Compliance Training 2012Compliance Training 2012

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Training ObjectivesTraining ObjectivesTraining ObjectivesTraining Objectives

•• Understand the purpose of theUnderstand the purpose of theUnderstand the purpose of the Understand the purpose of the Corporate Compliance Program.Corporate Compliance Program.

•• Understand the role of the Corporate Understand the role of the Corporate Compliance Department.Compliance Department.

•• Understand your role in compliance.Understand your role in compliance.

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What is ComplianceWhat is ComplianceWhat is ComplianceWhat is Compliance Compliance can be described as conducting Compliance can be described as conducting

a business and oneself in an ethical, moral, a business and oneself in an ethical, moral, and legal manner.and legal manner.

The SIH Compliance Program has an The SIH Compliance Program has an emphasis on fraud and abuse in theemphasis on fraud and abuse in theemphasis on fraud and abuse in the emphasis on fraud and abuse in the Medicare and Medicaid programs, but also Medicare and Medicaid programs, but also includes other laws and regulationsincludes other laws and regulationsincludes other laws, and regulations.includes other laws, and regulations.

It is doing the right thing and the RIGHT It is doing the right thing and the RIGHT

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g g gg g gthing to do!thing to do!

Recovery Audit Contractor Recovery Audit Contractor yy(RAC)(RAC)

Hired by the federal government to identify improper Hired by the federal government to identify improper payments and recover overpayments on Medicare payments and recover overpayments on Medicare claims States also hiring RACs to audit Medicaidclaims States also hiring RACs to audit Medicaidclaims. States also hiring RACs to audit Medicaid.claims. States also hiring RACs to audit Medicaid.

Paid percentage of findingsPaid percentage of findings

Request up to 278 medical records every 45 days for Request up to 278 medical records every 45 days for retrospective reviews and 278 every 45 days for retrospective reviews and 278 every 45 days for

t i f i ti t tt i f i ti t tprepayment reviews of inpatient staysprepayment reviews of inpatient stays

Reviewing Medicare claims paid as far back as 3 Reviewing Medicare claims paid as far back as 3 g pg pyears. Medicaid RACs will look back 5 years.years. Medicaid RACs will look back 5 years.

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Government OversightGovernment OversightCongress

OIGCMS SurveysCourts

Attorneys GeneralZPIC

PERMMedi-Medi

DOJ

Attorneys GeneralHealth Boards

LicensureLocal Government

MedicaidRAC

Medi

QIOMIC

(Medicaid)

CERT

RAC(Medicare)

DEA

FDARACOMIGMFCUQIO

CarrierFIMAC

IRS

FBIVA

DOT

HealthcareProvider

DOLJCAHO & HRSAFCCFTC

EPA

IRSOSHA

TreasurySECother accrediting agencies

HRSAFCCFTC

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Corporate Compliance ProgramCorporate Compliance ProgramCorporate Compliance ProgramCorporate Compliance Program

I t ll d l dI t ll d l dInternally developed Internally developed program that promotes program that promotes ethical and legal businessethical and legal businessethical and legal business ethical and legal business practices. It is designed practices. It is designed to prevent, detect, correct to prevent, detect, correct ppand, if necessary, report and, if necessary, report nonnon--compliant activity to compliant activity to the appropriate Federalthe appropriate Federalthe appropriate Federal the appropriate Federal and State authorities.and State authorities.

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Compliance Compliance ProgramProgrampp gg Helps our organization remain on the right Helps our organization remain on the right

path so we canpath so we canpath, so we can path, so we can •• live our mission and valueslive our mission and values

h ld t ti i th ith ld t ti i th it•• uphold our reputation in the communityuphold our reputation in the community•• care for patientscare for patients

Help SIH maintain a moral and ethical Help SIH maintain a moral and ethical culturecultureculture.culture.

Checks Checks --nn-- Balance SystemBalance System

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Code of Ethics and ConductCode of Ethics and ConductCode of Ethics and ConductCode of Ethics and ConductWhy have a Code of Ethics and Conduct?Why have a Code of Ethics and Conduct?–– To uphold our mission values and ethics The core ofTo uphold our mission values and ethics The core ofTo uphold our mission, values, and ethics. The core of To uphold our mission, values, and ethics. The core of

SIH/SIMS.SIH/SIMS.

Who do they apply to?Who do they apply to?Who do they apply to?Who do they apply to?–– Everyone! We should incorporate the Code of Ethics in our day Everyone! We should incorporate the Code of Ethics in our day

to day operations.to day operations.

What does the Code of Ethics cover?What does the Code of Ethics cover?–– Things like treatment of patients, documentation, integrity and Things like treatment of patients, documentation, integrity and

security of business records, patient and employee safety, security of business records, patient and employee safety, obligation to report compliance violations.obligation to report compliance violations.

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Where can you find the Code of Ethics?Where can you find the Code of Ethics?–– The Intranet, SIH website, and the Compliance Program.The Intranet, SIH website, and the Compliance Program.

SIH Compliance HelplineSIH Compliance Helplinep pp pYou have questions . . .

’ll t !we’ll get answers!

1 800 965 45831.800.965.4583 or

618 529 2540618.529.2540The Helpline is available 24 hours a day, 7 days a week.The Helpline is available 24 hours a day, 7 days a week.

All calls are confidential. SIH prohibits retaliation against anyone who in good

f i h l i l i l i

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faith reports an actual or potential violation.

The Compliance Department O th W b

For more information about the Compliance

On the WebFor more information about the Compliance Department check out our new Intranet webpage!! To access, click on Departments at the top of the Intranet home page.

•Contact us (phone or email)•Meet our staff•Compliance Program“E O ” l tt•“Eye On” newsletters

•Report compliance issues (on-line Helpline)

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Compliance CommitteesCompliance CommitteesCompliance CommitteesCompliance Committees

•• Corporate (includes Board membersCorporate (includes Board membersCorporate (includes Board members Corporate (includes Board members & senior leaders)& senior leaders)

•• Herrin HospitalHerrin HospitalHerrin HospitalHerrin Hospital•• Memorial Hospital of Carbondale Memorial Hospital of Carbondale •• St Joseph Memorial HospitalSt Joseph Memorial HospitalSt. Joseph Memorial Hospital St. Joseph Memorial Hospital •• System OfficesSystem Offices•• SIMSSIMS•• SIMSSIMS

These Committees advise and assist

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ese Co ttees ad se a d ass stthe Compliance Officer.

Compliance TrainingCompliance TrainingCompliance TrainingCompliance Training

A significant element of the Corporate A significant element of the Corporate Compliance Program is education. Compliance Program is education. gg

ALLALL SIH workforce members receiveSIH workforce members receiveALLALL SIH workforce members receive SIH workforce members receive Compliance Training.Compliance Training.

Employees receive Employees receive annual refresher training.annual refresher training.

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Compliance DepartmentCompliance DepartmentCompliance DepartmentCompliance Department

•• Risk assessment surveyRisk assessment surveyRisk assessment surveyRisk assessment survey•• Audit and monitorAudit and monitor•• Research rulesResearch rules•• Research rulesResearch rules•• Review outside audit activityReview outside audit activity•• EducateEducate•• EducateEducate•• Participate on multidisciplinary teamsParticipate on multidisciplinary teams

Interact with government and private/ third partyInteract with government and private/ third party•• Interact with government and private/ third party Interact with government and private/ third party auditorsauditors

•• Help maintain strong compliance programHelp maintain strong compliance program•• Help maintain strong compliance programHelp maintain strong compliance program

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Compliance StaffCompliance Staff Nurse AuditorsNurse Auditors: RNs who compare the legal : RNs who compare the legal

medical record (medical record (ChartMaxxChartMaxx) to charges on the ) to charges on the ti t’ tti t’ tpatient’s accountpatient’s account

Janice Brewer (MHC)Janice Brewer (MHC) Linda Walkup (MHC) Linda Walkup (MHC) Carolyn Johnson (HH)Carolyn Johnson (HH) Sarah Gill (SJ)Sarah Gill (SJ) Carolyn Johnson (HH) Carolyn Johnson (HH) Sarah Gill (SJ)Sarah Gill (SJ)

Internal AuditorInternal Auditor, Jessica , Jessica KranawetterKranawetter, and , and Compliance AuditorCompliance Auditor JennyJenny HertterHertter perform auditsperform auditsCompliance AuditorCompliance Auditor, Jenny , Jenny HertterHertter, perform audits , perform audits and investigations, and research topics and and investigations, and research topics and answer questions in their areas of expertiseanswer questions in their areas of expertise

Compliance AnalystCompliance Analyst, Jenny Baggett, researches , Jenny Baggett, researches new services and other issues and representsnew services and other issues and represents

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new services and other issues, and represents new services and other issues, and represents Compliance at revenue cycle and other meetingsCompliance at revenue cycle and other meetings

Compliance StaffCompliance StaffppClinical Compliance AuditorsClinical Compliance Auditors: Audit and investigate : Audit and investigate provider documentation coding and other issuesprovider documentation coding and other issuesprovider documentation, coding, and other issuesprovider documentation, coding, and other issues

Marybeth Roe (at CMA)Marybeth Roe (at CMA) Christy Williams (at LPC) Christy Williams (at LPC)

Government AuditGovernment Audit team responds to RAC audit team responds to RAC audit requests and findings, tracks/trends/reports, and requests and findings, tracks/trends/reports, and prepares appealsprepares appealsprepares appealsprepares appeals

Christi Roach, CoordinatorChristi Roach, Coordinator BethenyBetheny Johnson, AsstJohnson, Asst

IT AuditorIT Auditor, Lisa , Lisa CavittCavitt, collaborates with IT , collaborates with IT department, performs audits and investigations, department, performs audits and investigations, creates and runs reports and involved in systemcreates and runs reports and involved in system

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creates and runs reports, and involved in system creates and runs reports, and involved in system implementation/upgrades. implementation/upgrades.

Response to a ProblemResponse to a ProblemResponse to a ProblemResponse to a Problem

Once an issue is discovered, it must be Once an issue is discovered, it must be investigated.investigated.gg

Once investigated and confirmed, the Once investigated and confirmed, the issue must be corrected and anyissue must be corrected and anyissue must be corrected and any issue must be corrected and any overpayment refunded (60 day limit).overpayment refunded (60 day limit).

Once corrected, a followOnce corrected, a follow--up review must up review must be conducted.be conducted.

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Disciplinary StandardsDisciplinary StandardsDisciplinary StandardsDisciplinary Standards

C t i ti lC t i ti l Create an organizational Create an organizational culture that emphasizes culture that emphasizes thi l b h ithi l b h iethical behavior.ethical behavior.

See See Improvement Improvement Counseling Counseling policypolicy, , gg p yp y,,SYSY--HRHR--401.401.

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Be familiar with Compliance Be familiar with Compliance Policies:Policies:

Protocol for Search Warrants (SYProtocol for Search Warrants (SY--LELE--004)004)

Identify the agent in chargeIdentify the agent in charge Identify the agent in charge.Identify the agent in charge. Ask to see identification.Ask to see identification. Request a delay until SIH’s General Request a delay until SIH’s General

Counsel or his designee can be present.Counsel or his designee can be present.Obtain a copy of the warrant.Obtain a copy of the warrant. Request permission to copy medicalRequest permission to copy medical

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Request permission to copy medical Request permission to copy medical records before releasing them. records before releasing them.

Identity Theft Red Flags (SYIdentity Theft Red Flags (SY--COCO--028)028)

Protect patient’s health and financial info and Protect patient’s health and financial info and the integrity of the medical record by positively the integrity of the medical record by positively identifying the patient at registration and identifying the patient at registration and before carebefore care

Report red flag (warning sign) to your Report red flag (warning sign) to your immediate supervisor or the house supervisor, immediate supervisor or the house supervisor, p pp pwho will review and, if necessary, will contact who will review and, if necessary, will contact our Privacy Officer, Marcia Matthias, for our Privacy Officer, Marcia Matthias, for

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further investigation.further investigation.

GiftsGiftsAcceptableAcceptable-- N i l l ift h f d flN i l l ift h f d fl Nominal value gifts, such as food or flowers, Nominal value gifts, such as food or flowers, preferably given to the entire department or unit.preferably given to the entire department or unit.

Not AcceptableNot Acceptable-- Cash or Gift CertificatesCash or Gift Certificates Cash or Gift CertificatesCash or Gift Certificates

Note: Government has strict limits on gifts to and from referral sources and vendorssources and vendors.

Please refer to the following policies for more info:Business Gratuities, SIH system wide policy SY-CO-006B i G t iti SIMS SM AD 012

2020

Business Gratuities, SIMS, SM-AD-012Gifts from Patients, system wide policy SY-CO-008

False Claims Act False Claims Act (SY(SY--COCO--019)019)

Federal law has existed since the Civil War. Federal law has existed since the Civil War. Government tool for fighting fraudulent, abusive or Government tool for fighting fraudulent, abusive or

f l l i i l di th b itt d t thf l l i i l di th b itt d t thfalse claims, including those submitted to the false claims, including those submitted to the Medicare and Medicaid programs. Medicare and Medicaid programs.

Illi i h f l l i t titl dIlli i h f l l i t titl d Illinois has a false claims act entitled, Illinois has a false claims act entitled, Whistleblower Reward and Protection ActWhistleblower Reward and Protection Act. It . It encourages employees with knowledge ofencourages employees with knowledge ofencourages employees with knowledge of encourages employees with knowledge of compliance issues to come forward.compliance issues to come forward.

SIH has implemented a False Claims Act Policy toSIH has implemented a False Claims Act Policy to

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SIH has implemented a False Claims Act Policy to SIH has implemented a False Claims Act Policy to raise awareness of importance of documentation.raise awareness of importance of documentation.

Examples of Compliance FailuresExamples of Compliance FailuresExamples of Compliance FailuresExamples of Compliance Failures• Behavioral therapist, $164K and 18 months in jail, fraud,

inflating amount of time spent with patientsinflating amount of time spent with patients

• Medical corporation, $997K, fraud, billing for services not provided (no reimbursement for what was being done, so coded as another service), physical therapy not done by qualified persons, billing for physician services when physician not in office, billing Medicare and VA for same servicesg

• Health care facility, $448K, False Claims Act, billing female Lupron dose (pays better) even when male dose administered, failure to self disclose when facility discovered problem in 2009failure to self disclose when facility discovered problem in 2009

• Doctor indicted for $8.1M conspiracy to commit healthcare fraud, instructed CRNAs to document 31 minutes for all ,endoscopies & colonoscopies when actual time was less

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Your ResponsibilityYour ResponsibilityYour Responsibility. . .Your Responsibility. . . Perform job duties in an ethical and compliant Perform job duties in an ethical and compliant

manner.manner. Adhere to all policies and procedures.Adhere to all policies and procedures. Report potential violations of policies, Compliance Report potential violations of policies, Compliance

Program, or Code of Ethics.Program, or Code of Ethics. Cooperate with the Compliance Department Cooperate with the Compliance Department

during investigations and audits.during investigations and audits.

Ask questions & report your Ask questions & report your W k W k

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concerns. We want to know.concerns. We want to know.

IMPORTANTIMPORTANTIMPORTANT IMPORTANT

Compliance ultimately depends on each Compliance ultimately depends on each individual within the organization individual within the organization

choosing to do the right thing, even when choosing to do the right thing, even when it is inconvenient or takes more time.it is inconvenient or takes more time.

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Questions?Questions?Questions?Questions?

Thank You!!2525

Thank You!!