Kusserow on Compliance: Achieving compliance support from the Board and CEO

Carrie Kusserow, has been working with and making presentations to Boards and CEOs for over 15 years. She highlights the need reinforce CEO and Board expectations for the compliance program—expectations then can cascade down through the entire organization. She finds that often Boards and CEOs played a major role in kicking off the compliance effort, but over time their interest and support wane. The real test is keeping the commitment, support, and spirit for the compliance program over time, which requires a concerted effort on their part of the compliance officer. Key to making this possible is for the compliance officer to hlep the CEO and Board understand their roles in the compliance program and what is needed from them to meet that obligation.

Al Bassett, J.D., has over 35 years in compliance including building and reinforcing dozens of compliance programs. He emphasizes the importance for the Board and CEO being directly involved in the hiring decision for the compliance officer. They need to select someone in terms of proven experience and competence, but ethical consideration should play a large role. Once appointed, there must be continued contact and monitoring of performance with the person reporting and accountable to the CEO on a day to day basis, as well as having direct access to the Board, as needed.

Steve Forman, CPA, has decades of experience as a compliance consultant as well has having served as compliance officer for a large system and as in an interim capacity for others. He makes the point that the compliance officer needs to provide the CEO and Board with evidence of what is needed to improve the program. This is the best way to keep communication channels open and ensure continued interest and support. A very important principle for the compliance program is open and ongoing communication with all the leadership, including gaining the attention and support of first and second line management.

Expert thoughts for compliance officers’ consideration:

  1. Develop a strategy to carry the compliance message from executive leadership to first and second line managers.
  2. Recruit compliance office staff possessing the character and competence to carry out the duties of the office and advance the compliance message to the entire workforce.
  3. Prepare meaningful briefings and education for the Board and executive leadership on what is required of them.
  4. Focus on creating education and training programs that reinforce the compliance message.
  5. Ensure that those reporting suspected problems are not made subject to any form of reprisal or retaliation that would undercut the entire compliance program ethos.
  6. The compliance culture of the organization is an important factor in establishing an effective compliance program and finding methods to document and measure it.
  7. Further away from headquarters, the greater the likelihood that something can get lost in translation, therefore pay special attention to business units or individuals that operate away from the shadow of the corporate leadership.
  8. Uniform enforcement of the rules is critical and any departure from this can seriously undermine confidence and support for the compliance program.

Carrie Kusserow is COO of Strategic Management and can be found at ckusserow@strategic.com, Al Bassett (abassett@strategicm.com) and Steve Forman (sforman@strategicm.com) are Senior VPs at Strategic Management.

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.

Connect with Richard Kusserow on Google+ or LinkedIn.

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Copyright © 2018 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: CMS increases audits to address Medicaid fraud and abuse

In efforts to prevent Medicaid fraud and reduce improper payments, CMS is in the process of implementing eight “new or enhanced” program integrity initiatives and strategies to address reported billions in improper Medicaid payments. These initiatives include target auditing of selected state programs and known vulnerabilities. The stated aim is to promote transparency and accountability. The CMS announcement noted that Medicaid spending has risen more than 26 percent in the three years leading up to 2017, from $456 to $576 billion. A significant part of the increase was as result of states expanding their Medicaid programs under the Patient Protection and Affordable Care Act (ACA). Most of this increase was covered by the federal government, with its share rising 38 percent, from $263 billion to $363 billion, over the same three-year period. CMS efforts include evaluating the impact of this expansion on program integrity. The announced new initiatives followed a Senate hearing that lambasted CMS, reporting that Medicaid pays out $37 billion a year of improper payments, an increase of 157 percent since 2013.  The new initiatives will be designed to address previously identified activities that harmed Medicaid’s program integrity, and address problems identified by the GAO and OIG and include:

  1. Targeted audits of certain state MCOs. CMS will review financial reports from MCOs in targeted states to ensure they match actual claims experience.
  2. New audits of beneficiary eligibility. States that had OIG reviews of Medicaid beneficiary eligibility will have follow-up determinations reviewed by CMS.
  3. Claims and provider data optimization. CMS will validate the quality and completeness of state-provided data in the Transformed Medicaid Statistical Information System (TMSIS) using data analytics and other techniques to improve data quality and to flag potential problems that require further investigation.
  4. Data analytics pilots. CMS will use analytics and other IT tools on state-provided data to optimize state data to identify areas that need additional investigation.
  5. Provider screening on an opt-in basis. CMS will pilot a plan to screen Medicaid providers on behalf of states, in the belief that centralizing this process will improve efficiency and coordination across Medicare and Medicaid. This, in turn, should reduce state and provider burden, and address one of the biggest sources of error as measured by the Payment Error Rate Measurement (PERM) program.
  6. State-federal data sharing and collaboration. CMS is giving states access to the SSA’s master file of death records to help with managing provider enrollment.
  7. Publicly report state performance. The Medicaid scorecard will indicate how well states perform on certain measures pertaining to their Medicaid programs. This scorecard will include the state’s “integrity performance measures,” such as PERM.
  8. Provider education to reduce improper payments. CMS will bolster education efforts for Medicaid providers to reduce billing errors, including targeting comparative billing reports and provider-facing tools currently in development.

 

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.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2018 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: DOJ establishes new Medicare Strike Force for the Newark/Philadelphia area

The DOJ announced the formation of the Newark/Philadelphia Regional Medicare Fraud Strike Force (Regional Strike Force). The Strike Force operations are part of a joint initiative between the DOJ and HHS to focus their efforts to prevent and deter fraud and enforce current anti-fraud laws around the country. Since its inception in March 2007, the prosecutors in the 10 Medicare Fraud Strike Force locations have charged over 3,700 defendants who collectively have falsely billed the Medicare program for over $14 billion. The new Strike Force will focus its efforts on aggressively investigating and prosecuting cases involving fraud, waste, and abuse within the federal health care programs, and cases involving illegal prescribing and distribution of opioids and other dangerous narcotics. Prior to the announcement, there were only 10 cities that had such tasks forces.

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.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2018 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: Stark law to undergo interagency review

The CMS Administrator announced plans to convene an inter-agency group to focus on how to minimize the regulatory barriers created by Stark law, which was established in 1989 and underwent expansion in the 1990s. Providers have raised concerns from the beginning of the implementation of the Stark law. The agencies involved in the review will include CMS, OIG, HHS General Counsel, and the DOJ. The Stark law prohibits doctors from referring Medicare patients to hospitals, labs and colleagues with whom they have financial relationships unless they fall under certain exceptions. It also prevents hospitals from paying providers more when they meet certain quality measures, such as reducing hospital-acquired infections, while paying less to those who miss the goals. The result is the law is viewed as making it difficult for physicians to enter innovative payment arrangements because they are not susceptible to fair market value assessment—a Stark requirement. These prohibitions are seen as interfering with key factors related to value-based care. Unlike the Anti-Kickback Statute, which is enforced by the OIG, the Stark law is considered regulatory and falls under CMS jurisdiction. From a regulatory standpoint, there is only so much that CMS can do to make substantive changes. Any real changes in the law will have to come from Congress.

This is not the first time the CMS has tried to move the easing of rules concerning the Stark law.  In 2015, CMS published a Proposed rule relaxing aspects of the Stark law, including easing of some of the strict liability features of the law and CMS’ burden in dealing with the interpretation of key terms, requirements, and other issues. After reviewing an enormous amount of self-disclosures, CMS realized that a large part of the docket involved arrangements that may technically violate the statute but do not actually pose significant risks of abuse. Therefore, it appears that CMS seeks to reduce the number of self-disclosures reported. However, the proposed update is also intended to account for recent changes relating to health care reform and advancements in patient care and payment methodologies. CMS wanted to ensure that Stark does not inhibit Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) reforms and these are the same concerns driving the latest initiative.

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.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2018 Strategic Management Services, LLC. Published with permission.