medicaid , medicare & third-party biller Compliance Training

1. medicaid, medicare & third-party biller Compliance Training

2. Medicaid, medicare & third-party biller Compliance Training

3. Annual Compliance Training Navigation Tips You must have your PC’s sound on and close out all other programs from your PC. The navigation bar at the bottom of the slide will guide you through the training. When you finish the training course, you must complete and submit a certification/Acknowledgement Form in Module 5.

4. Annual Compliance Training EXIT Navigation Tips You must have your PC’s sound on and close out all other programs from your PC. The navigation bar at the bottom of the slide will guide you through the training. When you finish the training course, you must complete and submit a certification/Acknowledgement Form in Module 5.

5. Annual Compliance Training PREPARATION Coordinate with your supervisor to have your phone covered/forwarded so you won’t be interrupted. Schedule approximately 1 hour to complete the training. The training is narrated so headphones may help you focus and avoid distracting your co-workers. Have a pen and paper handy. If you have questions, write them down and at the end of the training, call or email the Compliance Officer. You must complete this entire mandatory training program before completing the Acknowledgement Form.

6. Annual Compliance Training EXIT PREPARATION Coordinate with your supervisor to have your phone covered/forwarded so you won’t be interrupted. Schedule approximately 1 hour to complete the training. The training is narrated so headphones may help you focus and avoid distracting your co-workers. Have a pen and paper handy. If you have questions, write them down and at the end of the training, call or email the Compliance Officer. You must complete this entire mandatory training program before completing the Acknowledgement Form.

7. annual compliance training COMPLIANCE OFFICE STAFF Compliance Officer – Barb Mottl barbm@jeffersoncountywi.gov (920) 674-8151 Compliance Analyst – Attorney Scott Scheibel scotts@jeffersoncountywi.gov (920) 674-8635

8. annual compliance training EXIT COMPLIANCE OFFICE STAFF Compliance Officer – Barb Mottl barbm@jeffersoncountywi.gov (920) 674-8151 Compliance Analyst – Attorney Scott Scheibel scotts@jeffersoncountywi.gov (920) 674-8635

9. annual compliance training • What is Compliance? • County’s Compliance Program • False Claims Act • Integrity Agreement • Certification TRAINING MODULES

10. annual compliance training • What is Compliance? • County’s Compliance Program • False Claims Act • Integrity Agreement • Certification EXIT TRAINING MODULES

11. annual compliance training MODULE 1 WHAT IS COMPLIANCE?

12. annual compliance training EXIT MODULE 1 WHAT IS COMPLIANCE?

13. annual compliance training WHAT IS COMPLIANCE? • Knowing and following Federal, State and County laws, regulations, rules, guidelines, policies and procedures that apply to our jobs. • Think about the agencies that regulate or oversee your activities. • Compliance is throughout all departments, divisions, programs that provide Mental Health Services. • Includes contractors, their employees and subcontractors.

14. annual compliance training EXIT WHAT IS COMPLIANCE? • Knowing and following Federal, State and County laws, regulations, rules, guidelines, policies and procedures that apply to our jobs. • Think about the agencies that regulate or oversee your activities. • Compliance is throughout all departments, divisions, programs that provide Mental Health Services. • Includes contractors, their employees and subcontractors.

15. annual compliance training OVERVIEW OF THE HEALTH CARE INDUSTRY Healthcare is Under Increased Scrutiny from Federal & State Governments. • Estimated 10% of 1 Trillion spent on healthcare fraud/waste or abuse • Federal and State healthcare programs facing financial difficulty Government Response • Healthcare is enforcement priority • Government personnel added and coordinated efforts (e.g. FBI, DOJ, OIG) • New/tougher laws & regulations enacted including the Patient Protection & Affordable care Act of 2010 (the “Healthcare Reform Act”). The Act contains numerous provisions relating to healthcare fraud/waste/abuse, program integrity and new enforcement measures and resources. Also requires all healthcare providers participating in federal programs to establish and maintain a compliance program as a condition of their continued participation.

16. annual compliance training EXIT OVERVIEW OF THE HEALTH CARE INDUSTRY Healthcare is Under Increased Scrutiny from Federal & State Governments. • Estimated 10% of 1 Trillion spent on healthcare fraud/waste or abuse • Federal and State healthcare programs facing financial difficulty Government Response • Healthcare is enforcement priority • Government personnel added and coordinated efforts (e.g. FBI, DOJ, OIG) • New/tougher laws & regulations enacted including the Patient Protection & Affordable care Act of 2010 (the “Healthcare Reform Act”). The Act contains numerous provisions relating to healthcare fraud/waste/abuse, program integrity and new enforcement measures and resources. Also requires all healthcare providers participating in federal programs to establish and maintain a compliance program as a condition of their continued participation.

17. annual compliance training HEALTHCARE FRAUD & ABUSE FRAUD • False statements of representation of facts to obtain payment/benefit to which not otherwise entitled. • Committed for one’s own benefit or on behalf of another. • Must establish acts were performed knowingly, willfully and intentionally. • Civil fraud violations have a lower standard of proof. • Usually involve sanctions and financial penalties. ABUSE • Practices that directly or indirectly result in unnecessary increased costs to clients. • Medically unnecessary over- utilization. • Not in conformance with industry standards. • Fees that are unreasonable or unfair. • Restrictive of patient choice.

18. annual compliance training EXIT HEALTHCARE FRAUD & ABUSE FRAUD • False statements of representation of facts to obtain payment/benefit to which not otherwise entitled. • Committed for one’s own benefit or on behalf of another. • Must establish acts were performed knowingly, willfully and intentionally. • Civil fraud violations have a lower standard of proof. • Usually involve sanctions and financial penalties. ABUSE • Practices that directly or indirectly result in unnecessary increased costs to clients. • Medically unnecessary over- utilization. • Not in conformance with industry standards. • Fees that are unreasonable or unfair. • Restrictive of patient choice.

19. annual compliance training RELEVANCE OF COMPLIANCE PROGRAMS • Government believes the best way to protect public healthcare dollars is to prevent fraud/abuse. • Educating individuals on the laws, regulations and organization’s standards that apply to them in the workplace. • Encouraging individuals to ask questions or voice their concerns to the compliance officer.

20. annual compliance training EXIT RELEVANCE OF COMPLIANCE PROGRAMS • Government believes the best way to protect public healthcare dollars is to prevent fraud/abuse. • Educating individuals on the laws, regulations and organization’s standards that apply to them in the workplace. • Encouraging individuals to ask questions or voice their concerns to the compliance officer.

21. annual compliance training WHY ARE COMPLIANCE PROGRAMS IMPORTANT? Promote open communication and problem resolution. Maintain Federal, State, County and industry standards to comply with increased government regulations. Demonstrate organization’s commitment to comply with all legal and ethical responsibilities. Keep pace with trend in the health care industry.

22. annual compliance training EXIT WHY ARE COMPLIANCE PROGRAMS IMPORTANT? Promote open communication and problem resolution. Maintain Federal, State, County and industry standards to comply with increased government regulations. Demonstrate organization’s commitment to comply with all legal and ethical responsibilities. Keep pace with trend in the health care industry.

23. annual compliance training Employees & Contractors Code of Conduct Ethics ELEMENTS OF A COMPLIANCE PROGRAM

24. annual compliance training Employees & Contractors Code of Conduct Ethics EXIT ELEMENTS OF A COMPLIANCE PROGRAM

25. annual compliance training MODULE 2 JEFFERSON COUNTY’S COMPLIANCE PROGRAM

26. annual compliance training EXIT MODULE 2 JEFFERSON COUNTY’S COMPLIANCE PROGRAM

27. annual compliance training JEFFERSON COUNTY’S COMPLIANCE PROGRAM • Required by Title 42 CFR Section 438.608 • 7 Specific Requirements • Standards & Procedures • Compliance Officer and Committee • Training and Education • Communication • Enforcement • Internal Monitoring/Auditing • Prompt response/corrective action

28. annual compliance training JEFFERSON COUNTY’S COMPLIANCE PROGRAM • Required by Title 42 CFR Section 438.608 • 7 Specific Requirements • Standards & Procedures • Compliance Officer and Committee • Training and Education • Communication • Enforcement • Internal Monitoring/Auditing • Prompt response/corrective action

29. annual compliance training EXIT JEFFERSON COUNTY’S COMPLIANCE PROGRAM • Required by Title 42 CFR Section 438.608 • 7 Specific Requirements • Standards & Procedures • Compliance Officer and Committee • Training and Education • Communication • Enforcement • Internal Monitoring/Auditing • Prompt response/corrective action

30. annual compliance training COMPLIANCE REQUIREMENT #1: Standards & Procedures Mission Statement Code of Conduct Code of Ethics (For County employees only) View by clicking on the appropriate link below: Code of Conduct for Employees (section only)

31. annual compliance training EXIT COMPLIANCE REQUIREMENT #1: Standards & Procedures Mission Statement Code of Conduct Code of Ethics (For County employees only) View by clicking on the appropriate link below: Code of Conduct for Employees (section only)

32. annual compliance training COMPLIANCE REQUIREMENT #1: Standards & Procedures Mission Statement: Jefferson County Human Services Department will comply with applicable laws, regulations, rules or guidelines governing the provision of mental health services. All employees and contractors, who provide and receive payment for mental health services, are expected to conduct themselves honestly, fairly and with a high degree of integrity. Accordingly, the County has implemented a Compliance Program to ensure, to the extent reasonably possible, that all employees invoke a high degree of business honesty and integrity required of health care professionals and providers. In addition, this program has been instituted as a means of preventing fraud, abuse and false billings to any third-party payer. Strict adherence to the Compliance Program is expected of all mental health employees and contractors.

33. annual compliance training EXIT COMPLIANCE REQUIREMENT #1: Standards & Procedures Mission Statement: Jefferson County Human Services Department will comply with applicable laws, regulations, rules or guidelines governing the provision of mental health services. All employees and contractors, who provide and receive payment for mental health services, are expected to conduct themselves honestly, fairly and with a high degree of integrity. Accordingly, the County has implemented a Compliance Program to ensure, to the extent reasonably possible, that all employees invoke a high degree of business honesty and integrity required of health care professionals and providers. In addition, this program has been instituted as a means of preventing fraud, abuse and false billings to any third-party payer. Strict adherence to the Compliance Program is expected of all mental health employees and contractors.

34. annual compliance training COMPLIANCE REQUIREMENT #1: Standards & Procedures Conduct Standards • The County is committed to full compliance with all applicable laws, regulations, rules and guidelines that apply to its mental health operations and services. • Employee and contractor conduct is at the core of this commitment. • County employees and contractors must adhere to: • The Code of Conduct and the Compliance Program • County employees must also adhere to the county’s Code of Ethics.

35. annual compliance training EXIT COMPLIANCE REQUIREMENT #1: Standards & Procedures Conduct Standards • The County is committed to full compliance with all applicable laws, regulations, rules and guidelines that apply to its mental health operations and services. • Employee and contractor conduct is at the core of this commitment. • County employees and contractors must adhere to: • The Code of Conduct and the Compliance Program • County employees must also adhere to the county’s Code of Ethics.

36. annual compliance training COMPLIANCE REQUIREMENT #1: Standards & Procedures Code of Conduct County’s behavior expectations County’s commitment to its employees and contractors and to promote compliance with all applicable laws, etc. Familiarize staff with the basic legal principles of ethical standards of behavior expected in the provision, documentation, coding or billing of mental health services. Code of Ethics Established by the Board of Supervisors Applies to all county employees

37. annual compliance training EXIT COMPLIANCE REQUIREMENT #1: Standards & Procedures Code of Conduct County’s behavior expectations County’s commitment to its employees and contractors and to promote compliance with all applicable laws, etc. Familiarize staff with the basic legal principles of ethical standards of behavior expected in the provision, documentation, coding or billing of mental health services. Code of Ethics Established by the Board of Supervisors Applies to all county employees

38. annual compliance training COMPLIANCE REQUIREMENT #1: Standards & Procedures Certification All employees and contractors must sign the Acknowledgement and Agreement Form and submit it to the Compliance Officer. Form and instructions are in Module 5.

39. annual compliance training EXIT COMPLIANCE REQUIREMENT #1: Standards & Procedures Certification All employees and contractors must sign the Acknowledgement and Agreement Form and submit it to the Compliance Officer. Form and instructions are in Module 5.

40. annual compliance training COMPLIANCE REQUIREMENT #1: Standards & Procedures Documenting Compliance Activities • Protects integrity of the compliance process and confirms the effectiveness of the Compliance Program. • Must document, at a minimum: • Trainings • Investigations • Anonymous Reporting • Self-disclosure • Modifications to the Compliance Program • Results of the County’s auditing/monitoring efforts

41. annual compliance training EXIT COMPLIANCE REQUIREMENT #1: Standards & Procedures Documenting Compliance Activities • Protects integrity of the compliance process and confirms the effectiveness of the Compliance Program. • Must document, at a minimum: • Trainings • Investigations • Anonymous Reporting • Self-disclosure • Modifications to the Compliance Program • Results of the County’s auditing/monitoring efforts

42. annual compliance training COMPLIANCE REQUIREMENT #2: Compliance Officer and Committee Compliance Officer Responsibilities Oversight of the Compliance Program Establish and maintain the Code of Conduct & Policies and Procedures Chair the Compliance Committee Ensure an ongoing training/education program Establish auditing/monitoring procedures Compliance investigations Promote awareness and understanding of the positive, ethical and moral practices consistent with the mission and values of the county and those required by applicable laws, regulations, rules or guidelines. Report findings to the Agency Director.

43. annual compliance training EXIT COMPLIANCE REQUIREMENT #2: Compliance Officer and Committee Compliance Officer Responsibilities Oversight of the Compliance Program Establish and maintain the Code of Conduct & Policies and Procedures Chair the Compliance Committee Ensure an ongoing training/education program Establish auditing/monitoring procedures Compliance investigations Promote awareness and understanding of the positive, ethical and moral practices consistent with the mission and values of the county and those required by applicable laws, regulations, rules or guidelines. Report findings to the Agency Director.

44. annual compliance training COMPLIANCE REQUIREMENT #2: Compliance Officer The Compliance Officer has the full authority to stop any work process that may be the cause of, or is contributing to non-compliance, until the process has been reviewed and/or corrected, if needed.

45. annual compliance training EXIT COMPLIANCE REQUIREMENT #2: Compliance Officer The Compliance Officer has the full authority to stop any work process that may be the cause of, or is contributing to non-compliance, until the process has been reviewed and/or corrected, if needed.

46. annual compliance training COMPLIANCE REQUIREMENT #2: Compliance Officer & Committee Compliance Committee • Responsibilities include: • Organizational Support • Promote awareness of the Compliance Program • Advise the Compliance Officer • Implement the Compliance Program • Monitor/assess effectiveness of compliance with applicable laws, etc. • Address areas of concern or risk

47. annual compliance training EXIT COMPLIANCE REQUIREMENT #2: Compliance Officer & Committee Compliance Committee • Responsibilities include: • Organizational Support • Promote awareness of the Compliance Program • Advise the Compliance Officer • Implement the Compliance Program • Monitor/assess effectiveness of compliance with applicable laws, etc. • Address areas of concern or risk

48. annual compliance training Employee & Contractor Roles & Responsibilities in Compliance Help the county operate a successful Compliance Program Comply with the Code of Conduct & Code of Ethics Adhere to the Compliance Program and all applicable laws, rules, regulations, guidelines, policies and procedures Report a violation or suspected violation.

49. annual compliance training EXIT Employee & Contractor Roles & Responsibilities in Compliance Help the county operate a successful Compliance Program Comply with the Code of Conduct & Code of Ethics Adhere to the Compliance Program and all applicable laws, rules, regulations, guidelines, policies and procedures Report a violation or suspected violation.

50. annual compliance training COMPLIANCE REQUIREMENT #3: Training & Education All county employees and contractors, including contractor’s employees and subcontractors, must be trained and retrained to keep abreast of changes in Federal, State and County laws, rules regulation, policies and procedures.