Session Objectives Key Points

Transcription

1 KNOCK KNOCK - WHO'S THERE? PROTECTING YOUR RIGHTS & COOPERATING WITH AUTHORITIES HCCA 16 th Annual Compliance Institute Las Vegas, April 30, 2012 Brian D. Annulis, JD, MHA, CHC Nancy J. Beckley, MS, MBA, CHC Lynn S. McGivern, JD, LLM Session Objectives Key Points 2 Developing a protocol for responding to an investigator s knock at your door Training employees to respond appropriately and to protect your rights Develop a written "red envelope" response packet to guide employee response Brian Annulis, Nancy Beckley, Lynn McGivern 1

2 Who is Knocking? (Literally and Figuratively) 3 MAC representatives State officials Survey & Certification Medicaid program Recovery Auditors (f/k/a RACs) ZPICs DOJ FBI OIG Medicare Strike Force Licensing Boards OCR VA and other payors Others.. Why Are They Knocking? 4 Do you have a door? Or is it just painted on the wall? Enrollment Medicare enrollment verification Changes to existing enrollment (change of address, change of ownership, etc.) Physical location, hours posted Looks like, smells like, appears to be a valid entity, staffed and equipment, patients during operating hours Medicare re-validation verification Enrollment risk categories Brian Annulis, Nancy Beckley, Lynn McGivern 2

3 At Moderate or High Risk 5 By Location By Provider Type By location Not so sunny in South Florida! Strike Force cities Special investigations Double jeopardy High/Moderate risk provider types in high risk locations Moderate Risk DMEPOS (revalidating) CORF PT in Private Practice Hospice Independent Labs CMHC High Risk Home Health (new) DMEPOS (new) Why Are They Knocking? 6 Survey & Certification activities State Agency Accreditation Agency Overpayment Recoveries Recovery Auditors ZPICs Health Information Privacy and Security OCR VA Brian Annulis, Nancy Beckley, Lynn McGivern 3

4 Watching for Clues 7 OIG Work Plan CERT Reports by contractor and aggregated Recovery Auditors post approved issues and reports MAC probes OIG and Medicare Strike Force Provider grapevine Role of social media The Red Envelope Policy 8 Contents of the Envelope Policy on handling investigations Training staff on the policy Dear Investigator letter Investigation checklist Brian Annulis, Nancy Beckley, Lynn McGivern 4

5 Contents of the Red Envelope 9 Facility policy on investigations Dear Investigator letter Investigation checklist Policy on Handling Investigations 10 Elements of Policy Policy to cooperate Procedure for unannounced Government representative visit or audit Procedure for authorities present with a Search Warrant Procedure for authorities present with a subpoena Brian Annulis, Nancy Beckley, Lynn McGivern 5

6 Training Staff on Investigations 11 Corporate and Board level Endorsement and support of Board and/or compliance committee Executive Team Outside counsel Management and Staff Annual compliance training New employee orientation Focus on clinic directors and front office personnel Monitoring activities to ensure compliance knowledge Dear Investigator 12 Fully cooperate.inspection, audit, inquiry or investigation, valid warrants and subpoenas Employees expected to respond in a courteous and professional manner and not interfere Direct questions to most senior staff or corporate official If you don t know the answer, don t speculate Committed to adhering to state, federal and local laws Actively and openly participate in any investigatory process Brian Annulis, Nancy Beckley, Lynn McGivern 6

7 Investigator Checklist 13 Consistent framework if you have multiple locations, department or sites: follow the same process Direct the process so staff do not have to worry or panic Adhere to corporate policy on managing the situation Information back to compliance team to analyze and reframe for future action Case Study 14 ATI Physical Therapy 150+ clinics in 6 states 2200 employees Moderate enrollment risk: PT in Private Practice High enrollment risk: DME provider Deploying the policy and waiting for knock on the door Knock, Knock #1 the case of enrollment validation Knock, Knock #2 the case of DME enrollment Knock, Knock #3 the case of Medicaid enrollment The glitch Brian Annulis, Nancy Beckley, Lynn McGivern 7

8 Cooperating & Not Cooperating 15 Discussion ZPIC Case Study 16 ZPIC role in Program Integrity Onsite visits Lights, camera, action Clearly identify the investigator in charge; verify identity and credentials Fax in advance for record pull Investigations Special investigations Let me help you Medical review Who s on 1 st? Patient interviews and visits Providing context without interfering Pre-payment merry-goround Post-payment review piled on Working with CMS and your representatives in Congress Brian Annulis, Nancy Beckley, Lynn McGivern 8

9 Wild Cards 17 Calling on patients and families Knocking on employee doors after dinner I ll try to help you, please write a letter We don t know what that denial code means Transection of Conditions of Participation with Conditions of Payment You can t make this up: ZPIC: We aren t reviewing records, MAC is... MAC: We aren t reviewing records, ZPIC is... Privileges & Rights 18 I know my rights (they just vary from case to case)!! Response to execution of a search warrant Right to obtain copy of search warrant, inventory of items seized, but no right to interfere. Staff need not talk to investigators, but you cannot stop them from doing so. Best policy=send them all home while warrant is being executed. Call your (criminal defense) lawyer, but don t interfere. The guys with guns don t like that. Brian Annulis, Nancy Beckley, Lynn McGivern 9

10 Privileges & Rights 19 I know my rights (they just vary from case to case)!! Response to subpoena Expectation of timely response and cooperation, but justifiable extensions are granted Non-compliance could result in exclusion Privileges & Rights 20 I know my rights (they just vary from case to case)!! Response to other record requests and demands Expectation of timely response and cooperation Non-compliance could result in non-payment, pre-payment review, overpayment recovery and/or exclusion Takeaways Very few absolute rights in life and health care Train your staff to knows its rights and obligations Brian Annulis, Nancy Beckley, Lynn McGivern 10

11 Contact the Speakers 21 Brian D. Annulis, MHA, JD, CHC Partner Meade & Roach LLP Nancy J. Beckley, MS, MBA, CHC President Nancy Beckley & Associates LLC Lynn S. McGivern, JD, LLM Chief Compliance Officer ATI Physical Therapy x7193 Brian Annulis, Nancy Beckley, Lynn McGivern 11