2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate...

71
Corporate Compliance Training: Corporate Compliance Training: Corporate Compliance Training: Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs Patients 3.Combating Medicare Fraud, Waste and Abuse 3.Combating Medicare Fraud, Waste and Abuse Revised January 2017 1

Transcript of 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate...

Page 1: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

Corporate Compliance Training:Corporate Compliance Training:Corporate Compliance Training:Corporate Compliance Training:1.Cultural & Linguistic Competence2.Model of Care for Special Needs Patients3.Combating Medicare Fraud, Waste and Abuse3.Combating Medicare Fraud, Waste and Abuse

Revised January 2017

1

Page 2: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

This training presentation contains confidential and proprietary trade secrets of and copyrights belonging to RadNet Management, Inc., its subsidiaries, and/or affiliates (collectively, "RadNet").

This training presentation may only be used by a RadNet Center, RadNet's representatives or upon the express written permission of RadNet, and may not be reproduced in any media, either in whole or in part Any reproduction of these documents ineither in whole or in part. Any reproduction of these documents, in whole or in part, or any use of these documents, other than as directed or agreed upon in writing by RadNet, is strictly prohibited and constitutes a violation of law.

2

Page 3: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

Anyone who provides services to Medicare patients must complete annual compliance trainingmust complete annual compliance training.

This three-part training series is required for us to be able to bill for servicesable to bill for services.

Attestations must be completed annually for our payors stating this training has been completed by allpayors stating this training has been completed by all RadNet employees and affiliates (contractual staff).

3

Page 4: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

4

Page 5: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

CultureCulture is the learned and shared knowledge that specificgroups use to generate their behavior and interpret theirg p g pexperience of the world.

It is transmitted through social and institutional traditions to succeeding generations.

Culture is a paradox: While many aspects remain the same,

languagesbeliefs practices communication

it is also constantly changing.

thoughts courtesiesrituals rolesrelationships

values customs expectedbehaviors

manners ofinteracting

5

Page 6: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

Cultural Diversity The term Cultural Diversity is used to describe differencesthat distinguish one group or individual from another.

nationality; ethnic or racial classificationgender identity, self-identificationphysical and intellectual abilitiesphysical and intellectual abilitiessocioeconomic statuspersonal appearancereligion spiritualityreligion, spiritualitysexual orientationeducation levelllanguagegenderage

6

Page 7: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

Cultural Competence

behaviors policiespracticesbehaviors policiespractices

attitudes structures

Cultural Competence requires that organizations have a clearly defined, congruent set of values and principles, and y , g p p ,demonstrate behaviors, attitudes, policies, structures, and practices that enable them to work effectively cross-culturally.

7

Page 8: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

5 Elements of C lt l C t

On an Individual Level

Cultural Competence1. Acknowledge and value the cultural differences of others2. Understand your own culturey3. Engage in a self-assessment of your acceptance level4. Acquire cultural knowledge & skills5. View people’s behavior within a cultural contextThese five elements must be manifested at every level of an

i i d fl d i i i dorganization and reflected in its attitudes, structures, policies, practices, and services in order to be a Culturally Competent Company.p p y

8

Page 9: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

Organizational & Personal Ch

H i li th h ll

ChangeHerein lies the challenge:

Being a culturally competent organization requires changes in people’s values attitudes and/or habits of behaviorin people s values, attitudes and/or habits of behavior.

Start thinking about the intention of cultural diversity and the behavioral criteria needed to be accepting of everyonethe behavioral criteria needed to be accepting of everyone who comes to our centers for service.

Take action by being aware of how you interact with ourTake action by being aware of how you interact with our patients, visitors and referrers, and make every effort to give Everyone the Same Positive Experience.

9

Page 10: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

Your RoleIf you are already accepting of all persons, no matter what their race religion age gender languagewhat their race, religion, age, gender, language, socioeconomic status, education level, religion, physical abilities, intellectual status, sexual orientation, gender id i lf id ifi i l h ’identity, self-identification or personal appearance, that’s great.

If you realize you have a bias toward someone who mayIf you realize you have a bias toward someone who may be different than you, it’s important that you understand you cannot allow that bias to affect how you deal with those persons in the workplace.

10

Page 11: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

Things You Can Do1. View the world through a cultural lens. Acknowledge that

people with different cultural backgrounds have different needs.2. Share your cultural experience with other employees.

Understanding cultural differences leads to better acceptance. 3 Accept the diversity of others Remove bias prejudice3. Accept the diversity of others. Remove bias, prejudice,

stereotyping, and discrimination from the workplace. Treat all patients and visitors equally.

4 Add i l th i li i ti d hi di iti4. Address racial, ethnic, linguistic, and geographic disparities. Address the needs of each person in a professional manner, no matter what their cultural background or lifestyle may be.

5. Collaborate with others when you are unable to address the needs of a specific person. Get help if you are unable to provide what someone needswhat someone needs.

11

Page 12: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

Be Culturally CompetentAs a Culturally Competent Company, we must all be capable of interacting positively with people who do not:g p y p p

Look likeTalk likeMove likeThink likeBelieve likeAct likeLive like UsLive like…..Us

12

Page 13: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

13

Page 14: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

The Centers for Medicare and Medicaid Services (CMS) created the Models of Care Plans to:

Improve patient access to medical, mental health and social services,

Improve access to affordable care,

Improve coordination of health care Improve coordination of health care,

Assure cost-effective service delivery,

And improve beneficiary health outcomes.

14

Page 15: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

A Model of Care for Special Needs Patients is considered a vital component for ensuring the unique needs of each patient are identified and addressed.

It is important that RadNet is able to provide services f h bl hfor patients who are unable to access care in the same way as someone without special needs.

Thi i l d b i li i d i i h This includes, but is not limited to, patients with severe medical conditions, physical needs, language needs, and gender needs or self-identification needs., g

15

Page 16: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

Special Needs Plans were also created by Congress under the Medicare Modernization Act as a way to focus on certain vulnerable groups of Medicare and Medicaid beneficiaries: The institutionalized and The institutionalized, and Beneficiaries with severe or disabling chronic conditions.

These beneficiaries are typically more challenging to These beneficiaries are typically more challenging to treat.

16

Page 17: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

While the American With Disabilities Act and RadNet’s Special Accommodations Policy already address patients with physical mobility and communication impairments;with physical mobility and communication impairments; And RadNet’s Limited English Proficient Patients Policy addresses patients with English language limitations; The Centers for Medicare and Medicaid Services proposed regulations to ensure patients in LGBTQ communities have equal access to care.q

This includes establishing same-sex spouses being considered a person’s representative, regardless of state law, for the purposes of exercising a patient’s health care rights to ensure they receive equal care in medical facilities.

17

Page 18: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

The Centers for Medicare and Medicaid Services also created an Oncology Care Model.

Under this Special Needs Plan, physician practices are entering into payment arrangements that include financial and performance accountability for episodesfinancial and performance accountability for episodes of care surrounding chemotherapy administration to cancer patients.

For those that are not already aware, RadNet is involved in an oncology practice on the west coast.

CMS is also partnering with several commercial payers in this model.

18

Page 19: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

Although RadNet does not coordinate an interdisciplinary care team (such as an HMO), our Company believes it is important to understand that:

1. All patients need to have equal access to care; and

2. Be treated in a professional and equal manner.

19

Page 20: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

20

Page 21: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

Every year, billions of dollars are improperly spent because of health care fraud waste and abusebecause of health care fraud, waste and abuse.

As someone who provides services for Medicare enrollees your every action potentially affects theenrollees, your every action potentially affects the Medicare Program and Medicare Trust Fund.

This training will help you understand prevent detect This training will help you understand, prevent, detect and correct fraud, waste and abuse.

21

Page 22: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

Statutes, regulations and policies govern the Medicare, Medicaid and MediCal programs.

RadNet must follow the guidelines of: 42 Code of Federal Regulations: §422.503g § 42 Code of Federal Regulations: §423.504. Section 50.3 of the Compliance Program Guidelines Among many other health care regulations

22

Page 23: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

The centers for Medicare & Medicaid Services (CMS) requires RadNet to have an effective Compliance P th tProgram that: Demonstrates RadNet’s commitment to legal and

ethical conduct;ethical conduct; Provides guidance on how to handle compliance

questions and concerns; andq ; Provides guidance on how to identify and report

compliance violations.

23

Page 24: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

An effective compliance program is essential to prevent, detect and correct Medicare non-compliance,

ll f d d bas well as fraud, waste and abuse. RadNet’s Compliance Program includes the seven (7)

Core Regulatory Requirements:Core Regulatory Requirements: Written Policies, Procedures and Standards of Conduct Compliance Officer & Committee with a High Level of Oversight Effective Training and Education Effective Lines of Communication Well-Publicized Disciplinary Standards and Prompt Response Routine Monitoring, Auditing & Identification of Compliance Risks Prompt response to Compliance Issues

24

Page 25: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

As part of the Medicare Program, RadNet employees and affiliates must conduct themselves in an ethical and legal manner.

It’s about doing the right thing! Act fairly and honestly; Adhere to high ethical standards in all you do; Comply with all applicable laws, regulations and CMS

requirements; and Report suspected violations.

25

Page 26: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

RadNet’s Code of Conduct states our Company’s compliance expectations and the principles and values by which we operate our businessby which we operate our business.

Related concepts include honor and moral codes.

R dN t l d ffili t RadNet employees and affiliates are required to complete a Code of Conduct Policy yAcknowledgement.

The Code of Conduct includes seven (7) ethical standards.

26

Page 27: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

1. I will perform my duties in good faith and to the best of m abilit I ill act in the best interest ofbest of my ability. I will act in the best interest of RadNet, and refrain from any illegal conduct.

2. I will not engage in any corrupt business intended to obtain favorable treatment by or additional business from any government entity physician patientfrom any government entity, physician, patient, vendor or any other party in a position to benefit RadNet.

27

Page 28: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

3. I will not pay any person or entity for the referral of patients, nor will I accept any payment for referrals.

f l ll b d l l h b f hReferrals will be made solely on the basis of what is best for the patient, without regard for the value or volume of business which any person or entity can y p yprovide to RadNet.

4. I will not participate in any false billing of patients,4. I will not participate in any false billing of patients, government entities or any other party. I will promptly report any suspicious billing practices to my supervisor or to the Corporate Compliancemy supervisor or to the Corporate Compliance Officer.

28

Page 29: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

5. I will not engage in any conduct which conflicts with the interests of RadNet without the express writtenthe interests of RadNet without the express written consent of the RadNet Board of Directors. I will avoid even the appearance of impropriety and

ill t ll t fli t t th C twill report all apparent conflicts to the Corporate Compliance Officer.

29

Page 30: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

6. I will not use RadNet confidential or proprietary information gathered during my employment with RadNet for my own personal benefit while I am employed at RadNet or at any time thereafter. I will not disclose confidential financial medical or othernot disclose confidential financial, medical or other information obtained from patients without their express written permission and in accordance with ll li bl li i d d f R dN tall applicable policies and procedures of RadNet.

7. I will promptly report all suspected violations of this C d f C d b h R dN lCode of Conduct by other RadNet employees or agents to the Corporate Compliance Officer………….

30

Page 31: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

RadNet is committed to conducting its business in a lawful and ethical manner. RadNet's employees and affiliated h d l h ll l bl lphysicians are required to comply with all applicable laws,

regulations, and policies affecting the operations of RadNet's business, including but not limited to rules relating to: Billing for items or services not actually provided; Improper coding practices; Providing medically unnecessary services; Failure to provide sufficient documentation; Failure to provide sufficient documentation; Improper reassignment of Medicare payments; Supervision of diagnostic services; Improper referral arrangements; Waivers of co-payments and deductibles; Improper patient inducements; Required payments to referral sources that violate the anti-kickback statute; Improper marketing activities; Improper marketing activities; Contracts with suppliers, independent contractors, other medical practices,

physician management companies, billing agents, etc. Joint ventures with other physicians, vendors, hospitals, and managed care

organizations; and Other physician investments

31

Page 32: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

Non-compliance is conduct that does not conform to the law, Federal health care program requirements or R dN t’ b i li iRadNet’s business policies.

CMS has identified the Medicare high-risk areas:Advance Beneficiary Notices Advance Beneficiary Notices

Conflicts of interest Claims processing Credentialing and provider networks Ethics Oversight and monitoringOversight and monitoring HIPAA Privacy Act Quality of care

32

Page 33: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

Failure to follow Medicare Program requirements and CMS guidance can lead to serious consequences:

C i i / L f b i d Contract termination / Loss of business and revenue Criminal penalties Exclusion from participation in all Federal health care programs Civil monetary penalties

Those who engage in non-compliant behavior may be g g p ysubject to any of the following disciplinary standards: Mandatory retraining Disciplinary action Disciplinary action Termination of employment or contract

33

Page 34: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

Without programs to prevent, detect and correct non-compliance, we all risk: Harm to beneficiaries, such as: Delayed services Denial of benefitsDenial of benefits Difficulty in using providers of choice Other hurdles to care

Less money for everyone, due to: Higher insurance copayments and premiums Lower benefits for individuals and employers Lower benefits for individuals and employers Lower ratings Lower profits

34

Page 35: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

Fraud is intentionally submitting false information to the government or a government contractor in order to get money or a benefitorder to get money or a benefit.

Knowingly and willfully executing, or attempting to execute a scheme to defraud any health careexecute, a scheme to defraud any health care benefit program;

Or to obtain any of the money or property owned Or to obtain any of the money or property owned by, or under the custody or control of, any health care benefit program by means of false or f d lfraudulent pretenses, representations, or promises.

35

Page 36: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

Knowingly billing for services not furnished or supplies not provided, including billing Medicare for appointments that the patient failed to keepappointments that the patient failed to keep.

Knowingly altering claim forms, medical records, or receipts to receive a higher paymentreceipts to receive a higher payment.

The Health Care Fraud Statute makes it a criminal offense to knowingly and willfully execute a scheme tooffense to knowingly and willfully execute a scheme to defraud a health care benefit program. Health care fraud is punishable by imprisonment for

up to 10 years. It is also subject to criminal fines of up to $250,000.

36

Page 37: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

Waste includes overusing services, or other practices that, directly or indirectly result in unnecessary coststhat, directly or indirectly result in unnecessary costs to the Medicare Program.

Waste is generally not considered to be caused by g y ycriminally negligent actions, but rather by the misuse of resources.

Unlike fraud, the provider has not knowingly or intentionally misrepresented facts to obtain payment.

37

Page 38: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

Examples of actions that may constitute Medicare waste include, but are not limited to:

Conducting excessive office visits or writing excessive prescriptions.

Administering and billing for contrast during a non-contrast ordered exam when it was not necessary for th di i f ifi ditithe diagnosis of a specific condition.

Ordering excessive diagnostic exams or laboratory t ttests.

38

Page 39: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

Abuse includes actions that may directly or indirectly result in unnecessary costs to the Medicare Program.result in unnecessary costs to the Medicare Program.

Abuse involves payment for items or services when there is not legal entitlement to that payment and the g p yprovider has not knowingly and/or intentionally misrepresented facts to obtain payment.

39

Page 40: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

Examples of actions that may constitute Medicare abuse include, but are not limited to:Billing for unnecessary medical services.Charging excessively for services or supplies.Misusing codes on a claim, such as upcoding or

unbundling codes. Billing for brand name drugs when generics are

dispensed.

40

Page 41: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

There are differences between fraud, waste and abuse.

The primar difference is intent and kno ledge The primary difference is intent and knowledge.

Fraud requires the person to have intent to obtain payment and the knowledge that their actions arepayment and the knowledge that their actions are wrong.

Waste and Abuse may involve obtaining an improper Waste and Abuse may involve obtaining an improper payment or creating an unnecessary cost to the Medicare Program, but does not require the same intent and knowledge.

41

Page 42: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

To detect fraud/waste/abuse, you need to know the law.

The following slides provide information about: The following slides provide information about: Civil FalseClaimsAct,HealthCareFraudStatute,CriminalFraud Anti-Kickback Statute Stark Statute Exclusion

H l h I P bili d A bili A (HIPAA) Health Insurance Portability and Accountability Act (HIPAA)

If you’d like more details on these specific laws, such as f h b i i lt th li bl t t tsafe harbor provisions, consult the applicable statute

and regulations.

42

Page 43: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

The Civil False Claims Act makes a person liable to pay damages to the Government if he or she knowingly: Conspires to violate the False Claims Act. Carries out other acts to obtain property from the

G b i iGovernment by misrepresentation. Knowingly conceals or improperly avoids or

decreases an obligation to pay the Governmentdecreases an obligation to pay the Government. Makes or uses a false record or statement supporting

a false claim.a false claim. Presents a false claim for payment or approval.

43

Page 44: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

Any person who knowingly submits false claims to the Government is liable for three times the Government’s d d b th i l t l ltdamages caused by the violator, plus a penalty.

The Civil Monetary Penalty may range from $5,500 to $11 000 for each false claim$11,000 for each false claim.

A whistleblower is a person who exposes information or activity that is deemed illegal dishonest or violatesor activity that is deemed illegal, dishonest, or violates professional or clinical standards.

Persons who report false claims or bring legal actions Persons who report false claims or bring legal actions to recover money paid on false claims are protected from retaliation.

44

Page 45: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

The Health Care Fraud Statute states that “Whoever knowingly and willingly executes, or attempts to

t h t d f d h lth b fitexecute, a scheme to defraud any health care benefit program shall be: FinedFined Imprisoned not more than 10 years Or both

Conviction under the statute does not require proof that the violator had knowledge of the law or specific intent to violate the law.

45

Page 46: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

True story about someone violating the Health Care Fraud Statute.

A Pennsylvania pharmacist submitted claims to Medicare for non-existent prescriptions and for drugs

d dnot dispensed. He was found guilty of health care fraud. He received a 15-month prison sentence and

$166,000 fine.

46

Page 47: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

Persons who knowingly commit Criminal Fraud by making a false claim may be subject to: Criminal fines up to $250,000 Imprisonment for up to 20 years

Or both Or both

If the violations resulted in death, the individual may be imprisoned for any term of years or for lifebe imprisoned for any term of years or for life.

47

Page 48: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

The Anti-Kickback Statute prohibits knowingly and willfully soliciting, receiving, offering or paying

ti (i l di ki kb k b ib b t )remuneration (including any kickback, bribe or rebate) for referrals for services that are paid, in whole or in part, under a Federal health care program (including the Medicare Program).

Violations are punishable by: A fine of up to $25,000 Imprisonment for up to 5 years Or both

48

Page 49: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

True story about someone violating the Anti-Kickback Statute.

A radiologist who owned and served as medical director of a diagnostic testing center in New Jersey obtained nearly $2 million in payments from Medicareobtained nearly $2 million in payments from Medicare and Medicaid for diagnostic imaging procedures.

He was found to have paid doctors for referring He was found to have paid doctors for referring patients.

He was guilty of violating the Anti-Kickback Statute.g y g He was sentenced to 46 months in prison.

49

Page 50: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

The Start Statute prohibits a physician from making f l f t i d i t d h lth i treferrals for certain designated health services to an

entity if the physician (or a member of his/her family): Has an ownership or investment interest; orp ; A compensation arrangement (exceptions apply).

Medicare claims tainted by an arrangement that does not comply with the Stark Statute are not payable.

Penalties include:$ f f h d d Up to a $15,000 fine for each service provided

Up to a $100,000 fine for entering into an unlawful arrangement or schemearrangement or scheme

50

Page 51: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

True story about someone violating the Stark Statute.A h i i ti l f d M di ti t t A physician routinely referred Medicare patients to an oxygen supply company that he owned.

He was found guilty of violating the Stark Statute He was found guilty of violating the Stark Statute. He had to pay the Government $203,000 to settle the

allegations.allegations.

51

Page 52: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

The Office of Inspector General (OIG) may impose Civil Monetary Penalties for a number of reasons, including: Arranging for services or items from an excluded

individual or entity.d h l l d d Providing services or items while excluded.

Failing to grant OIG timely access to records. Knowing of an overpayment and failing to report and

return it.M ki f l l i Making false claims.

Paying to influence referrals.

52

Page 53: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

The penalties range from $10,000 to $50,000 depending on the specific violation.

Violators are also subject to three times the amount: Claimed for each service or item; or

Of remuneration offered paid solicited or received Of remuneration offered, paid, solicited or received.

Real life example of violating Civil Monetary Penalties law. A California pharmacy and its owner submitted claims

to Medicare Part D for brand name prescription drugs that could not have been dispensed based on inventorythat could not have been dispensed based on inventory records.

He had to pay over $1.3 million to settle the allegations.

53

Page 54: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

The Office of Inspector General (OIG) has authority to exclude individuals and entities from federally funded h lthhealth care programs.

They maintain a List of Excluded Individuals at https://exclusions org hhs gov on the internethttps://exclusions.org.hhs.gov on the internet.

The U.S. General Services Administration also administers the Excluded Parties List System which ycontains debarment actions taken by Federal agencies at https://www.sam.gov.

RadNet may not employ or do business with anyone or any company that is excluded.

54

Page 55: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

The Health Insurance Portability and Accountability Act created greater access to health insurance and protection g pof health care data, and promoted standardization and efficiency in the health care industry.

HIPAA safeguards help prevent unauthorized access to protected health care information.

RadNet employees and affiliates with access to protected health information must comply with HIPAA.

Violations may result in Civil Monetary Penalties.

In come cases, Criminal Penalties may apply.

55

Page 56: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

True story about someone violating HIPAA.A h it l l f d ilt f bt i i A hospital employee was found guilty of obtaining protected health information with intent to use it for personal gain.p g

He was sentenced to 12 months and 1 day in prison. He was also terminated from employment. He was also terminated from employment.

56

Page 57: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

FIRST: You must comply with all applicable statutory, regulatory and other Medicare requirements includingregulatory and other Medicare requirements, including adopting and following RadNet’s Compliance Program.

SECOND: You have a duty to the Medicare Program to SECOND: You have a duty to the Medicare Program to report any compliance concerns, as well as suspected or actual violations that you may be aware of.

THIRD: You have a duty to follow RadNet’s Code of Conduct that articulates our Company’s commitment to standards of conduct and ethical rules of behavior.

57

Page 58: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

B f ili ith l l ti d R dN t li i Be familiar with laws, regulations and RadNet policies.

Conduct yourself in an ethical manner.

Ensure data and billing are both accurate and timely.

Verify all information provided to you, whether from a Verify all information provided to you, whether from a co-worker or a patient.

Be on the lookout for suspicious activities and pmistakes.

58

Page 59: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

Everyone is required to report suspected instances of Fraud, Waste or Abuse. RadNet's Code of C d l l h blConduct clearly states this obligation.

RadNet will not retaliate against you for making a d f ith ff t i tigood faith effort in reporting.

Do not be concerned about whether it is fraud, waste or abuse Just report any concerns so we canwaste or abuse. Just report any concerns so we can evaluate the issue.

Our goal is to fix problems before they become a Our goal is to fix problems before they become a bigger issue.

59

Page 60: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

RadNet has 3 mechanisms in place for employees to report potential fraud, waste or abuse.

If you suspect Fraud, Waste or Abuse, or have made an error that you need assistance with:1. Talk to your supervisor or team leader 2. Call the Compliance Department 3. Call the Compliance Hotline if you wish to remain

anonymous Compliance DepartmentCompliance DepartmentCompliance Department Compliance Department

11--310310--966966--85158515Compliance HotlineCompliance HotlineCo p a ce ot eCo p a ce ot e11--877877--785785--00090009

60

Page 61: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

If warranted, RadNet must report fraudulent activity to Government authorities, such as the Office of Inspector General, the Department of Justice, or the Centers for Medicare & Medicaid Services.

The Self-Disclosure Protocol gives providers the opportunity to avoid the costs and disruptions associated with a Government-directed investigationassociated with a Government directed investigation and civil or administrative litigation.

RadNet’s Compliance & Quality Assurance Department RadNet s Compliance & Quality Assurance Department will handle all such agency reporting to ensure proper documentation is gathered and provided.

61

Page 62: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

Once fraud, waste or abuse has been detected, it must be promptly corrected.

Correcting the problem ensures you are in compliance with government requirements and RadNet policies.

Consult with Compliance Department staff to find out the process for corrective action plan development.

Corrective actions will vary depending on the specific circumstances.

62

Page 63: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

Corrective actions may include:

Returning money that was improperly collected Returning money that was improperly collected

Adopting new document review requirements

Providing educational materials to staff

Revising policies or proceduresg p p

Sending warning letters

Taking disciplinary action Taking disciplinary action

Terminating an employee or contractual relationship

63

Page 64: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

ISSUE: Does the exam order look altered or possibly forged? Is the person receiving the service the actual

beneficiary? (identity theft) Does the beneficiary’s medical history support the Does the beneficiary s medical history support the

services being requested?

CORRECTIVE ACTION:CORRECTIVE ACTION: Check orders for authenticity. Check photo ID during registration. Check photo ID during registration. Check history to ensure it matches the services

requested.

64

Page 65: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

ISSUE:

Original orders are not scanned or documented in the RIS medical record.

CORRECTIVE ACTION:

All orders must be scanned and documented in the RIS medical record.

65

Page 66: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

ISSUE:Verbal orders are not consistently documented in the y

RIS medical record.

CORRECTIVE ACTION:CORRECTIVE ACTION:Verbal orders must be documented in RIS and must

include the following information. The names, titles and other identifying information for

both parties to the call The authority of the person giving the verbal order The date and time of the call The specific order relayed The exam and clinical indicationThe exam and clinical indication

66

Page 67: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

ISSUE:The exam to be performed differs from the exam orderedThe exam to be performed differs from the exam orderedwhere amended orders are not consistently obtained.

CORRECTIVE ACTION:When an exam is going to be different from the one

ordered or an exam is going to be added on anordered, or an exam is going to be added on, an amended order must be obtained from the referring physician.

All exams must be medically necessary.

67

Page 68: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

ISSUE: Documentation of clinical indications in RIS are

inconsistent with the order This can occur wheninconsistent with the order. This can occur when clinical information is obtained from the patient and the radiologist uses this in the report.

CORRECTIVE ACTION: When information is obtained from the patient, it should

be noted in the medical record (RIS) that the patientbe noted in the medical record (RIS) that the patient supplied the information.

The Radiologist should dictate the ordered clinical i di i i h If h R di l i i l d hindication in the report. If the Radiologist includes the information obtained from the patient, he or she should make mention that patient provided the information. p p

68

Page 69: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

ISSUE: ABN not obtained when needed or is obtained when ABN not obtained when needed or is obtained when

not necessary. ABNs not completed correctly or are incomplete.

CORRECTIVE ACTION: RadNet ABN Training course provides instruction on RadNet ABN Training course provides instruction on

completing the ABN form. Medicare coverage guidelines can help you Medicare coverage guidelines can help you

understand when an ABN may be necessary.

69

Page 70: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

If you have questions after reviewing this training d l d f h i lmodule or need further assistance, please contact:

◦ Laura Foster, VP of Regulatory Affairs at 310 966 8515310-966-8515

Or your Regional Quality Assurance Specialist:

◦ West Coast: Carol Meena 909-322-1237◦ East Coast: April Dickerson 443-801-3020

70

Page 71: 2017 Corporate Compliance Training.ppt - RadNet · Corporate Compliance Training:Corporate Compliance Training: 1.Cultural & Linguistic Competence 2.Model of Care for Special Needs

Please complete the corresponding Compliance Quiz to make sure

you understand the information presented.

71