Hospital Compliance Programs: Updating and Assessing

Planning Notes

Hospital Compliance Programs: Updating and Assessing

Title: Hospital Compliance Programs: Updating and Assessing

Objective: To review the development of hospital compliance programs, the process of making objective assessments of current programs, identify and discuss various hospital compliance issues including updated topics from the OIG’s work plans. Emphasis is placed on prioritizing compliance issues within the hospital environment and to understand Corporate Integrity Agreements (CIAs) and negotiated settlements after audits and/or whistle blower incidents.

Upon Completion the Participants Will:

1. Understand the scope of hospital compliance activities and the need to develop appropriate action plans.

2. Appreciate the role of Medicare and OIG audits and their impact on hospital compliance activities.

3. Appreciate the severity of current compliance issues, the auditing process, demand letters, safe harbors, and the associated penalties.

4. Understand the process for identifying potential compliance problem areas and the systematic process for investigating potential problem areas.

5. Appreciate the impact of being under a Corporate Integrity Agreement (CIA).

6. Understand how Medicare’s various PPSs (Prospective Payment Systems) impact compliance including DRGs, APCs, RUGs-III, HHPPS, LTCH PPS and the IRF PPS.

7. Have reviewed the hospital related topics from the OIG Work Plans.

8. Have a listing of typical hospital compliance concerns and the generalized action steps needed to address the given area.

9. Appreciate the need to prioritize activities in order to address the compliance issues with the greatest potential liability.

10. Appreciate the role of internal auditing activities and the use of Independent Review Organizations (IROs) to assist in assuring compliance.

11. Appreciate the use of external consultants and attorneys relative to various compliance auditing techniques.

12. Have knowledge of various information resources relative to the development, assessment and planning for hospital compliance.

Audience: All personnel involved in any aspect of hospital compliance including coding, billing and reimbursement compliance activities. Compliance officers, internal auditors, consultants, coding staff, billing staff, service area support staff, charge master coordinators, reimbursement specialists, nursing supervisors, physicians, nurses as appropriate, insurance experts, cost accountants and administrative staff as appropriate.

Method of Presentation: The primary method is LectureRecitation with the use of case studies. Interaction and questions from the audience are HIGHLY encouraged.

Course Materials: Extensive Class Notes (including copies of Overhead Transparencies). Class Notes will include copies of selected readings and special materials as appropriate.

Student Materials: No student materials are required. Concerns about various compliance areas should be brought to class.

Prerequisites: A general knowledge of health care compliance and the current activities of the OIG, DOJ, FBI and related federal agencies. Some experience and/or associated knowledge of hospital coding, billing and reimbursement is highly recommended.

Course Times: This is a special full day workshop – 9:00 a.m. to 4:00 p.m.

Outline:

  1. Introduction
  2. Compliance Overview
  3. Importance Of Meeting Compliance Rules & Regulations
  4. Special Health Care Compliance – OIG Model Plans
  5. OIG Work Plan Issues
  6. Systematic Approach To Maintaining Compliance
  7. Review of HIPAA
  8. Overview of the Auditing Process
  1. Hospital Compliance Planning
  2. Seven Key Principles
  3. Chief Compliance Officer
  4. Internal Auditing Staff
  5. Review & Audit Activities
  6. Policy and Procedure Development
  7. Preparing For External Audits
  1. OIG Work Plan Issues
  2. SpecificHospital Issues
  3. Hospital Board Issues
  4. Physician Related Issues
  5. Home Health Issues
  6. Other Issues
  1. Payment Systems - Statutory/Contractual Compliance
  2. Cost Based Payment Systems
  3. Prospective Payment Systems
  4. Physicians – RBRVS
  5. Inpatient – DRGs
  6. Outpatient - APCs/APGs
  7. Nursing Facility – RUGs
  8. Home Health PPS
  9. Rehabilitation PPS
  10. Managed Care & Capitation
  11. Contractual Compliance
  12. Statutory Compliance
  1. Special Compliance Areas
  2. Conditions of Participation (CoPs)
  3. Conditions for Payment (CfPs)
  4. EMTALA
  5. HIPAA
  6. Privacy
  7. Transaction Standards
  8. Security
  9. Provider-Based Status
  10. Other
  1. The OIG and Auditing
  2. CIAs – Corporate Integrity Agreements
  3. OIG Audits versus Medicare Audits
  4. Use of RAT-STATS
  5. Extrapolation and Overpayments
  1. Sources for Continued Study/Development

Notes:

  1. This is an intensive one-day workshop emphasizing practical applications.
  2. Questions submitted prior to the class are encouraged!
  3. Reference materials will be made available to class participants as a part of their notes.

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