment.

6. Fraud and Abuse Laws False Claims Act Anti-Kickback Statute
Physician Self-
Referral Statute: (Stark Law)
Exclusion Statute
Civil Monetary
Penalties Law
Don’t worry we wont put you on the spot: Raise your hand if you have heard of any of these laws? Ok, we are going to review all of them 
The laws that we are going to talk about today are the false claims act, the anti-kickback statute, the physician self-referral statute – also known as the stark law, the exclusion statute and the civil monetary penalties law.

7. False Claims Act
Prohibits the submission of false or fraudulent claims to the Government
HANDOUT-FALSE CLAIMS ACT
The False Claims Act makes it illegal to submit false or fraudulent claims for payment to
Medicare or Medicaid.
For False Claims Act violations, you can be fined up to three times the program’s loss,
plus $11,000 per claim. And fines add up quickly because each claim can be a separate ground for liability.

8. Know or should have known…
US Government pursues criminal and civil penalties for providers who:
Have actual knowledge of fraud and abuse or
Should have known about it when it occurs

9. You do not have to intend to defraud the Government to violate the False Claims Act.
You can be punished if you act with deliberate ignorance or reckless disregard of the truth.
This means you cannot hide your head in the sand and avoid liability.
Deliberate Ignorance

10. Who Monitors Fraud & Abuse?
US Department of Health and Human Services Office of Inspector General (OIG)
Department of Justice (DOJ) /U.S. Attorneys
FBI
State Medicaid Fraud Control Units (MFCUs)
Centers for Medicare & Medicaid Services (CMS)
Postal Fraud Investigators
Inspector General TRICARE
Secret Service
IRS

11. Incentives to report fraud
Up to 30% of any False Claims Act Recovery
Whistleblower Protections
More Info: Tax Payers Against Fraud-taf.org
The False Claims Act:
Creates a partnership between the public and the government working to uncover and stop fraud.
Allows citizens with evidence of fraud (aka whistleblowers) to sue on behalf of the government (Qui Tam).
Provides a strong financial incentive to whistleblowers to report fraud. Whistleblowers can receive up to 30 percent of any False Claims Act recovery.
Each year hundreds of millions of dollars, even into the billions of dollars, are being recovered.
Provides strong whistleblower protections, which we will talk about a little later.
Example: One such case was brought by a patient who discovered his healthcare provider had billed for so many fraudulent services in his name that they had exceeded a monthly Medicaid cap, resulting in his being denied needed services. That case resulted in the provider agreeing to pay 121 million.
If you’re interested you can go to the taxpayers against fraud website taf.org Some very interesting information on ther about the False Claims Act and cases that have been prosecuted.

12. Examples of Fraudulent Activities:
Billing for services not actually provided
Upcoding and bill padding
Billing for services that were not medically necessary
Kickbacks
Billing Medicare/Medicaid for a service that has already been paid for by another party
Drug companies promoting a drug for a use for which it has not been approved
Billing in order to increase revenue instead of billing to reflect actual work performed
Upcoding is when someone bills for a service that pays at a higher rate than the service they provided.
Example: An endocrinologist billed routine blood draws as critical care blood draws to capture higher reimbursement. He paid $447,000 to settle allegations of upcoding and other billing violations.
Billing for services that have already been paid for by another party.
Examples:
The claim might have been paid by another insurance company or by a grant. It might also have been paid for under another claim.
A cardiologist was prosecuted under the False Claims Act for submitting claims for evaluation and management (E&M) services even though he had already received payment for the same services under previously billed stress test claims. He paid the Government $435,000 and entered into a 5-year Integrity Agreement.
Billing for a service not actually provided
VIDEO CLIP

13. Anti-Kickback Statute
The AKS prohibits soliciting or receiving anything of value, e.g., "in-kind” kickbacks, bribes or rebates in return for:
Referring patients for Medicare covered services
Buying an item or service covered by Medicare
In some industries, it is acceptable to reward those who refer business to you.
However, asking for or receiving any remuneration in exchange for referrals for Federal health care program business is a crime under the Anti-Kickback Statute.
“Remuneration” is basically anything of value. The law prohibits obvious kickbacks, like cash for referrals, as well as more subtle kickbacks, like free rent, paid trips, or gift certificates.
The Anti-Kickback Statute applies to both payers and recipients of kickbacks. Just asking for or offering a kickback could violate the law.

14. Prison Time Program Exclusion
Penalties for Kickbacks
Prison
Time
Fines
Kickbacks are illegal because they harm the Federal health care programs and program beneficiaries. They can lead to:
• overutilization of items or services,
• increased program costs,
• corruption of medical decision-making,
• patient steering, and
• unfair competition.
Violating the Anti‐Kickback Statute carries stiff penalties.
Violators can be found liable under the False Claims Act.
Violations can result in prison sentences and fines and penalties of up to $50,000 per kickback plus three times the amount of the remuneration.
Additionally, physicians can be excluded from participation in the Federal health care programs for violating the Anti‐Kickback Statute.
Program Exclusion

15. Physician Self-Referral Statute (Stark Law)
Limits physician referrals when you have a financial relationship with the entity
The Stark Law specifically refers to physicians and referrals. And unlike the Anti-Kickback Statute that applies to any Federal Healthcare program, the Stark Law applies only to Medicare programs.
Prohibits physicians from:
Referring Medicare patients for designated health services to entities with which they have direct or indirect financial relationship.
Prohibits the entity from billing for services which are the product of a prohibited referral.
Examples:
Doctor is part owner in a local lab and refers his clients to that lab
A doctor’s wife (relative) owns interest in a medical equipment store and the doctor refers clients to that store.
Consequences:
Denial of payment
Repayment of all monies
Civil Monetary Penalties
Exclusion potential
Potential False Claims Act Liability.

16. Exclusion from Medicare and Medicaid Mandatory exclusions
Under the Exclusion Authorities, Office of Inspector General (OIG) may exclude providers from participation in the Federal health care programs.
There are two categories of exclusions:
• mandatory exclusions—imposed on the basis of certain criminal convictions and
• permissive exclusions—based on sanctions by other agencies, such as a state medical board suspending or revoking a medical license, or other misconduct including defaulting on health education loans or providing unnecessary or substandard care.
The OIG reports that “No program payment will be made for anything that an excluded person furnishes, orders, or prescribes.”
This payment prohibition also applies to:
Employer
Contracts
Hospital or any provider the excluded person provides services
The exclusion applies regardless of who submits the claims and applies to all administrative and management services furnished by the excluded person.”
Example-
A psychiatrist was fined $400,000 and permanently excluded from participating in the Federal health care programs for misrepresenting that he provided therapy sessions requiring 30 or 60 minutes of face-to-face time with the patient, when he had provided only medication checks for 15 minutes or less. The psychiatrist also misrepresented that he provided therapy sessions when in fact a non-licensed individual conducted the sessions.
We will be going over Shasta County’s excluded person’s policy a little later in the presentation.
Mandatory exclusions
Permissive exclusions

17. Balanced Budget Act (BBA)
Three strikes and you’re out!
Second health care related conviction: minimum ten year exclusion.
Persons with three health care related convictions face permanent mandatory exclusions from health care programs.
Individual professionals and organizations can be excluded.

18. Civil Monetary Penalties Law
Penalties range from $10,000 to $50,000
per violation
OIG may seek civil monetary penalties for a wide variety of abusive conduct, including presenting a claim that is false or fraudulent because it is for a medically unnecessary procedure.
OIG also may impose civil monetary penalties for violating the Medicare assignment agreement by overcharging or double billing Medicare beneficiaries.

19. COME-PLY WITH US!
We’re going to spend some time now talking about Shasta County’s Compliance Program.

20. Compliance Program Prevent and Detect: Inaccuracies Violations
Quality of Care Issues
Training Needs
Handout—Compliance Contacts
The Compliance Program is designed to:
Promote a culture of ethical behavior and commitment to compliance with the law (hopefully reducing inaccuracies)
Prevent and detect wrong doing
Provide a “safe” mechanisms for reporting and seeking help
Raise awareness, therefore increasing quality of care
Can have a positive impact to our organization’s reputation
The Compliance Program includes:
Compliance Officer.
Compliance Committee.
Code of Conduct Communication to all employees.
Policies and Procedures.

21. Shasta County Mental Health, Alcohol & Drug Celeste Buckley, MBA, Compliance Officer
The Compliance Officer is responsible for:
Development and implementation of policies, procedures, and practices pertaining to laws and regulations of federal healthcare programs
Responsibility for the following lies specifically with the County Administrative Officer, Compliance Officer and/or the HIPAA Officer:
Analyze legal requirements.
Promote compliance.
Recommend and monitor internal systems
and controls.
Monitor compliance and implement
corrective action.
Review the Code of Conduct annually.

22. Compliance Committee
Committee members: Director, Deputy Director, Compliance Officer, Division Chiefs, Medical Chief, Deputy Compliance Officer, and Alcohol/Drug Program Administrator and others as determined by the committee.
Meets quarterly.
The Compliance Committee is established to advise the Compliance Officer and assist in the implementation of the Compliance Program.

23. Compliance Training New employees Annually for all MH employees
Shasta County HHSA will provide training to:
all employees and contract providers to promote compliance with all statutes, regulations, and guidelines pertaining to Federal health care programs.
Each employee who has responsibility for preparation or submission of claims will receive training to include:
Submission of accurate bills.
Policies and procedures applicable to the documentation of medical records.
Legal Sanctions for improper billings.
Examples of proper and improper billing practices.
New employees
Annually for all MH employees
Contract Providers

24. Disclosure Program Non-Retribution, Non-Retaliation Policy
Handout—Non-Retribution/Non-retaliation Policy
Shasta County’s Disclosure Program is designed:
To promote and provide “safe” mechanisms for reporting and seeking help
You may disclose any concerning and/or deemed inappropriate issues or questions associated with HHSA’s policies, practices, or procedures pertaining to a Federal health care program.

25. Disclosure
The toll-free confidential compliance line is:
As an employee at SC HHSA it is your responsibility and duty to disclose your concerns to the Compliance Officer, if you become aware of actual fraud or abuse, or have concerns about policies, practices or procedures.

26. Whistleblower Protections
Refer to previous handout—page 2
The government has mandated strong protections for whistleblowers. Any employee who is discharged, demoted, harassed, or otherwise discriminated against because of lawful acts by the employee in furtherance of an action under the False Claims Act is entitled to all relief necessary to make the employee whole. Such relief may include:
Reinstatement 
Double back pay 
Compensation for any special damages including litigation costs and reasonable attorneys' fees.

27. Ineligible Persons Screening
List of Excluded Individuals and Entities – LEIE
Handout—Excluded individuals/entities Policy
Shasta County HHSA will:
Not hire or contract with any person or entity that is ineligible, including any individual or entity who:
is currently excluded, suspended, debarred, or otherwise ineligible to participate in the Federal health care programs; or
has been convicted of a criminal offense related to the provisions of health care
Shasta county screens all prospective employees and contract providers by looking on the OIG LEIE.
We also…
Review the Exclusion Lists semi-annually in January and again in July.
Require employees and contract providers to disclose any event that makes them an ineligible person immediately. **Remove ineligible persons from responsibility for business operations.

28. Shasta County Mental Health, Alcohol and Drug Code of Conduct
Laws and regulations
Ethics
Quality of care
Accurate billing
Responsibilites
Handout—Code of Conduct
Shasta County HHSA maintains high ethical standards and is committed to complying with all applicable laws and regulations; and each of its employees and contract providers shall follow the established Code of Conduct.
All staff are required to receive, understand, sign, and adhere to the Code of Conduct.
Have everyone read the code and answer any questions. Have everyone sign.

29. Employee Roles and Responsibilities
Be alert & Disclose
Provide high quality care
Ask questions
It is your responsibility to:
Provide high quality client/patient care.
Follow the letter and spirit of the Code of Conduct.
Make a good faith effort to detect and prevent any wrongdoing in your day-to-day activities before it happens.
Raise questions or concerns to Coordinators, Division Chiefs, compliance staff, or the Compliance Officer.
Part of providing good quality care is documentation
It’s important to know your job responsibilities and expectations
Understand the regulations that impact your day-to-day activities.
Ask questions when you are confused or unsure.
Identify new training needs
Do not take actions (provide services) that you are not capable of performing or that is outside of your scope of practice.
Documentation

30. Code of Conduct - Failure to Comply
Failure to comply with the Code of Conduct or failure to report reasonably suspected issues of noncompliance may subject the employee to disciplinary action, up to or including termination of employment status.

31. Shasta County Confidentiality Policy
HANDOUT—2 CONFIDENTIALITY POLICIES TO EACH.
Each person needs 2 of these, one for you to sign and turn in and one for you to keep.
Engage Audience in Discussion: “What does confidentiality mean to you?” What are some examples from your job?
Confidentiality is the legal and ethical responsibility of every employee.
___________ ‘s employees must keep confidential, all information about a patient’s identity, health, and /or finances, also known as Protected Health Information (PHI).
IS KEY

32. Shasta County Confidentiality Policy
Legal action may be taken against an employee if , at any time they:
Have, use, copy or read PHI which is outside the scope of their assigned duties;
Give or allow access to any PHI which is not authorized or otherwise allowed by law; or
Release PHI without proper authorization.
Never access patient information that is outside the scope of your duties. For instance, looking in a client’s chart because you’re curious However, if it is within your scope of duties to audit a client’s chart for Utilization Review purposes, that would be permissible access.
HAVE ATTENDEES SIGN THE CONFIDENTIALITY AGREEMENT AND COLLECT.

33. T M I

34. Stay Alert!
Having an ethical culture in an organization is extremely important. We’ve all seen what can happen when people and organizations lose their sense of ethical direction. The past four years in the financial and mortgage banking industries has given us a very clear and painful picture of that. Ethics can be a very slippery slope and it is imperative that we all be alert to our own attitudes and practices and the practices of the organization in which we work.

35. Compliance Officer Celeste Buckley, MBA
Toll Free Disclosure Line
Your call will be handled with utmost confidentiality and anonymity.
Don’t forget about the disclosure line.
For confidential disclosure or concerns, please use the toll free disclosure line.

36. Compliance Questions Celeste Buckley..245-6957
Micki Mills……
Lynda Hughes…
Sarah Hayes……
Justina Larson…
Remember you can always call us with questions. If we don’t know the answer we will find it.

37. Did we accomplish our Goals?
Do you feel comfortable to ask questions?
Do you know to whom to contact to ask questions?
Do you understand your responsibility to disclose?
Do you know you have a safe and confidential place to disclose?

38. THANK YOU