What is a Compliance Program

1. 1 What is a Compliance Program? System-wide program structured to promote collaborative participation at all levels. Focus on the detection and prevention of violations of federal, state and local laws. Fosters an environment in which employees and affiliated professionals comply with all relevant laws and regulations and report any concerns about business practices.

2. 2 Why have a Compliance Program? Minimize the occurrence of intentional and unintentional actions that are improper or illegal. Detect improper or illegal actions first so that remedial action can be taken and proper disclosure made to the government. Mitigate the financial risk to the organization and individuals involved in any investigations.

3. 3 Compliance is not new to Health Care Federal and State Health Care Statutes and Regulations and Federal, State and Private Health Care Program Requirements Hazardous Waste Disposal Employment Law- EEO, Wage & Hour, etc... Fiscal Operations - Generally Accepted Accounting Principles and Single Audit Requirements

4. 4 Who enforces the Regulations? Office of the Inspector General with DHHS � (OIG) Investigates suspected fraud/abuse and negotiates corporate integrity agreements Department of Justice (DOJ) � Civil and criminal prosecution often under False Claims Act Federal Bureau of Investigation � (FBI) Assists DOJ and OIG by investigating suspected fraud/abuse Centers for Medicare & Medicaid Services � (CMS) Responsible for administering Medicare & Medicaid - Rule making authority and jurisdiction over Stark physician self-referrals Medicaid Integrity Program

5. 5 Who enforces the Regulations? Office of Civil Rights � (OCR) Investigates violations of HIPAA Privacy regulations for protection of patient information State Medicaid Fraud Control Unit � (MFCU) Investigates and prosecutes fraud and patient abuse/neglect in State Medicaid program Private Payors � Establish special security units to investigate fraud Whistleblowers or qui tam relators � citizens with evidence of fraud against government contracts or programs can sue on behalf of the government.

6. 6 What are the Enforcement Laws? False Claims Act � Civil liability on organizations and individuals that make or cause to be made a false or fraudulent claim Federal Anti-Kickback Statute � Prohibits the intentional offer, payment, solicitation or receipt of any form of remuneration in return for referral Stark II � Regulates referrals from doctors of Medicare patients HIPAA � Governs the privacy and security of protected health information and has civil and criminal penalties for unauthorized release

7. 7 What are the Enforcement Laws? Emergency Medical Treatment and Labor Act � (EMTALA) Addresses hospital delivery of emergency care Civil Monetary Penalty Act � Expansion through HIPAA to impose civil penalties of up to three times the amount of the infraction Alaska Medicaid Assistance Fraud Statute � State statue governing Medicaid fraud. Reduction in mental state from intentional to reckless Coming in 2008 -Alaska False Claims Act?

8. 8 What are the Enforcement Laws? Federal Deficit Reduction Act of 2005 This law is the most significant rewrite of the Medicaid regulations since they were enacted. The Act requires: Mandatory compliance program for any entity that receives over $5 million in Medicaid payments per year. Mandatory training of employees and incorporation of information on the Qui Tam provisions of the False Claims Act be included in Employee Code of Conduct manual.

9. 9 Federal False Claims Act The Act establishes liability when any person or entity improperly receives from or avoids payment to the Federal government--tax fraud excepted. In summary, the Act prohibits: Knowingly presenting, or causing to be presented to the Government a false claim for payment; Knowingly making, using, or causing to be made or used, a false record or statement to get a false claim paid or approved by the government;

10. 10 Federal False Claims Act Conspiring to defraud the Government by getting a false claim allowed or paid; Falsely certifying the type or amount of property to be used by the Government; Certifying receipt of property on a document without completely knowing that the information is true; Knowingly buying Government property from an unauthorized officer of the Government, and; Knowingly making, using, or causing to be made or used a false record to avoid, or decrease an obligation to pay or transmit property to the Government.

11. 11 Federal False Claims Act A civil penalty of not less than $5,000 and not more than $10,000, plus 3 times the amount of damages which the Government sustains because of the act of that person. If the person fully cooperates with any Government investigation the court may assess not less than 2 times of the amount of damages. The person is also liable for the costs of the trial.

12. 12 FCA and Whistleblowers A whistleblower is an employee, former employee, or member of an organization who reports misconduct to people or entities that have the power to take corrective action. Generally the misconduct is a violation of law, rule, regulation and/or a direct threat to public interest �fraud, health, safety violations, and corruption are just a few examples.

13. 13 The False Claims Act contains qui tam, or whistleblower, provisions. Qui tam provisions allows citizens with evidence of fraud against government contracts and programs to sue, on behalf of the government, in order to recover the stolen funds. In compensation for the risk and effort of filing a qui tam case, the citizen whistleblower or "relator" may be awarded a portion of the funds recovered, typically between 15 and 30 percent.�

14. 14 Non-Retaliation The False Claims Act has provisions for non retaliation against whistleblowers. ACMHS also has policies and procedures that forbid retaliation against any employee or former employee who reports suspected fraud and abuse. 700-007-1 � Problem Reporting and Non-Retaliation

15. 15 Alaska Medicaid Fraud Regulations AS 47.05.210 � Medical Assistance Fraud Knowingly submits or authorizes the submission of a claim to a medical assistance agency for property, services, or a benefit with reckless disregard that the claimant is not entitled to the property, service or benefit; Knowingly prepared or assists another person to prepare a claim for submission to a medical assistance agency for property, services, or a benefit with reckless disregard that the claimant is not entitled to the property, service or benefit; Except as otherwise authorized under the medical assistance program, confers, offers to confer, solicits, agrees to accept, or accepts property, services or a benefit A. To refer a medical assistance recipient to a health care provider, or

16. 16 B. For providing health care to a medical assistance recipient if the property, services, or benefit is in addition to payment by a medical assistance program. Does not produce medical assistance records to a person authorized to request the records; Knowingly makes a false entry in or falsely alters a medical assistance record; Knowingly destroys, mutilates, suppresses, conceals, removes, or otherwise impairs the verity, legibility, or availability of a medical assistance record knowing that the person lacks the authority to do so� or Violates a provision of AS 47.07 or AS 47.08 or a regulation adopted under AS 47.07 or AS 47.08.

17. 17 Medical Assistance Fraud carries criminal penalties that include both felony and misdemeanor penalties.

18. 18 �Reckless Disregard� Acts in deliberate ignorance of the truth or falsity of the information or, Acts in reckless disregard of the truth or falsity of the information, and No proof of specific intent to defraud is required.