COMPLIANCE CONCEPTS Developed by University of Washington School of Dentistry Staff and Faculty 2016

Transcription

1 COMPLIANCE CONCEPTS Developed by University of Washington School of Dentistry Staff and Faculty 2016

2 Introduction to Compliance Concepts Welcome to University of Washington School of Dentistry web-based general compliance training. This training module is required for all workforce members at the time of hire, appointment or matriculation. You may also be taking this module to meet your annual compliance training requirement.

3 Training Objectives After completing this module, you will be able to: 1. Understand why School of Dentistry has a Compliance Program 2. Identify basic principles and key elements of the School s Compliance Program 3. Determine when and how to report potential compliance concerns 4. Identify some of the regulations School of Dentistry must follow 5. Know your personal compliance role and responsibilities

4 Importance of Compliance The School of Dentistry is an international leader in education, research and clinical services. In this role of leadership and as a public agency, we must be accountable to the public we serve. A strong Compliance Program is essential to ensure our decisions meet legal and ethical requirements and that we protect our patients and their confidential information.

5 Compliance Functions The School s Compliance Program supports the School by seeking to prevent, detect and resolve events and situations that may violate compliance standards. The School is dedicated to providing care to Medicare and Medicaid patients and to following applicable federal and state rules and regulations. Compliance provides assistance in understanding and following rules for documentation, coding, billing, HIPAA and special laws applicable to state employees. Compliance responds to reported concerns by investigating and recommending corrective actions.

6 Compliance Program Benefits Benefits of a compliance program may include: Fulfill legal duty to ensure false and inaccurate claims are not submitted to government or private payers Clearly demonstrate to workforce and the community a commitment to honest and responsible conduct Identify and prevent criminal and unethical conduct Reduced number of appeals and improved appeal success rate Improved quality of patient care Centralized source for distributing information on regulations related to fraud and abuse System that encourages workforce to report potential problems Identify weaknesses in internal systems and management

7 Government Expectations of Compliance The federal government believes that an effective compliance program should address risk areas such as: Billing for services not rendered Providing medically/dentally unnecessary services Teaching physician and resident requirements Up-coding Duplicate billing Failure to refund patient credit balances Failure to return insurance overpayments within 60 days

8 Government Recommendations The federal government recommends seven specific elements for effective compliance programs 1. Written policies and procedures 2. Compliance Officer and Compliance Committee 3. Conducting effective training and education 4. Developing effective lines of communication 5. Auditing and monitoring 6. Enforcement 7. Response and corrective action

9 The School s Compliance Program The School of Dentistry s Compliance Program establishes general principles that guide the School in its compliance efforts. In addition, detailed policies, procedures and guidelines are in place to guide workforce in preventing non-compliant behavior. The School of Dentistry s website has a section dedicated to compliance at: All workforce members also receive the School s Integrity at Work handbook which is available on the website at:

10 Compliance Program Basic Principles The School s Compliance Program Basic Principles are: Integrity Demonstrate the highest levels of professional conduct in all actions/decisions Compliance with Legal Standards Follow all applicable federal and state laws and regulations Accurate Billing and Records Maintain accurate documentation and billing records that reflect services provided. Address and correct errors appropriately.

11 Following Basic Principles Each individual associated with the School is responsible for carrying out the Compliance Program Basic Principles by: Performing personal duties with integrity Learning, understanding and following legal standards that pertain to his/her role Creating and maintaining accurate documentation and billing records that reflect services provided Addressing and correcting documentation and billing errors appropriately Asking questions and reporting any questionable activities or situations

12 Participation & Responsible Officer The School s Compliance Program is structured on ten elements. The 1 st and 2 nd elements are: 1. Participation It is the responsibility of each faculty member, staff, student and independent contractor to follow applicable laws and regulations and support the School s compliance efforts. 2. Responsible Officer The School has designated the Compliance Director as the individual within the School responsible for overall implementation and operation of the Compliance Program.

13 Compliance Committee & Oversight The School s Compliance Program is structured on ten elements. The 3 rd and 4 th elements are: 3. Compliance Committee The School s Compliance and Training Committee advises and assists the Compliance Director with implementation of the Compliance Program. 4. Oversight The Compliance Director reports at least twice a year to the Compliance and Training Committee on the status of compliance within the School.

14 Employee/Vendor Screening & Education The School s Compliance Program is structured on ten elements. The 5 th and 6 th elements are: 5. Employee and Vendor Screening The School shall not contract with, employ or extend privileges to any individual or entity that is excluded from participation or is otherwise ineligible to participate in federal health care programs. 6. Education The School provides ongoing, effective education and training programs for all faculty, staff and students on Organizational Professionalism and the Compliance Program.

15 Auditing/Monitoring & Risk Assessment The School s Compliance Program is structured on ten elements. The 7 th and 8 th elements are: 7. Auditing and Monitoring The School establishes procedures for monitoring the effectiveness of the Compliance Program. 8. Risk Assessment The School conducts ongoing risk assessments and takes appropriate steps to reduce the risk of law violation identified through the assessment process.

16 Enforcement/Prevention & Response The School s Compliance Program is structured on ten elements. The 9 th and 10 th elements are: 9. Enforcement and Prevention Individuals violating the standards of this Compliance Program will be subject to progressive discipline, up to and including termination. Sanctions will be applied in accordance with relevant staff personnel policies, School policies/procedures and/or faculty code as appropriate. 10. Organizational Response The School responds to potential violations of the Compliance Program and/or applicable federal and state laws/regulations reported by staff, students, faculty members or others that have questions or concerns regarding School activity.

17 Compliance Program Policies The 10 policies included in the School s Compliance Program ensure we follow federal and state regulations and adhere to the principles and elements described in the previous slides. The School s Compliance Program document can be found at: ce-program/

18 Compliance Policies The School has many other detailed policies in addition to the 10 general policies included in the Compliance Program document. All compliance policies, procedures and guidelines, including HIPAA policies, can be found on the website at:

19 Compliance Director The Compliance Director is responsible for the development, implementation and management of the School s Compliance Program. The Dean of Dentistry and Executive Leadership ensure the Compliance Director is provided with the appropriate resources to effectively manage and meet the elements of the Program.

20 Compliance and Training Committee Members The School s Compliance and Training Committee is made up of the following members: Committee Chair Compliance Director Executive Director and Privacy Official, Health Sciences Administration Associate Dean, Finance and Resources (ex-officio) Associate Dean, Clinical Affairs (ex-officio) Associate Dean, Information Management and Quality Improvement (ex-officio) Assistant Attorney General (advisor/ex-officio) Assistant Dean, Clinical Services (ex-officio) Information Technology Director Department Educational and Information Technology Director Faculty representative for ethics and professionalism knowledge Faculty representative for research expertise Faculty representative for clinical expertise Pre-doctoral student Graduate student/resident

21 Compliance and Training Committee Role The Compliance and Training Committee meets monthly. Some of the Committee s responsibilities are: Advise and assist the Compliance Director with implementation of the Compliance Program Serve as compliance leaders for staff, faculty and students by supporting compliance efforts Reinforce compliance laws, regulations and School policies Recommend School risk posture to the Dean Review concerns brought forward by the Compliance Director Provide feedback on proposed policies and requirements Monitor overall status of School compliance

22 Federal False Claims Act (FCA) The Federal False Claims Act The False Claims Act is the single most important tool U.S. taxpayers have to recover billions of dollars stolen through fraud every year. Those who knowingly submit false claims are liable for civil penalties of $5,500 to $11,000 per false claim plus three times the government s damages. Citizens with evidence of fraud (whistleblowers) can sue on behalf of the government and may be awarded a portion of funds recovered (typically 15 25%).

23 False Claims Act & WA State Law The Federal False Claims Act continued Those involved in a False Claims Act violation are often required to enter into a Corporate Integrity Agreement with the government and may face exclusion from federal health care programs like Medicare and Medicaid. Washington State has a law that is very similar to the Federal False Claims Act (RCW 74.09) that works to discourage frauds committed against the state government.

24 False Claim Examples Examples of frauds prosecuted under the False Claims Act: Billing for services not provided Performing inappropriate or unnecessary medical/dental procedures Overpayments not returned within 60 days Double billing Billing in order to increase revenue instead of billing to reflect work performed Recommending a type of treatment or prescribing a medication in order to win kickbacks from labs, pharmaceutical companies or other vendors Billing for services, such as Radiology, without a documented order

25 Anti-Kickback Statute The Anti-Kickback Statute Prohibits any person or entity from offering, providing, requesting, or accepting anything of value with an intent to induce or influence a referral, lease, order or purchase of items or services reimbursable by a federal health care program. Violation of the Statute constitutes a felony and can result in fines, civil money penalties, and imprisonment. Violation can also result in exclusion from federal health care programs such as Medicare and Medicaid.

26 Stark Statute Stark Law - Physician Self-Referral Prohibition The Stark statute is intended to prohibit or limit financial interests that may conflict with the physician s clinical judgment. The Stark statute applies only to physicians who refer Medicare and Medicaid patients for designated health services (E.g., lab, radiology, prosthetics) to entities with which they (or an immediate family member) have a financial relationship. There are nearly 20 exceptions to this statute.

27 HIPAA Privacy & Security Federal Privacy and Security rules help protect the privacy of patient s health information. The School is required to have policies in place to ensure we follow these rules. School of Dentistry adopted UW Medicine HIPAA policies in 2007 and these policies can be accessed at:

28 State Ethics Laws All state employees, including temporary employees and those with minimal pay, are bound by the State Ethics in Public Service Act, RCW This Act, commonly known as the ethics law, addresses conflicts of interest, improper use of state resources, compensation for outside activities, and gifts. The University of Washington has some of its own additional State Ethics policies that address unique University concerns such as faculty consulting. State Ethics information can be found on the Attorney General s Office website at:

29 Communicating Potential Problems Communication is essential to maintain an effective compliance program. All School faculty, staff and students are individually responsible for asking questions and seeking clarification when they encounter potential violations. Faculty, staff and students are encouraged to share compliance-related concerns as soon as possible so appropriate action can be taken.

30 How to Report Potential Problems Compliance-related concerns can be reported through any of the following channels: Your direct supervisor Anyone in a School leadership role The Compliance Director at or dcomply@uw.edu The School s Anonymous Compliance Hotline at Answered by a pre-recorded message and no attempt is made to identify caller number or location

31 Workforce Compliance Responsibilities All faculty, staff and students are personally responsible for: Understanding and adhering to relevant policies and procedures Participating in required training Reporting compliance concerns Seeking answers to questions Responding timely to compliance requests (audits, investigations, etc.)

32 Additional Responsibilities for Leadership Workforce members in leadership positions have compliance responsibilities beyond the general workforce. In addition to general workforce responsibilities discussed previously, School leaders/supervisors are responsible for: Communicating compliance expectations Ensuring that appropriate compliance training is taken Implementing and enforcing compliance policies Monitoring compliance

33 Summary of Training Objective #1 Understand why the School has a Compliance Program The School s Compliance Program is necessary to ensure rules and regulations are followed, to prevent, identify and respond to potential violations, and to provide education and assistance in meeting our compliance and ethical standards.

34 Summary of Training Objective #2 Identify the 3 basic principles of the School s Compliance Program 1. Integrity 2. Compliance with legal standards 3. Accurate billing and records Identify the 10 key elements of the School s Compliance Program 1. Participation 2. Responsible Officer 3. Compliance Committee 4. Oversight 5. Employee & Vendor Screening 6. Education 7. Auditing & Monitoring 8. Risk Assessment 9. Enforcement & Prevention 10. Organizational Response

35 Summary of Training Objective #3 Know when and how to report potential compliance concerns Report all potential concerns as soon as possible Report potential compliance concerns to any of the following: Your supervisor Anyone in a School leadership role The School s Compliance Director The anonymous Compliance Hotline

36 Summary of Training Objective #4 Identify some of the Regulations School of Dentistry must follow The Federal False Claims Act Anti-Kickback Statute Stark Statute HIPAA Privacy and Security Laws Washington State Ethics Laws

37 Summary of Training Objective #5 Know your personal compliance responsibilities as a general workforce member Understand and adhere to relevant policies and procedures Participate in required training Report compliance concerns Seek answers to questions Respond timely to compliance requests (audits, investigations, etc.) Know your personal compliance responsibilities as a School leader Understand and adhere to relevant policies and procedures Participate in required training Report compliance concerns Seek answers to questions Respond timely to compliance requests (audits, investigations, etc.) Communicate compliance expectations Ensure that appropriate compliance training is taken Implement and enforce compliance policies Monitor compliance

38 Training Completion & Credit You have completed the Compliance Concepts online training. You are required to take a knowledge assessment in order to receive credit for this module. The link is provided on the next page. Thank you for your participation. Please send any comments and questions to: dcomply@uw.edu

39 Knowledge Assessment Please take the following knowledge assessment for Compliance Concepts online training. An electronic record will be sent to the School s Compliance department when you have completed the assessment. This training module and its knowledge assessment are required training material for all School of Dentistry workforce members. It is a good idea to print and save a copy of your knowledge assessment confirmation page for your records.