Barry County

Community Mental

Health Authority

Compliance

Annual Training

Brenna Ellison LLMSW RAC Corporate Compliance Officer

Barry County Community Mental

Health Authority

Compliance Program

Barry Mental Health Authority is committed to the prevention & detection of fraud & abuse. In order to accomplish this, we have a Corporate Compliance Program and accompanying policies & procedures to provide guidance for doing business.

What is our Compliance Program?

A formal organizational support function that: Documents & monitors compliance with laws,

regulations, standards, policies & procedures

Facilitates positive change Ongoing Communication

Ongoing Education

Resulting in the identification, prevention & reduction of risk to the agency & staff

8 Elements of an Effective Program from the

Federal Sentencing Guidelines Oversight by Compliance Officer & Committee

Written Code of Conduct

Policies & Procedures

Communication

Education & Training

Auditing & Monitoring

Detecting Offenses & Corrective Action

Annual Risk Assessment

Benefits of a Effective Compliance/Ethics Program

Demonstrates commitment of legal & ethical behavior

Provides guidance to staff

Promotes ethical behavior

Improves quality, efficiency & consistency of service

Encourages staff to report their concerns

Provides prompt & thorough investigations of alleged misconduct

Initiates appropriate & decisive corrective action

Identifies & prevents criminal conduct

Ethical vs. Legal

Ethical – accepted principles of right & wrong that govern our behavior

Legal – rules & regulations which guide one’s actions

Why is this Important?

Identification and prosecution of health care fraud is a top priority for the Office of Inspector General and Department of Justice

Why is this Important?

Noncompliance has its costs, regardless of the reason, intentional or not, serious consequences can effect service providers, recipient of services, and organizations responsible for oversight.

Consequences are not always drastic when the choice is made not to comply or an individual makes an error in the process, but in some situations they are lost lives, lost jobs, fines, and/or imprisonment.

Fraud is: In general, the intentional deception or

misrepresentation by a person with the knowledge the deception could result in unauthorized benefit to him/herself or some other person. In other words:

It is intentionally attempting to deceive or execute a scheme to falsely obtain money or other benefit from a healthcare program &/or

Providing false information to someone or some entity that you know is false

Examples of Fraud

Knowingly billing for services not provided

Performing medically unnecessary services solely to obtain payments

Altering documentation or bills to obtain higher payment (upcoding)

Deliberate duplicate billing

Abuse is: Practices that are inconsistent with

sound fiscal, business or medical practices & result in an unnecessary cost to the payer, or in reimbursement for services that are not medically necessary or fail to meet professionally recognized standards for healthcare.

Examples of Abuse

Charges in excess for services & supplies

Submitting claims not in compliance with billing guidelines

Providing medically unnecessary services

Providing services that do not meet professionally recognized standards of care

Submitting bills to Medicare/Medicaid instead of the primary insurer

Abuse vs. Fraud: Understanding the Difference

Abuse results from practices that directly/indirectly result in unnecessary cost

Abusive billing practices may not result from “intent” or it may be impossible to prove that the intent to defraud existed

Abuse may develop into fraud if there is evidence of the subject knowingly & willfully conducting an abusive practice

Fraud requires evidence of intent to defraud (e.g. acts were committed knowingly, willfully & intentionally).

Civil and Criminal penalties

Waste

Improper practices that are inconsistent with sound fiscal, business, or clinical practices & result in unnecessary cost or reimbursement for services that are not medically necessary or fail to meet professionally recognized standards of care.

Examples of Waste

Healthcare spending that can be eliminated without reducing the quality of care, such as overuse and/or underuse or ineffective use of treatments or medication

Inefficiency in redundant testing, delays in treatment & making processes unnecessarily complex

False Claims

A false claim is prohibited by several different statutes. In general, a violation of the false claims law includes submitting or causing to be submitted a claim for payment when the claim is false or fraudulent. This includes using a false record to get the claim approved or paid.

Examples

Billing for services not provided

Billing for services greater than provided

Billing for services not documented

Billing for services not medically necessary

Billing for worthless services

Forging or altering documents

Misrepresenting information on documents

Lying about credentials

Such poor documentation habits that there is no evidence of ‘non-intent’

Michigan False Claims Act

The Michigan False Claims Act has been approved by the Federal Government. This approval allows Michigan to receive an additional 10% of recoveries from false claims. The reason for this is Michigan’s False Claims Act has tougher requirements than the Federal False Claims Act.

Medical Necessity Medical necessity is the underlying concept

under which payment decisions are made Medical necessity is established within the

Assessment Treatment Plans guide you on how to provide

medically necessary services Documentation of services allows the provider to

verify that the services provided to the consumer are medically necessary Tell me what you did for the consumer not just what

the consumer did

Medical necessity of the continuation of services is established within the periodic review

Quality of Care Providing the best quality of care to our clients

Assuring good quality services is an ethical obligation of providers

Enforcement priority for health care regulators

Adequate staffing to ensure health & safety

Medication errors

Following all licensing rules

Substandard or worthless services

$$$ - paybacks across all aspects of health care

What is a worthless service?

Deemed ineffective for a given condition based upon professionally recognized standards of care

Directly or indirectly results in unnecessary cost (did you get what you paid for and/or did you pay too much)?

Focus Areas Targeted by investigators and fraud

detection activities:

Quality of Care and Safety

Mental Health Provider Enrollment & Credentialing

Billing and Payments

Evaluation & Management Service Documentation

Residential Service Documentation

CLS Service Documentation

Questionable Billing for Outpatient Mental Health Services

Focus Areas Cont’d

Protected Health Information

Electronic Medical Record Safeguards

Security of Portable Devices

Program Integrity

Medicaid Managed Care Organizations Identify & Address Potential Fraud Incidents

Beneficiary Protections

Access to Services/Care

How Do We Reduce Risk?

Effective Compliance Program:

• Auditing & Monitoring

• Education & Training

• Documentation of Compliance Efforts

• Self Disclosure

• Communication

• Federal Exclusion Monitoring

Policies & Procedures

Compliance Plan – Code of Conduct

Code of Ethics

Ethical Billing Practices

Fraud Prevention and Detection

Claims Fraud and Abuse

Responding to a Government Investigation

Whistleblower’s Protection Act

A law that provides protection to employees who report a violation or suspected violation of state, local or federal law

Provides protection to employees who participate in hearings, investigations, legislative inquiries, or court actions & prescribes remedies & penalties

Whistleblower’s Protection Act

An employer shall not discharge, threaten, or otherwise discriminate against an employee because the employee reports or is about to report a violation

An employer shall post notices & use other appropriate means to keep employees informed of Whistleblower’s protections

We Believe Our Compliance Program

Enables you to do the

Right thing for the Right

Reason

Questions, Concerns or Suggestions

Talk to Brenna Ellison

269.948.8041 ext 142 or brleedy@bccmha.org

Talk to your Immediate Supervisor

Call the Hotline 800-218-8290

Who is Responsible for

Compliance?

Everyone

When in doubt

point it out!!

References Troklus, D; Waraner, G. (2006) Compliance 101, second

edition. Healthcare Compliance Association. Minneapolis MN.

HCProfessor. (2002) Compliance Training Handbook for the General Healthcare Staff. Opus Communications, Inc.

US Department of Health and Human Services, Office of Inspector General. (28 January 2014) 2014 Work Plan. http://www.oig.hhs.gov/reports-and-publicaitons/workplan/index.asp

Revised 2/2014