Kusserow on Compliance: OIG calls for more compliance expertise in reviewing CIAs

The HHS Office of the Inspector General (OIG) has recently increased oversight and accountability in their Corporate Integrity Agreements (CIAs). For years, a key requirement under CIAs involved engaging an Independent Review Organization (IRO) to oversee entity compliance with the substantive requirements. Years ago, IROs would also oversee the compliance program, but most have discontinued that practice and the government has relied upon the entity certifying/attesting to having implemented an effective compliance program.

More recently, the OIG has determined that enlisting an independent compliance expert to review the program is necessary. This also reinforced the increased emphasis on Board oversight of the entity. It is now common for a CIA to mandate that Boards engage a compliance expert to assist entities in meeting their obligation of the compliance program oversight. This is serious business as Board members are now being mandated to make certain personal certifications concerning the compliance program and compliance with the terms of the CIA. This was a topic widely discussed in sessions dealing with CIAs at the recent Health Care Compliance Association (HCCA) Compliance Institute in Las Vegas, Nevada.

Compliance experts engaged by Boards are required to have expertise in federal health care program compliance requirements and application of those requirements in order to develop a work plan. They must then issue a Compliance Program Review Report that addresses the defined issues, along with their recommendations for improvements or corrective actions. A copy of the report must be made part of each annual report under the CIA. Copies of materials provided by the compliance expert to the Board and minutes of meetings with them are to be made available to the OIG upon request.

All of this should not be surprising to anyone that has been following the OIG’s publicly stated positions on the subject. Calling for Boards to enlist compliance experts has been proposed by the OIG for some time. A year ago, the “Practical Guidance for Health Care Governing Boards on Compliance Oversight” was issued in conjunction with the American Health Lawyers Association (AHLA), HCCA, and the Association of Healthcare Internal Auditors (AHIA). It promoted the use of independent compliance experts by Boards and organizations to assist in evidencing an effective compliance program, as well as ensuring they meet all of their fiduciary duties and obligations in overseeing corporate compliance, whether or not a CIA is involved.

Steve Forman, CPA, who has years of experience as a compliance officer and has served on multiple occasions as a Board-engaged compliance expert observed that the Practical Guidance “provides almost identical language about Boards’ use of compliance experts as they do in CIAs today. Compliance Officers may be well advised to let their boards know about this trend.”

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2016 Strategic Management Services, LLC. Published with permission.


Bipartisan group asks CMS for data on seniors’ mental health conditions

Although CMS’ performance releasing Medicare data in many areas has been “commendable,” very little information is available about the mental and behavioral health conditions of seniors. House Ways and Means Committee Chairman Kevin Brady (R-Texas), Ranking Member Sander Levin (D-Mich), Health Subcommittee Chairman Pat Tiberi (R-Ohio), and Health Subcommittee Ranking Member Jim McDermott (D-Wash) sent a letter to CMS Acting Administrator Andy Slavitt, asking the agency to collect, analyze, and publish additional data on Medicare beneficiaries’ mental and behavioral health.

The bipartisan letter seeks more robust data about the extent and nature of mental and behavioral health conditions among Medicare beneficiaries. In current data releases, information about depression and psychosis/schizophrenia is included; however, data about mood or personality disorders is not, leaving the public and policymakers without access to valuable information. The letter also refers to the ongoing opioid epidemic, which the legislators note affects seniors just like Americans of other ages, and urges ensuring seniors’ privacy when such data is released.

Mental and behavioral health conditions are often not given as much attention as other health conditions; this omission is particularly egregious when taking into consideration that depression accompanies senior health conditions like diabetes and coronary artery disease, leading to significantly higher health costs. The legislators asked CMS for more detailed data, specifically about anxiety disorders, bipolar disorder, personality disorders, and traumatic brain injury, to allow Medicare to meet the needs of seniors. Substance abuse data should also be made more widely available, with privacy measures such as de-identifying the data.

Highlight on North Dakota: three priorities highlight health needs assessment

Although numbers indicate that by the end of March 2016, more than 20,000 North Dakotans had signed up for private insurance or renewed their coverage on the marketplace under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), local public health officials still had plenty of residents’ health needs to address. Access to affordable care, chronic disease, and obesity/poor nutrition/lack of exercise were three health concerns identified as priorities in the Bismarck-Burleigh Public Health (BBPH) agency’s strategic implementation plan for 2016 through 2018, issued April 12, 2016.

A previously completed survey in 2012 had identified five areas of concern: pediatric obesity, child poverty, binge drinking, substance abuse, and affordable housing. These key concerns served as a guide for public health efforts in Bismarck at that time.

Needs assessment. In 2015, BBPH partnered with local hospitals CHI St. Alexius Health and Sanford Health in Bismarck, North Dakota, to complete a community health needs assessment with online and paper surveys. As a result, the community health needs assessment identified and ranked the top 10 concerns for Bismarck in 2015: lack of affordable housing, chronic disease, access to affordable health care, obesity, access to mental health services, child abuse, homelessness, coordination of care between health care providers and services, drug use, and stress.

Priorities and strategy. In turn, BBPH chose access to affordable health care, chronic disease, and obesity as its priorities for 2016 through 2018. In order to improve access to affordable health care, BBPH noted that it would conduct outreach and educational activities to promote access to affordable health care opportunities for minorities, underserved, and vulnerable populations. As for addressing chronic disease, BBPH also stressed that it would educate individuals to be more active in health care choices. Finally, in order to address obesity, poor nutrition, and the lack of exercise, BBPH made it a priority to support healthy behaviors at work.

Highlight on Rhode Island: Wave of health care innovations in Ocean State

The smallest state in America is working to improve its residents’ health through a number of new initiatives. From a pilot program that will provide children with access to behavioral health care in their schools to new programs to compile large-scale data on public health and insurance claims, these innovative projects will enable Rhode Island to track and improve health care.

School behavioral health initiative

Providence Public Schools, The Providence Center, and Behavioral Health Solutions are partnering in a program that will put behavioral health clinicians in two elementary and four middle schools. Rhode Island has a shortage of child behavioral health providers, and  most child psychologists in the state don’t accept insurance, leaving children in the state at risk. The public-private initiative will make it easier for public school children to receive necessary services.  The program will make care more accessible, with specialists on-site and available during school hours, and will allow teachers and principals to directly refer students for help quickly. Clinicians will not bill the school system, but rather will charge the students’ health insurance, including Medicaid and the Children’s Health Insurance Program, for services provided. Providence Mayor Jorge Elorza hopes this initiative will be the first step in providing behavioral health services to all area students in need. The program began with a pilot at West Elementary School, which has made counseling and referral services available to 44 students.

Pilot public health dashboard

Providence was chosen as one of four cities to participate in the Municipal Health Data for American Cities Initiative, launched by the National Resource Center and part of the White House Initiative on Strong Cities, Strong Communities. Providence residents face health challenges that include high chronic disease and related risk factor burdens. Low-income residents and communities of color are disproportionately affected. Providence will employ population-based strategies focusing on high-risk, vulnerable groups to expand the reach and health impact of improvements across sectors. Although it is not yet clear what data will be available through the dashboard, the initiative will frame federal and county data at the municipal level, extract key benchmarks that are embedded in existing city-level data, and create entirely new indicators through big data and social media activity. Elorza hopes to use the dashboard to see where Providence ranks among other cities in New England with regard to the city’s health levels, and then improve to be one of the fittest cities in the region. The other cities chosen to participate are Flint, Michigan; Waco, Texas; and Kansas City, Kansas.

All-payer claims database

Rhode Island recently launched the HealthFacts RI Database, an all-payer claims database that provides medical and pharmacy claims data from all private and public health insurers and administrators in the state, and the most comprehensive collection of health care claims data that the state has ever compiled. The database is intended to help state agencies and researchers learn where health care dollars are going, how effective various uses of dollars are, and track overall trends. It includes data from nearly 825,000 Rhode Islanders–using what the state calls “extensive precautions” to protect patient privacy –with claims totaling $18 billion between 2011 and 2014. Rhode Island is one of 18 states with such all-payer claims databases, though the Supreme Court’s recent decision in Gobeille v. Liberty Mutual Insurance Company makes it more difficult for states to require some plans to report data. The Gobeille Court found that the Employee Retirement Income Security Act (ERISA) preempts Vermont’s law requiring insurers to participate in that state’s all-payer claims database.