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Corporate compliance

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Corporate compliance

  2. 2. HISTORY • Center for Medicare & Medicaid (CMS) paid $20,000,000,000 in error ! • Improper payment due to: CODING & BILLING ERRORS FRAUD & ABUSE • Enormous financial losses for government
  3. 3. PASSAGE OF HIPAA 1996 Government $$$$ for resources to detect fraud & abuse Criminal Offense OIG strongly recommends Corporate Compliance
  4. 4. HEALTHCARE FRAUD n.[<Lat. Fraus, deceit.] 1. Any scheme to obtain money or property of any healthcare benefit plan by means of false or fraudulent pretenses, representations or promises. 2. A deliberate deception practiced so as to secure unlawful gain. .
  5. 5. HEALTHCARE FRAUD = A CRIMINAL OFFENSE This applies to all claims under health benefit programs Fines Prison Restitution Sanctions Corporate Probation
  6. 6. CORPORATE COMPLIANCE PROGRAM • Designed to detect and prevent violations of law by employees & physicians • Offer a framework of ethical guidelines and expectations for the workplace – standards of conduct • Goal is to ensure that the employees & physicians comply with applicable laws and regulations • Essential to any organization committed to ethical conduct and sound business practices
  7. 7. GOALS • Improve Quality of Care • Improve Documentation • Minimize Billing Mistakes • Increase Awareness > Decrease Risk • Reaffirm Commitment to Our Mission
  8. 8. BENEFITS • Established high ethical standards • Improved financial performance • Improved quality care • Improved documentation • Early detection of potential problems
  9. 9. 7 BASIC ELEMENTS OF A COMPLIANCE PROGRAM 1. Standards of conduct 2. Designated Compliance Officer 3. Effective education and training 4. Audits and other evaluation techniques 5. Internal reporting processes 6. Disciplinary mechanisms 7. Investigation and remediation
  10. 10. CORPORATE COMPLIANCE: AN ONGOING PROCESS 1.Prevent 2. Detect/Correct 3. Defend/Mitigate RISK
  11. 11. THE 3C DECISION MAKING MODEL Compliance: • Violation of a law, regulation or internal law or procedure Conscience: • Violation of an ethical principle Conduct: • Decide on appropriate course of action with which to resolve the situation
  12. 12. Guides To Determine Appropriate Behavior • Integrity • Common Sense • Sound Judgment
  13. 13. Ask Yourself These Questions… • Are my actions legal? • Is it fair and honest? • Is this in the best interest of the Center and the patients we serve? • Will my actions stand the test of time?
  14. 14. • How will I feel about myself afterwards? • Will I sleep soundly tonight? • What would I tell my child to do? • How would my words and actions look if reported in the newspaper?
  15. 15. Examine Your Conscience - If You Think or Hear… • “Shred that document.” • “No one will get hurt.” • “You never heard me say that.” • “It can’t hurt just this once…” • “No one will ever find out…” • “Everyone does it.”
  16. 16. REPORTING A VIOLATION TSC Hotline 973 477-7217 Anyone can report a violation without fear of ANY retaliation by: Phone Verbal E-mail Written
  17. 17. CORPORATE COMPLIANCE PROGRAM 1. Written Policies and Procedures 2. Quality Care and Services 3. Reporting and Communication Policy 4. Compliance with Laws and Regulations 5. Medical Records 6. Personnel 7. Safe Work Environment 8. Conflicts of Interests 9. Coding, Billing and Documentation 10.Protecting Property
  18. 18. HINT HINT HINT HINT • Corporate Compliance is NOT a JCAHO requirement • Corporate Compliance is NOT just for healthcare industries • ANYONE can report a violation • Corporate Compliance Officer is Meg Oser