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Presented byPaula Saddler

Maggie SteenrodAnn Dunham

September 16, 2014

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Why have a Comp Committee? Paula

How do you Organize a Comp Comm? Maggie

Getting the Most out of a Comp Comm Ann

Questions and Answers? Everyone

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By Paula Saddler, CCEP, CFE

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Protect Persons, Property, Natural Resources

Feedback on Org’s Compliance Efforts

Report to the Board of Directors

CC at the Board of Director’s Level

One state’s support for CCs at the BOD level

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BOD is accountable to shareholders

CC to BOD helps in oversight & fulfill responsibilities

Encourages accountability from top to bottom

Compliance Officer is not = Compliance Committee

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CC is not a rote exercise in compliance

Safeguard persons, property, natural resources

People – clients & employees, innocent bystanders

Property – Of Org & others

Natural Resources, water, land, air

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Anthony Delmundo New York Daily News

CREDIT: AP PHOTO/STEVE HELBER

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Associated Press

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Operations

Federal, State & Local Laws

Professional Standards

Industry Standards

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Compliance Duties of BOD

American Health Lawyers Assn USOIG HHS

Joint Publication

BOD – Fiduciary Responsibility

Duty of Care – Reasonable Inquiry

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NYS has 2 laws re robust compliance plan

NYS Laws follow US Sentencing Guidelines

Due Diligence prevent\detect criminal conduct

Promotes org culture that encourages ethical conduct & compliance to law

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Written Policies & ProceduresDesignate compliance officer with responsibility

Train & educate employeesCompliance officer communicates with other units

Disciplinary policies & procedures Identify complex risk areas + non compliance

System to respond to compliance issues Policy of non-intimidation & non retaliation

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Billing for unnecessary services "Phantom" billingMultiple billing Improper UpcodingKickbacksSelling drugs/forging or altering prescriptions

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NYS Office of Medicaid Inspector General James C. Cox Medicaid Inspector General

Medicaid providers certify to NYS re robust compliance plan

NYSOMIG receives: certifications from providers conducts on-site reviews

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Sanctions

Pro-active advice

Recommendations strengthened in Dec 2013

“How to Road Map” for BOD

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Compliance activities reported>BODBOD as a wholeBOD – Compliance Committee

Compliance Committee at BOD LevelRegular interaction with Comp Officer/ProgramTraining on complianceInteractions with Compliance teamOversight on qualifications of Comp Officer + Team

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By Maggie Steenrod, CCEP, SPHR

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Conforming with stated requirements through management processes which

Identify the applicable requirements Assess the state of compliance Assess the risks and potential costs of non-

compliance against the cost to achieve compliance

Prioritize, fund and initiate corrective action

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Single business?Multiple business units?

Domestic?Global?

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Compliance structure and complexity determined by:◦ Organization size◦ Geographic location◦ Variation of business and

services Compliance function

should be structured accordingly

Board of Directors

Compliance Committee Business Units

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Diversified/Multi-national companies may need multiple Compliance Committees

Goal is to establish a compliance reporting structure that is comprehensive and responsive

Board of Directors

Compliance CommitteeRegion 1

Compliance CommitteeRegion 2

Executive Compliance Committee

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Identify Determine root cause Measure Evaluate Mitigate Monitor

Anticipate issues arising from noncompliance

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Mission/Charter: What is the committee called to do? What results are expected? Focus on proactive approach Prevent and respond to compliance issues Be prepared to react to crises as they arise

Responsibility, Authority, Accountability: Responsibility as a group Authority of the committee as a group To whom is the committee accountable?

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Board of Directors sets governing policy Executives execute that policy Compliance Committee:◦ Advises on policy ◦ Offers specific recommendations◦ Provides objective feedback in implementation of

the policy (what was the result?)◦ Accountability

a key factor in feedback

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What happened? Why did it happen? What steps have been

taken to ensure it doesn’t happen again?

A well-functioning compliance committee should increase Board comfort in

responding to these questions

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Make the Board comfortable that compliance is being managed

Give the Board sufficient detail supporting Committee reports and recommendations

Deliver summary of company’s compliance risks Include issues, compliance concerns, compliance

regulatory changes, and the like Provide evidence the compliance program is

working, and steadily improving (or not)

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Filtering occurs with every layer of management Most compliance issues are known at the lowest

levels of the organization Ensuring that reports of compliance issues

“percolate up” is critical for employee perception that company intends to remain compliant

Needs demonstrated commitment at the top so employees knowcompany is not just paying lip service to compliance

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All functions with potential compliance impacts (e.g., Finance, Legal, HR, IT, Audit, Facilities, business units)

Representatives from key business units

No more than 12 members Committee needs high-level

leadership and operational supportto champion compliance

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Considered leaders in their respective functions

Appropriate level of management represented

Member job description sets expectations

Including participation in members’ own job description provides motivation

Request commitment

Recognition and reward

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Reports of regulators Hotline reports of complaints Reports of risk assessments/investigations Reports of legal office re regulatory matters Reports of external events impacting

company operations or reputation Hot topics that need immediate attention

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Scheduled reviews of audit report findings

Review of company’s progress in addressing report results

Annual review and update of compliance plan

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Determine root cause: Understand what groups were involved Understand what happened (or didn’t happen) Understand why it happened (situation)

Recommend correctiveaction Process to prevent

recurrence

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Ensure standard templates and assessment tools are in place that:

Set expectations Efficiently gather necessary data Reduce rework Eliminate subjectivity Promote a culture of compliance

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Examine the process Utilize best practices Use metrics to manage and track the

organization’s compliance Ensure compliance is part of the equation

Courtesy of WikiHow.com

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Design a reporting cadence based on your company’s compliance needs:◦ Ensure the schedule supports Board of Director

deadlines◦ Provide sufficient time for management to gather

and review information prior to committee review Develop a cadence with:◦ Recurring regular meetings ◦ Ability to add special sessions or urgent meetings

as needed

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By Ann Dunham, SPHR, MBA

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Compliance Committee Meeting agenda

Have the appropriate members at the table

Engaged committee members

Audit Schedule

Annual Review of Compliance Plan

Create a safe zone

Appoint a note taker

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Core agenda items to have at every meeting

Important items can and should be continually added to agenda

Stay on track with agenda

My agenda probably will not look exactly like your agenda

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COMPLIANCE COMMITTEEMay 8, 2014 – 9:00 a.m.

AGENDARespect - Integrity - Service – Excellence

1. Minutes (March 13, 2014) Attached ............................................................ Dunham

2. Follow-Up a. RAC Audits ....................................................................................................Ash b. HIPAA Policy Revisions ................................................................................ Davis c. Business Associate Agreement .................................................................... Morrison d. ICD-10 .........................................................................................................Ash e. Status of Cloning (Cut & Paste) of EHR ..........................................................Cooper

3. Accreditation & Licensure Reporting a. Stroke Center Designation .............................................................................Smith b. TJC Survey......................................................................................................Smith

4. Compliance Audits a. Chargemaster Audit .................................................................................... Horn b. HRMG Insurance & ID Audit.......................................................................... Dunham c. Safety Survey Reports................................................................................... Dunham

5. New Business a. Hotline Calls/Complaints ............................................................................ Dunham b. HIPAA Report .............................................................................................. Morrison c. EMTALA Policy Revision ............................................................................... Dunham

6. Exit Interview Results a. Have Any Compliance Concerns ....................................................................Jones b. Do You Know of Anyone Not Following Compliance Policies..........................Jones

7. Employee Compliance Issues/Level of Discipline ..........................................Jones

8. Next Meeting: June 12, 2014 – 9:00 a.m.

9. Adjourn

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Knowledgeable in their own field

Able to alert committee of any risk possibilities in own area and recommend corrective action.

Well respected

Understand being committed to Compliance

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Recommend members be at Director level due to high level nature of discussions

Appointed by CEO and Compliance Officer

Members could be called upon to assist with compliance investigations

Willing to be visible advocates of compliance

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Willing to discuss tough issues openly and honestly

Meaningful discussions are necessary –uncover any and all important facts.

Willing to advocate for culture of Compliance

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Shows up to Compliance meetings

Respectful of others opinions and offer suggestions

Takes compliance information back to their superior and direct reports

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Committee should create annual Compliance Audit schedule every year. At least one audit per month.

Committee member is the “Accountable person” in charge of making sure audits are done.

Any delays of audit completion should be reported back to the committee.

Results of all audits must be reported to committee. Then goes on to Senior Leadership and Board of Directors.

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Plan for one meeting per year to review current Compliance Plan.

Stress importance to committee members to re-read Compliance Plan before coming to the meeting where it will be discussed.

Updates or changes might need to be made.

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Compliance Officer must lay the ground work for creating a “safe zone”.

Everyone’s opinions and recommendations are welcomed.

There are no stupid questions or ideas.

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Appoint a note taker - usually a lot of dialogue that should be documented.

I have an Executive Assistant take notes and provide each month’s agenda and last month’s minutes.

The Compliance Officer should review minutes to ensure important items are included in the final version of the minutes.

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Have a thorough agenda with core items

Have engaged and committed committee members at the table

Committee must set annual Compliance Audit Schedule

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Committee should do an annual review of Compliance Plan

Create a safe zone for the committee to talk freely

Appoint a note taker

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It takes the entire Compliance Committee to successfully promote a culture of compliance.

Thank your committee members often for their time and efforts!

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Why have a Comp Committee? Paula

Organizing a Comp Committee Maggie

Real World Examples for Comp Comm Ann

Questions and Answers?

Resources - Handouts

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Paula Saddler Mobile: (917) 757-1822coi@coireview.com

Maggie Steenrod Mobile: (206) 799-1276masteenrod@gmail.com

Ann Dunham Phone: (573) 406-1603ann.dunham@hrhonline.org