3/17/2015. Disclaimer. Objectives

Transcription

1 Two Medical Schools, Two Unique Faculty Practice Plans, Two Compliance Officers, One University Under a CIA: A Compliance Program Challenge Deborah L. Carlino, RN, MBA, CHC, CHRC Director of Healthcare Compliance and Audit and Anthony G. Caroleo, MA, CHC Senior Compliance Officer Disclaimer This presentation is for general education purposes only. The information contained in these materials, lecture, ideas and concepts presented is not intended to be, and is not, legal advice or even particular business advice relevant to your personal circumstances. The laws and regulations presented in this lecture are open to interpretation. Objectives Understand the differences and similarities between the two faculty practices, identifying the unique risks inherent in the two programs Understand the challenges faced when the billing for one faculty practice is performed by a related entity not covered under a CIA Understand the role of the Compliance Officers in each program and the deferent methods used to identify and mitigate risks and benefits of collaborating when possible. 1

2 ALL ABOUT RUTGERS Quick Points Founded in Became New Jersey s State University in 1956 One of the 62 leading research universities in the United States and Canada comprising the Association of American Universities (AAU) Member of the Committee on Institutional Cooperation, the nation s premier higher education consortium Joined the Big Ten Conference, one of the most prestigious conferences in intercollegiate sports, in 2014 Fast Facts 33 schools Approximately 24,400 faculty and staff More than 65,000 matriculated students from all 50 states and more than 115 countries Nearly 450,000 alumni, one of the nation s largest alumni networks Campuses in New Brunswick/Piscataway, Newark, and Camden, with additional locations throughout New Jersey 2

3 A Leader in Academic Health Care With the establishment of Rutgers Biomedical and Health Sciences (RBHS) in 2013, Rutgers now stands as one of America s largest, most comprehensive academic centers for studying and improving human health and health care. Patient Care RBHS includes two medical schools, a dental school, other health-related schools, research centers and institutes, and leading faculty practices Rutgers patient care practices log 1.7 million patient visits annually Rutgers Cancer Institute of New Jersey is the only National Cancer Institute-designated Comprehensive Cancer Center in New Jersey and one of only 41 in the nation For More Information Visit rutgers.edu or call INFO 3

4 THE OFFICE OF ENTERPRISE RISK MANAGEMENT, ETHICS AND COMPLIANCE Office of Enterprise Risk Management, Ethics & Compliance Centralized Compliance Department Interim SVP Enterprise Risk Management (ERM), Ethics and Compliance (Chief Compliance Officer) Director of Healthcare Compliance and Audit Unit Senior Compliance Officers Centralized ERM Hotline Centralized ERM Investigations Unit Centralized Compliance Audit/Review Function with Centralized Rutgers Audit Committee of the Board of Governors Unit Specific Annual Compliance Work Plans CORPORATE INTEGRITY AGREEMENT 4

5 Corporate Integrity Agreement The CIA was a result of problems that were discovered at UMDNJ prior to 2009 and led to the Deferred Prosecution Agreement and the federal monitor. As a result of those problems UMDNJ dramatically transformed the manner in which it conducted business Many employees were required to complete approximately one hour of training annually to ensure an understanding of the CIA and of UMDNJ s compliance programs. Other employees were required to complete additional training, up to five hours annually, such as those employees whose responsibilities involve coding and submission of healthcare claims, documentation of medical records and the submission and preparation of cost reports and contracts The CIA agreement covers a period of five years Corporate Integrity Agreement On July 1, 2013, the New Jersey Medical and Health Sciences Restructuring Act, dissolved the University of Medicine and Dentistry of New Jersey Rowan University School for Osteopathic Medicine University Hospital became stand alone State facility Rutgers got everything else 1 CIA with 3 entities 4 th reporting year for UMDNJ was shortened to 9 months 5 th reporting year for Rutgers (and the other 2 entities) was lengthened to 15 months Ended September 25, 2014 THE SCHOOLS 5

6 New Jersey Medical School (NJMS) NJMS is committed to educating humanistic, culturally competent physicians who will respect every patient regardless of race, ethnicity, economic status or language. Core values serve as the framework for learning for all NJMS students and include not only clinical and academic excellence, integrity, ethical and professional behavior but also compassion NJMS Key Dates 1954 Founded as Seton Hall College of Medicine and Dentistry of New Jersey (SHCMD), oldest in New Jersey 1960 Receives full accreditation 1969 Move to Newark is complete Medicine and Dentistry Education Act establishes the College of Medicine and Dentistry of New Jersey - combining Rutgers Medical School and the New Jersey College of Medicine and Dentistry under one Board of Trustees. The medical school is officially named New Jersey Medical School Dr. Robert L. Johnson is appointed as the eighth Dean of NJMS NJMS Key Facts With 743 students; 597 residents and fellows; 2,478 fulltime, part-time and volunteer faculty; and 27 centers and institutes, New Jersey Medical School is the largest school of allopathic medicine in the state In addition to the MD degree, with our partner schools, we offer the following dual-degree programs: MD/MBA; MD/MPH; MD/PhD and MD with thesis in addition to an accelerated BA and BS/MD program with several colleges in New Jersey The school sponsors 43 accredited residency and fellowship programs, the school partners with several area healthcare facilities, including University Hospital in Newark, its flagship teaching hospital and New Jersey s busiest Level 1 Trauma Center 6

7 University Physician Associates (UPA) Faculty Practice Plan of Rutgers Biomedical and Health sciences (Rutgers) / New Jersey Medical School (NJMS). The Faculty Practice Plan is the organization that bills for, collects, and distributes the clinical receipts, and provides additional administrative support to the practice of the faculty of NJMS University Physician Associates (UPA) The mission of UPA is to promote and foster the clinical activities of the Faculty of Rutgers-NJMS, to use the revenue that such activity generates to: Support the missions of NJMS in post-graduate, undergraduate and public education; Advance the body of knowledge in both the clinical and basic science of medicine through research; Offer the school's patients state-of-the-art, competent, compassionate and cost-effective medical care UPA Governance UPA is an independent not-for-profit corporation, closely aligned with the Medical School. It s governance is comprised of faculty members that are elected every other year, and includes NJMS and Rutgers officials such as the Dean, the CEO of University Hospital, and the Senior Vice President for Administration and Finance of Rutgers 7

8 Physician Prospective Review Process Beneficial Attributes Internal process Prospective process Educational process Collaborative process Limit the disruption of the practice Limit the disruption of billing in a timely manner Risk Assessment and Vulnerability Physician Prospective Review Process Review Assumptions Physicians with extremely low volume/charges will continuously be held, reviewed and released until a reasonable minimum is attained. Sample selection methodology used for large volume/charges will be systematic sampling (select every nth ) and no more than 50 charges. Time frames are based upon the availability of supportive documentation and charges. Physician Prospective Review Process Tier 1 1. Introductory Meeting scheduled to discuss the Review Process 2. A hold of available population of visits is requested in the Physician Charge Capture System (up to 15 encounters). 3. Encounters free of errors released for billing 4. Preliminary review findings are reviewed with Physician. Additional training is provided by the Physician Compliance Coder Auditor. 8

9 Physician Prospective Review Process Tier 1, Con t 5. A score below 70% results in a re-review within 30 days of completion of mandatory education and training. 6. A score of 90% or more will trigger a Letter of Acknowledgement 7. A claims correction form to Department Administrator for Physician signature and the corrected claims are released for billing. Physician Prospective Review Tier 2 For a review result below 70% 1. A new sample of E&M charges is placed on hold, up to 50 encounters encounters from the new sample are reviewed 3. All charges are placed on hold pending outcome of the review. 4. Of the charges reviewed, those free of errors will be released for billing 5. A score of 70% or better, refer to previous steps Physician Prospective Review Tier 2, Con t. 6. If the re-review score remains below 70%, Faculty Practice Compliance reviews remaining population of charges on hold. Physician is subject to mandatory training. 7. Proceed to Tier 3 9

10 Physician Prospective Review Process Tier 3 This review is conducted by Faculty Practice Compliance in collaboration with Medical School Compliance 1. All expenses arising from this review are charged back to the Department Practice funds 2. If the Faculty Practice Compliance review of the remaining Tier 2 sample does not conform to the findings of the Medical School Compliance Team, a discussion will occur before the review is deemed closed. The re-review schedule will be based upon the final score as agreed by Faculty Practice and Medical School Compliance Physician Prospective Review Process Tier 3, Con t. 3. A collaborative training session with Medical School Compliance and Faculty Practice Compliance and the physician is scheduled. 4. If the Faculty Practice Compliance review of the remaining Tier 2 sample conforms to the findings of Medical School Compliance, the following actions may take place, with consultation including Faculty Practice Compliance, Medical School Compliance, Physician representation, Department Leadership and the Medical School Dean: Results of 3 Tiers of review explained a. Education/in-service provided b. Stop-bill c. 100% pre-bill review d. Formal documented Corrective Action Plan Robert Wood Johnson Medical School As one of the nation's leading comprehensive medical schools, Robert Wood Johnson Medical School is dedicated to the pursuit of excellence in education, research, health care delivery, and the promotion of community health. 10

11 Robert Wood Johnson Medical School In cooperation with Robert Wood Johnson University Hospital, the medical school's principal affiliate, they comprise New Jersey's premier academic medical center. Robert Wood Johnson Medical School has 34 other hospital affiliates and ambulatory care sites throughout the region. The medical school has more than 2,800 full-time, parttime, and volunteer faculty members. Robert Wood Johnson Medical School Robert Wood Johnson Medical School encompasses 20 basic sciences and clinical departments. It has 6 major institutes including: The Cardiovascular Institute, the Child Health Institute of New Jersey, the Center for Advanced Biotechnology and Medicine, the Environmental and Occupational Health Sciences Institute, and the Stem Cell Institute of New Jersey Robert Wood Johnson Medical School There are more than 450 residents and fellows trained each year through the Graduate Medical Education programs. Robert Wood Johnson Medical School sponsors 49 programs in graduate medical education. Robert Wood Johnson Medical School provides charitable clinical care at an estimated cost of $38 million annually. The Medical School received $89 million in research grant awards in FY

12 RWJ Medical Group Mission: In support of the education, research, patient care, and community outreach missions of Robert Wood Johnson Medical School Robert Wood Johnson Medical Group Robert Wood Johnson Medical Group, the medical school s multi-specialty group practice, is the largest in New Jersey, with more than 500 physicians. It has 14 clinical specialty departments that provide a broad spectrum of advanced patient care representing 210 specialty and sub-specialty programs In addition to Robert Wood Johnson University Hospital, the medical school's principal affiliate, Robert Wood Johnson Medical School has 34 other hospital affiliates and ambulatory care sites throughout the region that are managed by the Medical Group. Robert Wood Johnson Medical Group Provides a full range of Primary Care Services to patients through Family Medicine, General Internal Medicine, and Pediatrics Is also the practice group for The Rutgers Cancer Institute of New Jersey Supports clinical services of the 6 Major Centers and Institutes for Research and Patient Care It has a fully functioning electronic medical record system. 12

13 RWJMG Governance Governed by a Board of Governors The Dean of RWJ Medical School is the Chair of the Board and CEO President of the Group is also the COO. The Executive Director of Finance serves as the CFO. A Member must be a full time faculty provider (bill and collect for their professional services); or, a part time faculty provider who bills and collects for a portion of their service. RWJ Medical Group The group functions as the practice business office (accounting, budget management and financial reports). All Billing and Collections are performed by the Medical Group. Negotiates and manages all contracts and agreements on behalf of the Medical Group Providers billing through the Medical Group do not receive direct compensation from the Group. RWJMG Payor Mix 13

14 The Partnership with The Group Sharing of Medical Group data with Compliance Physician billing and documentation Compliance Coding and Audit Staff and Medical Group participation in one-on-one physician education sessions. Challenges One method of approach doesn t always fit Differing legal opinions Differing Compliance approaches Prospective versus Retrospective Review Differing policies Differing processes Challenges Information/data report access RAC Letters Charge capture Paid claims 14

15 Challenges Employee Issues Adherence to policies Discipline Flexibility within the practices Challenges Different fiduciary goals School versus physician member Alignment of goals with the Academic Medical Center Take-Aways If multiple entities are challenged with a CIA, prior to signing, NEGOTIATE! Understand the definitions of covered persons Understand how the ownership of an entity may impact inclusion or exclusion under the CIA Might be the time to engage a consultant that has negotiated CIA s before 15

16 Take-Aways In a highly regulated environment, meticulous attention must be paid to regulatory compliance Try to focus on common goals Try to standardize processes as much as possible Collaborate and forge a close relationship with all parties Transparency is key (to the extent two separate organizations can) Any Questions 16