Developing a Healthcare Finance Fraud, Abuse & Compliance Program

Compliance is a comprehensive program that helps institutions and their employees conduct operations and activities ethically; with the highest level of integrity, and in compliance with legal and regulatory requirements. To have an effective compliance program, an organization must establish and maintain an organizational culture that “encourages ethical conduct and a commitment to compliance with the law.” U.S. Federal Sentencing Guidelines §8B2.1(a)(2)

The local county has voted in approval to build a large state-of-the-art level IV hospital. With so many tasks ahead of the developers and the healthcare organization, you were recently hired as the new Chief Finance Officer (CFO). One of the first priorities you have been tasked to complete is the design and implementation of a comprehensive Healthcare Finance Fraud, Abuse & Compliance Program in order to establish a gateway between revenue and reimbursement practices and the ethical and professional adherence to applicable federal laws. 

Deliverables: The final product to submit is a comprehensive Healthcare Finance Fraud, Abuse & Compliance Program that includes the following. Submit one (1) single Microsoft PowerPoint presentation for Part I. and one (1) single Microsoft Word for Part II.

PART I.

Using the following website https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0ahUKEwjGj5Ky3rXRAhVGQSYKHcKIAVYQFggcMAA&url=http%3A%2F%2Fwww.healthcarefinancenews.com%2Fslideshow%2Fbiggest-healthcare-frauds-2015-running-list&usg=AFQjCNE0m_a8U_MTceXrs2VkA1qK3xjv9Q&sig2=mVKRT1mtGXwn776VKbrqhg, or feel free to utilize the Office of Inspector General (OIG) website at  https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0ahUKEwjWxuae5rXRAhVGRyYKHQDlAXYQFggaMAA&url=https%3A%2F%2Foig.hhs.gov%2F&usg=AFQjCNGPpHJtl49p2CqafCVyTJJLGPL2Vg&sig2=Hytz150zh2Oe7rXEDTAncg&bvm=bv.142059868,d.eWE, select a real-time healthcare fraud news report in order to feature within your Power Point presentation to educate the organization on the various cases, the importance of healthcare finance compliance practices and the potential criminal and monetary fines that can be imposed on the individual and/or organization. Design a 7-10 slide Power Point presentation that provides a succinct overview of healthcare finance fraud, abuse and compliance the intent is for a future mandatory automated training; therefore audio is required).

The name of the organization
Discuss the events that occurred
Identify if the events that occurred is a violation of one of the following related federal laws and explain why:

The Anti-Kickback Statute
The False Claims Act
The Physician Self-Referral Law (Stark Law)
Exclusion Statute
Civil Monetary Penalties Law

Identify the parties involved
What penalties were enforced
A summary of lessons learned that can serve as a teachable moment for your organization
Presentation can include clip art, links to additional sources
Must include recorded audio of each presentation’s slide

PART II.

Adopting MedPro Group, Seven Fundamental Steps of a Compliance Plan, create a comprehensive plan that aligns with the following seven steps:

Element One: Implementing Written Policies, Procedures, and Standards of Conduct

Devise at least 3 healthcare finance related fraud and compliance policies and accompanying procedures. Your policies and procedures MUST… 
Explain legal requirements so that employees understand their obligations and how to conform their behavior to meet them
State your plans on how to encourage managers and employees to report suspected fraud and other improprieties without fear of retaliation 
Should be made easily available (identify in a written statement where and/or how one can access the above policies and procedure)

Element Two: Designating a Compliance Officer and Compliance Committee to Provide Program Oversight 

Note; this task was completed with your initial hiring as the new CFO. However, you are to develop a 1-2 page job description in order to seek a compliance officer that will report directly to you.
Develop the proposed overview of the Compliance Committee that will be chaired by the above compliance officer. Identify the proposed frequency of meetings (simple schedule over a calendar year) (the committee is expected to meet monthly), the preferred number of committee members and the various departments/areas that each member will represent, identify at least six purposes/responsibilities that the committee is expected to carry out and outline the proposed method of communication (during the scheduled monthly meetings and outside of scheduled meetings)

Element Three: Using Due Diligence in the Delegation of Authority

This task is completed, as you are the delegated person of authority that oversees the proposed healthcare finance, fraud, abuse and compliance program 

Element Four: Educating Employees and Developing Effective Lines of Communication 

Note; this task was partially completed with the above Power Point presentation; however let’s prepare take your work to the next level…
Develop clear and practical steps that will be taken in order to  disseminate information about the organization’s compliance program and its policies and processes 
Devise a training schedule (identify the frequency of the conducted training’s, identify who will be required to attend) along with an assessment to monitor the effectiveness of the training session. Draft a one-page agenda that outline the proposed topics of discussion that will be covered in the training session
As a continuation of Element One, discuss how employees can report suspected fraud. For example, you may establish an anonymous reporting contact number or electronic email reporting system. Draft a generic automated response that an individual will receive after submitting a report. This will include a thank you line as a confirmation. The estimated time for a response and a person or number to contact for further assistance

Element Five: Conducting Internal Monitoring and Auditing

Discuss the efforts that will be taken to ensure that the financial practices are compliant and adheres to ethical guidelines and standards
Outline the process of conducting internal monitoring and auditing practices
Design a healthcare fraud, abuse and compliance calendar template that includes the following:

Department
Regulation/Statute/Law
Department
Name of the Individual Completing the Calendar
Date & Signature Line
Actions Steps to Compliance: Steps/Description, Responsibility and Completion Date
Standards Section that will be evaluated (this should be included as a column): requirement, deadline/due date, responsible office/department and status

Element Six: Enforcing Standards Through Well-Publicized Disciplinary Guidelines 

Develop a generic outline that addresses the following:

Explains who is covered
Standards of conduct
Discipline and enforcement 
Reporting (obligations), whistleblower, non-retaliation

Create a five (5) Q&A handout for the intent of distributing to employees. Devise questions and answers that are appropriate to healthcare finance, fraud, abuse and compliance
Element Seven: Responding Promptly to Detected Offenses and Undertaking Corrective Action 

Provide a generic response in terms of responding to detected offenses. Create a four (4) step corrective action approach that aligns with your Human Resource (HR) guidelines and standards as it relates to employee disciplinary actions

 
Resources:

Ethics Resource Center: www.ethics.org
Compliance Building: www.compliancebuilding.com 
Office of the Inspector General: http://oig.hhs.gov/fraud/complianceguidance.asp

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