How to Develop an Effective Compliance Program
Overview: Fraud, waste and abuse are spiraling out of control in the United States. The federal government is the biggest target for fraudsters because it spends hundreds of billions of dollars subsidizing federal programs. Medicare, the federal health insurance program for millions of Americans who are over age 65, disabled or have end stage renal disease, is the largest federal health care program. Because of rising health care costs and the proliferation of fraud, waste and abuse in the health care industry, the government continues to pass legislation and enforcement activities directed at the health care industry.
The U.S. Department of Health and Human Services' (HHS) and the Office of Inspector General (OIG) believe that an effective compliance program can significantly reduce fraud, waste and abuse. In addition, prosecutors may not pursue a criminal action against organizations that have an effective compliance program. Consequently, implementing an effective compliance program could minimize the consequences resulting from a violation of the law. In fact, the U.S. Sentencing Commission Guidelines specifically mandate lesser criminal sanctions for companies that have effective compliance. Generally, the OIG will look to the effectiveness of the compliance program as a factor when determining the level of sanctions, penalties, and/or exclusions to be imposed on the provider.
In addition to reducing the risk of criminal and civil liabilities and sanctions, compliance programs offer many other benefits. Primarily, a compliance program fulfills the provider's legal duty to ensure that it is not submitting false or inaccurate claims to government and private payors. Equally important, a compliance program helps a provider fulfill its care-giving mission to residents and patients and the community. It improves quality of care and operations because it assists the provider to identify weaknesses and to improve upon internal systems and business office management. Furthermore, an effective compliance plan and program concretely demonstrates to employees and the community at large the provider's strong commitment that it is honest and ethical in its corporate conduct. In addition, it helps provide a more accurate view of employee and contractor behavior relating to fraud and abuse.
A compliance program reduces the likelihood of wrongdoing, aids in the early detection of issues, and establishes a structure for internal reporting and investigation. In addition, it helps prevent criminal activity and illustrates a lack of intent to perform unlawful acts; thus, in cases where the government uncovers fraud, it shows that reasonable efforts have been made by management to prevent and detect any misconduct that occurs within the entity. By initiating immediate and appropriate corrective action; and through early detection and reporting, you can minimize the loss to the government from false claims, and thereby reduce your exposure to civil damages and penalties, criminal sanctions, and administrative remedies, such as program exclusion.
Why should you attend: SNFs face complex challenges that require new and coordinated approaches by the quality, compliance and risk management teams. A survey finding of immediate jeopardy could be followed by a wrongful death lawsuit, attorney general investigation, professional licensure actions, 'qui tam' civil lawsuit or criminal enforcement action. SNF leadership won't want to miss this insightful presentation that will review the key strategies and tactics necessary to evaluate and update current program efforts to maximize outcomes, while minimizing the typical program 'gaps' that leave SNFs vulnerable to the 'perfect storm' that churns up complex issues tied to quality, compliance and risk management.
Areas Covered in the Session:
Review ACA requirements for nursing facility compliance programs
Discuss what the requirements mean for nursing facilities
Learn proactive compliance measures to take to ensure your facility is meeting compliance program expectations
Learn the seven required elements of a Medicare Compliance Program
Who Will Benefit:
Healthcare Executives and Managers
Physician Executives and Leaders
Under the Affordable Care Act (the"Ac"), skilled nursing facilities and nursing facilities participating in Medicare and Medicaid programs must implement an effective compliance and ethics program by March 23, 2013. Fortunately, enforcement was delayed until later in the year, so there is still time.
Failure to implement these core compliance program features will create additional opportunities for regulatory and law enforcement scrutiny, as well as potential False Claims Act liability for failure to prevent or identify improper federal healthcare program claims and payments. The existence or lack of robust provider compliance program controls, when paired with the stronger sanctions and expanded application of the federal False Claims Act, Civil Monetary Penalties Law, and Anti-Kickback Law will be subject to enhanced focus in fraud and abuse inquiries and prosecutions.
Dr. Freville is an independent consultant who advises healthcare clients regarding many regulatory issues including but not limited to compliance and HIPAA/HITECH program effectiveness.
She establishes compliance department operations to include planning, designing, and implementing system-wide Corporate Compliance and HIPAA/HITECH Programs. She writes Codes of Ethical Conduct and compliance policies and procedures for providers.
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How to Develop an Effective Compliance Program
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