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Compliance Programs inLong Term Care:

Learn to Love It

Julie Hamilton, MBA, CHC Billie Pendleton, RN, BSN, CHC

i1C/Integrity First Consulting CRISTA Senior Living

April 12, 2011

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Today’s Objectives

At the end of today’s presentation – participants

will be able to:

� Understand the effect Healthcare reform on LTC Industry

� Identify the “7” elements of an Effective Compliance Programs for Nursing Facilities as outlined by the Office of Inspector General (OIG)

� Identify key components of a “White Paper”

� Outline a Three year strategy for your organization

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Purpose of a

Compliance Program?

� Support the organization in making business decisions that include high legal and ethical standards

� Be a resource to staff

� Detect and prevent activities contrary to organizational standards, policies and laws

� Create and maintain a culture of integrity

� A commitment to doing the right thing

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Today’s Regulatory Landscape

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Affordable Care Act (ACA)

� Nursing Home (NH)Transparency Requirements {Section 6101}

� Accountability - Compliance Programs for Nursing Facilities required by March 2013 {Section 6102}

� Changes to Federal Sentencing Guidelines and the OIG’s seven elements of an Effective Compliance Program {Section 6102}

� Quality of Care {Section 6102 & 6103}

� OTHER {Section 6104-6107}

� Fraud and Abuse {Section 6111}

� Elder Justice Act {Section 6701-6703}

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� Recovery Audit Contractors (RAC) Demonstration Project• Medicare Modernization Act of 2003

• $353 Million errors in first year

� Affordable Care Act: Expanded RAC implementation

• All states by 2010

• Medicaid programs

• Medicare Parts C and D

� Alphabet Soup of Audit Contractors:

• Recovery Audit Contractors (RAC)

• Medicaid Integrity Contractors (MIC)

• Zone Program Integrity Contractors (ZPIC)

Increased Enforcement Activities

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Enforcement Activity

Medicare RACs

MACs

Medicaid RACs

Z-PICs

CERTQUIOs

MICs

PSCs

OIG

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� Exclude officers or managing employees

� Suspend payments “pending an investigation of a credible allegation of fraud”..

� Increased financial penalties and criminal penalties:

• HITECH affects on HIPAA: up to $1.5 mil and 10 years in jail

• CMP law: allows a $50,000 penalty for each false record or statement submitted

• False Claims Act: retention of overpayment implicates FCA; up to $11,000 per claim + 3x damages

Increased Penalties

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Compliance Program Guidance

� OIG - responsible for protecting the integrity of the DHHS programs and its beneficiaries / Medicare & Medicaid

� OIG - guidelines for Nursing facilities in 2000 and approved supplemental guidance in 2008

� Defined the 7 elements of a compliance program / based on federal sentencing guidelines

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Compliance Guidance for

Nursing Facilities – 7 elements

1. Compliance Standards

2. Compliance Personnel

3. Effective Training & Education

4. Effective Lines of Communication

5. Monitoring & Auditing

6. Enforcement through Disciplinary Guidelines

7. Corrective Action Initiatives

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� Compliance Officer

� Board Accountability

� Investigations

� Measure Effectiveness of Compliance Program

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Additionally, Federal Sentencing

Guidelines (updated 11/1/10)

WHEW

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The Three Year Plan:A Case Study

Year 1: Getting Started

Year 2: Keeping it Moving

Year 3: Maturity and Growth

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Year 1: Getting Started

� White Paper

� Identify Personnel• Compliance Officer

• Compliance Coordinator

• Compliance Committee Members

� Compliance Guidelines for Nursing Facilities

� Program Documents

� OIG Work Plan

� Gap Analysis

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The White Paper

� History & Background

� OIG Annual Work Plan

� Today – Post Health Care Reform

� New Requirements

� Recommendations

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Compliance Personnel

� Compliance Officer

• Authority / Leadership

• Structure

• Organizational Chart

� Other staff

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Program Documents

� Program Description

• Introduction to your organization

• Mission, Vision, Values

• Organize by 7 Elements /Guidelines for NF

� Compliance Committee Charter

• Roles & responsibilities

• Members

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Gap Analysis

� Compliance Guidelines as baseline

� Identify gaps

� Identify areas to work on /dates

� Prioritize the work – low hanging fruit

� Draft your workplan

� Include elements form OIG annual workplan

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Gap Analysis / sample

Requirement Specifics Exists

YES

Exists

NO

Recommendation

Code of Conduct

Program Description

Policies & Procedures

Develop Matrix

Compliance language

added to Performance

Review process

1. Compliance Standards

Due Diligence in

delegating authority:

• Background Checks

• Federal Sanctions

List

• Policy & Procedure

Compliance Officer

Compliance Committee

2. Compliance Personnel

Board Responsibility

new employees training Code of Conduct 3. Effective Training and

Education training for all employees

Access to Compliance

Personnel

Anonymous Reporting

Investigation of reports

of misconduct

4. Effective Communication

Summary Report for

Compliance Committee,

CEO and Board

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Year 2: Keeping it Moving

� Leadership and Board Involvement

� Closing the Gap

� The annual workplan

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Leadership & Board Involvement

� Identify key stakeholders• CEO & Board

• The White Paper re-visited

� Identify key players• HR

• IT

• Marketing

• Billing & Finance

� Establish some face time

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Closing the Gap

� Gap Analysis – working document

� Regular scheduled meetings

� Culture Change

• Compliance Posters

• Staff Education

� Updating your Compliance Documents

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Your Annual Work Plan:

� Annual review of OIG site

� Track progress

� Close out completed areas

� Use it at every Committee Meeting

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Year 3: Maturity & Growth

� Your 1st Risk Assessment

• Keep it simple

• Engage help from others

� Your Annual Work Plan

� Board Reports / Dashboard

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Risk Assessment

� Try to outline all regulations

� Keep it high level

� Keep it simple

� Risk Identification process

• Research

• Interviews

� Put it all together

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Your Annual Work Plan

� Prioritize highest risk areas/Risk Assessment

� OIG Annual Work Plan elements

� Monitoring & Auditing Plans

� Policy & Procedure development

� Education Plans

� Board Reports

� “Watch List”

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Board Report

� Opening Summary Statement

� Program Development /7 Elements

� Other Regulations

� Accomplishments

� Watch List

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Resources

� OIG Compliance Guidance for Nursing Facilities (NF), 2000: http://www.oig.hhs.gov/authorities/docs/cpgnf.pdf

� OIG Supplemental Compliance Guidance for NF, 2008: http://oig.hhs.gov/fraud/docs/complianceguidance/nhg_fr.pdf

� OIG 2011 Workplan: http://oig.hhs.gov/publications/workplan/2011/FY11_WorkPlan-All.pdf

� Healthcare Reform Law/ Affordable Care Act:

http://www.ncsl.org/documents/health/ppaca-consolidated.pdf

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Resources

� Office for Civil Rights Privacy & Security Information: http://www.hhs.gov/ocr/privacy/hipaa/understanding/index.html

� Red Flag Rules – Identity Theft: http://www.ftc.gov/redflagsrule

� Health Care Compliance Association: http://www.hcca-info.org

� i1C / Integrity First Consulting: http://www.i1Consulting.com

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Questions?

Julie Hamilton, MBA, CHC

Managing Partner

i1C/ Integrity First Consulting

206-300-5791

julie@i1consulting.com

Billie Pendleton, RN, BSN, CHC

Executive Director & Comp. Specialist

CRISTA Senior Living

206-546-7573

bpendleton@crista.net

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