INTEGRATED%20CARE%20ALLIANCE,%20LLC%20Corporate%20Compliance%20Training - PowerPoint PPT Presentation

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Title: INTEGRATED%20CARE%20ALLIANCE,%20LLC%20Corporate%20Compliance%20Training


1
INTEGRATED CARE ALLIANCE, LLCCorporate
Compliance Training
  • Debra Schuchert, Compliance Officer

2
INTEGRATED CARE ALLIANCE, LLCCorporate
Compliance Program
  • It is the policy of Integrated Care
    Alliance to comply with all laws governing its
    operations and conduct business in keeping with
    legal and ethical standards. It is also the
    policy of Integrated Care Alliance to deal with
    employees and customers using the highest
    clinical and business ethics.
  • Integrated Care Alliance strives to maintain a
    corporate culture which promotes the prevention,
    detection, and resolution of possible violations
    of laws and unethical conduct.
  • Integrated Care Alliance supports the government
    in its goal to decrease financial loss from false
    claims and has as its own goal, the reduction of
    potential exposure to criminal penalties, civil
    damages, and administrative actions.
  • Integrated Care Alliance believes that a
    compliance program guides the Management Board,
    President/CEO, managers, employees, and health
    professionals in the efficient management and
    operation of the company and in improving the
    quality of its services.

3
Corporate Compliance ProgramElements
  • Integrated Care Alliance maintains written
    standards, a Code of Conduct, a Risk Management
    Plan and Compliance policies and procedures.
  • Integrated Care Alliance has a Compliance
    Department consisting of staff responsible for
    compliance efforts, Corporate Compliance
    Committee, and affiliate Compliance officials.
    The Corporate Compliance Committee conducts
    quarterly meetings.
  • Integrated Care Alliance conducts education and
    training programs for employees and maintains an
  • Ethics Hotline (866) 724-7544
  • (24 hours a day, seven days a week)
  • DWMHA Compliance Hot Line (313) 833-3502
  • (24 hours a day, seven days a week)
  • to foster an open atmosphere for employees to
    report issues and concerns free from retaliation.
  • Integrated Care Alliance may use audits or other
    evaluation techniques to monitor compliance with
    identified risk area.

4
Corporate Compliance ProgramElements
  • Integrated Care Alliance maintains a system and
    procedures to respond to allegations and detected
    offenses. If it is determined that there is a
    current deficiency or area of non-compliance, the
    development of a corrective action plan is
    completed to resolve the issue.
  • Integrated Care Alliance educates and trains its
    employees on the requirements for the Compliance
    Program, and the disciplinary policy for
    employees who violate the compliance policies
    and applicable laws. Disciplinary action may
    include oral warnings, suspensions, and
    termination of employment depending on the
    circumstances and severity of the violation.
  • Integrated Care Alliance believes that compliance
    with the law means not only following the law,
    but also conducting business so the Company
    deserves and receives recognition as good and
    law-abiding corporate citizens. The goal is to
    inspire confidence from clients, consumers,
    employees, the community, and our government.

5
Corporate Compliance policies
  • CC-001 - Integrated Care Alliance Partners
    Corporate Compliance Department
  • Ensure important
    aspects of Compliance are monitored
  • CC-002 - Confidentiality
  • Maintain confidentiality
    of Integrated Care Alliance information
    integrity of compliance program
  • CC-003 - Integrated Care Alliance Internal
    Corporate Compliance Investigation
  • Respond to and
    investigate possible violations of applicable
    federal, state or local law and non-compliance
    with
  • Integrated Care
    Alliances Code of Conduct
  • CC-004 - Responding to a Governmental Inquiry or
    Investigation
  • Guidelines for
    responding to both federal and state government
    investigations
  • CC-005 False Claims
  • Compliant with federal /
    state law and regulations related to the billing
    payment of claims involving federal, state or
    private programs
  • CC-006 Omnibus rules as related to
    Anti-Kickback, Self Referral, and Stark Laws
  • Guidelines for Integrated
    Care Alliance to comply with federal and state
    anti-referral and anti-kickback laws and
    regulations
  • CC-007 Compliance Record Storage Retention
  • Guidelines for the retention of
    documents related to the Compliance program

6
Corporate Compliance Facts
  • Possible penalties for NON-Compliance include the
    following
  • Imprisonment , Fines, Termination
    of Employment
  • Compliance is the responsibility
    of
  • Compliance Officer , Federal Government, and
    Employee
  • The following constitutes the filing
    of a false claim knowingly and willfully
    submit
  • Up-coding the level of
    service provided
  • Improper documentation
    practices
  • Double billing resulting
    in duplicate payment
  • Failure to properly use coding modifiers
  • Billing for items or services not rendered or
    not provided as billed
  • Submit false information
  • Failure to refund
    credit balances

7
What makes a claim FALSE ?
  • Factually False Claims A factually false claim
    means that the services on the bill did not
    actually happen. This type of false claim can
    take the form of billing for services not
    provided ,billing for more expensive services
    than those actually rendered (called up coding),
    double-billing for services, or billing for
    services that were medically unnecessary, even if
    they were actually performed.
  • Legally False Claims A legally false claim
    occurs when the circumstances of the services on
    the claim or the claim itself create or reflect a
    violation of an underlying law or regulation. For
    example, claims for physician services rendered
    pursuant to an arrangement that violate the Stark
    Law (prohibiting self-referrals) or the
    Anti-Kickback Statute are legally prohibited and
    are thus false, if made knowingly. The
    submission of the claim itself is evidence of the
    providers implied certification that the claim
    is valid, such that even if the provider (or
    biller) has not affirmatively represented that
    the claims are legally compliant, submitting
    legally invalid claims is generally viewed as
    knowing misrepresentation under the False Claims
    Act (FCA).
  • Reverse False Claims A reverse false claim is
    failure to return overpayments (made by the
    Federal Government) within the 60 day time
    frame imposed in 2010 by the Affordable Care Act
    (ACA). The ACA added a requirement that all
    overpayments be returned to the government within
    sixty days of when the claim is identified, and
    if not reported creates a False Claims Act
    liability for failing to do so. The Centers of
    Medicare and Medicaid Services (CMS) has issued
    proposed rules on the subject.
  • Payment for a False Claim is a felony, punishable
    by imprisonment for not more than 10 years, or by
    a fine of not more than 50,000, or both.
  • False Claims Training form should be signed by
    the MCPN staff and contracted Providers.

8
Corporate Compliance Facts
  • Who is liable under the False Claims Act?
  • Any person or entity connected with the
    submission of a false claim can be liable,
    including
  • Providers
  • Beneficiaries
  • Health plans that do business with the
    Federal government
  • Billing companies
  • Contractors
  • If a concern or question about compliance
    arises, you should
  • Ask the Compliance Officer, Manager, or
    notify Compliance Officer anonymously
  • Anti-Kickback Federal Penalties
  • Criminal Penalties
  • - Criminal Statue-felony charges (
    5yrs and /or 25k Fine)
  • - Potential financial liability
    under False Claim Act
  • Civil Money Penalties
  • - Loss of Medicare Medicaid
    provider status
  • - Civil Monetary penalties of 50K
    per act, plus damages equal to 3x remuneration
  • involved.

9
Corporate ComplianceFacts
  • Compliance programs and claims may be
    audited by Recovery Audit Contractors hired by
    the Federal Government and State of Michigan
    Contractors.


A directive of the Affordable Care Act (ACA) is
a provision that requires states to expand their
Recovery Audit Contractor Programs (RACs) to
prevent provider fraud, waste, abuse and improper
payments, and to take administrative action to
recoup overpayments as may be necessary. The
Affordable Care Act requires the return of any
Federal Health-Care program overpayment no later
than 60 days after the overpayment is identified.
Medicare has been successfully conducting audits
and is now increasing the spread of these
recovery audits to Medicaid.
It is believed that the Affordable Care Act
requires the States to up their examinations of
Medicaid accounting , which could result in
recovering a total of nine to ten billion
dollars for the government.
10
Corporate ComplianceFacts
  • Things that should be reported
  • Violations of law
  • Inappropriate gifts, entertainment or gratuities
  • Improper use of Authority property
  • Violations of patient confidentiality
  • Discrimination or harassment
  • Stealing/Misuse of assets
  • Embezzlement of funds
  • Obstruction of Criminal or Internal
    Investigations

11
Office of Inspector General (OIG) Audits
  • The OIG distributes an annual work plan that lays
    out the areas that will be targeted during an
    audit. In addition, to our annual onsite audits,
    the following audits will be conducted according
    to the OIG work plan -2015.
  • Audits
  • OIG monthly Employee Exclusion Search
  • Unallowable Room Board Charges
  • Community Supports while consumer is in the
    hospital
  • Skill Building
  • Adult Foster Care Employee Training
  • Adult Foster Care Reimbursement for Community
    Living Support Services Personal Care
  • Supported Independent Living Providers
  • Direct Care Wages
  • Ability to Pay
  • Claims Billing
  • HIPAA Security
  • Annual Compliance Training for Employees and VCE
    Online Training course
  • Respite

12
Office of Inspector General (OIG) Audits
  • Audit Forms
  • OIG Employee Exclusion Search - The employee
    exclusion search must be performed on a monthly
    basis.
  • Compliance Statement - Integrated Care Alliance
    requires each provider to sign the Compliance
    Statement as proof that the provider is
    maintaining Compliance standards and trainings
    within their organization.
  • Compliance Breach Notification on Protected
    Health Information and Personal Record
    Information Statement Integrated Care Alliance
    requires each provider to sign the statement as
    proof that the provider is maintaining policies
    and procedures to safeguard Protected Health
    Information (PHI) and Personal Record
    Information (PRI).
  • Documentation Statements - Integrated Care
    Alliance requires providers to have
    documentation complete, accurate, and available
    upon request for a provider or consumer audit.
    If an onsite audit is conducted there is a 24
    hour time frame to produce documentation if not
    already available. A sampling of provider
    services audit requires a 48 hour time frame to
    produce documentation if not already available.
    This does not apply to providers that have
    started a new program, their documentation must
    be present upon request.
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