Compliance 101 QUESTIONS AND ANSWERS

compliance program - Answer- prevention, detection, collaboration, and enforcement Effective compliance program - Answer- must be an ongoing process and commitment to an ethical way of conducting business Office of Inspector General and Justice Department - Answer- is responsible for enforcing the rules and regulations under the Medicare and Medicaid laws outline as part of the SSA by CMS. Benefits of compliance program addressed by OIG - Answer- safeguards the organizations' legal responsibility to abide by applicable laws and regulations. Corporate Integrity Agreement (CIA) - Answer- government imposed compliance program Why compliance programs are essential - Answer- prevent paybacks, probation, government designed programs, exclusion, reduce threat of lawsuits from whistleblowers (qui tam). OIG Top 10 reasons to implement a compliance program - Answer- demonstrates a strong commitment to honesty and responsible corporate relations, reinforces employees sense of right and wrong, fulfill legal duty to payers, cost effective, more accurate view of what is going on, quality of care to clients, provides procedures to promptly correct misconduct, mitigate any sanction imposed by government. Health Insurance Portability and Accountability Act of 1996 (HIPAA) - Answer- a criminal offense to submit claims based on incorrect codes or medically unnecessary services, and government has the power to exclude an organization from Medicare/caid and other govt programs. Balanced Budget Act of 1997 - Answer- three strikes and your out clause , requiring permanent expulsion if found guilty of fraud a third time. False Claims Act (FCA) - Answer- empowers the govt to investigate and bring civil action in fraud cases. Implemented in Civil War to control price gouging. Qui tam - Answer- is a whistleblower who brings the fraud to light. A whistleblower can receive a % of the govt's total award - Answer- 15-25% if DOJ assumes the case or 25-30% if DOJ declines