CHC EXAM Compliance Program Administration
Advocating for compliance resources Conduct research, provide data, search for free resources, negotiate,
communicate benefits to organization, developed a resource management plan
Report and Compliance program activity Provide regular reports generally at least quarterly as well as an annual report,
provide clear and concise explanations to reduce the need for unnecessary
questioning, provide an outline of report to the members, update any new area of
risk so the members are not caught off guard when issues arise, present
supporting data, utilize the same reporting process for each presentation so the
members know what to expect, encourage input from members and show
respect for their contributions, fall through on any advice or directions for action
Responsibilities of compliance oversight committee The OIG recommends that organizations have both a compliance officer to
manage and moderate compliance issues in a compliance oversight committee
to provide advice in guidance to the compliance officer. The clients committee
must have autonomy in authority to enforce Compliance. Functions include:
1. Analyze the legal requirements for industry in areas of increased risk.
2Assessment of existing policies and procedures.
3. Development of standards of conduct in collaboration with other departments
to share compliance
4. Development of internal systems and controls for monitoring and carrying out
organizations policies and procedures in collaboration with other departments.
5. Ensuring proper reporting of misconduct and violations.
Fundamental elements and complains programs 1.Written policies and procedures
2. Compliance professional
3. Effective training
4. Effective communication
5. Internal monitoring program
6. Enforcing of standards
7. Prompt response
Fraudulent practices Billing for items or service is not provided, providing services that are medically
unnecessary, upcoding claims, DRG creep, billing for outpatient services
provided to inpatients, Teaching position and resident requirements for teaching
institutions, duplicate billing, false costs reports, Unbundling charges, Billing for
discharge instead of transfer, patience freedom of choice, failure to refund credit
balance, violations of anti-kickback statute or other federal or state statute and
regulations, joint ventures that may violate anti-kickback statue, financial
arrangements between hospitals and hospital-based physicians, stark law
violations, knowing failure to provide covered services or necessary care to
members of an HMO, patient dumping
Areas of concern for compliance for home health Billing for services to patients who are not homebound, billing for services to
agencies patients who do not qualify for care, Overutilization or Underutilization of
services, knowingly billing for inadequate or substandard care, insufficient
Documentation to support reimbursement, billing for unallowable costs,Billing for
unqualified unlicensed clinical personnel, fall stating of amendments to nurses
notes, falsified plans of care, forge beneficiary signatures on visit slips or logs
that verify performance of services, improper patient solicitation activities,
inadequate oversight of contracted services, discrimination and discharge or
admission,Improper influence over referrals by hospitals that on HH agencies,
patient abandonment
Areas of OIG concern for compliance for nursing facilities In adequate assessment of residential functional capacity and lack of
comprehensive plan of care, inappropriate or insufficient Treatment or series to
address resident's conditions, Failure to accommodate resident needs or
preferences, failure to properly prescribe/administer/monitor prescription drugs,
In adequate staffing or insufficiently train staff, tell her to apply appropriate
therapy services and to assist with ADLs, failure to prove an ongoing activities
program to meet individual needs, failure to report incidence of miss treatment
abuse neglect to administrator and officials as required by law
, CHC EXAM Compliance Program Administration
Areas of OIG concern for compliance for hospices Uninformed consent for use of Medicare hospital benefit, omission of patients
who are not terminally ill, arrangement with other healthcare provider who is
submitting claims for services already covered by Medicare hospice benefit,
phosphide medical records/Plans of care/untimely or Forge position certification
of care, inadequate or a complete services by interdisciplinary group, Insufficient
patient oversight, violations of anti-kickback or some other statues or regulations,
overlap of services provided by nursing home, providing nursing home hospice
services prior to finalized written agreement , if required, Billing for higher level
than needed for inadequate or substandard care, Pressure on patients to revoke
hospice benefit when care becomes expensive to provide, billing or services
provided by unqualified or unlicensed personnel, high-pressure marketing to an
eligible beneficiaries, in adequate management or oversight of subtracted
services, sales commissions based on length of stay in hospice, deficient
coordination of volunteers, non-response to late referrals or underutilization of
services, Failure to adhere to licensing requirements and Medicare conditions pf
participation/misuse of provider certification numbers/ failure to return over
payments
Evaluating compliance program effectiveness Conducting surveys, interviews and observations, auditing processes, checking
revisions, assessing documentation including choice of language and grade
level, conducting document reviews and audits for compliance, comparing code
of conduct with mission and vision statement, reviewing completion rates and
test scores for training programs, determining if written plans match activities,
carrying out a process review, review budget and resource utilization, assessing
risk identification In corrective action plans, assessing evidence of retaliation,
adding conflict of interest statements/ credentialing/ screening processes /ijob
descriptions, conducting audits and vendors and third-parties to determine if they
meet compliance requirements, conducting billing and coding audits, assessing
the use of report methods such as hotline, adding the risk assessment process,
assessing the consistency of investigation processes
Credibility and integrity Provide accurate information and researching when necessary to provide the
best available information, responding promptly to inquiries and reports,
providing clear explanations for compliance needs and correct of action plans,
Respect and confidentiality and anonymity and avoiding gossip a negative
communications, Demonstrating knowledge of subject matter in confidence and
job performance, treating all workforce members fairly, listening and showing
respect for the opinions of others, providing ample opportunities for reporting,
providing consistency and upholding values, Leading through example and being
honest and open with interactions with others, providing progress reports on
regular basis in recognizing and giving credit to key participants, excepting
accountability for both successes and failures, demonstrating loyalty to the
organization and the workforce, Focusing on goals and strategies to achieve
those goals, keeping current in laws and regulations, Continuing to learn and
share knowledge
Attorney-Client Privilege Communication between the attorney and the client relating to legal advice is
privilege but this does not apply to other types of advice, such as regarding a
business operation. that
Work Product Privilege Documents that are prepared for litigation purposes are protected by work
product privilege so that opposing counsel cannot view the documents as part of
discovery.
Cochrane database Primary resource and development of evidence-based practice. Provides a
collection of different medical databases in the Cochran library for easy Internet
access.
National healthcare safety network NHSN Integrates and replaces three separate programs the national nosocomial
infections surveillance NNIS, Dialysis Serveillance Network DSN, Natural
surveillance system for healthcare workers NaSH. Provides valuable
comparative data, allows for reporting and sharing data. Three components are
patient safety, healthcare worker safety, and research and development.
Hospital compare website Provides information comparing more than 4000 hospitals in the United States.
Complete data sets which the compliance confessional can use to generate
reports, can be downloaded from data. Medicare.gov.
Institute for Healthcare Improvement (IHI) Nonprofit organization whose goal is to improve healthcare throughout the world.
It provides both free and fee-based programs and services. Has launched a
number of initiatives related to healthcare and offers books videos and audio
tapes to provide guidance and quality improvement as well as a series of free
white papers.
Advocating for compliance resources Conduct research, provide data, search for free resources, negotiate,
communicate benefits to organization, developed a resource management plan
Report and Compliance program activity Provide regular reports generally at least quarterly as well as an annual report,
provide clear and concise explanations to reduce the need for unnecessary
questioning, provide an outline of report to the members, update any new area of
risk so the members are not caught off guard when issues arise, present
supporting data, utilize the same reporting process for each presentation so the
members know what to expect, encourage input from members and show
respect for their contributions, fall through on any advice or directions for action
Responsibilities of compliance oversight committee The OIG recommends that organizations have both a compliance officer to
manage and moderate compliance issues in a compliance oversight committee
to provide advice in guidance to the compliance officer. The clients committee
must have autonomy in authority to enforce Compliance. Functions include:
1. Analyze the legal requirements for industry in areas of increased risk.
2Assessment of existing policies and procedures.
3. Development of standards of conduct in collaboration with other departments
to share compliance
4. Development of internal systems and controls for monitoring and carrying out
organizations policies and procedures in collaboration with other departments.
5. Ensuring proper reporting of misconduct and violations.
Fundamental elements and complains programs 1.Written policies and procedures
2. Compliance professional
3. Effective training
4. Effective communication
5. Internal monitoring program
6. Enforcing of standards
7. Prompt response
Fraudulent practices Billing for items or service is not provided, providing services that are medically
unnecessary, upcoding claims, DRG creep, billing for outpatient services
provided to inpatients, Teaching position and resident requirements for teaching
institutions, duplicate billing, false costs reports, Unbundling charges, Billing for
discharge instead of transfer, patience freedom of choice, failure to refund credit
balance, violations of anti-kickback statute or other federal or state statute and
regulations, joint ventures that may violate anti-kickback statue, financial
arrangements between hospitals and hospital-based physicians, stark law
violations, knowing failure to provide covered services or necessary care to
members of an HMO, patient dumping
Areas of concern for compliance for home health Billing for services to patients who are not homebound, billing for services to
agencies patients who do not qualify for care, Overutilization or Underutilization of
services, knowingly billing for inadequate or substandard care, insufficient
Documentation to support reimbursement, billing for unallowable costs,Billing for
unqualified unlicensed clinical personnel, fall stating of amendments to nurses
notes, falsified plans of care, forge beneficiary signatures on visit slips or logs
that verify performance of services, improper patient solicitation activities,
inadequate oversight of contracted services, discrimination and discharge or
admission,Improper influence over referrals by hospitals that on HH agencies,
patient abandonment
Areas of OIG concern for compliance for nursing facilities In adequate assessment of residential functional capacity and lack of
comprehensive plan of care, inappropriate or insufficient Treatment or series to
address resident's conditions, Failure to accommodate resident needs or
preferences, failure to properly prescribe/administer/monitor prescription drugs,
In adequate staffing or insufficiently train staff, tell her to apply appropriate
therapy services and to assist with ADLs, failure to prove an ongoing activities
program to meet individual needs, failure to report incidence of miss treatment
abuse neglect to administrator and officials as required by law
, CHC EXAM Compliance Program Administration
Areas of OIG concern for compliance for hospices Uninformed consent for use of Medicare hospital benefit, omission of patients
who are not terminally ill, arrangement with other healthcare provider who is
submitting claims for services already covered by Medicare hospice benefit,
phosphide medical records/Plans of care/untimely or Forge position certification
of care, inadequate or a complete services by interdisciplinary group, Insufficient
patient oversight, violations of anti-kickback or some other statues or regulations,
overlap of services provided by nursing home, providing nursing home hospice
services prior to finalized written agreement , if required, Billing for higher level
than needed for inadequate or substandard care, Pressure on patients to revoke
hospice benefit when care becomes expensive to provide, billing or services
provided by unqualified or unlicensed personnel, high-pressure marketing to an
eligible beneficiaries, in adequate management or oversight of subtracted
services, sales commissions based on length of stay in hospice, deficient
coordination of volunteers, non-response to late referrals or underutilization of
services, Failure to adhere to licensing requirements and Medicare conditions pf
participation/misuse of provider certification numbers/ failure to return over
payments
Evaluating compliance program effectiveness Conducting surveys, interviews and observations, auditing processes, checking
revisions, assessing documentation including choice of language and grade
level, conducting document reviews and audits for compliance, comparing code
of conduct with mission and vision statement, reviewing completion rates and
test scores for training programs, determining if written plans match activities,
carrying out a process review, review budget and resource utilization, assessing
risk identification In corrective action plans, assessing evidence of retaliation,
adding conflict of interest statements/ credentialing/ screening processes /ijob
descriptions, conducting audits and vendors and third-parties to determine if they
meet compliance requirements, conducting billing and coding audits, assessing
the use of report methods such as hotline, adding the risk assessment process,
assessing the consistency of investigation processes
Credibility and integrity Provide accurate information and researching when necessary to provide the
best available information, responding promptly to inquiries and reports,
providing clear explanations for compliance needs and correct of action plans,
Respect and confidentiality and anonymity and avoiding gossip a negative
communications, Demonstrating knowledge of subject matter in confidence and
job performance, treating all workforce members fairly, listening and showing
respect for the opinions of others, providing ample opportunities for reporting,
providing consistency and upholding values, Leading through example and being
honest and open with interactions with others, providing progress reports on
regular basis in recognizing and giving credit to key participants, excepting
accountability for both successes and failures, demonstrating loyalty to the
organization and the workforce, Focusing on goals and strategies to achieve
those goals, keeping current in laws and regulations, Continuing to learn and
share knowledge
Attorney-Client Privilege Communication between the attorney and the client relating to legal advice is
privilege but this does not apply to other types of advice, such as regarding a
business operation. that
Work Product Privilege Documents that are prepared for litigation purposes are protected by work
product privilege so that opposing counsel cannot view the documents as part of
discovery.
Cochrane database Primary resource and development of evidence-based practice. Provides a
collection of different medical databases in the Cochran library for easy Internet
access.
National healthcare safety network NHSN Integrates and replaces three separate programs the national nosocomial
infections surveillance NNIS, Dialysis Serveillance Network DSN, Natural
surveillance system for healthcare workers NaSH. Provides valuable
comparative data, allows for reporting and sharing data. Three components are
patient safety, healthcare worker safety, and research and development.
Hospital compare website Provides information comparing more than 4000 hospitals in the United States.
Complete data sets which the compliance confessional can use to generate
reports, can be downloaded from data. Medicare.gov.
Institute for Healthcare Improvement (IHI) Nonprofit organization whose goal is to improve healthcare throughout the world.
It provides both free and fee-based programs and services. Has launched a
number of initiatives related to healthcare and offers books videos and audio
tapes to provide guidance and quality improvement as well as a series of free
white papers.
