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Compliance

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Compliance Thomas J. Dilts MT(ASCP),MBPA Vice Chair of Administraion and Operations VCUHS Department of Pathology Compliance An enterprise wide attitude,culture,and ... – PowerPoint PPT presentation

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Title: Compliance


1
Compliance
  • Thomas J. Dilts MT(ASCP),MBPA
  • Vice Chair of Administraion and Operations
  • VCUHS Department of Pathology

2
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Compliance
  • An enterprise wide attitude,culture,and
    commitment that supports honesty,integrity and
    diligence in the work place

4
HOW TO KEEP YOU OUT OF JAIL
5
COMPLIANCE DIRECTION
  • Laboratories are creatures of Federal and State
    Laws
  • Three Major compliance directions
  • a) regulatory compliance
  • b) financial compliance
  • c) patient rights/privacy compliance

6
History
  • EEOC-Equal Employment Opportunity Commission -
    1965
  • CLIA-Clinical Laboratory Improvement Act 1967
  • OSHA-Occupational Health and Safety Act 1970
  • ADA-American Disabilities Act 1990
  • HIPAA-Health Insurance Portability and
    Accountability Act 1996
  • OIG Guidance for Clinical Labs - 1998

7
Who does this affect?
  • You
  • Laboratory
  • Facility
  • Health care workers
  • Patients

8
Laboratory Compliance Plan (1998)
  • Written standard of conduct e.g. CPT-4,ICD-9
  • Chief Compliance Officer
  • Education and training programs
  • Hotline for complaints whistleblowers
  • System to respond to allegations
  • Use of audits monitor compliance
  • Investigation and correction of system problems

9
COMPLIANCE DIRECTION
  • Laboratories are creatures of Federal and State
    Laws
  • Three Major compliance directions
  • a) regulatory compliance
  • b) financial compliance
  • c) patient rights/privacy compliance

10
REGULATORY COMPLIANCE
11
Regulatory/Accrediting Agencies
  • CMS Centers for Medicare and Medicaid Services
  • CAP College of American Pathologists
  • JCAHO Joint Commission for Accreditation of
    Healthcare Organizations
  • FDA Food and Drug Administration
  • COLA Commission on Office Laboratory
    accreditation
  • AABB American Association of Blood Banks

12
Other Regulatory Agencies
  • OSHA Occupational and Safety Administration
  • DOT Department of Transportation
  • Department of Health and Human Services
    -----HIPAA Health Insurance Portability and
    Accountability Act ---- (consumer
    control,accountability,public responsibility,bound
    aries,security)

13
FINANCIAL COMPLIANCE
14
Medicare Billing and Reimbursement
  • Fraud and Abuse/Kickbacks - 1970s
  • Stark laws - 1980s
  • False Claims Act 1980s
  • Patient billing - 1990s
  • Billing code changes - 2000s

15
Patient Billing
  • CPT-4 (Current Procedural Terminology Code AMA)
  • ICD-9 (International Classification of Diseases,
    Ninth Revision WHO)
  • ABN (Advance Beneficiary Notice)
  • Charge master
  • Claims Submission
  • Ordering Tests

16
PATIENT RIGHTS/PRIVACY COMPLIANCE
17
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY
ACT--HIPAA
18
Laboratory Policies
  • Communicating Quality and Safety Concerns
  • Request for Release of Pathology Record, Slides,
    and/or Blocks
  • Specimen Collection Boxes
  • Electronic Mail(E-Mail) and Internet Access/Usage
  • Release of Autopsy Reports
  • Request for Release of Pathology Records, Slides,
    and/or Blocks

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Penalties - 1999
  • 490M paid in noncompliance
  • 390 defendants convicted
  • 2976 excluded from the Federal Health Care
    Program
  • Three times the governments damages plus civil
    penalties of 5,000 to 10,000 each offense
  • Sentinel events
  • Protection of whistleblowers

21
Penalties for Non-compliance-Today
  • 100 fine per day for each unmet standard (up to
    25,000 per year, per person, per standard).
  • 50,000 fine and one year in prison for improper
    disclosure of health information.
  • 100,000 fine plus five years in prison for
    obtaining health information under false
    pretenses.
  • 250,000 fine and ten years in prison for using
    health information for personal gain.

22
HIPAA
  • Big brother is watching
  • Job termination

23
RECOVERY AUDIT CONTRACTORS
  • RAC Auditors

24
Summary
  • Laboratories are creatures of Federal and State
    Laws
  • Three Major compliance directions
  • a) regulatory compliance
  • b) financial compliance
  • c) patient right compliance

25
References
  • Kurec AS, Schofield S and Watters MC (eds). The
    CLMA Guide to Managing a Clinical Laboratory. 3rd
    ed. Wayne, PA CLMA 2000
  • Roseff, S.D., Harris, A,L., Rodgers, C.H.,
    (submitted for publication 2004) Basic Concepts
    and the Current Health Care Environment. Section
    I,chapter 5. In Wilkinson,D.S.,(ed) Clinical
    Management in the 21st Century.ASM press
    Washington DC (to be in print 2004)

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