First Next Best Examples

Compliance 101 (4th Edition) notes on "FIRST", "NEXT" step or "BEST" references (read context) Chapter 1, p 2, 3 2, p 13 2, p 23 2, p 27 2, p 28 2, p 29 2, p 29 2, p 30 2, p 31 2, p 35 2, p 36 2, p 36 1. What's in a Name? / Who Needs a Compl Program? - In the Justice Department, health care fraud is a key ("first") priority ... The OIG specifically addresses the benefits of a compliance program in all its program guidances. First and foremost , of course, an effective compliance program safeguards the organization’s legal responsibility to abide by applicable laws and regulations. NOTE (p. 2): The HHS Office of the Inspector General (OIG) in conjunction with the Justice Department is responsible for enforcing the rules and regulations under the Medicare and Medicaid laws outlined as part of the Social Security Act and administered by the Centers for Medicare and Medicaid Services (CMS). 2. Seven Elements / Monitoring & Auditing - No matter what the circumstances, if you find you actually are doing something wrong , corrective actions should be put in place (ie: first) which could include repayment to the fiscal intermediary (FI). As soon as you suspect there is the possibility of serious wrongdoing , the first step is to contact your in-house or external counsel , who can make an assessment as to whether attorney-client privilege needs to be attached. 2. Seven Elements / Reporting & Investigating - For any reporting method to be effective, employees must accept that there will be no retaliation or retribution for coming forward. The concept of non-retaliation is fundamental to the compliance program, and a clearly stated policy regarding non-retribution is the first step . 2. Seven Elements / Enforcement & Discipline - the first step toward enforcement is distributing standards of conduct and policies and procedures and educating staff about them, including the consequences of noncompliance. 2. Seven Elements / Standards of Conduct/P&Ps - The first of the prescribed elements calls for “The development and distribution of written standards of conduct... The standards of conduct , first and foremost, demonstrate the organization’s ethical attitude and its “enterprise-wide” emphasis on compliance with all applicable laws and regulations. 2. Seven Elements / Enforcement & Discipline - re: handling a disciplinary problem (Chain of Command) - The first step in this process should be for the involved employee’s manager/supervisor to discuss the problem with the employee. The next step (via the HR Dept involved with documentation) - escalating to higher level of authority or written warning... Subsequent steps might include suspension without pay or probationary period. The final step is termination . 2. Seven Elements / Monitoring & Auditing - FIRST , risk assessment, THEN, next , prioritizing risks will help define the basis for what the compliance program should focus on for the next year in its plan. 2. Seven Elements / Monitoring & Auditing - Concurrent audit s are “real” time, but harder to execute, because the organization must collect all the needed information regarding events occurring in the present vs. in the past. However, this approach is the best way to change behavior. 2. Seven Elements / Enforcement & Discipline - But most infractions will be relatively minor and most likely unintentional. These may best be handled with education or additional training. 2. Seven Elements / Monitoring - a key tool for management to get a sense of their operational controls and help identify potential problem areas... A good place to begin ( first ) when monitoring a risk is by interviewing employees . They are a wealth of knowledge. Ask them openly about risk, about their daily activities, the processes, procedures, and whether these methods are sound. Ask if the policies and procedures are followed. Periodically send out questionnaires to staff for feedback or conduct focus groups. Set up systems for regular and sometimes random review of medical and financial records, especially written documentation. Data collection and tracking are the heart and soul (ie "best" method) of review because they provide trend analysis and a measure of progress. 2. Seven Elements / Monitoring - Who is responsible for auditing and monitoring compliance risk areas? Is this an internal auditor’s responsibility or the compliance office’s responsibility, or perhaps a combination of the two? First , to avoid duplication or overlap, consider if there are other departments in your organization doing auditing . 2. Seven Elements / Education Education and training are the first and possibly the most important lines of defense for a compliance program. In a field where the pages of regulations number in the thousands, education (& training) is the best strategy for prevention. Page 1 of 3 CHC Compliance 101 ref to First, Next, Best

2, p 38 -39 2, p 41 Chapter 3, p 43 3, p 44 3, p 46 3, p 46 3, p 50 3, p 51 3, p 55 3, p 55 - 57 (Ryan's notes) (Ryan's notes - p. 56) (Ryan's notes - p. 57) 2. Seven Elements / Response & Prevention - Your counsel will help decide whether the investigation should be handled under the attorney-client privilege. With attorney-client privilege, disclosure communications and most documents can be kept in confidence. While an internal investigation is the first step , (the NEXT STEP is) be sure to take the necessary steps immediately to stop or modify the procedures that are the alleged source of wrongdoing... After investigation, (next) team meeting to discuss findings and plan final report . OIG requires prompt reporting , no more than 60 days after determining there is credible evidence of violation, and no more than 30 days to avoid stricter fines... However, if after the internal investigation there is reason to believe the organization’s misconduct constituted a material violation of the civil law or the rules and regulations governing federally funded health care programs, then the organization must (next) take steps to disclose the violation to the government. (See provider self-disclosure protocol on page 40) 3. Organizational Steps / Board support - It is in the best interest of the organization to have the board take an active rather than a passive role in compliance . 2. Seven Elements / Response & Prevention - Understood, of course, is that any identified problem must (FIRST) be corrected immediately . Restitution of overpayments especially should be prompt ... And when the problem is rectified (NEXT) , the issue should be added to the list of topics to be addressed with regular internal monitoring . 3. Organizational Steps /Board (& Mgt) support - The first step toward implementation of a compliance plan is management’s communication of its commitment . A resolution or memo from the board stating its unequivocal support for the program is a strong beginning... One option is for the Board or CEO to distribute the memo or resolution to all managers. The managers then distribute the document to their managers so that the word trickles down and the message is reinforced that all managers endorse the compliance program. This approach also makes the compliance program directly accessible to staff and gives staff an opportunity to discuss the document in relatively small groups. 3. Organizational Steps / Staffing needs: A candidate who cannot answer basic questions on such a test does not belong in the organization’s coding or medical record auditing department. The first step toward prevention is to check competency up front . 3. Organizational steps / Staff Support - launching a compliance program to staff: Education is the first step , but also (next) look for ways to heighten awareness on a day-to-day basis . Develop Mission and Goals - One way is to have an annual retreat where the first retreat drafts a mission statement consistent with the organization's mission statement. 3. Organ. Steps / Develop a Code of Conduct - (important foundation to a compliance program) As a resource for all staff and affiliates, the code of conduct should also include a detailed outline of procedures for handling questions about compliance or ethical issues, beginning with a description of chain of command. The best reporting mechanism is an open door . 3. Organizational Steps / Staff Support - Staff buy-in will correlate directly with the organization’s ability to foster an environment of trust. As emphasized earlier, accepting the non-retaliation policy as nothing short of gospel will be the best way to ensure active staff participation. 3. Organ. Steps / Under "Six Tips for Saving on Future Costs of Compliance" - 5. Emphasize training —The best way to correct an error is to prevent its occurrence . 3. Organizational Steps / Conduct Risk Assessment - After the compliance program infrastructure is in place, i.e., compliance budget and staffing, the first step in launching an effective compliance program is to do a risk assessment . ... The first place to start is by reviewing any previous problem areas . ... After developing the list of risks, the next steps would include analyzing and evaluating the risks and the management controls in place related to those risks. Prioritizing (risks) would be a further next step . ...Once the risks are prioritized, (further next step is) management develops mitigation plans for the identified risks. ..It will serve as the “benchmark” to which future risks can be compared. Internal Assessments - One of the first steps in compliance is a baseline/snapshot audit : First , it outlines the current operational standards and how those are met, second , it identifies real and potential weaknesses, finally , it offers recommendations regarding necessary remedial action Drafting an Audit Agenda - First review any previous problem areas (from previous audits or reports), then (next) begin by interviewing managers. (next) Findings and recommendations should be discussed with executive management prior to final report preparation. Page 2 of 3 CHC Compliance 101 ref to First, Next, Best