Chapter_22_-_HC_Compliance_II_-_kmk.pptx

Effective Training and Education
Two types of mandatory training – General and Fraud, Waste, and Abuse (FWA).
Annually, part of new employee orientation.
Agenda for each type of training.
Training for employees, managers, governing board, FDR’s, temp workers, & volunteers
Various methods of delivery
Proof that training was delivered

Effective Lines of Communication
Between the CO and CC, and employees, managers, governing board, and FDR’s
To seek clarification on compliance issues or report suspected non-compliance or FWA
Insist that employees report suspected problems
Multiple reporting channels, well publicized, available 24 hours a day, readily accessible
Maintain confidentiality, allow anonymity, prevent retaliation

Well-Publicized Disciplinary Standards
To be applied in cases of misconduct, non-compliance, or FWA by employees
Well-publicized to employees and FDR’s
Criteria for disciplinary standards
Maintain records on disciplinary actions

Routine Monitoring, Auditing, and Identification of Compliance Risks (I)
Evaluate compliance with CMS program requirements, and effectiveness of the compliance program itself
Compare monitoring activities and audits
Systematic work plan – reflecting size and resources of the organization, and risks it faces
Content of typical work plan

Routine Monitoring, Auditing, and Identification of Compliance Risks (II)
Baseline assessment of risk areas, then prioritize the risk areas
Monitor and audit first tier entities
Responsible for compliant behavior of all FDR’s

Program Exclusions
Lists of people and organizations that are excluded from participation in Federal health care programs – as a result of fraudulent or other criminal acts they have committed
OIG List of Excluded Individuals and Entities (LEIE)
GSA Excluded Parties Lists System (EPLS)
Review these lists prior to hiring or contracting with any individual or organization

Data Analysis
Data analysis – tool for monitoring operations to detect and prevent FWA
Compare claim information with other data to identify unusual patterns suggesting errors or potential fraud and abuse
How good data analysis works

Special Investigation Units (SIU)
Internal unit that conducts surveillance, interviews, and other forms of investigation relating to potential FWA
Often separate from the Compliance Program
An SIU or comparable functions in the Compliance Program are mandatory
CMS has the right to perform its own audits of Sponsor or FDR activities related to Medicare

Procedures and System for Prompt Response to Compliance Issues
Ingredients of CMS-required response system
When matters must be referred to CMS or NBI-MEDIC
Corrective action – correct the underlying problems and make sure it does occur again
Corrective action plans for FDR’s as well

Self-Reporting of FWA
Self-reporting is voluntary but strongly advised
Report to NBI-MEDIC, OIG, or DOJ
Opportunity to minimize the potential cost and disruption of a full scale audit and investigation, to negotiate a fair monetary settlement, and to potentially avoid an OIG program exclusion

Enforcement Activities Regarding MAO’s
NBI MEDIC identifies & investigates Part C and Part D fraud and abuse, refers cases & gives advice to the OIG, and meets requests for information from law enforcement agencies
OIG 2013 Work Plan shows dissatisfaction with MAO fraud detection
CMS enforcement options: civil money penalties (CMP), intermediate sanctions, and contract terminations