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How Does Your Program Rate?Tried and True Principles of 

Compliance

Terri L. Gilbert, Senior Manger, Aegis Compliance & Ethics Center, LLP and

Lisa Taylor, Director & CCO, UC Health 

Welcome!  Who we are:

Lisa A. Taylor, JD, CCEPDirector & Chief Compliance OfficerUC Health513‐585‐8043

Terri Gilbert, CPC, CHC, CPMASenior ManagerAegis Compliance & Ethics Center, LLP513‐646‐9202

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Text Polling!Number to text: 22333

Message box: UCHPOLL (one word)

Return Message: “Participating with Kristin Kreuter”

And then text your poll response

Text Polling!Number to text: 22333

Message box: UCHPOLL (one word)

Return Message: “Participating with Kristin Kreuter”

And then text your poll response

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Text Polling!

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Session Friendly Interaction

• Introduce yourselves to your constituents

• Engage in short conversations

• Discuss what you would like to take away from today’s session

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Welcome to Compliance!

• What is the first thing you do as a Compliance Professional at a new place?

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Know the Players (or the acronyms)

• CEO/President

• COO

• CFO

• CMO

• EVP’s

• SVP’s

• VP’s

Make sure you get to all departments

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What do you ask at the meeting?

• What do you think about the 

compliance department?

• What would you change or keep the same?

• Do you know where to go to get information about the compliance department?

• Do you know where to call if you need to report a compliance concern?

• Have you read the Code of Conduct?  What do you think?

• Yours?

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My Worry List

• What keeps you up at night?

• What makes your organization stand out?

• Where are there limited controls?

• What are your outliers?

• Others?

Do you have the          elements in place?

1. Written Standards of Conduct, Policies, and Procedures 

2. Oversight and Organization of the Compliance Program

3. Education and Training

4. Open Lines of Communication

5. Auditing and Monitoring

6. Promptly Responding to Compliance Violations

7. Enforce the Compliance Program through Disciplinary and Incentive Guidelines

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If yes and they look good – no need to include in the  risk assessment

If yes but could use some reflection and   improvement – add to risk assessment

If no – add to risk assessment as high risk

Let’s move to the risk assessment 

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Developing the Risk Assessment• List risks and build assessment document

• Send to the appropriate leaders/employees

• Assessment completed based on importance, urgency, impact and likelihood

• Submission and Analysis of Assessment

• Individual meetings with leaders• Final plan – resources and risks

Types of Risk

Strategic Research Security

Financial Operational Human Resources

Safety Compliance Others?

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Build Your Assessment Document

Provide Definitions for Assessment

• Importance – how important is this to the organization?

• Urgency – how quickly do we need to address this issue?

• Impact – what impact will this risk have on our organization if it happens?

• Likelihood – how likely is this risk to occur to our organization?

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Send to Appropriate Leaders/Employees

CCO

CPO

Revenue

Cycle

Internal

Audit

Providers

Accounting

Finance

Gov’t Relations

Pharmacy

Human Resources

Research

Lab/Path

Regulatory

IS&T Security

Billing Complian

ce

CEO

CMO

COO

CFO

Assessment Completion

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Heat MapsUrgency

H

M

L

L M H

ImportanceImpact

5

4

3

2

1

1 2 3 4 5

Likelihood

Submission & Analysis of Assessment

• Leaders/Employees only assess impact and likelihood when importance and urgency land in the dark blue shaded areas

• List out your highest risks based on the assessment to impact and likelihood starting in the far right corner at the top

• Create a list and a heat map

• Outlier billing patterns – Bell Curve Data

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Mitigating Factors

• For high or medium risks, think through possible mitigating factors that are already in place

– Policies

– Procedures

– Audits

– Checklists

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Meetings

• Meet with leaders of your organization

• Always include physicians/NPPs

• Provide draft list

• Discuss agreement/disagreement

• Add risks

• Adjust risks based on leaders input

Finalize the List

• Create a final risk list based on the follow up meetings 

Risk Number Description of the Risk

1

2

3

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What to do?

• Based on the list and mitigating factors, you may decide to:

– Accept the risk where it is:  there is nothing else to do

– Develop a mitigation plan:  initial or re‐assessment

– Transfer the risk

– Avoid

Final Plan – Resources and Risks

• Decide if you have the capacity to address all, just red or just red and orange based on resources and risks

• Resources –

– How many resources

– Capacity = hours to devote to each risk/year

– Risk Timing = how long to work on mitigationRisk Number Description of Risk Action

1 Helpline is internal Transfer

2 We have no CCO Mitigation Plan

3 Need an Audit Plan Mitigation Plan

4 Education and Training for all  Mitigation Plan

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Develop Mitigation Plans

• It can be as simple as: 

Taken from:  http://www.caplaw.org/conferencesandtrainings/webinardocuments/2011/CAPLAW_RiskManagement_Plan_March2011.pdf

Develop Mitigation Plans

• Or as complex as this:

Taken from:  http://www.caplaw.org/conferencesandtrainings/webinardocuments/2011/CAPLAW_RiskManagement_Plan_March2011.pdf

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Some basic principles to help:

Written Standards of Conduct, Policies, and Procedures 

• Code of Conduct

• Policies

• Compliance Plan/Program

• Benchmark with other similar organizations

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Oversight and Organization of the Compliance Program

• Name a compliance officer

• Appropriately staff and budget the office

• Read the OIG’s Guidance for Board’s 

Education and Training

• “Official” education and training program

• Communicate often

• Develop a yearly plan for education and training

• Track

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Open Lines of Communication

• Anonymous HELPLINE– Internal or External

– Web reporting

• Employees know where to find you– Office

– Phone

– Email

• Multi‐level reporting – Mgmt, HR, You, Helpline

Auditing and Monitoring

• Where you will spend some time – lots of risks to look at in this area if your program is new

• Move toward a proactive instead of a reactive model

• Track

• Know the new 60‐Day Rule information

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Monitoring and Auditing

• Internal?

• Outsourced?

• Defining parameters

• Education (continuous improvement)

– Real Time Provider Shadowing

– Include actual scenarios

– Must be relevant, timely and meaningful

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Where are some of your risks that you may want to audit?

• CERT

• PEPPER Report

• OIG Work Plan

• Past Issues

• Outliers

• What about ICD‐10?

• New Implementation /Laws

• What keeps you up at night?

• What makes your organization stand out?

• Where are there limited controls?

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2016 Healthcare Compliance Concerns

1. Alternative payment models

2. Fraud and Abuse enforcement

3. Provider consolidation

4. Meaningful Use Stage 3 – Interoperability

5. Cybersecurity

2016 Healthcare Compliance Concerns

6. New Corporate Conduct Enforcement

7. Medicaid Managed Care

8. Affordable Care Act

9. Drug Costs

10. Mental Health Reform

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What Size Are Your Rocks?

Do Your Rocks Resemble This?

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Or This?

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Comprehensive Error Rate Testing (CERT)

• Annually a statistically valid sample from billed claims

• Fee‐for‐service payments

• CMS initiative

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Comprehensive Error Rate Testing (CERT) – 2/8/2016

Service Type Improper Payment Rate Improper Payment Amount

Inpatient Hospitals 6.2% $7.0B

Durable Medical Equipment (DME)

39.9%$3.2B

Physician/Lab/Ambulance 12.7% $11.5B

Non‐inpatient Hospital Facilities 14.7%$21.7B

Overall 12.1% $43.3B

EM Bell Curve

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EM Bell Curve

Bell Curve Comparisons

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PEPPER Report

https://www.pepperresources.org/

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PEPPER Report

https://www.pepperresources.org/

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OIG Work Plan

http://oig.hhs.gov/reports‐and‐publications/archives/workplan/2016/oig‐work‐plan‐2016.pdf

Annual OIG Work Plan• Physician home visits

• Hospital Outlier Payments

• Provider Based Status

• Inpatient Mechanical Ventilation

• Cardiac Catheterization & Endomyocardia Biopsies

• Bone Marrow or Stem Cell Transplants

• Clinical Laboratory Services

• Medical Device Credits

• SNF PPS Requirements

• Evaluation and Management Services (E&M)

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New Implementation/Laws

• If they pass it, they will audit it!

– Two Midnight Rule

– Sunshine Act

– Validation of hospital submitted quality data

– Anesthesia services

– Physician home visits

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Two Midnight Rule

• Difference between ordering “observation” or “in‐patient” in the hospital

• The visit must span two midnights or fit an exception

• The government cares because it impacts reimbursement

• Document, Document, Document

Sunshine Act (or Open Payments Law)

• Requirement of manufacturers of pharmaceuticals and medical devices to publically report payments to physicians and teaching hospitals.

• MLN Matters # SE1330 – June 2013

• Check the List

• Challenge the list if needed

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Hospital Submitted Quality Data

• Meaningful Use – Stage 3

– EHR Incentive Programs

Meaningful Use Stage 3• For the EHR Incentive Programs in 2015 through 2017, major provisions 

include:

• 10 objectives for eligible professionals including one public health reporting objective, down from 18 total objectives in prior stages.

• 9 objectives for eligible hospitals and critical access hospitals (CAHs) including one public health reporting objective, down from 20 total objectives in prior stages.

• Clinical Quality Measures (CQM) reporting for both eligible professionals (EPs) and eligible hospitals/CAHs remains as previously finalized.

• https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact‐sheets/2015‐Fact‐sheets‐items/2015‐10‐06‐2.html

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Meaningful Use Stage 3

• Preparation for 2015‐2017 EHR participation

• Medicare and Medicaid• https://www.cms.gov/Regulations‐and‐

Guidance/Legislation/EHRIncentivePrograms/Downloads/PrepForEHR.pdf

Anesthesia Services

• Continued focus review by the OIG

• AA or QK modifiers

• “Reasonable and necessary” services

• Anesthesia services‐non covered services

• Medical necessity

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Physician Home Visits

• Reasonableness of service

– “Reasonable and necessary”

• Since January 2013 Medicare has made $559 million in payments

• Physicians are required to document the medical necessity of a home visit in lieu of an office or outpatient visit

Prolonged Services

• Reasonableness of services

• Considered to be “rare and unusual”

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Concurrent Surgeries

• Two or more overlapping surgeries

• Language in the Medicare Teaching Physician Guidelines are vague – “key and critical portions”, “immediately available”, etc.

• Train, Document and Track

Mid‐Level Providers• When a hospital inpatient, outpatient or emergency department 

Evaluation and Management (E/M) service is shared between a physician and a Non‐Physician Practitioner (NPP) the service may be billed under either the physician's or the NPP's UPIN/PIN number.

– Employed by same employer

– Both fully credentialed 

– Both provide medically necessary face to face portion of the E/M encounter with the patient and document their participation

– Documentation must substantiate medical necessity and support the level of E/M code submitted 

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STARK

• Prohibits a physician from making a referral for certain designated health services to an entity in which the physician (or immediate family) has an ownership interest unless an exception applies

• Most often – Agreements

– More than 1 year

– FMV

– In writing

Kickback

• Knowingly and willfully offer, pay, solicit or receive any remuneration directly or indirectly to induce or reward referrals of items or services

• Beware ‐

– Below FMV

– Free

– State Law

– What you “give” to patients

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ICD‐10• ICD‐10 is the 10th revision of the International Statistical Classification of 

Diseases and Related Health Problems (ICD), a medical classification list by the World Health Organization (WHO). It contains codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases.

• Codes for Disease and Procedural Classifications = 16,000 Codes

Clinical Documentation Improvement• Clinician engagement

• Enhanced process

• Quality improvement

• Increased compliance

• Financial impact

• Minimizes “silos”

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Audit/Monitoring

• Audit looking at original risk and mitigation plan

• Was it successful?

– Yes

– No

• Continuous reflection and improvement

• Perpetual education!

Promptly Responding to Compliance Violations

• All calls investigated and provided with a response

• Prompt

• Response

• CMS 60‐Day Rule

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Enforce the Compliance Program through Disciplinary and Incentive Guidelines

• Discipline = equal for all similar fact patterns

• Incentives

– Performance Evaluations

– Media Attention

– Reward System

– Compliance & Ethics Week 

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Don’t forget to CELEBRATE Ethics & Compliance Week!

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Secrets from the front lines

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Your Attorney is your friend!

Attorney Client Privilege Review

OK – You found a real issue during your risk assessment or monitoring/auditing.  What to do?

• Call Molly!

• Engage

• Confidential and Privileged Communication

• Speak to no one…

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Attorney Client Privilege Review

• Development of review plan

• Probe Audit

• RATSTATS

• Do I need a personal attorney?

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Practical Tools for Living Compliance

• Online Sources – The Government is not TOP SECRET in compliance– https://www.cms.gov/

– http://oig.hhs.gov/

– http://www.hcca‐info.org/

– http://www.ahima.org/

– http://www.justice.gov/

– https://www.healthlawyers.org/Pages/Home.aspx

– https://www.pepperresources.org/

CMS Physician Resources

• https://www.cms.gov/Outreach‐and‐Education/Medicare‐Learning‐Network‐MLN/MLNProducts/Downloads/Avoiding_Medicare_FandA_Physicians_FactSheet_905645.pdf

• https://www.cms.gov/Medicare/Fraud‐and‐Abuse/PhysicianSelfReferral/index.html

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I’m on the site – now what?

• Sign up

– Organization

– List serves

– Notices

– Updates

– New Laws

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You are NOT alone!

The day of the business card swap is not over…..

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You will fall….but CELEBRATE your WINS!

Get a De‐Stress Device

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Extra Special Stress Relief

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THANK YOU!