VHA and VISN 21 Compliance & Business Integrity (CBI) ProgramMandatory Training for Contractors

Prepared: March 2007, Updated February 2012

VISN 21Compliance Officers List

• Jane Dutton Morris, MHA, CHCCompliance Specialist, Sierra Pacific

Network (707) 562-8377 Jane.Dutton2@va.gov

• Yvonne Brooks Compliance Officer San Francisco VA Medical Center(415) 221-4810 Ext. 4398Yvonne.Brooks@va.gov

• Jeffrey Petro, JDCompliance OfficerVA Palo Alto Health Care System (650) 493-5000 Ext. 67012Jeffrey.Petro.@va.gov

• Syndi DayCompliance Officer VA Central California Health Care System (559) 225-6100 Ext. 6691Syndi.Day1@va.gov

• Patricia Moran, RHIT, CPC Compliance Officer VA Northern California Health Care

System (707)437-1905 Patricia.Moran@va.gov

• Jon Sedran Compliance Officer VA Sierra Nevada Health Care System (775)788-5512 Jon.Sedran@va.gov

• Paul ChungCompliance Officer

VA Pacific Islands Health Care System (808)433-7545 Paul.Chung@va.gov

Background and Program Structure

Background & Program Structure (cont’d)

United States Sentencing Commission (USSC) Federal Sentencing Guidelines- http://www.ussc.gov/Guidelines/2011_Guidelines/index.cfm

Department of Health and Human Service (HHS) Office of Inspector General (OIG) Compliance Guidance for Hospitals (1998)- http://oig.hhs.gov/authorities/docs/cpghosp.pdf

HHS Supplemental OIG Compliance Guidance for Hospitals (2005)- http://oig.hhs.gov/fraud/docs/complianceguidance/012705HospSupplementalGuidance.pdf

VHA CBI Program established in 1999 to reduce fraud, waste and abuse and to promote high standards of business integrity and quality- http://vaww.cbi.va.gov/

VHA Definition of Compliance

Compliance is an oversight process which requires employees and contractors to conduct administrative and clinical duties in an honest, ethical and professional manner.

Behavior that is not consistent with ethical

business practices places Veterans Health Administration (VHA) facilities at risk for penalties, negative publicity and loss of public trust.

VHA’s Compliance ProgramThe VHA’s Compliance & Business Integrity (CBI) program focuses primarily on

the Revenue Cycle and Purchased Care to include the following business operations:

• Patient registration & intake• Medical documentation• Coding for medical procedures & visits• Billing for services provided • Collections from insurance companies• Fee Basis (Purchased care) services

Revenue Cycle Oversight

• Veterans may get charged a co-pay for medical visits and medications based upon their eligibility status (first party billing).

• The facility can also bill a patient’s insurance carrier for eligible visits and medications, and any collections first go to off-set the related co-pay charge that the Veteran may owe, and then the rest goes straight back to the facility for patient care (third party billing).

• This whole process- from enrollment and eligibility to billing and collections, is known as the revenue cycle. CBI is tasked with oversight of the entire revenue cycle.

Revenue Cycle

CBI Focus Areas

• Patient registration & intake: the enrollment and insurance identification process that Veterans go through when initially seeking care at a VA medical center. Types of information entered are demographics, disability rating, income status, and insurance information. Inaccurate data entry may lead to a Veteran being billed inappropriately for VA health care benefits received, or loss of revenue may result if the Veteran’s insurance data is not properly entered or identified.

• Medical Documentation: Medical documentation is the provider’s written description of what occurred during the patient visit, and is what billing is based on- both first and third party billing. Inaccurate documentation could lead to inappropriately billing the Veteran. Inaccurate and incomplete documentation could also lead to not enough or too much reimbursement from third party payers.

CBI Focus Areas (cont’d)• Coding for medical procedures & visits: After each visit that is

billable to an insurance company, medical coders will receive the medical record documentation related to that visit and assign numeric and alpha-numeric codes to the visit. These codes depict the procedures performed and the diagnoses treated during the visit. Medical coders are responsible for assigning and validating procedural & diagnostic codes based on provider documentation. These codes are the basis of insurance company reimbursement. Inaccurate coding could lead to potential billing fraud , or possibly a loss of third party revenue.

• Billing for services provided: Billers are responsible for generating timely, accurate and appropriate bills based on veterans’ eligibility and the service provided. A Veterans’ eligibility to be charged a co-pay depends on their disability rating(s), their income status, and the clinic where the appointment was scheduled. Inaccurate billing could lead to inappropriate co-pay charges to Veterans or missed billing opportunities from insurance companies.

CBI Focus Areas (cont’d)• Collections from insurance companies: Staff at the billing unit are

responsible for communicating with insurance companies about verifying insurance policy coverage and following up on collecting the money owed. Possible risk areas are retention of overpayment from the insurance company without the proper documentation showing the approval for keeping the overpayment, or untimely filing of claims resulting in the inability to collect any reimbursement from the insurance company.

• Fee Basis (Purchased Care) services: The purchased care program is widely used in order to provide timely and specialized care to eligible Veterans who can’t receive that care at a VA facility. This may be due to geographical distance or a medically necessary service/procedure not being offered at a VA facility. Part of each VA medical center’s budget is for purchased care, so it is important that these program dollars are not erroneously paid for fraudulent or unjustified services and supplies.

Purpose of VHA Compliance ProgramEnsure business operations comply with relevant

laws, rules and regulations;

Promote ethical practices and standards of excellence in patient care;

Help VHA maintain the public’s trust.

Elements of an Effective Compliance Program

1. Written policies &

procedures

2. Designation of a CBI

Officer & Committee

3. Risk Managem

ent

4. Open Lines of

Communication

5. Training &

Education

6. Monitoring

& Auditing

7. Investigation &

Response

8. Enforcement&

Discipline

9. Annual review of program

effectiveness

Elements of an Effective Compliance Program (cont’d)

• Written policies and procedures- Policies and procedures communicate the organizational values and expectations regarding employee behavior. They also outline the employee’s responsibility to uphold the policies and procedures set forth by the organization and must be consistent with VHA and compliance industry standards.

 • Designation of a CBI Officer and Committee- The CBI Officer is the person who

manages the day-to-day operations of the CBI program. However, it is imperative that all program activities be completed in a collaborative and cooperative environment with full employee participation. The organization’s Director formally establishes the Compliance Committee to provide advice to the CBI Officer and organizational leadership on the CBI program.

•  Risk Management- Risk management is an essential element of a compliance program, as it identifies those areas that may affect the organization’s reputation, organizational goals and objectives, or violates regulation and/or law. The goal of risk management is to identify risks to the organization and to reduce the identified risks to a level that is acceptable to the organization's leadership.

•  

Elements of an Effective Compliance Program (cont’d)

• Training & Education-  An effective training and education plan provides on-going education to all levels of the organization. General awareness training provides an overall view of the organization’s CBI program, while job-specific training is targeted for employees whose job functions directly influence revenue cycle operations.

• Open lines of communication- An effective CBI program encourages employees and other stakeholders to report suspected wrongdoings for investigation and follow-up. All employees should know how to report a compliance concern at any level of the organization (see slide 17) . Open lines of communication demonstrates the principal of if it doesn’t feel right, it probably isn’t and should be stopped.

• Auditing & Monitoring- Audits and monitors are tools used to mitigate risk. A monitor tests and an audit confirms compliance with laws, regulations and policies. An audit may be conducted retrospectively to identify the origin of a particular issue or concurrently to identify areas of vulnerability. Monitoring is completed on a recurring basis and is part of normal activities to determine if internal controls are adequate.

Elements of an Effective Compliance Program (cont’d)

• Investigation & Response- An effective CBI program has established processes and procedures to respond promptly to occurrences of suspected or actual wrongdoing within the organization. Part of the investigation process is not only to determine if wrongdoing has occurred, but also to determine what the origin is. Then, steps should be taken to correct the issue and redesign processes so it doesn’t happen again.

• Enforcement & Discipline- Within VHA, all employees must know and understand the “Standards for Ethical Conduct for Employees of the Executive Branch” (see slide 20). Employees who have knowingly violated organizational policy or laws should be disciplined based upon the infraction committed and not on the individual or position who committed the infraction.

• Annual Review of Program Effectiveness-  CBI Officers should review their CBI program plans and identify achievements accomplished, opportunities for improvement, assess the effectiveness of the CBI Program and future programmatic activities.

Open Lines of Communication• The VA has a Reporting Mechanism called the “CBI Helpline”

• The telephone number for the CBI Helpline is 1-866-842-4357 (1-866-VHA-HELP) , or e-mail to: vhacbihelpline@va.gov

• The CBI Helpline is available Monday through Friday from 8:00 am to 4:30 pm, EST. Anyone “internal” or “external” to the VA (this includes employees, patients or contractors) may call the CBI Helpline number to report potential compliance failures

• The caller may remain anonymous, however, the issue reported can not remain confidential. Also, people may guess who reported the issue

• The reporter is protected by the facility’s Non-Retaliation Policy, also known as the Whistleblower Protection Act

Open Lines of Communication (cont’d)

Tell your supervisor It’s our

responsibility

Call 1(866)VHA

-HELP

Call the CBI Officer

NO FEAR

Is it reportable?

Do the right thing

Tell your boss

Talk to your

supervisor

Duty to Report

Is it a compliance concern?

High Risk Areas

A high risk area is a clinical or business activity that may be unethical, illegal, a conflict of interest or in violation of national and local policies & procedures.

Employees and contractors should:

Be aware of high risk areas concerning VHA Not engage in fraud, waste, or abuse against VHA

Take appropriate actions- report all potential compliance failures to the VHA facility Compliance

Officer and/or the CBI Helpline.

Examples of High Risk Areas

Providing Medically Unnecessary Services: Providing services that the patient does not need or may cause the harm to the patient.

Failure to Report a Suspected Compliance Violation: knowing about a potential compliance failure and not reporting it.

Failure to Exert Due Diligence: Contracting with individuals or companies that have a propensity to engage in illegal activities or with which you have a financial interest.

Kickbacks and Bribes: Soliciting or receiving payment / gifts in return for referring a patient to another healthcare provider or for conducting business with a certain entity.

Appearing on the OIG Sanction List: Sanctioned individuals, entities, contractors listed on the DHHS Office of inspector General’s (OIG) Exclusionary List Database or the Excluded Persons (EPLS) database, cannot receive payments from any federal healthcare programs for services furnished.

Federal Employee and Contractor Responsibilities

• Contractors should not offer gifts to federal employees and federal employees should not accept gifts from entities that do business or are attempting to do business with the organization

• Federal employees should excuse themselves from activities in which they might have a financial interest

• Federal employees must remain impartial in conducting official duties

Applicable Laws, Regulations, and Policies: Code of Conduct

Employees must refrain from conflicts of interest as well as the appearance of conflicts. This includes:• Accepting gifts, lunches, tickets and other such items of

value from vendors and contractors with whom we do business

• Giving preferential treatment to any particular vendor or contractor during the contract process

• Accepting “kick backs” from contractors or vendors• Remember, when it comes to ethical behavior,

appearances count!

Reference: US Office of Government Ethics’ Employee Standards of Conduct- http://www.oge.gov/Laws-and-Regulations/Employee-Standards-of-Conduct/Employee-Standards-of-Conduct/

SummaryCompliance is Everybody’s Responsibility

Know who the Compliance Officers are and how to contact them (see slide 2)

Follow your own best instincts

Do your job ethically & legally

Be honest in all business transactions, and contracts / awards

Now…let’s test your knowledge!1. CBI’s major focus of oversight is in which of the following

areas? A. Business/Revenue Processes B. Law Enforcement C. Legal Services D. Facilities Management

2. What is VHA’s toll free number to report a compliance issue or concern? A. 1-800-488-8244 B. 1-866-COMPLY C. 1-800-CBI-4YOU D. 1-866-VHA-HELP

Still testing your knowledge…

3. Which of the following is an example of a high risk area?A. Giving wrong directions to a patient on purposeB. Providing medically unnecessary services C. Taking the last cookie when no one’s lookingD. Not pointing out the toilet paper stuck to your supervisor’s shoe

4. You work for Radiology and a GE representative wants to give you a cheap digital camera worth $9.99 A. OK, it’s $10.00 or less B. Ask for a memory card too C. No way, decline D. Exchange for free prints instead

Last question…

5. What is one purpose of a CBI program?A. To arrest people for committing policy violationsB. To conduct audits and monitorsC. To help VHA maintain the public’s trustD. To spoil everyone’s fun