1 PATIENT SAFETY & RIS K SOLUTIONS GUIDELINE Developing an Effective Compliance Plan: A Guide for Healthcare Practices
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3 CONTENTS INTRODUCTION... 5 OBJECTIVES... 5 BACKGROUND... 5 THE IMPORTANCE OF A COMPLIANCE PLAN... 6 THE FRAUD AND ABUSE LAWS... 6 The Anti-Kickback Statute... 7 The Physician Self-Referral Law (Stark Law)... 7 The False Claims Act... 7 Exclusion Statute... 8 Civil Monetary Penalties Law... 9 THE SEVEN FUNDAMENTAL ELEMENTS OF AN EFFECTIVE COMPLIANCE PROGRAM... 9 Element One: Implementing Written Policies, Procedures, and Standards of Conduct Element Two: Designating a Compliance Officer and Compliance Committee to Provide Program Oversight Element Three: Using Due Diligence in the Delegation of Authority Element Four: Educating Employees and Developing Effective Lines of Communication Element Five: Conducting Internal Monitoring and Auditing Element Six: Enforcing Standards Through Well-Publicized Disciplinary Guidelines Element Seven: Responding Promptly to Detected Offenses and Undertaking Corrective Action CONCLUSION RESOURCES ENDNOTES... 15
5 Guideline: Developing an Effective Compliance Plan 5 INTRODUCTION A compliance plan is a formal statement of a healthcare practice s intention to conduct itself ethically in regard to business operations, government regulations, and patient services and care. The purpose of a formal compliance plan is twofold: (1) it provides a blueprint for the practice s compliance program and accomplishing the aforementioned goals, and (2) it encourages employees to report unethical conduct. Federal law requires healthcare practices to develop and implement formal compliance programs. This guideline will discuss the role of compliance in healthcare and how practices can take steps to ensure they are meeting compliance obligations. OBJECTIVES The objectives of this guideline are to: Explain why compliance plans are important to healthcare practices Review federal fraud and abuse laws Describe the seven essential elements of an effective compliance plan BACKGROUND The Department of Health and Human Services Office of Inspector General (HHS-OIG) has published voluntary compliance program guidance for individual and small group healthcare practices for a number of years. HHS-OIG s primary function is to protect the integrity of HHS programs as well as the health and welfare of program beneficiaries. Since 1976, HHS-OIG has been working to prevent fraud, waste, and abuse in federally funded healthcare programs, such as Medicare, Medicaid, and the Children s Health Insurance Program (CHIP). In the 1990s, HHS-OIG began providing voluntary compliance tools and resources to help healthcare providers avoid submitting erroneous claims or engaging in unlawful conduct involving federal healthcare programs. However, because HHS-OIG s guidance was voluntary, not all healthcare providers and organizations felt compelled to develop compliance programs. With the implementation of the Patient Protection and Affordable Care Act (ACA) in 2010, compliance programs became mandatory. Section 6401 of the ACA stipulates that healthcare providers must establish compliance programs as a condition of enrollment in Medicare, Medicaid, or the Children s Health Insurance Program (CHIP). 1
6 Guideline: Developing an Effective Compliance Plan 6 THE IMPORTANCE OF A COMPLIANCE PLAN Having a compliance plan is important for many reasons beyond the most obvious it s required by law. An effective compliance plan is crucial for preventing fraudulent claims and erroneous billing, reducing the chance of billing audits, and avoiding potential ethical conflicts in business operations and patient care services. Additionally, if noncompliance with the law results in an HHS-OIG complaint and investigation, the consequences can be significant. Merely not understanding the law or failing to provide compliance training for staff usually is not a sufficient excuse for violations. The range of possible penalties that the government can impose for submitting fraudulent or erroneous claims or violating state or federal fraud and abuse laws include completion of a corporate integrity agreement; exclusion from Medicare, Medicaid, and CHIP programs; civil and criminal penalties; and/or a referral to the provider s state medical board. By implementing the requisite compliance plan, healthcare providers and practices will generally meet their legal obligation and send a clear message to staff and the public that the practice is committed to conducting itself in an ethical manner, promoting good employee conduct, and providing quality patient care. THE FRAUD AND ABUSE LAWS Not understanding the law or failing to provide compliance training for staff usually is not a sufficient excuse for violations. All healthcare administrators and practicing healthcare providers should have at least a basic understanding of state and federal fraud and abuse laws. The federal fraud and abuse laws that apply to healthcare providers are: The Anti-Kickback Statute The Physician Self-Referral Law (Stark Law) The False Claims Act The Exclusion Authorities The Civil Monetary Penalties Law The government agencies responsible for enforcing these laws are the U.S. Department of Justice, HHS-OIG, and the Centers for Medicare & Medicaid Services (CMS). This section will provide a brief overview of these important laws affecting all healthcare providers, organizations, and vendors. However, the information provided herein is for general reference only. For more detailed information about these laws, or for specific questions about how these laws pertain to your practice, consult with your personal legal counsel.
7 Guideline: Developing an Effective Compliance Plan 7 The Anti-Kickback Statute Physicians often are targeted as a potential source of referral to other healthcare providers, pharmaceutical companies, and medical supply companies. The Anti-Kickback Statute 2 prohibits the knowing and willful payment of anything of value to induce or reward patient referrals or the generation of business involving any item or service payable by federal healthcare programs. 3 This statute has safe harbor provisions that protect certain business arrangements; however, very specific requirements must first be met. Violations of the Anti-Kickback Statute can result in administrative sanctions, fines, jail terms, and exclusion from participation in federal healthcare programs. The Physician Self-Referral Law (Stark Law) The Stark Law 4 prohibits healthcare providers from referring Medicare or Medicaid patients for certain designated health services to an entity with which the healthcare provider or an immediate family member has a financial relationship, unless an exception applies under the law. 5 A financial relationship may include any form of ownership interest, an investment interest, or some other form of compensation arrangement. The Stark Law also prohibits the entity providing the designated health services from submitting claims to Medicare or Medicaid for services that involved a prohibited referral. Example of an Anti-Kickback Statute Violation A healthcare provider accepts money or expensive gifts from a pharmaceutical or durable medical equipment company in exchange for the provider referring patients to that vendor. Example of a Stark Law Violation An orthopaedic physician refers all of his patients to his privately owned physical therapy center without giving the patients other options or notice that he owns the physical therapy center. Examples of designated health services include clinical laboratory services, any form of outpatient therapy services (e.g., physical, occupational, and speech therapy), radiology and certain other imaging services, and durable medical equipment and supplies. The False Claims Act The civil False Claims Act 6 prohibits the submission of claims for payment to Medicare or Medicaid that the healthcare provider knows or should have known to be false or fraudulent.
8 Guideline: Developing an Effective Compliance Plan 8 Penalties for filing false claims may be up to three times the actual loss plus $11,000 per claim filed. 7 Further, an analogous criminal False Claims Act 8 can result in criminal penalties and imprisonment for submitting false claims. The False Claims Act includes a whistleblower provision (qui tam action) that allows individuals to file a lawsuit on behalf of the United States if they have knowledge that an Example of a False Claims Act Violation A physician submits claims for payment to a federally funded healthcare program for procedures that were not actually performed or treatments/services that were medically unnecessary. organization is defrauding the government. Whistleblowers can potentially receive up to 30 percent of the money the government recovers. The possibility of significant compensation and the desire to do the right thing has led many former or current employees of healthcare organizations to file whistleblower actions. Exclusion Statute Under the Exclusion Statute, 9 HHS-OIG must exclude individuals or entities from participation in all federal healthcare programs when certain offenses are committed. Examples of criminal offenses that will result in exclusion include: Medicare or Medicaid fraud Patient abuse or neglect Felony convictions for other healthcare-related fraud, theft, or other financial misconduct Felony convictions for unlawful manufacture, distribution, prescription, or dispensing of controlled substances HHS-OIG also has discretionary exclusion authority for certain offenses such as: Misdemeanor convictions for unlawful distribution, prescription, or dispensing of controlled substances Suspension, revocation, or surrender of a license for reasons bearing on professional competence, professional performance, or financial integrity Provision of unnecessary or substandard services Submission of false or fraudulent claims Engaging in unlawful kickback arrangements Defaulting on health education loans or scholarships Employers or contractors who bill directly or indirectly for items or services furnished by an excluded provider may also be subject to civil penalties. 10
9 Guideline: Developing an Effective Compliance Plan 9 Civil Monetary Penalties Law The Civil Monetary Penalties Law 11 allows HHS-OIG to seek civil monetary penalties ranging from $10,000 to $50,000 and/or exclusion for many offenses. Examples of chargeable offenses include violating the fraud and abuse laws, EMTALA violations, and making false statements or misrepresentations on applications or contracts to participate in the federal healthcare programs. Additionally, any healthcare provider who offers any type of compensation to Medicare and Medicaid beneficiaries as an incentive to see a certain provider is in violation of the Beneficiary Inducement provision of the Civil Monetary Penalties Law. 12 THE SEVEN FUNDAMENTAL ELEMENTS OF AN EFFECTIVE COMPLIANCE PROGRAM HHS-OIG has declared that the elements described in Chapter 8 of the 2010 Federal Sentencing Guidelines Manual are the seven fundamental elements of an effective compliance program. 13 These elements are meant to guide healthcare providers and organizations in the process of developing well-defined plans and strategies for their own compliance programs. Additionally, HHS-OIG encourages providers to seek help and support as needed from outside experts in billing and coding, legal counsel knowledgeable in fraud and abuse laws, and the comprehensive resources available at HHS-OIG s website ( The seven fundamental elements, as described by HHS-OIG, include: 1. Implementing written policies, procedures, and standards of conduct 2. Designating a compliance officer (CO) and compliance committee (CC) to provide program oversight 3. Using due diligence in the delegation of authority 4. Educating employees and developing effective lines of communication 5. Conducting internal monitoring and auditing 6. Enforcing standards through well-publicized disciplinary guidelines 7. Responding promptly to detected offenses and undertaking corrective action 14 Each of the elements will be discussed in greater detail in subsequent pages, along with implementation recommendations.
10 Guideline: Developing an Effective Compliance Plan 10 Element One: Implementing Written Policies, Procedures, and Standards of Conduct An effective compliance program is dependent on written policies, procedures, and standards of conduct. These documents memorialize the healthcare practice s expectations with regard to compliance. Further, they explain the practice s commitment to legal standards, ethical conduct, and quality care. Each healthcare practice s compliance policies should include a code of conduct that defines the organizational mission, values, expectations, and guiding principles for workplace behavior. A code of conduct identifies model behavior for employees and explains how to report suspected instances of compliance problems or unethical activity. The designated CO and CC should be involved in developing the policies, which should specifically delineate their respective duties. Once developed, compliance policies and procedures should be reviewed with and distributed to all employees of the practice. The review should occur within 90 days of hire and at least annually, and employees should be asked to acknowledge their review and understanding of the policies. Additionally, each practice should have guidelines for periodic review and updating of the compliance policies. Element Two: Designating a Compliance Officer and Compliance Committee to Provide Program Oversight As part of the second element, each healthcare practice should designate two key roles CO and CC and assign duties to the respective roles. The CO should report directly to the CEO or senior management and should have primary responsibility for the compliance program structure and administration. The CO should be very familiar with the practice s operational and compliance activities. This point is crucial because a CO without any delegated authority will likely not be very effective. The CO s daily duties may include: A code of conduct identifies model behavior for employees and explains how to report suspected instances of compliance problems or unethical activity. Understanding and administering the compliance program Being informed about the outcomes of audits and monitoring Reporting on compliance enforcement activities Assessing/reviewing the compliance program
11 Guideline: Developing an Effective Compliance Plan 11 For smaller healthcare practices, the CO might have other clinical and administrative duties aside from compliance duties. The practice also may choose to outsource the CO role to a vendor. The CC is a multidisciplinary committee that reports directly to the CEO or other highranking person or people in the organization. The CO and CC are jointly responsible for certain duties related to administering the compliance program. These responsibilities include: Developing, reviewing, and updating compliance policies and procedures Developing and auditing the work plan and risk assessment plan Attending meetings for operations staff Monitoring and auditing compliance performance Enforcing compliance program requirements at all levels of the organization Recommending policy, procedure, and process improvements Enforcing disciplinary standards Element Three: Using Due Diligence in the Delegation of Authority The third element of an effective compliance plan requires that each healthcare practice s management team takes responsibility for, and engages in, proper due diligence in the hiring and periodic assessment of management employees. This element implies that practice leaders should conduct thorough background checks on all new management employees and periodic background checks on existing management employees. The practice should undertake reasonable efforts to ensure that employees have not engaged in illegal activities or other conduct inconsistent with the practice s compliance and ethics program. Element Four: Educating Employees and Developing Effective Lines of Communication The fourth core element of an effective compliance program is training and education to ensure adequate understanding of the expectations set forth in the compliance plan and code of conduct. Compliance training should be mandatory for all employees. The initial training should be a comprehensive review of the compliance plan and code of conduct. Thereafter, an annual Training programs should be interactive and include actual compliance scenarios that employees and managers might encounter. review training should occur that highlights any compliance program changes or new developments and re emphasizes the practice s code of conduct. To aide in retention,
12 Guideline: Developing an Effective Compliance Plan 12 training programs should be interactive and include actual compliance scenarios that employees and managers might encounter. Additionally, the CO should communicate compliance messages via other informal training methods, such as posters, newsletters, and Intranet communications. The fourth element also includes developing effective lines of communication, which involves making communication about compliance issues an integral part of the practice and having an open-door policy throughout the organization. Recommendations for developing an open communication culture include the following: Ensure communication channels foster dialogue rather than one-way communication Educate employees about the importance of reporting issues in a timely manner Develop a formal process for managers to communicate compliance issues and results to staff Create an anonymous reporting process to prevent real or perceived retaliation (e.g., an anonymous hotline, an drop box, or a well-promoted open-door policy) Employees should have several ways to report compliance and ethical concerns. The CO and/or CC should evaluate the reporting process for effectiveness. Questions to consider include the following: Are employees familiar with what compliance/ethical issues they should report? Are employees aware of the reporting process and to whom they should report concerns? Are employees aware of the specified timeframe for reporting compliance/ethical issues? Furthermore, employees should feel comfortable reporting issues to multiple individuals within the practice (e.g., any manager, the CO, or CC). The CO should be available and accessible for routine questions about compliance or ethics. Element Five: Conducting Internal Monitoring and Auditing The fifth element of an effective compliance program is creating a system for monitoring and auditing the effectiveness of the program. This system will help providers comply with CMS requirements and identify compliance risks. Monitoring activities include reviewing procedures to gauge whether they are working as intended and following up on recommendations and corrective action plans to ensure they have been implemented. Monitoring should occur on a regular basis, such as weekly or monthly.
13 Guideline: Developing an Effective Compliance Plan 13 Auditing is a more comprehensive review and requires more effort than monitoring. Auditing ensures compliance with statutory and CMS requirements and includes routine evaluations of the compliance program to determine the program s overall effectiveness. Internal staff or an external contractor should conduct an audit at least annually. The audit should result in a written report of findings and recommendations that the CO and/or CC should follow up on as part of their responsibilities. Conducting a formal baseline risk assessment is a crucial component of developing monitoring and auditing work plans. The risk assessment should include areas of concern identified by CMS and other authoritative organizations, as well as classification of risk levels. Areas identified as high risk, such as coding/billing and working with excluded providers, should be audited more frequently. The monitoring work plan should cover frequency of monitoring, person(s) responsible, and issues of concern for the organization. The auditing work plan should cover methods the practice will use to conduct internal investigations, a time limit for closing investigations, corrective action guidelines, and criteria for external independent contractor review and/or referral to CMS or OIG. Element Six: Enforcing Standards Through Well-Publicized Disciplinary Guidelines The sixth element of an effective compliance program is to ensure consistent and timely discipline when an investigation confirms a violation. Disciplinary guidelines must be clearly written and describe expectations and consequences for noncompliance. Disciplinary guidelines must be clearly written and describe Guidelines should include sanctions for expectations and consequences failure to comply with the code of conduct, for noncompliance. failure to detect noncompliance when routine observation or due diligence would have provided notice, and failure to report actual or suspected noncompliance. The practice should review disciplinary guidelines at least annually with all employees, and the information should be readily available for review so that employees are well aware of their obligations. Element Seven: Responding Promptly to Detected Offenses and Undertaking Corrective Action The final element of an effective compliance program is the use of corrective actions when vulnerabilities, noncompliance, or potential violations are identified. Examples of corrective action include staff education, repayment of overpayments, and disciplinary action against responsible employees.
14 Guideline: Developing an Effective Compliance Plan 14 CONCLUSION Healthcare compliance is a complex topic that involves numerous regulations and layers of oversight. However, at its core, compliance is intended to promote ethical conduct and business practices. By developing an effective compliance plan and educating staff, healthcare practices can meeting their legal obligations, prevent fraudulent activity, promote ethical behavior and business practices, and support quality care. RESOURCES Centers for Medicare & Medicaid Services: Avoiding Medicare Fraud & Abuse: A Roadmap for Physicians Medicare-Learning-Network-MLN/MLNProducts/Downloads/Avoiding_Medicare_ FandA_Physicians_FactSheet_ pdf Centers for Medicare & Medicaid Services: Fraud and Abuse: Prevention, Detection, and Reporting Medicare-Learning-Network-MLN/MLNProducts/downloads/Fraud_and_Abuse.pdf Centers for Medicare & Medicaid Services: Provider Compliance MLN/MLNProducts/ProviderCompliance.html Health Care Compliance Association: Code of Ethics for Health Care Compliance Professionals HCCACodeOfEthics.pdf Health Care Compliance Association: HCCA Compliance Library: Manuals, Compensation Surveys, OIG Workplans, Standards National Conference of State Legislatures: Medicaid Fraud and Abuse U.S. Department of Health and Human Services, Office for Civil Rights: HIPAA Compliance and Enforcement compliance-enforcement/index.html U.S. Department of Health and Human Services, Office for Civil Rights: How OCR Enforces the HIPAA Privacy & Security Rules U.S. Department of Health and Human Services, Office of Inspector General: A Roadmap for New Physicians: Avoiding Medicare and Medicaid Fraud and Abuse U.S. Department of Health and Human Services, Office of Inspector General: Compliance 101 and Provider Education 101/index.asp
15 Guideline: Developing an Effective Compliance Plan 15 ENDNOTES 1 Patient Protection and Affordable Care Act, 42 U.S.C et seq. (2010) U.S.C. 1320a 7b(b) 3 U.S. Department of Health and Human Services, Office of Inspector General. (n.d.). A roadmap for new physicians: Avoiding Medicare and Medicaid fraud and abuse. Retrieved from compliance/physician-education/roadmap_web_version.pdf 4 42 U.S.C. 1395nn 5 HHS-OIG, A roadmap for new physicians, roadmap_web_version.pdf 6 31 U.S.C HHS-OIG, A roadmap for new physicians, roadmap_web_version.pdf 8 18 U.S.C U.S.C. 1320a-7 10 HHS-OIG, A roadmap for new physicians, roadmap_web_version.pdf U.S.C. 1320a 7a U.S.C. 1320a-7a(a)(5) 13 United States Sentencing Commission. (2010, November) federal sentencing guidelines manual. Retrieved from 14 USSC, 2010 federal sentencing guidelines manual, Chapter 8,
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Building a Healthy ACO Compliance Program HCCA 2014 Compliance Institute Mary C. Malone, Esq. Hancock, Daniel, Johnson & Nagle, P.C. Disclaimer: The content of this presentation does not constitute legal
CATHOLIC CHARITIES OF THE ROMAN CATHOLIC DIOCESE OF SYRACUSE, NY and TOOMEY RESIDENTIAL AND COMMUNITY SERVICES Compliance Plan False Claims Act & Whistleblower Provisions Purpose/Policy/Procedures Purpose:
EFFECTIVE DATE: January 1, 2007 PAGE: 1 of 8 Reference: Federal Deficit Reduction Act of 2005 (DRA) see, 6032 et seq; Office of the Medicaid Inspector General Provider Compliance guidance and CenterLight
CMS Mandated Training for Providers, First Tier, Downstream and Related Entities I. INTRODUCTION It is the practice of Midwest Health Plan (MHP) to conduct its business with the highest degree of ethics
FRAUD, WASTE, & ABUSE Kimberly Parks NEIGHBORHOOD LEGAL SERVICES MICHIGAN ELDER LAW & ADVOCACY CENTER 12121 Hemingway Redford, Michigan 48239 (313) 937-8291 Why It s Important Fraud, Waste and Abuse drain
CPCA California Primary Care Association Managing the Compliance Risk of Fraud, Abuse and the False Claims Act CPCA CFO Conference Larry Garcia Kenneth Julian April 30, 2010 Background The Patient Protection
Touchstone Health Training Guide: Fraud, Waste and Abuse Prevention About the Training Guide Touchstone is providing this Fraud, Waste and Abuse Prevention Training Guide as a resource for meeting Centers
Medicare Advantage and Part D Fraud, Waste and Abuse Compliance Training Overview This Medicare Advantage and Part D Fraud, Waste and Abuse Compliance Training for first-tier, downstream and related entities
8. Compliance KP strives to demonstrate high ethical standards in its business practices. The Agreement details specific laws and contractual provisions with which you are expected to comply. This section