Harmony Healthcare Blog

Compliance Series - 7 Elements: #4 Prevention and Response 2019

Posted by Kris Mastrangelo on Thu, Feb 07, 2019


Edited by Kris Mastrangelo

C.A.R.E.

Compliance • Audits/Analysis • Reimbursement/Regulatory/Rehab • Education/Efficiency


Take Action Concept on the Mechanism of Metal Cogwheels.As a continuation of the 7-Part Blog Series on Compliance, today we will explore Prevention and Response. 

P-R-E-P-A-R-E

  1. Policies and Procedures
  2. Reporting and Investigating
  3. Education and Training
  4. Prevention and Response
  5. Auditing and Monitoring
  6. Responsibility/Oversight of Compliance Officer/Committee
  7. Enforcement, Discipline and Incentives

Prevention

One of the 20/80 percent principles for implementation of an effective compliance program is the prevention and detection of criminal conduct.

“The failure to prevent or detect the instant offense does not necessarily mean that the program is not generally effective in preventing and detecting criminal crimes (United States Sentencing Commission. (2015). Guidelines Manual, §3E1.1 (Nov. 2015), p.507.).

The False Claims Act (1863 and Amended 1943, 1986, 2009 and 2010) originally passed in 1863 as a result of a Union Army being defrauded by suppliers of goods during the civil war. The government imposes liability on persons and companies who defraud governmental programs.  

Patient-Driven Payment Model (PDPM)

The Goals of Prevention include:

  • Program Oversight via the Inclusion of high level executives to oversee the program.
  • The completion of Risk Assessments which identify the organizations risks that are prioritized based on severity, likelihood and impact.
  • Reduction of governmental settlements if investigated. 

CMS publicly releases areas of high risk fraud (i.e., sudden changes in billing, spikes in billing, billing by inappropriate specialties, billing by inappropriate diagnoses, increases beneficiary complaints, along with geographical changes in billing identify theft). It behooves organizations to assess these areas and implement internal controls. 

For example, Harmony Healthcare International (HHI) uses the PEPPER Report in conjunction with the RUGs Analysis to depict areas of further review and analysis.  Our clients receive monthly audits and monitoring of high risk areas which is a compliance method for preventing systemic issues which may result in False Claims and exorbitant fines.   This system in itself depicts knowledge and response to metrics the governments deems risky. 

Response 

How an organization responds to a violation is equally, if not more important, than the original error. On a regular basis Harmony Healthcare International (HHI) fields calls from organizations across the country.  More often than not, the caller is unaware of the negative implications resulting from an improper response to an issue.  It is imperative that the response: 

  • Includes an investigation which is prompt, through and conducted in a professional manner.
  • Identifies the cause of the problem.
  • Implements a correction and a system to prevent  from recurring.
  • Determines the need for transparency

In addition, the methodology of the response and the process of investigation may require client attorney privilege. This decision requires insight and discussion via the legal and compliance consulting team. 

Harmony Healthcare International (HHI) is available to provide assistance You can contact us by clicking here. Looking to train your staff?  Join us in person at one of our upcoming Competency/Certification Courses.  Click here to see the dates and locations. 


 
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