Healthcare Compliance Presentation
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This document summarizes a presentation on healthcare compliance. It discusses how mandatory compliance requirements have increased in recent years through various laws and regulations. Specifically, the Affordable Care Act requires companies to have compliance programs with core elements in place by March 2013 or risk exclusion from federal healthcare programs. The presentation recommends that organizations conduct background checks on all employees, licensed and unlicensed, to various degrees to avoid noncompliance penalties that can include fines, damages, and exclusion from Medicare/Medicaid billing. It provides examples where lack of compliance oversight resulted in millions paid in penalties and kickbacks.
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Healthcare Compliance Presentation
- 1. CINNTI – “confirmation of workplace protection for everyone” Presenter: Kendall Brune, PhD, MBA, LNHA Fellow – American College of Healthcare Administrators Compliance and Beyond It does not matter how small or LARGE your complex is 12 room ILF- VA 276 bed SNF It is a Scary Proposition~!
- 2. Compliance is a LEAP of FAITH
- 3. CINNTI – “confirmation of workplace protection for everyone” Compliance and Beyond Healthcare companies have seen the development of mandatory compliance requirements increase over the past few years. The sources of these requirements include: • US Sentencing Guidelines • OIG/Health and Human Services Guidance • Medicare Part C & D Mandatory Compliance Guidelines • Affordable Care Act • FAR Acquisition Regulations.
- 4. CINNTI – “confirmation of workplace protection for everyone” Compliance and Beyond Recently, mandatory compliance requirements were enacted through statute in the Affordable Care Act (Sections 6102 and 6401). Under the ACA, companies are prohibited from participating in Federal heath care programs unless their compliance programs contain certain core elements. The ACA sets out required core elements. The HHS regulations are likely to draw from the statute and from earlier regulatory proceedings which solicited input on the basic compliance program requirements. Nursing homes will be expected to have operational compliance programs that are effective in preventing criminal and civil health care violations, and promoting quality of care by March 23, 2013. What does this NH regulation have to do with my ALF?
- 5. CINNTI – “confirmation of workplace protection for everyone” Compliance and Beyond Healthcare and Long Term Care Compliance What is a ―sanctioned entity ? Entity convicted of any criminal offense that triggers a mandatory exclusion under Section 1128(a), including: • Felony conviction for health care fraud; • Conviction related to patient abuse and/or neglect; • Failure to repay Health Education Assistance Loans; • Conviction related to fraud against non‐health care programs; • Misdemeanor conviction for controlled substances; • License revocation or suspension; and • Misdemeanor health care fraud conviction. Share FBI and OIG cards – Welcome to my ALF~!
- 6. Fact Sheet ALF and Wrongful Deaths? Public defender Kathryn Benson, left, talks with Richard Allen Williams following his arraignment in Boone County (Mo.) Circuit Court. Williams, 36, pleaded innocent Monday to 10 counts of first-degree murder for allegedly killing patients a decade ago while working as a nurse at the Truman Memorial Veterans Hospital in Columbia, Mo. Boone County Prosecutor Kevin Crane told the court he would seek the death penalty in the case. (July 23, 2002) An investigation by the FBI and the Office of Inspector General in the Department of Veterans Affairs determined that 41 people died on Ward 4E between May and August 1992 while Williams was on duty. Investigators concluded patients were 20 times more likely to die while Williams was working than while 11 other nurses were on duty.
- 7. Owners did not check out his Background? His license was not suspended…. The VA did not report any problems…. The Administrator was glad an RN applied…. Meanwhile, the number of deaths increased at Ashland during the time Williams was there. From June 1993 to June 1994, more than half the home's 55 residents died - nearly triple the average death rate for nursing homes in Missouri. The Boone County medical examiner's office focused on 30 deaths that occurred during the year Williams worked at Ashland. Six residents died in the 10 months after Williams' dismissal from the home on July 13, 1994. No charges resulted. Williams was removed after state inspectors found that he had failed to adequately supervise staff to ensure the safety, treatment and care of residents. http://murderpedia.org/male.W/w/williams-richard-allen.htm
- 9. CINNTI – “confirmation of workplace protection for everyone” Compliance and Beyond Healthcare and Long Term Care Compliance Affordable Care Act (ACA) core requirements should include: 1. Written policies, procedures and standards of conduct to prevent and detect inappropriate behavior. 2. Designation of a chief compliance officer. 3. Effective education and training programs for the governing body for all employees. 4. Maintenance of a hotline and anonymous reporting procedures to protect the anonymity of complainants and to protect whistleblowers from retaliation. 5. A system to respond to allegations of improper conduct and the enforcement of appropriate disciplinary action against employees who have violated internal compliance policies, applicable statutes, regulations or Federal health care program requirements. 6. The use of audits and/or other evaluation techniques to monitor and track compliance and assist in the reduction of identified problem areas. 7. The investigation and remediation of identified systemic problems including making any necessary modifications to the organization’s compliance and ethics program.
- 10. CINNTI – “confirmation of workplace protection for everyone” Compliance and Beyond Healthcare and Long Term Care Compliance What are you doing about your compliance and how comfortable are you that your current licensed staff / vendors? • Are properly licensed • Have no Sanctions or Disciplinary Actions • Maintain required Certificates • Are not Excluded or Debarred by OIG/GSA • Maintain proper Continuing Education • Files are ready for Joint Commission or State audits Rooting out health care fraud is central to the well-being of both our citizens and the overall economy. http://www.fbi.gov/about- us/investigate/white_collar/health-care-fraud
- 11. CINNTI – “confirmation of workplace protection for everyone” Compliance and Beyond Healthcare and Long Term Care Compliance Recommended program levels for current licensed staff and vendors: Compliance Plans Minimum Medium Maximum General Services Administration Excluded Parties List System (GSA) X X X Office of the Inspector General List of Excluded Individuals/Entities (OIG) X X X Office of Foreign Assets Control Specially Designated Nationals (OFAC) X X X State exclusions, sanctions, and debarment X X X Instant SSN (social security number) Trace X X X National Practitioner Data Bank (NPDB) X X Professional License Verification X X Nationwide Federal Criminal Record Search X X Statewide Criminal Records Search X X Registered Sex Offender Search X X Ethics Training X Continuing Education Training X
- 12. CINNTI – “confirmation of workplace protection for everyone” Compliance and Beyond Healthcare and Long Term Care Compliance Licensed Employees Only? Do you have one place to go to determine the compliance for your entire organization? 2012, American Senior Communities recently settled with the OIG for $376,000 for employing 7 excluded providers. Fines included CNA's and kitchen staff. Housekeepers? Drivers? Transporters? Dietary Staff – OH Yes VOLUNTEERS? My Dietary Manager
- 13. CINNTI – “confirmation of workplace protection for everyone” Compliance and Beyond Healthcare and Long Term Care Compliance Recommended program levels for non-licensed staff and vendors: Compliance Plans Minimum Medium Maximum Instant SSN (social security number) Trace X X X Nationwide Federal Criminal Record Search X X X Statewide Criminal Records Search X X X Registered Sex Offender Search X X X Ethics Training X X X Employment & I9 Verification X X W-9 Verification X X Workers Compensation Insurance Verification X X General Liability Insurance Verification X X Business Partner / Owner Search X X County Civil / Lawsuit Search X
- 14. CINNTI – “confirmation of workplace protection for everyone” Compliance and Beyond Healthcare and Long Term Care Compliance The cost of not knowing? Medicare/Medicaid Billing Participation 1. Up to $10,000 fine for each item/service billed 2. Treble (3x) damages 3. Possible exclusion 4. Charges under Federal False Claims Act Legal Liability 1. Negligent hire or retention 2. Loss of CMS Reimbursement Privileges (PPACA 6502) 3. State fines for practicing without a license Has it effected you, it has me~! RN & LPN story
- 15. CINNTI – “confirmation of workplace protection for everyone” Compliance and Beyond Healthcare and Long Term Care Compliance The cost of not knowing? – 2 examples Example #1 - The U.S. Justice Department has accused RehabCare Group Inc. of paying more than $10 million in kickbacks to gain access to Medicare and Medicaid patients in Missouri nursing homes. RehabCare began making payments in 2006 to induce a Missouri nursing home chain to grant RehabCare a contract to provide therapy services. RehabCare’s revenue-sharing arrangement with the nursing home owner -- Sikeston, Mo.-based Health Systems Inc. -- defrauded the federal Medicare and Medicaid programs of millions of dollars, federal investigators allege. Example # 2 - California’s Attorney General announced that the former director of nursing at a hospital in the Kern Valley Healthcare District was sentenced to three years in state prison for the “convenience drugging” of elderly patients, including one who ended up dying. Gwen D. Hughes, the former nursing director, was charged with the deaths of three patients in the original lawsuit. She pled no contest to a single felony count of elder abuse last October, with a special allegation that the abuse resulted in the death of a patient.
- 16. CINNTI – “confirmation of workplace protection for everyone” Compliance and Beyond Healthcare and Long Term Care Compliance The cost of not knowing? OIG also excluded 3,131 individuals and entities from participation in Federal health care programs in FY 2012. OIG reported 778 criminal actions against individuals or entities that engaged in crimes against HHS programs; and 367 civil actions. The OIG reported $6.9 billion in expected recoveries which consisted of $923.8 million in audit receivables and $6 billion in investigative receivables for FY 2012. Date Provider Self- Disclosure? Amount of CMP Assessed 11/13/12 Hospital Yes $248,362.78 10/12/12 Hospital & Cardiology Practice Yes $172,604.00 10/12/12 Physician d/b/a Physician’s Medical Clinic Yes $43,014.80 10/07/12 Home Health Agency Yes $81,102.06 10/07/12 Hospital Yes $150,000.00 09/26/12 Hospital Yes $120,580.25 09/25/12 Treatment Center Yes $105,794.24 09/19/12 Neighborhood Health Clinic Yes $103,485.79 09/19/12 Hospital Yes $417,440.78 08/22/12 Hospital Yes $138,452.00 08/02/12 Hospital Yes $206,669.53 07/13/12 Community Clinic Yes $207,440.19 Sample listing
- 17. CINNTI – “confirmation of workplace protection for everyone” Compliance and Beyond Healthcare and Long Term Care Compliance GCT Advantages • More than just a background check • Each compliance package is customized • Employee and vendor screening • No Cost for certifying outside vendors • International capabilities • Our system monitors monthly for changes • Nationwide databases • Secure documentation management • State of the art security to protect all data • On-site user interface for security or visitor center GCT is a simple, efficient, cost-effective solution to manage your compliance with confidence. We also recognize that your operations must always remain audit ready. Why? We’ve been there as licensed Administrators~!...been there with Federal Surveyors, with FBI and OIG. It is NOT pretty or a cake walk.
- 18. CINNTI – “confirmation of workplace protection for everyone” Compliance and Beyond Healthcare and Long Term Care Compliance For any questions contact: GCT – Healthcare and Long Term Care Compliance Expert Kendall Brune PhD, MBA, LHNA, FACHCA [email protected] Phone: 314-757-0131 Global Compliance Tracker a KAEGEM division 2800 West Higgins Road, Suite 980 Hoffman Estates, Illinois 60169 Toll Free:1-888-327-6067 E-mail: [email protected]