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annual compliance training
Annual Compliance Training

Navigation Tips

You must have your PC’s sound on and close out all other programs from your PC.

The navigation bar at the bottom of the slide will guide you through the training.

When you finish the training course, you must complete and submit a certification/Acknowledgement Form in Module 5.

annual compliance training1
Annual Compliance Training

EXIT

Navigation Tips

You must have your PC’s sound on and close out all other programs from your PC.

The navigation bar at the bottom of the slide will guide you through the training.

When you finish the training course, you must complete and submit a certification/Acknowledgement Form in Module 5.

annual compliance training2
Annual Compliance Training

PREPARATION

Coordinate with your supervisor to have your phone covered/forwarded so you won’t be interrupted.

Schedule approximately 1 hour to complete the training.

The training is narrated so headphones may help you focus and avoid distracting your co-workers.

Have a pen and paper handy. If you have questions, write them down and at the end of the training, call or email the Compliance Officer.

You must complete this entire mandatory training program before completing the Acknowledgement Form.

annual compliance training3
Annual Compliance Training

EXIT

PREPARATION

Coordinate with your supervisor to have your phone covered/forwarded so you won’t be interrupted.

Schedule approximately 1 hour to complete the training.

The training is narrated so headphones may help you focus and avoid distracting your co-workers.

Have a pen and paper handy. If you have questions, write them down and at the end of the training, call or email the Compliance Officer.

You must complete this entire mandatory training program before completing the Acknowledgement Form.

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annual compliance training

COMPLIANCE OFFICE STAFF

Compliance Officer – Barb Mottl

barbm@jeffersoncountywi.gov

(920) 674-8151

Compliance Analyst – Attorney Scott Scheibel

scotts@jeffersoncountywi.gov

(920) 674-8635

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annual compliance training

EXIT

COMPLIANCE OFFICE STAFF

Compliance Officer – Barb Mottl

barbm@jeffersoncountywi.gov

(920) 674-8151

Compliance Analyst – Attorney Scott Scheibel

scotts@jeffersoncountywi.gov

(920) 674-8635

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annual compliance training
  • What is Compliance?
  • County’s Compliance Program
  • False Claims Act
  • Integrity Agreement
  • Certification

TRAINING MODULES

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annual compliance training
  • What is Compliance?
  • County’s Compliance Program
  • False Claims Act
  • Integrity Agreement
  • Certification

EXIT

TRAINING MODULES

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annual compliance training

MODULE 1

WHAT IS COMPLIANCE?

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annual compliance training

EXIT

MODULE 1

WHAT IS COMPLIANCE?

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annual compliance training

WHAT IS COMPLIANCE?

  • Knowing and following Federal, State and County laws, regulations, rules, guidelines, policies and procedures that apply to our jobs.
  • Think about the agencies that regulate or oversee your activities.
  • Compliance is throughout all departments, divisions, programs that provide Mental Health Services.
  • Includes contractors, their employees and subcontractors.
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annual compliance training

EXIT

WHAT IS COMPLIANCE?

  • Knowing and following Federal, State and County laws, regulations, rules, guidelines, policies and procedures that apply to our jobs.
  • Think about the agencies that regulate or oversee your activities.
  • Compliance is throughout all departments, divisions, programs that provide Mental Health Services.
  • Includes contractors, their employees and subcontractors.
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annual compliance training

OVERVIEW OF THE HEALTH CARE INDUSTRY

Healthcare is Under Increased Scrutiny from Federal & State Governments.

  • Estimated 10% of 1 Trillion spent on healthcare fraud/waste or abuse
  • Federal and State healthcare programs facing financial difficulty

Government Response

  • Healthcare is enforcement priority
  • Government personnel added and coordinated efforts (e.g. FBI, DOJ, OIG)
  • New/tougher laws & regulations enacted including the Patient Protection & Affordable care Act of 2010 (the “Healthcare Reform Act”). The Act contains numerous provisions relating to healthcare fraud/waste/abuse, program integrity and new enforcement measures and resources. Also requires all healthcare providers participating in federal programs to establish and maintain a compliance program as a condition of their continued participation.
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annual compliance training

EXIT

OVERVIEW OF THE HEALTH CARE INDUSTRY

Healthcare is Under Increased Scrutiny from Federal & State Governments.

  • Estimated 10% of 1 Trillion spent on healthcare fraud/waste or abuse
  • Federal and State healthcare programs facing financial difficulty

Government Response

  • Healthcare is enforcement priority
  • Government personnel added and coordinated efforts (e.g. FBI, DOJ, OIG)
  • New/tougher laws & regulations enacted including the Patient Protection & Affordable care Act of 2010 (the “Healthcare Reform Act”). The Act contains numerous provisions relating to healthcare fraud/waste/abuse, program integrity and new enforcement measures and resources. Also requires all healthcare providers participating in federal programs to establish and maintain a compliance program as a condition of their continued participation.
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annual compliance training

HEALTHCARE FRAUD & ABUSE

FRAUD

    • False statements of representation of facts to obtain payment/benefit to which not otherwise entitled.
    • Committed for one’s own benefit or on behalf of another.
    • Must establish acts were performed knowingly, willfully and intentionally.
    • Civil fraud violations have a lower standard of proof.
    • Usually involve sanctions and financial penalties.

ABUSE

  • Practices that directly or indirectly result in unnecessary increased costs to clients.
  • Medically unnecessary over- utilization.
  • Not in conformance with industry standards.
  • Fees that are unreasonable or unfair.
  • Restrictive of patient choice.
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annual compliance training

EXIT

HEALTHCARE FRAUD & ABUSE

FRAUD

    • False statements of representation of facts to obtain payment/benefit to which not otherwise entitled.
    • Committed for one’s own benefit or on behalf of another.
    • Must establish acts were performed knowingly, willfully and intentionally.
    • Civil fraud violations have a lower standard of proof.
    • Usually involve sanctions and financial penalties.

ABUSE

  • Practices that directly or indirectly result in unnecessary increased costs to clients.
  • Medically unnecessary over- utilization.
  • Not in conformance with industry standards.
  • Fees that are unreasonable or unfair.
  • Restrictive of patient choice.
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annual compliance training

RELEVANCE OF COMPLIANCE PROGRAMS

  • Government believes the best way to protect public healthcare dollars is to prevent fraud/abuse.
    • Educating individuals on the laws, regulations and organization’s standards that apply to them in the workplace.
    • Encouraging individuals to ask questions or voice their concerns to the compliance officer.
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annual compliance training

EXIT

RELEVANCE OF COMPLIANCE PROGRAMS

  • Government believes the best way to protect public healthcare dollars is to prevent fraud/abuse.
    • Educating individuals on the laws, regulations and organization’s standards that apply to them in the workplace.
    • Encouraging individuals to ask questions or voice their concerns to the compliance officer.
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annual compliance training

WHY ARE COMPLIANCE PROGRAMS IMPORTANT?

Promote open communication and problem resolution.

Maintain Federal, State, County and industry standards to comply with increased government regulations.

Demonstrate organization’s commitment to comply with all legal and ethical responsibilities.

Keep pace with trend in the health care industry.

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annual compliance training

EXIT

WHY ARE COMPLIANCE PROGRAMS IMPORTANT?

Promote open communication and problem resolution.

Maintain Federal, State, County and industry standards to comply with increased government regulations.

Demonstrate organization’s commitment to comply with all legal and ethical responsibilities.

Keep pace with trend in the health care industry.

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annual compliance training

Employees & Contractors

Code of Conduct Ethics

ELEMENTS OF A COMPLIANCE PROGRAM

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annual compliance training

Employees & Contractors

Code of Conduct Ethics

EXIT

ELEMENTS OF A COMPLIANCE PROGRAM

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annual compliance training

MODULE 2

JEFFERSON COUNTY’S COMPLIANCE PROGRAM

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annual compliance training

EXIT

MODULE 2

JEFFERSON COUNTY’S COMPLIANCE PROGRAM

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annual compliance training

JEFFERSON COUNTY’S COMPLIANCE PROGRAM

  • Required by Title 42 CFR Section 438.608
  • 7 Specific Requirements
    • Standards & Procedures
    • Compliance Officer and Committee
    • Training and Education
    • Communication
    • Enforcement
    • Internal Monitoring/Auditing
    • Prompt response/corrective action
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annual compliance training

JEFFERSON COUNTY’S COMPLIANCE PROGRAM

  • Required by Title 42 CFR Section 438.608
  • 7 Specific Requirements
    • Standards & Procedures
    • Compliance Officer and Committee
    • Training and Education
    • Communication
    • Enforcement
    • Internal Monitoring/Auditing
    • Prompt response/corrective action
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annual compliance training

EXIT

JEFFERSON COUNTY’S COMPLIANCE PROGRAM

  • Required by Title 42 CFR Section 438.608
  • 7 Specific Requirements
    • Standards & Procedures
    • Compliance Officer and Committee
    • Training and Education
    • Communication
    • Enforcement
    • Internal Monitoring/Auditing
    • Prompt response/corrective action
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annual compliance training

COMPLIANCE REQUIREMENT #1: Standards & Procedures

Mission Statement

Code of Conduct

Code of Ethics (For County employees only)

View by clicking on the appropriate link below:

Code of Conduct for Employees (section only)

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annual compliance training

EXIT

COMPLIANCE REQUIREMENT #1: Standards & Procedures

Mission Statement

Code of Conduct

Code of Ethics (For County employees only)

View by clicking on the appropriate link below:

Code of Conduct for Employees (section only)

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annual compliance training

COMPLIANCE REQUIREMENT #1: Standards & Procedures

Mission Statement: Jefferson County Human Services Department will comply with applicable laws, regulations, rules or guidelines governing the provision of mental health services. All employees and contractors, who provide and receive payment for mental health services, are expected to conduct themselves honestly, fairly and with a high degree of integrity.

Accordingly, the County has implemented a Compliance Program to ensure, to the extent reasonably possible, that all employees invoke a high degree of business honesty and integrity required of health care professionals and providers. In addition, this program has been instituted as a means of preventing fraud, abuse and false billings to any third-party payer.

Strict adherence to the Compliance Program is expected of all mental health employees and contractors.

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annual compliance training

EXIT

COMPLIANCE REQUIREMENT #1: Standards & Procedures

Mission Statement: Jefferson County Human Services Department will comply with applicable laws, regulations, rules or guidelines governing the provision of mental health services. All employees and contractors, who provide and receive payment for mental health services, are expected to conduct themselves honestly, fairly and with a high degree of integrity.

Accordingly, the County has implemented a Compliance Program to ensure, to the extent reasonably possible, that all employees invoke a high degree of business honesty and integrity required of health care professionals and providers. In addition, this program has been instituted as a means of preventing fraud, abuse and false billings to any third-party payer.

Strict adherence to the Compliance Program is expected of all mental health employees and contractors.

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annual compliance training

COMPLIANCE REQUIREMENT #1: Standards & Procedures

Conduct Standards

  • The County is committed to full compliance with all applicable laws, regulations, rules and guidelines that apply to its mental health operations and services.
  • Employee and contractor conduct is at the core of this commitment.
  • County employees and contractors must adhere to:
      • The Code of Conduct and the Compliance Program
  • County employees must also adhere to the county’s Code of Ethics.
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annual compliance training

EXIT

COMPLIANCE REQUIREMENT #1: Standards & Procedures

Conduct Standards

  • The County is committed to full compliance with all applicable laws, regulations, rules and guidelines that apply to its mental health operations and services.
  • Employee and contractor conduct is at the core of this commitment.
  • County employees and contractors must adhere to:
      • The Code of Conduct and the Compliance Program
  • County employees must also adhere to the county’s Code of Ethics.
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annual compliance training

COMPLIANCE REQUIREMENT #1: Standards & Procedures

Code of Conduct

County’s behavior expectations

County’s commitment to its employees and contractors and to promote compliance with all applicable laws, etc.

Familiarize staff with the basic legal principles of ethical standards of behavior expected in the provision, documentation, coding or billing of mental health services.

Code of Ethics

Established by the Board of Supervisors

Applies to all county employees

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annual compliance training

EXIT

COMPLIANCE REQUIREMENT #1: Standards & Procedures

Code of Conduct

County’s behavior expectations

County’s commitment to its employees and contractors and to promote compliance with all applicable laws, etc.

Familiarize staff with the basic legal principles of ethical standards of behavior expected in the provision, documentation, coding or billing of mental health services.

Code of Ethics

Established by the Board of Supervisors

Applies to all county employees

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annual compliance training

COMPLIANCE REQUIREMENT #1: Standards & Procedures

Certification

All employees and contractors must sign the Acknowledgement and Agreement Form and submit it to the Compliance Officer.

Form and instructions are in Module 5.

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annual compliance training

EXIT

COMPLIANCE REQUIREMENT #1: Standards & Procedures

Certification

All employees and contractors must sign the Acknowledgement and Agreement Form and submit it to the Compliance Officer.

Form and instructions are in Module 5.

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annual compliance training

COMPLIANCE REQUIREMENT #1: Standards & Procedures

Documenting Compliance Activities

  • Protects integrity of the compliance process and confirms the effectiveness of the Compliance Program.
  • Must document, at a minimum:
    • Trainings
    • Investigations
    • Anonymous Reporting
    • Self-disclosure
    • Modifications to the Compliance Program
    • Results of the County’s auditing/monitoring efforts
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annual compliance training

EXIT

COMPLIANCE REQUIREMENT #1: Standards & Procedures

Documenting Compliance Activities

  • Protects integrity of the compliance process and confirms the effectiveness of the Compliance Program.
  • Must document, at a minimum:
    • Trainings
    • Investigations
    • Anonymous Reporting
    • Self-disclosure
    • Modifications to the Compliance Program
    • Results of the County’s auditing/monitoring efforts
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annual compliance training

COMPLIANCE REQUIREMENT #2: Compliance Officer and Committee

Compliance Officer Responsibilities

Oversight of the Compliance Program

Establish and maintain the Code of Conduct & Policies and Procedures

Chair the Compliance Committee

Ensure an ongoing training/education program

Establish auditing/monitoring procedures

Compliance investigations

Promote awareness and understanding of the positive, ethical and moral practices consistent with the mission and values of the county and those required by applicable laws, regulations, rules or guidelines.

Report findings to the Agency Director.

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annual compliance training

EXIT

COMPLIANCE REQUIREMENT #2: Compliance Officer and Committee

Compliance Officer Responsibilities

Oversight of the Compliance Program

Establish and maintain the Code of Conduct & Policies and Procedures

Chair the Compliance Committee

Ensure an ongoing training/education program

Establish auditing/monitoring procedures

Compliance investigations

Promote awareness and understanding of the positive, ethical and moral practices consistent with the mission and values of the county and those required by applicable laws, regulations, rules or guidelines.

Report findings to the Agency Director.

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annual compliance training

COMPLIANCE REQUIREMENT #2: Compliance Officer

The Compliance Officer has the full authority to stop any work process that may be the cause of, or is contributing to non-compliance, until the process has been reviewed and/or corrected, if needed.

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annual compliance training

EXIT

COMPLIANCE REQUIREMENT #2: Compliance Officer

The Compliance Officer has the full authority to stop any work process that may be the cause of, or is contributing to non-compliance, until the process has been reviewed and/or corrected, if needed.

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annual compliance training

COMPLIANCE REQUIREMENT #2: Compliance Officer & Committee

Compliance Committee

  • Responsibilities include:
    • Organizational Support
    • Promote awareness of the Compliance Program
    • Advise the Compliance Officer
    • Implement the Compliance Program
    • Monitor/assess effectiveness of compliance with applicable laws, etc.
    • Address areas of concern or risk
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annual compliance training

EXIT

COMPLIANCE REQUIREMENT #2: Compliance Officer & Committee

Compliance Committee

  • Responsibilities include:
    • Organizational Support
    • Promote awareness of the Compliance Program
    • Advise the Compliance Officer
    • Implement the Compliance Program
    • Monitor/assess effectiveness of compliance with applicable laws, etc.
    • Address areas of concern or risk
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annual compliance training

Employee & Contractor Roles & Responsibilities in Compliance

Help the county operate a successful Compliance Program

Comply with the Code of Conduct & Code of Ethics

Adhere to the Compliance Program and all applicable laws, rules, regulations, guidelines, policies and procedures

Report a violation or suspected violation.

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annual compliance training

EXIT

Employee & Contractor Roles & Responsibilities in Compliance

Help the county operate a successful Compliance Program

Comply with the Code of Conduct & Code of Ethics

Adhere to the Compliance Program and all applicable laws, rules, regulations, guidelines, policies and procedures

Report a violation or suspected violation.

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annual compliance training

COMPLIANCE REQUIREMENT #3: Training & Education

All county employees and contractors, including contractor’s employees and subcontractors, must be trained and retrained to keep abreast of changes in Federal, State and County laws, rules regulation, policies and procedures.

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annual compliance training

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COMPLIANCE REQUIREMENT #3: Training & Education

All county employees and contractors, including contractor’s employees and subcontractors, must be trained and retrained to keep abreast of changes in Federal, State and County laws, rules regulation, policies and procedures.

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annual compliance training

COMPLIANCE REQUIREMENT #3: Training & Education

  • Timelines:
    • Within 30 days of hire or contract effective date
    • Annually

General Compliance Training

  • Mandatory for all employees & contractors who:
    • Provide mental health services
    • Work in any mental health program or paid with MH $$
    • Are responsible for the billing, claiming, accounting or cost reporting of mental health services
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annual compliance training

EXIT

COMPLIANCE REQUIREMENT #3: Training & Education

  • Timelines:
    • Within 30 days of hire or contract effective date
    • Annually

General Compliance Training

  • Mandatory for all employees & contractors who:
    • Provide mental health services
    • Work in any mental health program or paid with MH $$
    • Are responsible for the billing, claiming, accounting or cost reporting of mental health services
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annual compliance training

COMPLIANCE REQUIREMENT #4: Communication

Maintain open lines of communication

Annual trainings

Post the Code of Ethics and Code of Conduct

Post information regarding options for reporting compliance violations or concerns anonymously

Non-retaliation Policy

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annual compliance training

EXIT

COMPLIANCE REQUIREMENT #4: Communication

Maintain open lines of communication

Annual trainings

Post the Code of Ethics and Code of Conduct

Post information regarding options for reporting compliance violations or concerns anonymously

Non-retaliation Policy

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annual compliance training

COMPLIANCE REQUIREMENT #4: Communication

Reporting Violations

Employees and contractors are EXPECTED To report any activity that may violate the Compliance Program’s mission, standards and any applicable law, regulation, rule or guideline.

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annual compliance training

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COMPLIANCE REQUIREMENT #4: Communication

Reporting Violations

Employees and contractors are EXPECTED To report any activity that may violate the Compliance Program’s mission, standards and any applicable law, regulation, rule or guideline.

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annual compliance training

COMPLIANCE REQUIREMENT #4: Communication

Non-Retaliation Policy

Jefferson County prohibits retaliation against any person making a report.

Any employee engaging in any form of retaliation will be subject to disciplinary action.

For a contractor engaging in any form of retaliation, termination of their contract may result.

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annual compliance training

EXIT

COMPLIANCE REQUIREMENT #4: Communication

Non-Retaliation Policy

Jefferson County prohibits retaliation against any person making a report.

Any employee engaging in any form of retaliation will be subject to disciplinary action.

For a contractor engaging in any form of retaliation, termination of their contract may result.

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annual compliance training

COMPLIANCE REQUIREMENT #4: Communication

Disclosure Program

Reporting Methods

  • Anonymously:
    • Mail: Barb Mottl, Compliance Officer

1541 Annex Road

Jefferson, WI 53549

  • Direct to the Compliance Officer
    • Phone (920) 674-8151
    • Email: Barbm@jeffersoncountywi.gov
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annual compliance training

EXIT

COMPLIANCE REQUIREMENT #4: Communication

Disclosure Program

Reporting Methods

  • Anonymously:
    • Mail: Barb Mottl, Compliance Officer

1541 Annex Road

Jefferson, WI 53549

  • Direct to the Compliance Officer
    • Phone (920) 674-8151
    • Email: Barbm@jeffersoncountywi.gov
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annual compliance training

Anonymous Reporting Scenario

Steve White has falsified documentation. He documented and billed for services for days he wasn’t even at work. His supervisor lets him get away with it. Someone needs to look into this.

Q) Does this report contain sufficient information to begin an effective investigation?

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annual compliance training

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Anonymous Reporting Scenario

Steve White has falsified documentation. He documented and billed for services for days he wasn’t even at work. His supervisor lets him get away with it. Someone needs to look into this.

Q) Does this report contain sufficient information to begin an effective investigation?

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annual compliance training

Anonymous Reporting Scenario

Steve White has falsified documentation. He documented and billed for services for days he wasn’t even at work. His supervisor lets him get away with it. Someone needs to look into this.

A) No - the information provided lacks the detailed need to effectively investigate the concern: Who? What? Where? When? Why? How?

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annual compliance training

EXIT

Anonymous Reporting Scenario

Steve White has falsified documentation. He documented and billed for services for days he wasn’t even at work. His supervisor lets him get away with it. Someone needs to look into this.

A) No - the information provided lacks the detailed need to effectively investigate the concern: Who? What? Where? When? Why? How?

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annual compliance training

Anonymous Reporting Scenario

Steve White, an LCSW who works for the ABC Clinic on Plaza Street, has falsified documentation. He documented and billed for services for 11/20, 12/7 & 8 which are days he wasn’t even at work. I mentioned my concern to Ron Wood, his supervisor, but Ron said that he’s too busy to keep track of everyone and besides, he trusts Steve.

Q) Does the anonymous report contain sufficient information to begin an effective investigation?

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annual compliance training

EXIT

Anonymous Reporting Scenario

Steve White, an LCSW who works for the ABC Clinic on Plaza Street, has falsified documentation. He documented and billed for services for 11/20, 12/7 & 8 which are days he wasn’t even at work. I mentioned my concern to Ron Wood, his supervisor, but Ron said that he’s too busy to keep track of everyone and besides, he trusts Steve.

Q) Does the anonymous report contain sufficient information to begin an effective investigation?

annual compliance training65
annual compliance training

Anonymous Reporting Scenario

Steve White, an LCSW who works for the ABC Clinic on Plaza Street, has falsified documentation. He documented and billed for services for 11/20, 12/7 & 8 which are days he wasn’t even at work. I mentioned my concern to Ron Wood, his supervisor, but Ron said that he’s too busy to keep track of everyone and besides, he trusts Steve.

A) Yes, it provides answers to Who? What? Where? When? Why? How?

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annual compliance training

EXIT

Anonymous Reporting Scenario

Steve White, an LCSW who works for the ABC Clinic on Plaza Street, has falsified documentation. He documented and billed for services for 11/20, 12/7 & 8 which are days he wasn’t even at work. I mentioned my concern to Ron Wood, his supervisor, but Ron said that he’s too busy to keep track of everyone and besides, he trusts Steve.

A) Yes, it provides answers to Who? What? Where? When? Why? How?

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annual compliance training

Code of Conduct

Question:

You have a compliance concern and/or believe that a fraudulent activity is occurring. What should you do?

Select the best answer below:

  • Don’t report and see if the fraudulent activity stops.
  • Report your concerns to your supervisor or department head.
  • Immediately report your concerns to the Compliance Officer.
  • Any of the above.
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annual compliance training

EXIT

Code of Conduct

Question:

You have a compliance concern and/or believe that a fraudulent activity is occurring. What should you do?

Select the best answer below:

  • Don’t report and see if the fraudulent activity stops.
  • Report your concerns to your supervisor or department head.
  • Immediately report your concerns to the Compliance Officer.
  • Any of the above.
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annual compliance training

COMPLIANCE REQUIREMENT #5: Enforcement

  • Fair, reasonable but enforced
  • Communicate enforcement & discipline standards
  • Prohibits prejudice, bias or other non-standard conduct
  • Employee subject to appropriate disciplinary action by his/her department head
  • County Personnel Rules (HR0540) and progressive discipline used:
    • Oral, Written, Suspension w/o pay, Salary Reduction, Demotion, Dismissal
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annual compliance training

EXIT

COMPLIANCE REQUIREMENT #5: Enforcement

  • Fair, reasonable but enforced
  • Communicate enforcement & discipline standards
  • Prohibits prejudice, bias or other non-standard conduct
  • Employee subject to appropriate disciplinary action by his/her department head
  • County Personnel Rules (HR0540) and progressive discipline used:
    • Oral, Written, Suspension w/o pay, Salary Reduction, Demotion, Dismissal
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annual compliance training

COMPLIANCE REQUIREMENT #6: Internal Monitoring & Auditing

Reviews conducted to measure compliance with:

Billing and Coding

Exclusion List

Compliance Education

Medical Reviews

Operating Licenses

Clinical Staff Licensure

Correction Documentation

Report findings to Compliance Officer, Compliance Committee and Director, as required.

Internal Compliance Review and Monitoring

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annual compliance training

EXIT

COMPLIANCE REQUIREMENT #6: Internal Monitoring & Auditing

Reviews conducted to measure compliance with:

Billing and Coding

Exclusion List

Compliance Education

Medical Reviews

Operating Licenses

Clinical Staff Licensure

Correction Documentation

Report findings to Compliance Officer, Compliance Committee and Director, as required.

Internal Compliance Review and Monitoring

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annual compliance training

COMPLIANCE REQUIREMENT #6: Internal Monitoring & Auditing

  • Background & Sanction Screening
    • Licensing boards and National Practitioner Databanks
    • Ensures that the county does not hire or contract with an individual or entity that is suspended or excluded from Federal healthcare programs.
    • County's Sanction Screening Policy to identify suspended or excluded persons:
      • Screen all prospective employees, contractors and volunteers/interns against the exclusion list prior to hire/contract/engaging their services and bi-annually thereafter.
    • Exclusions lists:
      • HHSOIG List of Excluded Individuals/Entities (LEIE)
      • System for Award Management Exclusion Report (SAM)
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annual compliance training

EXIT

COMPLIANCE REQUIREMENT #6: Internal Monitoring & Auditing

  • Background & Sanction Screening
    • Licensing boards and National Practitioner Databanks
    • Ensures that the county does not hire or contract with an individual or entity that is suspended or excluded from Federal healthcare programs.
    • County's Sanction Screening Policy to identify suspended or excluded persons:
      • Screen all prospective employees, contractors and volunteers/interns against the exclusion list prior to hire/contract/engaging their services and bi-annually thereafter.
    • Exclusions lists:
      • HHSOIG List of Excluded Individuals/Entities (LEIE)
      • System for Award Management Exclusion Report (SAM)
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annual compliance training

COMPLIANCE REQUIREMENT #6: Internal Monitoring & Auditing

  • Other areas monitored/audited:
    • Disclosure Program
    • Billing Committee decisions
    • Business Office functions/processes
    • Modifications/updates to EHR system
    • Cost Reports
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EXIT

COMPLIANCE REQUIREMENT #6: Internal Monitoring & Auditing

  • Other areas monitored/audited:
    • Disclosure Program
    • Billing Committee decisions
    • Business Office functions/processes
    • Modifications/updates to EHR system
    • Cost Reports
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COMPLIANCE REQUIREMENT #7: Response & Corrective Action

  • Prompt Investigation
  • Corrective Action
  • Follow-up
  • Further Action
  • Prompt Refund of Overpayments
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COMPLIANCE REQUIREMENT #7: Response & Corrective Action

  • Prompt Investigation
  • Corrective Action
  • Follow-up
  • Further Action
  • Prompt Refund of Overpayments
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COMPLIANCE PROGRAM REVIEW

  • The purpose of the County’s Code of Conduct is to:
      • Promote the county’s commitment to compliance.
      • State the county’s behavior expectations, legal standards and ethical requirements.
      • Address all county mental health employees, volunteers and contractors (including contractor’s staff).
      • All of the above.
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EXIT

COMPLIANCE PROGRAM REVIEW

  • The purpose of the County’s Code of Conduct is to:
      • Promote the county’s commitment to compliance.
      • State the county’s behavior expectations, legal standards and ethical requirements.
      • Address all county mental health employees, volunteers and contractors (including contractor’s staff).
      • All of the above.
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COMPLIANCE PROGRAM REVIEW

  • The purpose of the County’s Code of Conduct is to:
      • Promote the county’s commitment to compliance.
      • State the county’s behavior expectations, legal standards and ethical requirements.
      • Address all county mental health employees, volunteers and contractors (including contractor’s staff).
      • All of the above.
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EXIT

COMPLIANCE PROGRAM REVIEW

  • The purpose of the County’s Code of Conduct is to:
      • Promote the county’s commitment to compliance.
      • State the county’s behavior expectations, legal standards and ethical requirements.
      • Address all county mental health employees, volunteers and contractors (including contractor’s staff).
      • All of the above.
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COMPLIANCE PROGRAM REVIEW

  • What is the role of the Compliance Committee?
      • To assist and advise the Compliance Officer.
      • To assist in the development or review of compliance related policy and procedures.
      • To rule on appropriate discipline for compliance violation issues.
      • To assist in the implementation of the Compliance Progam.
      • All of the above.
      • A, B & D only.
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COMPLIANCE PROGRAM REVIEW

  • What is the role of the Compliance Committee?
      • To assist and advise the Compliance Officer.
      • To assist in the development or review of compliance related policy and procedures.
      • To rule on appropriate discipline for compliance violation issues.
      • To assist in the implementation of the Compliance Progam.
      • All of the above.
      • A, B & D only.
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COMPLIANCE PROGRAM REVIEW

  • What is the role of the Compliance Committee?
      • To assist and advise the Compliance Officer.
      • To assist in the development or review of compliance related policy and procedures.
      • To rule on appropriate discipline for compliance violation issues.
      • To assist in the implementation of the Compliance Progam.
      • All of the above.
      • A, B & D only.
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COMPLIANCE PROGRAM REVIEW

  • What is the role of the Compliance Committee?
      • To assist and advise the Compliance Officer.
      • To assist in the development or review of compliance related policy and procedures.
      • To rule on appropriate discipline for compliance violation issues.
      • To assist in the implementation of the Compliance Progam.
      • All of the above.
      • A, B & D only.
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COMPLIANCE PROGRAM REVIEW

We have the right to report breaches without fear of retaliation?

TRUE

Or

FALSE

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EXIT

COMPLIANCE PROGRAM REVIEW

We have the right to report breaches without fear of retaliation?

TRUE

Or

FALSE

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annual compliance training

COMPLIANCE PROGRAM REVIEW

We have the right to report breaches without fear of retaliation?

TRUE

Or

FALSE

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EXIT

COMPLIANCE PROGRAM REVIEW

We have the right to report breaches without fear of retaliation?

TRUE

Or

FALSE

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COMPLIANCE PROGRAM REVIEW

For county employees, discipline for a violation of a compliance issue falls outside the normal disciplinary process?

TRUE

Or

FALSE

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COMPLIANCE PROGRAM REVIEW

For county employees, discipline for a violation of a compliance issue falls outside the normal disciplinary process?

TRUE

Or

FALSE

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COMPLIANCE PROGRAM REVIEW

For county employees, discipline for a violation of a compliance issue falls outside the normal disciplinary process?

TRUE

Or

FALSE

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COMPLIANCE PROGRAM REVIEW

For county employees, discipline for a violation of a compliance issue falls outside the normal disciplinary process?

TRUE

Or

FALSE

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MODULE 3

False Claims Act

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MODULE 3

False Claims Act

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FALSE CLAIMS ACT

Accuracy is critical in our billing/claim documents because the specific intent to defraud is NOT required under the Federal and State False Claims Act.

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FALSE CLAIMS ACT

Accuracy is critical in our billing/claim documents because the specific intent to defraud is NOT required under the Federal and State False Claims Act.

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Federal Civil False Claims

31 U.S.C. SECTION 3729(A)

Any person who knowingly presents, or causes to be presented to the Federal Government a false claim, is liable to the U.S. Government for a civil penalty, for EACH claim of not less than $5,000 and not more than $10,000, plus three times the amount of the damages.

For Example: Erroneous billings of 120 claims for $12,000 could result in a penalty of over $1.2 million.

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EXIT

Federal Civil False Claims

31 U.S.C. SECTION 3729(A)

Any person who knowingly presents, or causes to be presented to the Federal Government a false claim, is liable to the U.S. Government for a civil penalty, for EACH claim of not less than $5,000 and not more than $10,000, plus three times the amount of the damages.

For Example: Erroneous billings of 120 claims for $12,000 could result in a penalty of over $1.2 million.

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Federal False Claims Act

31 U.S.C. SECTION 3730

Includes provisions that allow a private citizen (relator) to file suit alleging false claims on behalf of the relator and the government. This is known as:

“Qui Tam Action”

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EXIT

Federal False Claims Act

31 U.S.C. SECTION 3730

Includes provisions that allow a private citizen (relator) to file suit alleging false claims on behalf of the relator and the government. This is known as:

“Qui Tam Action”

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Federal Whistleblower Protection

31 U.S.C. SECTION 3730(h)

Provides protection to employees

against discharge, demotion

suspension, threats, harassment

or discrimination by the employer,

for cooperating with or stating a

False Claims Act investigation.

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EXIT

Federal Whistleblower Protection

31 U.S.C. SECTION 3730(h)

Provides protection to employees

against discharge, demotion

suspension, threats, harassment

or discrimination by the employer,

for cooperating with or stating a

False Claims Act investigation.

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Federal Criminal False Claims

18 U.S.C. SECTION 1035

Criminalizes false or fictitious statements involving a Federal health care benefit program.

PENALTIES

up to 5 years in prison, and/or

$25,000 fine

.

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EXIT

EXIT

Federal Criminal False Claims

18 U.S.C. SECTION 1035

Criminalizes false or fictitious statements involving a Federal health care benefit program.

PENALTIES

up to 5 years in prison, and/or

$25,000 fine

.

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Wisconsin False Claims Act

2007 Wisconsin Act 20

Section 20.931 of Wisconsin Statutes applies to claims made to any officer, employee or agency of this state.

.

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Wisconsin False Claims Act

2007 Wisconsin Act 20

Section 20.931 of Wisconsin Statutes applies to claims made to any officer, employee or agency of this state.

.

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Wisconsin False Claims Act

The federal Deficit Reduction Act of 2005 provided states with a financial incentive to pursue more civil fraud cases against Medical Assistance providers.

WI Act 20:

Establishes civil liability for individuals or entities that submit false or fraudulent claims to the Medical Assistance program;

Requires civil penalties of three times the amount of damages sustained by the State, and assessments of at least $5,000 but no more than $10,000 for each violation; and

.

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EXIT

Wisconsin False Claims Act

The federal Deficit Reduction Act of 2005 provided states with a financial incentive to pursue more civil fraud cases against Medical Assistance providers.

WI Act 20:

Establishes civil liability for individuals or entities that submit false or fraudulent claims to the Medical Assistance program;

Requires civil penalties of three times the amount of damages sustained by the State, and assessments of at least $5,000 but no more than $10,000 for each violation; and

.

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Wisconsin False Claims Act

The Wisconsin False Claims Act also includes provisions that allow a private citizen to bring a civil action for violation of this article as a “qui tam plaintiff”

The Act rewards individuals who bring a case to civil court on the State’s behalf against another person or entity for making a false or fraudulent claim for Medical Assistance, including rewards of at least 15% but not more than 30% of any proceeds of the action or settlement of the claim.

.

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Wisconsin False Claims Act

The Wisconsin False Claims Act also includes provisions that allow a private citizen to bring a civil action for violation of this article as a “qui tam plaintiff”

The Act rewards individuals who bring a case to civil court on the State’s behalf against another person or entity for making a false or fraudulent claim for Medical Assistance, including rewards of at least 15% but not more than 30% of any proceeds of the action or settlement of the claim.

.

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Wisconsin Whistleblower Protections

An employer may not discharge, discipline, retaliate against or otherwise discriminate against an employee because the employee has exercised certain rights, filed a complaint, or testified or assisted in an enforcement action relating to a violation of the state’s labor laws.

Government workers are also protected if they exercise their free speech rights by publicly disclosing information about believed violations of any state or federal law; mismanagement or abuse of authority in state government; a substantial waste of public funds; or a danger to public health or safety. In addition, workers may sue their employer in circuit court for damages, court costs and attorney fees.Citations: Sections 46.90, 50.07, 111.322, 230.80-230.89, and 895.65, Wisconsin Statutes.

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Wisconsin Whistleblower Protections

An employer may not discharge, discipline, retaliate against or otherwise discriminate against an employee because the employee has exercised certain rights, filed a complaint, or testified or assisted in an enforcement action relating to a violation of the state’s labor laws.

Government workers are also protected if they exercise their free speech rights by publicly disclosing information about believed violations of any state or federal law; mismanagement or abuse of authority in state government; a substantial waste of public funds; or a danger to public health or safety. In addition, workers may sue their employer in circuit court for damages, court costs and attorney fees.Citations: Sections 46.90, 50.07, 111.322, 230.80-230.89, and 895.65, Wisconsin Statutes.

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Recent Cases/Convictions Related to Healthcare Fraud

MILWAUKEE - September 29, 2009, a Milwaukee business owner entered a plea of guilty to one count of felony Medical Assistance Fraud. The charge is against Quality Life Care Management, a Medicaid funded business entity that was expected to help Medicaid recipients obtain the services they need. According to the Criminal Complaint filed by the Department of Justice, the company’s owner billed the Medicaid program for more hours than were actually worked by company employees. Company payroll records show that between June 2005 and November 2005, Medicaid was billed for 5,617 more hours than were actually worked causing $141,275.00 in overpayments by the program.

The business owner was sentenced to 12 months in the House of Corrections and ordered to repay $141,275.00 in the Medicaid program and $14,474 in court obligations. This was investigated by the WI DOJ.

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Recent Cases/Convictions Related to Healthcare Fraud

MILWAUKEE - September 29, 2009, a Milwaukee business owner entered a plea of guilty to one count of felony Medical Assistance Fraud. The charge is against Quality Life Care Management, a Medicaid funded business entity that was expected to help Medicaid recipients obtain the services they need. According to the Criminal Complaint filed by the Department of Justice, the company’s owner billed the Medicaid program for more hours than were actually worked by company employees. Company payroll records show that between June 2005 and November 2005, Medicaid was billed for 5,617 more hours than were actually worked causing $141,275.00 in overpayments by the program.

The business owner was sentenced to 12 months in the House of Corrections and ordered to repay $141,275.00 in the Medicaid program and $14,474 in court obligations. This was investigated by the WI DOJ.

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annual compliance training

Recent Cases/Convictions Related to Healthcare Fraud

Whistle-blower case on hospice fraud settled for $25 million

JS Online: Milwaukee - March 1, 2012 One of the nation's largest providers of hospice care has agreed to pay $25 million to settle a Medicare fraud case initiated after a former company nurse in Milwaukee filed a whistle-blower suit. It was the second such settlement in six years for the healthcare organization which paid the federal government $12.5 million in 2006 after another Wisconsin-based employee sued.

“The whistle blowers don't do too badly, either.

Under the False Claims Act, they are entitled to a

cut of the recovery and will share about

$4.6 million.”

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Recent Cases/Convictions Related to Healthcare Fraud

Whistle-blower case on hospice fraud settled for $25 million

JS Online: Milwaukee - March 1, 2012 One of the nation's largest providers of hospice care has agreed to pay $25 million to settle a Medicare fraud case initiated after a former company nurse in Milwaukee filed a whistle-blower suit. It was the second such settlement in six years for the healthcare organization which paid the federal government $12.5 million in 2006 after another Wisconsin-based employee sued.

“The whistle blowers don't do too badly, either.

Under the False Claims Act, they are entitled to a

cut of the recovery and will share about

$4.6 million.”

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Summary

  • Legal authority for government investigations comes from:
    • Federal False Claims Act
    • Federal Criminal False Claims Provisions
    • WI Act 20: False Claims Act
  • Intent is NOT necessary for false claims liability. Penalties can be:
    • Civil monetary penalties
    • Criminal prosecution and prison time
  • Both Federal and Wisconsin laws contain whistleblower protections
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Summary

  • Legal authority for government investigations comes from:
    • Federal False Claims Act
    • Federal Criminal False Claims Provisions
    • WI Act 20: False Claims Act
  • Intent is NOT necessary for false claims liability. Penalties can be:
    • Civil monetary penalties
    • Criminal prosecution and prison time
  • Both Federal and Wisconsin laws contain whistleblower protections
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annual compliance training

MODULE 4

Integrity Agreements

in·teg·ri·ty

1. adherencetomoral and ethical principles; soundness of moral character; honesty.

2. the state of beingwhole,entire,orundiminished: to preserve the integrity of the empire.

3. a sound, unimpaired, orperfect condition: the integrity of a ship'shull

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MODULE 4

Integrity Agreements

in·teg·ri·ty

1. adherencetomoral and ethical principles; soundness of moral character; honesty.

2. the state of beingwhole,entire,orundiminished: to preserve the integrity of the empire.

3. a sound, unimpaired, orperfect condition: the integrity of a ship'shull

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What is an Integrity Agreement?

Negotiated compliance obligations between the U.S. Office of Inspector General (OIG) and health care providers.

Provider consents to these obligations as part of the civil settlement. In exchange, the OIG agrees not to exclude that provider from participation in Federal health care programs (Medicare and Medicaid).

OIG has permissive exclusion authority under the False Claims Act or Civil Monetary Penalties Law.

Typical term is 5 years.

These compliance measures seek to ensure the integrity of Federal health care program claims submitted by the provider.

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What is an Integrity Agreement?

Negotiated compliance obligations between the U.S. Office of Inspector General (OIG) and health care providers.

Provider consents to these obligations as part of the civil settlement. In exchange, the OIG agrees not to exclude that provider from participation in Federal health care programs (Medicare and Medicaid).

OIG has permissive exclusion authority under the False Claims Act or Civil Monetary Penalties Law.

Typical term is 5 years.

These compliance measures seek to ensure the integrity of Federal health care program claims submitted by the provider.

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Integrity Agreements are a result of a Medicare or Medicaid fraud investigation when problems are discovered:

Examples of problems:

  • Non-covered services
  • Incorrect units of service
  • Services were not provided
  • Documentation is missing

Results:

  • Repayment of erroneous billings
  • Payment of penalties and attorney fees
  • Implement of an Integrity Agreement (5 years)
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Integrity Agreements are a result of a Medicare or Medicaid fraud investigation when problems are discovered:

Examples of problems:

  • Non-covered services
  • Incorrect units of service
  • Services were not provided
  • Documentation is missing

Results:

  • Repayment of erroneous billings
  • Payment of penalties and attorney fees
  • Implement of an Integrity Agreement (5 years)
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annual compliance training

If Jefferson County is ever subject to an Integrity Agreement, once it concludes, the county can never be subject to another in the future?

TRUE

Of

FALSE

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EXIT

If Jefferson County is ever subject to an Integrity Agreement, once it concludes, the county can never be subject to another in the future?

TRUE

Of

FALSE

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annual compliance training

If Jefferson County is ever subject to an Integrity Agreement, once it concludes, the county can never be subject to another in the future?

TRUE

Of

FALSE

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EXIT

If Jefferson County is ever subject to an Integrity Agreement, once it concludes, the county can never be subject to another in the future?

TRUE

Of

FALSE

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Jefferson County could be excluded from participating in Federal Healthcare Program for failing to meet documentation & Billing Standards during a Federal or State Review?

TRUE

Of

FALSE

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EXIT

Jefferson County could be excluded from participating in Federal Healthcare Program for failing to meet documentation & Billing Standards during a Federal or State Review?

TRUE

Of

FALSE

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annual compliance training

Jefferson County could be excluded from participating in Federal Healthcare Program for failing to meet Documentation & Billing Standards during a Federal or State Review?

TRUE

Of

FALSE

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EXIT

Jefferson County could be excluded from participating in Federal Healthcare Program for failing to meet Documentation & Billing Standards during a Federal or State Review?

TRUE

Of

FALSE

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MODULE 5

Certification

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MODULE 5

Certification

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Certification Instructions

  • Click here to access the Acknowledgement Form.
  • Print, complete and sign the form.
  • Keep a copy for your records.
  • Send the original, signed form to the Compliance Officer:
    • County employees use interoffice mail;
    • Contractors mail to:

Barb Mottl, Compliance Officer

1541 Annex Road

Jefferson, WI 53549

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Certification Instructions

  • Click here to access the Acknowledgement Form.
  • Print, complete and sign the form.
  • Keep a copy for your records.
  • Send the original, signed form to the Compliance Officer:
    • County employees use interoffice mail;
    • Contractors mail to:

Barb Mottl, Compliance Officer

1541 Annex Road

Jefferson, WI 53549

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If you have any questions, please contact the Compliance Office:

(920) 674-8151 Barb Mottl

Thank you!