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VHA and VISN 21 Compliance Business Integrity CBI Program

Compliance Officers. Jane Dutton Morris, MHACompliance Specialist, Sierra Pacific Network (707) 562-8377 Jane.Dutton2@.va.gov Yvonne Brooks, CCP Compliance Officer VA San Francisco Medical Center(415) 221-4810 Ext. 4398Yvonne.Brooks@med.va.govCaroline Chaderjian, MHACompliance Officer

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VHA and VISN 21 Compliance Business Integrity CBI Program

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    1. VHA and VISN 21 Compliance & Business Integrity (CBI) Program Mandatory Training for Contractors Prepared: March 2007 VHA and VISN 21 Compliance & Business Integrity (CBI) Program Mandatory Training for Contractors Prepared Jan. 2006VHA and VISN 21 Compliance & Business Integrity (CBI) Program

    2. Compliance Officers Jane Dutton Morris, MHA Compliance Specialist, Sierra Pacific Network (707) 562-8377 Jane.Dutton2@.va.gov Yvonne Brooks, CCP Compliance Officer VA San Francisco Medical Center (415) 221-4810 Ext. 4398 Yvonne.Brooks@med.va.gov Caroline Chaderjian, MHA Compliance Officer VA Palo Alto Health Care System (650) 493-5000 Ext. 63315 Caroline.Chaderjian@va.gov Patty Almond, RHIT, CPC Compliance Officer VA Central California Health Care System (559) 225-6100 Ext. 5581 Patricia.Almond@va.gov Compliance Officers: Jane Dutton Morris Yvonne Brooks Caroline Chaderjian Patty AlmondCompliance Officers:

    3. Compliance Officers- continued Patricia Moran, RHIT CPC Compliance Officer VA Northern California Health Care System (707)437-1905 Patricia.Moran@va.gov Peggy Ashcraft Compliance Officer VA Sierra Nevada Health Care System (775)328-1212 MargaretPeggy.Ashcraft@med.va.gov Craig Oswald, MHA VA Pacific Islands Health Care System (808)433-0103 Craig Oswald@med.va.gov

    4. VHA Definition of Compliance Compliance is an oversight process which requires employees and contractors to conduct administrative and clinical duties in an honest, ethical and professional manner. Behavior that is not consistent with ethical business practices places Veterans Health Administration (VHA) facilities at risk for penalties, negative publicity and loss of public trust.

    5. VHA’s Compliance Program Currently the VHA’s Compliance & Business Integrity program focuses on the REVENUE CYCLE to include the following business operations: 1) Patient registration & intake 2) Medical documentation 3) Coding for medical procedures & visits 4) Billing for services provided 5) Collections from insurance companies

    6. Purpose of VHA Compliance Program Ensure business operations comply with relevant laws, rules and regulations; Promote ethical practices and standards of excellence in patient care; Help VHA maintain the public’s trust.

    7. Effective Compliance Program An Effective Compliance Program Has 7 Elements: 1. Designating Compliance Officer & Committee 2. Written Policies and Procedures 3. Education and Training 4. Auditing and Monitoring 5. Reporting Mechanisms 6. Investigation and Remediation 7. Disciplinary Action

    8. Medical Documentation, Coding & Billing by Contractors Physicians or healthcare providers are responsible for completely and accurately documenting patient care services. Coders are responsible for assigning and validating procedural & diagnostic codes based on provider documentation. Billers are responsible for generating timely, accurate and appropriate bills based on veterans’ eligibility and the service provided. Accurate and complete services reduce the negative consequences associated with fraud and maximize reimbursement from insurance companies which, in turn, allows VHA to provide more services to our patients.

    9. Open Lines of Communication

    10. CBI Helpline- continued The CBI Helpline is available Monday through Friday from 8:00 to 4:300, EST. Anyone “internal” or “external” to the VA (this includes employees, patients or contractors) may call the CBI Helpline number to report potential compliance failures. The caller may remain anonymous.

    11. HIGH RISK AREA A high risk area is a clinical or business activity that may be unethical, illegal, a conflict of interest or in violation of national and local policies & procedures. Employees and contractors should: Be aware of high risk areas concerning VHA Not engage in fraud or abuse against VHA Take appropriate actions- report all potential compliance failures to the VHA facility Compliance Officer and/or the CBI Helpline.

    12. EXAMPLES of High Risks Fraudulent Coding : Up-coding (using higher codes) to get higher reimbursement from 3rd party insurance companies. Erroneous Billing: Billing for services not provided to the patient; Billing for Services Provided by Residents (physicians in training) without adequate supervision by a credentialed physician. Providing Medically Unnecessary Services: Providing services that the patient does not need or may cause the harm to the patient. Failure to Report a Suspected Compliance Violation: knowing about a potential compliance failure and not reporting it.

    13. EXAMPLES of High Risks (continued) Failure to Exert Due Diligence: Contracting with individuals or companies that have a propensity to engage in illegal activities. Kickback: Soliciting or receiving payment / gifts in return for referring a patient to another healthcare provider or for conducting business with a certain entity. Appearing on the OIG Sanction List: Sanctioned individuals, entities, contractors listed on the Office of inspector General’s (OIG) Exclusionary List Database cannot receive payments from any federal healthcare programs for services furnished.

    14. Identifying & Reporting High Risk Areas STEP 1: Ask yourself some key questions Does the action fit with the organization’s values? Would you feel good about yourself if you did it? Would you be comfortable discussing this with your family and friends? If you answer “no” to any of these questions, you should go to the next step. STEP 2: Discuss your concern with the facility Compliance Officer and/or call the CBI Help-Line at 1-866-842-4357

    15. Federal Employee and Contractor Responsibilities 1. Contractors should not offer gifts to federal employees and federal employees should not accept gifts from entities that do business or are attempting to do business with the organization 2. Federal employees should excuse themselves from activities in which they might have a financial interest 3. Federal employees must remain impartial in conducting official duties.

    16. SUMMARY Compliance is Everybody’s Responsibility; Know who the Compliance Officers are and how to contact them; Follow your own best instincts; Do your job ethically & legally; Be honest in all business transactions/ and contracts / awards.

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