Corporate Compliance Test 1

• The Compliance Officer shall: Be an employee and member of senior management + Report directly to the Chief Executive Officer
• Medicare a federal health insurance program for:

  Elderly with Social Security / Long Term Disability

  Individuals under 65 with: End stage Renal Disease
• CMS develops CfC and CoP that health care organizations must meet health and safety standards to qualify with medicare/medicaid
• office of inspector general (OIG) was established in 1976 to protect integrity of the department of health and human services
• OIG conducts: Audits, Investigations, Evaluations
• CMS: Centers for Medicaid and Medicare Services
• Reduced Damages: The court may assess not less than 2 times the amount of damages
• False Claim Act Violation: Being overpaid by the government for the sale of a good/service and not reporting overpayment
• What is corporate compliance? 

  Following rules and regulations
• Office of the Medicaid Inspector General (OMIG): a program integrity agency established to prevent wasteful spending in Medicaid programs
• The Compliance Officer shall: chair a Compliance Committee that includes other members of senior management such as billing, clinical, human resources, audit, and operations
• Culpability Score: standard mechanism for determining the fine based on an assessment of the compliance program
• Medicaid is: payer of last resort
• The provider is: prohibited from billing the enrollee
• Compliance Program: must enable individuals to disclose any identified or suspected internal policies
• Investigations must be conducted independently and objectively by qualified individuals not directly involved
• Investigations must be written in a report of findings
• Training must be conducted and tailored to: Size of audience , Sophistication level of audience , Company history (covers prior compliance incidents)
• Compliance Training: industry standard is at least once per year
• Audit Findings : must be shared with management, CEO and board of directors.
• Reporting is mandatory (not optional) a failure to report is a code of conduct violation.
• Methods of Communication: Compliance Hotline , Toll-free number , Available 24/7
• Compliance programs must include: Investigation of reports of identified or suspected internal polices, conduct, practices or procedures that may violate criminal, civil, or administrative law
• Investigations must be conducted within a reasonable amount of time by qualified individuals not directly involved, under the direction of a compliance officer
• Health care organizations are required to discipline individuals responsible for violating compliance policies
• Failure to discipline individuals who violate compliance program policies and local laws indicates an ineffective compliance program
• Deficit Reduction Act: entity recieves payment of $5 million or less
• Developing an Effective Compliance Program: size of the organization , areas of business risk , and prior history
• Governing Board Oversight: for assessing the effectiveness of Compliance Program
• In the State of New York, health care organizations are required to certify their compliance programs annually if they receive $500,000+
• The OIG negotiates CIAs with health care providers and health care companies
• Corporate Integrity Agreement (CIA) not meant to punish healthcare providers or organizations, instead the goal is to set compliance standards
• NYS Department of Health (DOH): exercises overall supervision of theMedicaid Program