2014 Trillium Health Compliance Plan

15 Pages·2014·0.85 MB·English

Trillium

HEALTH

AC Center, Inc.,
dba
Trillium Health and
Pleasant Street Apothecary

COMPLIANCE
PLAN
COMPLIANCE PLAN

AG Genter, Inc., dba Trilium Health and Pleasant Street Apothecary. hereby
calle ‘the organization,” is strongly commitied to and nas a longstanding
reputation for knwful and ethical conduct, We taka pride in merting the tust of
those we serve, government regulators and one another.

Giver the many laws, rules and regulations goverring healthcare, the
organization has established a comprehensive compliance program lo help us
live up to aur commitment to adhere lo the highest elhical standards of conduct
in all business practices.

‘The organization voluntarily implements a compliance program aimed at fraud.
waste, and abusa pravention while at the same tire advancing the mission of
providing quality patient and client care. Our compliance elforts are aimed at
preventian, detection, and resolution of variances.

‘The eight elerrents of the crganization's Compliance Pian are:

41. Commitment to Compliance
A, Standards of Conduct
B. Patiant and Client Righis
. Peisonal Health InformationiHIPAA‘Article 27-F Compliance:
D. Medical Necessity
E. Billing
F. Compliance with Applicable HHS Fraud Alerts
G. Marketing
H. Anli-Kick Back/inducements
|. Relationships with Vendors and Suppliers
4. Ratantion af Records/Cncumentation
K. Medical Records/Chant Record Documentation
L Prescription Drugs snd Conlralled Substances

2, Designation of a Compliance Ofiear!Committes
23, Conducting Training and Edueation Programs

4, Communication

5, Disciplinary Guidelines

8. Auditing ard Monitoring

7. Corrective Action

8, Response 9 Special Agent's Visit for the Purpose of Investigating Allegations.
of Fraud and Abuse

4. COMMITMENT TO COMPLIANCE
A, Standards of Conduct

‘The organization promotes adheronce ta the Compliance Program as en elernent
inthe performance evaluation of all staff members.

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‘The organization's employees are bound to comply, in all official acts and duties,
with all applicable laws, rules, regulations, standards of conduct, including, but
not limited to laws, rules, regulations, and directives of the federal government
and tha stata of Now York, also rules and policies and procedures of the
organization, These current and future standards of conduet are incorporated by
reference in this Compliance Plan,

All candidates for employment shall undergo @ reasonable and prudent
‘background investigation, including a reference and criminal background check.
Due diligence will he used in the recruitment and hiring pracess to prevent the
appointment tc pasitions with substantial discrelionary authority, persons whose
record (professional licensure, credentials. prior employment. criminal record or
specific “exclusion from Medicaid funded programs) gives reasonable cause to
believe the individual has a propensity to fal to adhare to applicabla standards af
conduct.

All new employees will receive orlentatlon and trainlag In compllance policies and
procedures. Participation in required training is a concition of employment
Failure (o participate in required training may resuit in disciplinary actions, up to
and including, termination of amploy-nent,

Every employes is ssked to sign a statement cerlifying they have received, read,
and understood the Gonlents of Uke compliance plan,

Every employee will roccive poriodie training updates in compliance protocals as
they relate to the employee's individual duties.

Non-cumpliance with the plan or violations will result in sanctioning of the
involved employee(s) up to. and including, termination of employment.

B. Pationt/Client Rights

We treal our palignisicients wilh respect and dignity and provide care that is
both necessary and appropriate, No distincton is made in the admission,
transfer. discharge or care of individuals on the basis of race, croee, religion,
national origin, gender, gender expression, sexual orientation, source of payment
oF disability. Clinical cara is provided based on identfied healtheare needs and
Case Management is provided based on needs identified through @ uniform
assessment tool, not on financial cfiteria, and no treatment or action is,
Undertaken without the Informed consent of the patient ar an authorized
representative, Patients/c ionts are provided with @ written statement of rights
which corfoms to all applicable laws, and their autonomy and privacy are
raspactad within the context of a safe congregate setting,

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Employees involved in patientclient care ere expected to know and camply with
all applicable laws and regulst ons and our policies and provecures gaveming
their particular program,

. Personal Health Informatioa/HIPAA/Article 27-F Compliance
‘The organization collects personal nealth information about aur palienssialients to

provide the best possible care. We realize ihe sensitive nature of this information,
and! are committed to safeguarding patients’ clients’ privacy

‘The organization has ereated the Privacy Officer position in accordance with the
HIPAA Privacy Rule. The Privacy Officer is responsible for development and
implementation of policies, pravadures and educalional programs that will ensure
that the organization will continue fo be cempliant with the Privacy regulations
ariel will also ensure that protected health information is secure.

In order to ensure that confidentia ity is maintained, employees end their
representatives must adhere ta the following rules:

© Do not discuss protacted health information (PHI! client information in
public areas such as clovators, nallways, common gathering areas.

+ Limit release of PHitclient information to the minimam reasonably
necessary for the purpose of the disclosure,

© Do not discinsa PHI witho.t an appropriate consent signed by the
patianticl ent unless it is related ta tne person's care, paymert of care, oF
health care operations of tre organization. In an emergency siluatior, a
palignt's conser may not be required when a healthcare provider treating
the patient requests informacion, but tre name and affllation of tia parson
requesting the information must be confirmed and documented in the
medical record,

+ Honor any restrislions on uses of disclosure of information placed by the
plientel ent

Make sura PHielient informatinn stored in the computer system is
properly secured

+ Be familiar with and comply with special confidentiality rules governing the
disclosure of HIVIAIDS, alenhcl, substance abuse and mental heath
sreatment,

D. Medical Necessity
The crganizalion will take reasonable measures to ensure that only claims for

services that are reasonable and necessary, given the patient's condition! client's
needs are billed.

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Documentation will supporl tie determinations of medical necessity'aient need

when providing services.

‘The arganization is aware that private and governmental third party payers will
only pay for tests that reet the coverage crileria and ane reasunable and
‘necessary to treat of diagnose a patient. Therefore, the organization's Providers
will Use prudent ordering practicas,

In requosting diagnostic procadures or tests, the organization's Providers will
make an independent medical necessity decision with regard to each item
ordered. A disgrosis will be submitted for all tests ordered. Documentation of
‘Indings and dlagnoses will support the medical necessity of the service.

Tho oganization’s Providers understand that private and governmental third
party payers generally hava limitations on labaratary and diagnostic tests;
therefore, the pitar autharization process wil be followed.

The organization's providers wil order tests or services that are medically
necessary for the approoriate traatmert of tra patient.

E. Billing

All claims for serices submitted :o pitvate and governmental thied party payers
or other health benefits programs will correctly identify the services ordered,

Only those tests ordered oy an authorized Provider that are performed and that
maa private and gavernmartal third party payer's criteria wil be billed,

Intentionally or knowingly up coding (the selection of @ code to maximize
reimbursement when such code is not the must appropriate desciptor of the
service offered) may result in immediate termination. The organization's
providers must provide documentation to support the current CPT and ICD codes
sed based on macical findings and diagnoses.

Immediate disciplinary action, up to and including temnination will be
implemented for instances of intentional misrepresentation of any service
provided that results in over billing,

All irdiv duals who pravide billing information and billing cenartment employees
who prepare or submit billing slalemenis must comply wilh all applicable laws,
rules and regulations and the organization's policies.

The organization will promptly retum to payers any payments which wa
datermine da nat conform te ur eolicies ard applicable laws.

If erronequs claims have been made to Medicaid from the Health Homes or Adult

Day Health programs, the applicable AIDS Institute cowract manager will be
noted.

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As healihcarefhutnan service Providers, our business involves reimbursement
under govemment programs which require submission of certain teports ot our
costs of operations, The organization complies with all federal and state laws and
ragulations ralating ta cost reports, which define what costs are allowable and
oser-be the appropriate mathodolagies to clam reimbursement for the cost of
services provided to program beneficiaries. Given the complexity of this area, all
issues related lo the cumpletion and settlament of cost reports must be
communicated through or coordinated with tha Chief Financial Officer as well as
the Ch ef Compliance Office.

F. Compliance with Applicable HHS Fraud Alerts
‘The Compliance Officer will review tha Modicaid/Mediearc Fraud Alerts

‘The Compliance Officer will ensure that any conduct disparaged by the Fraud
Alert is immediately ceased, implemen! corieclive ac:ions, and take reasonable
factions lo ensure that future vie ations do not accur.

G. Marketing

‘The organization will promole only honast, straightforward, fully informative, and
non-decentive marketing, We use marketing fo educate the public, increase
awareness of our services and recruit employces. All marketing materials must
accurately describe our services and programs. In order to ensure thst no
incorrect information is dissemizaled, employaes mus! ccordinale ak marketing
materials with and direct all media requests to the Vice President of
Organizational Advancement or Vice Prasident of Organizational Performance
Management, if the formar position is vacant. The Organization will only use
andior disciosa any paticnticient protected health information for marketing
‘activities if a writtan prior aulharization is obtained

H. Anti-Klckback/Inducements

‘The organization will not part cipate in nor condane tre provision of inducements
fo recaipt of kiakhacks fe gain business or influerice referrals, The organizalion's
Providers will consider the palienticient's interests in offering referral for
treatment, diagnostic, or service options.

Federal and state laws prohibit any form of kicknack, bribe or rebate, cither

directly or in directly, in cash or in kind, to induce the purchase or referral of
goods, sorvices or lems paid for by Medicare or Medicaid.

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Self-referral laws prohibit a Provider from referring a alien! for verlain lypes of
health servicas te an entity with which the Provider or members of his or her
immediate farrily has a financial ralationship.

Since violations of these laws may subject both the organization and the
individual involvad to civil and criminal penalties and exclusion from government
funded healthcare programs, all prososed transactions with healthcare Providers
must be reviewed with fogal coun

Any employee involved in promoting or accepting kickbacks or offering
inducements ‘nay be terminated immediately.

| Relationships with Vendors and Suppliers

‘The omgarization is committed to employing the highest ethical standards in its
Telationships wilh vendors and suppliers with respect to source selection,
negotiation, determination of contract awards, and administ-ation of purchasing
actiatias. Al" vendors and suppliers are to be selected solely on the bass of
objective criteria; personal ralationships ard frendships play no part in the
selection process. The organization doas nat knawingly contract or da business
willl a vendor thal has been excluded from a govemment-funded healthcare
program, Any vendor or suppler who has access to the Organization’s PHI and
1s not a covered entity, will be required to enter into a Business Associate
Agreement to comply with HIPAA rules and the HITECH Act

J. Retention of Records/Documentation

The organization wik ensure that all records required by federal andior state faw
ara created and maintained. All records will be maintained for a period of no lass
than seven years,

Documentation of compliance efforts will include staff meeting and committee
minutes, audit reports, memoranda concerning compliance protocols, problems
identified and corrective acticns taken, the results of any investigations, and
documentation supportive cf assessment findings, diagnoses, treatments, and
plan of care,

K, Medical Record Documentation

Timely, accurate and complete documentation is important to clinical patient
are. This documentation not only facilitates. high quality patient care, but also
serves to verify that billing is accurate as subrmiltad,

‘The otganizalion requires thal Providers follow Ihese documentation guidelines:

‘+The medical record! client record is cornplote and legible

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= Documentation is timely

+ The documentation of each patient encounter includes the reagan for the
encounter, any relevant history, physical examination findings, prior
agnostic test results, assessment, clinical impression or diagnosis, plan
of care, and date and legible identity at the observer.

» OPT and ICD-8 codes used for clair-s submission are supported by
documentation In the medical record

Appropriate health risk factors are identified. The patient's progress, his or
her response to treatment

+ Care management encounters will be documented per New York State
Department of Health guidelines.

LL. Prescription Drugs and Controlled Substances

The organization's employees routinely have access to prescription drugs,
conirolied substances and olher medical supplies. in accordance with federal,
state and local laws, itis strictly prohibited to divert prescription drugs and
contyolled substances te unauthorized individuals. to administer them without
propar ardars, to distrhute adulterated, mishranded, mislabeled ar expired drugs
fr devices, of to fail to repart significant adverse events. Any employee of the
organization who becomes aviare of a potential lapse in security or the improper
diversion of druys musl reporl the incident immediately <0 his‘her supervisor or
she Compliance Officer.

IL DESIGNATION OF A COMPLIANCE OFFICER AND/OR A COMPLIANCE
COMMITTEE

The organization designates the Sr. Vice Presiden: of Organizational
Performance Management fn sarva as the Compliance Officer and coordinator of
all complianca actiitias,

Compliance Officer:
The responsibilties of the Compliance Officer are:

+ Ghair the Compliance Commitee and serve as a spokesperso9 for the
committee

+ Overseeing and monitoring the implementation of the compliance
program,

+ Reporting periodically to the Compliance Committee, the President and
the Board of Diractors on the progress of implamentation of compliance
initiatives, corrective actions and recommendations to reduce the
vulnerability to allegations of fraud, waste, and abuse.

+ Developing and distributing all writen compliance policies and procedures
to all affected employees,

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+ Parindically ravising the program in light of changes in the needs of the
organization and in the law; and changes in policies and procedures af
government and private payer health plans.

+ Developing, cuerdinating, and participating in a multifaceted educational
and! training program that focuses on the elements of the compliance
Program and socks to ensure that all employees are knowledgeable of,
‘and comply with, pertinent federal. state, and private payer standants.

+ Coordinating with lhe Human Resources Department ta ensure that
‘employees do nol appear in any of the "excluded, dabarred or suspended’
personnel listings published by Medicare and Medicaid.

+ Ensuring that all ProvidersiGare Management Slaif are informed of
compliancs program standards with respect te coding, billing
documentation, and marketing. et.

+ Assisting in coordivaling intemal compliance raviow and mentoring
activiies, including annual or p-r.n. raviows of policies.

+ Review the results of compliance audits, including internal reviews of
compliance, indopendent reviews and extemal compliance audits.

+ Indepandently investigating and acting on matters related to compliance,
including the flexibly to design and coordinate intemal investigations.

+ Developing policies and programs that encourage managers and
employees to report stspactad fraud and other improprieties wilhoul fear
of retaliation. (See Wristicblover Policy)

+ Interacting with extemal legal counsel lo discuss the Organization's
initiatives an regulatory compliance,

+ Handling inquiries by employees, volunteers, affiliates, consumers and
family members regarding compliance issucs.

‘The Compliance Officer has the authority to review all documents. and ther
information relative to compliance activities, including, but aot limited to
HRiPersannel records, requisition forms, billing information, claims infonmatian,
‘and records conceming marketing afforts and arrangements with cliers.

Compliance Committee:

‘Tha organization will designate a Compliance Committee to advise the
Compliance Officer and assist in the implementation of the compliance program
as needed. The Compliance Committee will consist af at least the Chief Financial
Dfficer, Chief Medical Officer, President, and one or more Board members. The
Compliance Officer will alsa’ sclect designees representing Human Resources.
and other Depariments/Divisions as needed. The Compliance Oficer is the
Chair of the Compliance Committee, which reports to the Executive Cammittee of
the Board at least twice per year.

‘The functions of the Compliance Committee are:

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+ Analyzing the Qiganivation’s regulatory environment, the legal
requirements with which it must comply, and specific risk areas.

+ Assessing existing policies and procedures that addrese risk areas for
possible incorporation into the Compliance Program,

+ Working within the Organization's standards o* conduct and policies and
procedures to promote complianca,
Reonmmending and monitoring the development of intemal systems and
controls to Implement standards, policies, and procedures as parl of the
daily operations.

+ Delermining Ihe appropriate strategylapproach to promote compliance
with the program and detection of any potential problarrs or violations.

+ Developing a system to solicit, avaluata, and respond to complaints and
orab ams,

ill. CONDUCTING EFFECTIVE TRAINING AND EDUCATION

‘The organization requires all employees ta artend spociic training upon hire and
fon an annual and p.r.n, basis thereafter. This will include training in federal and
State statutes, regulations, program requirements, policies of private payers, and
corporate eth cs. The training will emphasize the Organizalion’s corrmilment to
compliance wilh these legal ‘equirements and policies,

The training programs will include sessions highlighting the Organization's
Compliance Program, summaries of fraud and abuse laws, discussions of coding
requirements, claim development, claim submission processes, and marketing
practices ihal reflect current legal and program standards.

The Gamplianaa Officer or other dosignatad staff mamber will dacument the
attordecs, the subjects covered, and any materials distributed at the training

Basic training wil include:

+ Governmert and private payer reimbursement principles.
General prchibitions on paying or receiving remuneration to induce

referrals.

Proper translation of narrative diagnoses,

Only billing for services ordered, performed, and reported.

Examples of fraud, waste, and abuse,

Duly to repart misconduct

Iv, DEVELOPING EFFECTIVE LINES OF COMMUNICATION

The organization will protact whistls-blowars from retaliation. The organization
‘will not rotal ate against cmployees who, in good faith, have mace a protest or

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