We’re not in Kansas anymore!

1. We’re not in Kansas anymore! Healthcare has changed and we need courage, knowledge and a big heart to survive the change!

2. How did we get here Toto? MEDICARE • BBA Balanced Budget Act 1997 • DRG’s, Perspective Payment System, APC’s • HIPAA – Health Information Portability & Accountability Act - 2001 • MMA - Medicare Modernization Act 2003 • Created Stark, Sarbanes Oxley (SOX), Anti-kickback, • Physician Referral guidelines, Medicare Fraud & Abuse • DRA – Deficit Reduction Act 2005 • Created Medicaid Integrity Program (MIP) • Dramatically Increased Resources of CMS & HHS-OIG to Fight Medicaid Fraud • Funding - $560M over 5 Years

3. How did we get here Toto? Medicare Contract Reform (MCR) • POA’s – Present on Admission Indicators • HAC’s – Hospital Acquired Infections • RAC’s – Recovery Audit Contractors • MAC’s – Medicare Administrative Contractors MS-DRG’s – from 500+ to 745 • Adds Severity Levels • DRG w/ no cc/mcc – $2500 • DRG w/cc - $3500 • DRG w/cc & mcc - $5000

4. How did we get here Toto? • In Georgia – • 2003 - Medicaid ACS conversion from EDS • 2006 - 3 New Medicaid CMO’s for pregnant women and children • 2009 – SHBP Plan Changes • - CAHABA Part A – MAC on May 4th • - Reimbursement cuts – 5% • 2010 – Change Medicaid Payer from ACS to EDS

5. How did we get here Toto? • In Georgia – • 2003 - Medicaid ACS conversion from EDS • 2006 - 3 New Medicaid CMO’s for pregnant women and children • 2009 – SHBP Plan Changes • - CAHABA Part A – MAC on May 4th • - Reimbursement cuts – 5% • 2010 – Change Medicaid Payer from ACS to EDS

6. The Bad Witch CMS REGULATORY COMPLIANCE - OIG • MEDICARE LOST AN ASTONISHING $23 BILLION IN 1996 due to corporate fraud, waste, and error, according to former Secretary of Health and Human Services Donna Shalala.

7. OIG Core Principles HHS OIG guidelines - Core principles 1) implement written policies, procedures, and standards of conduct; 2) designate a compliance officer; 3) conduct effective training; 4) develop effective lines of communication;

8. OIG Core Principles HHS OIG guidelines - Core principles 5) enforce standards through well-publicized disciplinary guidelines; 6) conduct internal monitoring and auditing; and 7) respond promptly to detected offenses, developing corrective action and reporting to the government.

9. IMPLEMENT FRAUD PREVENTION POLICIES Written policies, procedures, and standards of conduct address specific risk areas such as: • patient rights, • billing and cost reporting, • employee screening, • kickbacks, • inducements, and self-referrals.

10. IMPLEMENT FRAUD PREVENTION POLICIES According to the guideline, these policies and procedures should ensure: 1) Complete and accurate medical record documentation, and compliance should be required and used as an evaluative tool during employee performance appraisals. 2) Furthermore, the guideline requires creation of a code of conduct that is easy to read and details the health-care facility's expectations and general principles as applicable to employees.

11. DESIGNATE COMPLIANCE OFFICER The second HHS OIG guideline requires "designation of a compliance officer and compliance committee charged with the responsibility for developing, operating, and monitoring the compliance program, and who reports directly to the owners, governing body, and/or CEO." The compliance officer has the authority to review all documents and information pertinent to compliance activities.

12. TRAIN EMPLOYEES The HHS OIG guidelines consider the "development and implementation of regular, effective education and training programs for all affected employees" a critical element of compliance.

13. TRAIN EMPLOYEES The HHS OIG also encourages specific program topics, including: • compliance with Medicare requirements; • appropriate and sufficient documentation for clinical and financial records; • patients rights; and • the duty to report misconduct. The HHS OIG's emphasis on both general and specific training underscores its importance in an effective compliance program.

14. COMMUNICATE EFFECTIVELY Communication is the backbone of an internal control system.

15. COMMUNICATE Anonymously-Whistle Blower Hotline The HHS OIG guidelines require "the creation and maintenance of an effective line of communication between the compliance officer and all employees, including a process, such as a hotline or other reporting system, to receive complaints, and the adoption of procedures to protect the anonymity of complainants and to protect whistle blowers from retaliation."

16. HIRE THE RIGHT EMPLOYEES The fifth HHS guideline states the necessity of "the development of policies and procedures addressing the non-employment or retention of excluded individuals or entities and the enforcement of appropriate disciplinary actionagainst employees or contractor who have violated corporate or compliance policies and procedures, applicable statutes, regulations, or federal, state, or private payer health-care program requirements."

17. HIRE THE RIGHT EMPLOYEES The HHS OIG guidelines also require written standards of conduct to include procedures for handling disciplinary problems and the names of those who will be responsible for enforcing the discipline

18. AUDIT COMPLIANCE The HHS OIG guidelines specify "the use of audits and/or other risk evaluation techniques to monitor compliance, identify problem areas, and assist in the reduction of identified problems."

19. AUDIT COMPLIANCE These guidelines also state that an internal control program should include an ongoing evaluation process with periodic reviews to determine the effectiveness of the compliance program and to ensure that program goals are being met. This review process can include such practices as testing employees for knowledge of requirements, site visits, examination of complaint logs, trend analysis, and employee surveys.

20. AUDIT COMPLIANCE EMPLOYEE QUESTIONNAIRE • Annually • And at termination DO YOUR EMPLOYEES KNOW? • HAVE YOU OR ARE YOU AWARE OF VIOLATIONS? • HIPAA PRIVACY & SECURITY • FRAUD & ABUSE • REPORTING HOTLINE

21. RESPOND TO DETECTED OFFENSES AND IMPLEMENT CORRECTIVE MEASURES The final HHS OIG guideline stresses the need for diligence in discovering violations and swift action once violations are detected

22. RESPOND TO DETECTED OFFENSES AND IMPLEMENT CORRECTIVE MEASURES According to the guideline, "Violations of a facility's compliance program policies threaten the facility's reputation as a reliable, honest, and trustworthy health-care provider." If the facility detects but does not act on problems, it risks criminal prosecution and possible exclusion from the Medicare system.

23. RESPOND TO DETECTED OFFENSES AND IMPLEMENT CORRECTIVE MEASURES • Health-care providers should investigate these areas of concern and take corrective measures within 60 days after uncovering credible evidence of a violation. These measures include: • returning any overpayment; • sending a report to the government; • referring violators to criminal or civil law enforcement officials.

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