Writing Formats for Reporting False Injury Claims by kab10607

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									How to Design and Implement
  A Corporate Compliance
         Program
    Auditing and Monitoring
    Operations and Business
           Processes


                              1
      Our House Analogy
 The physical structure (walls, ceiling)
  Like the mechanical aspects of a
    compliance program
 The “furniture/appliances”

  The substantive laws/policies
  What we must “comply” with
    versus the “how we get there”
                                       2
    Prior Sessions: “Process”
       Aspects (The House)
   Some of the process pieces we’ve
    explored:
     Compliance officer/committee
     Employee education/training
     Checking exclusion status of
      employees & contractors
     Creating/retaining compliance
      records
                                       3
       Today: More Process
   Auditing and Monitoring Systems
    OIG: Integral to an “effective”
     compliance program
    Monitoring operations (business
     processes, quality, resident safety)
    And your compliance program’s
     effectiveness

                                       4
Auditing & Monitoring Is Just:
   Reliable, periodic systems to audit or
    check on identified “risk areas” in
    corporate/facility operations
    Not overly complex
    But comprehensive & reliable
    That specifies how it works and who’s
     responsible for auditing
    With reviews of systems for reliability

                                               5
                RISK
… “exposure to the chance of injury or
  loss”

1.   Business Risk
2.   Healthcare Company Risk
3.   Quality Risk


                                    6
                                  RISK
Lawsuit             Whistleblower      Investigation     Denials    Audit

          False claims                 Abuse             Conflict of Interest

Theft     Survey          Five Star       Background Check          PROBE

   Medical Necessity           Kickback           Referral          Disclosure

          Falsification        Supplementation    Class action     Labor

   Exclusion        Controls           Staffing          Consolidated Billing


Resident Trust      Triple Check       Reimbursement     Coding


HIPAA RUGS HR RAC MDS MAC PAC POC EEOC SOD SEC CMP OIG CMS DOJ AR PPD EIEIO



                                                                            7
LONG TERM CARE RISKS

          BUSINESS




            LTC
   HEALTHCARE
                  QUALITY
    COMPANY



                            8
Business Risks


                             Financial
Enforcement
                             Viability




           Sarbanes-
            Oxley
          (Public Company)



                                         9
Healthcare Company Risks


    Whistleblower         Regulatory




                OIG/DOJ


                                       10
Quality Risks


Litigation      Reimbursement




         Fraud/Abuse


                                11
  One Risk Management
        Approach
(aka “the Silo approach”)
       Business
                            Healthcare
       Risks
                            Company
                            Risks




                  Quality
                  Risks




                                     12
      Components
          of
Risk Management “Silos”
      Business
                                 Healthcare
      Risks
                                 Company
      External -
                                 Risks
      Internal
                                 OIG –
      Audit
                                 Compliance
      Dashboard
                                 Program

                   Quality
                   Risks
                   CMS-
                   Quality Improvement
                           - survey
                           - quality measures
                           - staffing      13
  Another Risk Management
           Approach
(aka “an Integrated Approach”
                  Quality Risk
                             CMS-
                             Quality Improvement
                                     - survey
                                     - quality measures
                                     - staffing
  Business Risk                Healthcare Company
    External -                          Risk
     Internal                          OIG –
       Audit                       Compliance
   Dashboard                          Program


                                                   14
           “DASHBOARD”
                  for
        Integrating Risk Data



   Data Metrics
    Quality
    Business
    Healthcare Company Compliance

                                     15
Dashboard Formats




                    16
    Dashboard Development
    Get constituent buy-in and allocate funds;
    Select project team;
     In-house
     Consultant /vendor
     Combination
     Determine data to be “rolled-up”;
     Don’t create new data
    Select dashboard format based on ease of data
     import (manually or through IT);
    Wide-distribution to constituents
     Act on indicators

                                               17
 Making Auditing and
 Monitoring Practical
A Step-By-Step Approach to Taking
 the Pulse of Your Operations and
       Compliance Program


                                    18
  1. Specifically target and
identify what you are auditing
   Possible audit “targets” come from:
    OIG “risk areas” (later webinars)
    Your own operations experience
       Internal/external finance or
        business audits
       Survey results, QI scores, QA
        meetings, complaints, hotline
        calls, satisfaction surveys
                                      19
    Poor “Targeting” = Poor
            Results
 With multiple targets, failure to
  clearly define, and give team clear
  direction = disorganization, missed
  issues & ineffective auditing
 Am I targeting med error rates,
  contract compliance with illegal
  kickbacks, improper MDS coding and
  resulting improper payment claims?
                                  20
       2. Design the Specific
    Auditing Steps You’ll Employ
 What source information/processes
  am I examining?
   Unlocked med carts in hall, sample
    of payment claims, facility
    contracts, hotline responses?
 Where is the information I’m testing
  located in terms of operations?

                                   21
       2. Design the Specific
    Auditing Steps You’ll Employ
   How will we audit those sources?
    Pulling/reviewing resident charts?
    Interviewing nursing staff, families,
     residents?
    Observing staff with residents?
    Observing compliance officer
     interactions with Board members?
                                       22
       2. Design the Specific
    Auditing Steps You’ll Employ
   How will we gather and report our
    findings?
     Preparing written reports, charts,
       or making oral reports?
     To whom?
         Maybe internal reporting and/or
          external to consultants/counsel

                                        23
       2. Design the Specific
    Auditing Steps You’ll Employ
   How frequently are we accessing our
    information sources?
     Annual audit of financial records?
     Quarterly review (med. regimen) ?
     Time-limited review of med error rates
       (spike in rates)?
         Followed by periodic check on the
          “fixes”
         The findings dictate frequency
                                           24
       2. Design the Specific
    Auditing Steps You’ll Employ
   Who’s responsible for the audit to
    make sure it’s targeted, examines the
    sources we’ve identified, on the
    schedule we’ve established?
     For internal/external audits, put
      one person in charge
        Even with audit “teams”
        Including for reporting function
                                      25
    3. Decide How We’ll Use the
       Audit Results Obtained
   Depends on the issue and company
    External CPA audit goes to CFO
     Care plan audit to DON, administrator,
        consultant, Quality Assurance
        Committee
   Purpose: spot an issue, analyze it, repair
    it, communicate repair, consider legal
    reporting requirements

                                             26
If You Want to Write a Specific
      Audit Flowchart
 These questions will direct how to do
  that
   Really, for any issue you can think
    of: quality, finance, business ops
 And, if you’re looking for an “audit &
  monitoring” policy for your
  compliance program, these
  questions will take you there

                                     27
        An Example

Compliance with Facility Obligations
       Under Medicare Part D
   [From OIG 2008 Supplemental
  Guidance for Nursing Facilities]

                                       28
1. Target / Identify What We’re
          Monitoring
    Audit/monitor following aspects of
     Medicare Part D compliance:
     Explaining Part D Plans to
       residents accurately/completely?
     Are our pharmacy contracts
       sufficient to ensure resident
       choice in Part D Plans?

                                     29
1. Target / Identify What We’re
          Monitoring
   Have mechanism to contract with
    additional pharmacies or with one
    (exclusive) with broader Plans?
   Avoid coaching, steering, requiring a
    resident to select a specific Part D Plan or
    specific pharmacy?
   Do employees/contractors accept items of
    value from Part D Plan or pharmacy to
    refer patients?
                                             30
    2. Designate Specific Audit
              Steps
 Review any policy/procedure and
  “scripts” used to explain Part D
  Plans to residents
 Observe 15 instances of staff
  explaining Plans to residents.
 Supplement with 15 interviews of
  staff, residents and families re how
  we explained Plans

                                         31
     2. Designate Specific Audit
               Steps
   Identify failures to describe Plan fully or
    accurately or respond to resident requests for
    Plans we don’t offer
   Observe 15 instances of pharmacy rep or
    contractor discussing Plans with residents
   Any instances of coaching, steering, requiring a
    specific Plan or pharmacy?
   Supplement with resident/family/staff interviews
    re those interactions.
   Counsel employees / consider discipline for
    violations & any corrective action required?

                                                  32
    2. Designate Specific Audit
              Steps
   Observe 15 interactions between resident
    and contract pharmcy(ies) to ensure no
    steering, coaching, etc.
   Report violations to compliance
    officer/committee
     Corrective action required?
   Examine how pharmacy contracts are
    negotiated / executed to ensure no items
    of value to induce contracts or referrals

                                           33
     2. Designate Specific Audit
               Steps
   Identify any items of value provided to
    facility staff, resident or family by facility
    staff, Part D Plan rep, or pharmacy rep
     Via interviews with staff, resident,
      family, contractors (I.D. #)
     Determine if permissible under
      applicable law (counsel / compliance
      officer)
     Identify who will perform these steps by
      title and frequency (if not above)

                                               34
3. Designate How We Will Use
      the Audit Results
   Share audit results and any
    noncompliance instances with compliance
    officer or designee as soon as practicable
    after audit
   And with QA Committee as directed by
    compliance officer
   Compliance officer will share results with
    Board and decide if additional steps
    required (corrections, external reporting)
                                           35
               Summary
   Our Q and A approach is one format
   Many ways to design audit system
   Keys are:
    Is it manageable?
    Does it work (finding problems)?
    Is it thorough?
    Are we actually using it and the results?
    Are we auditing the audit system to
      ensure it’s working also?

                                           36

								
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