KNOCK…..KNOCK

1. KNOCK…..KNOCK “Managing Audits and Compliance” Robert Saenz, President VIP Medical Consulting

2. Current Epidemic • “Dilly” • “Miss Emma” • “Good Fellas” • “Mary Jane”

3. Robert Saenz Graduate of both the U.S. Border Patrol Academy & the FBI National Academy. 20 years investigating federal crimes with the Department of Justice. Prior Field Director for the U.S. Congress working on legislative issues related to Federal & Healthcare law. Currently, PRESIDENT of VIP Medical Consulting www.VIPMEDICALCONSULTING.com (210) 643-4300

4. For Every One Death From Prescription Drug Misuse CDC Vital Signs: Overdoses of Prescription Opioid Pain Relievers in the U.S. 1999-2008 Atlanta, GA: Centers for Disease Control and Prevention, November 2011.

5. “DUE DILIGENCE”

6. DEA AUDIT and Chart Review • Overdose of a Patient • Patient/Employee Sells • Pharmacist • Whistleblower • New Patient Eval. • Patient Agreement • State PDMP • Drug Screen

7. Dr. Albert Yeh • Dr Yeh wrote over 6000 prescriptions in 1 yr • 11 separate DEA undercover visits • Brief History and Physical • Pain in My Toe • What has worked for you before? • X-Ray /MRI but no Drug Screen • NO PDMP • PA follow ups vs MD

8. DEA vs. Dr Yeh Since Dr. did not Act in Good Faith and in Accordance with Generally Accepted Medical Standards, this leads to arrest and seizure based on : • Racketeering (Dishonest/ Organized Crime) • Money Laundering (Dirty Money) • Billing Fraud (Deception) • Drug Dealing (self explanatory)

9. Medical Board ReviewsIt is a Battle of “Documentation” • “Were The Prescribing Guidelines followed” • Face to Face physical examination • Prevention of diversion • Assessment of Benefit of opiates or Benzos • Adjustment of treatment according to risk • Periodic Review and Notes delineating progress • Adequate and accurate record keeping

10. HEALTHCARE HISTORY 101 • 1965 Medicare was created • 1970 Kickbacks rampant • 1975 HEW (Health, Education, Welfare) • 1980 Pres. Reagan “Waste Fraud & Abuse”

11. Deterrence or Terror • 1981 -1991 OIG Richard Kusserow

12. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) establishes the Health Care Fraud and Abuse Control Program HCFAC or “The Program” TODAY…………… 30 Federal Agencies investigating HealthCare FBI OIG DEA HEAT

13. OIG Strategic Work Plan 2016-2017 With the Affordable Health Care Act known as Obama Care on the rocks and TRUMP Care on the Horizon sputtering as well and the Medicare program in financial jeopardy, the 2016-2017 OIG work plan may be more important today. More federal agencies are investigating Medicare fraud and abuse than ever before, with a “zero tolerance expectation” of physicians https://oig.hhs.gov/: Strategic work plan

14. “HEAT” TASK FORCE • Created On May 20, 2009 • Increased tools and resources, • Sustained focus by senior level leadership • Cabinet level commitment to prevent and prosecute health care fraud • HEAT jointly led by Deputy Attorney General and HHS Deputy Secretary • Comprised of top level agents, prosecutors, attorneys & auditors

15. ANTI KICKBACK • Prohibits Outright Bribes • Prohibits INDUCEMENT • Items or Services

16. 7 STANDARDS OF SAFE HARBOR • IN WRITING SIGNED BY BOTH PARTIES • COVER SPECIFIC SERVICES BY CONTRACTOR • SET SCHEDULE , LENGTH AND EXACT CHARGE FOR PART TIME • SPAN AT LEAST 1 YEAR • COMPENSATION SET IN ADVANCE (FAIR MARKET VALUE) • NOT INVOLVE SERVICES THAT INVOLVE PROMOTION OF BUSINESS SERVICES • SERVICES DO NOT EXCEED REASONABLY NECESSARY

17. Elements of Compliance • 1. Establish compliance standards by developing a code of conduct and writing policies and procedures. • 2. Assign compliance monitoring to a designated compliance officer. • 3. Conduct comprehensive training and education on practice ethics, policies and procedures. https://oig.hhs.gov/authorities/docs/cpglab.pdf

18. THANK YOU !VIP MEDICAL CONSULTINGwww.vipmedicalconsulting.com