Large Health System Compliance Focus Group Immersion ......Large Health System Compliance Focus...

Large Health System Compliance Focus Group Immersion Track

Operational Approaches to Compliance

HCCA 2003 Annual Compliance InstituteIndustry Immersion: Large Health Systems

April 27, 2003

Organizing for Compliance in Large Health SystemsGlenna Jackson, Mindy Hatton, Michael C. Hemsley

Approaches to Risk AssessmentsAndi Bosshart, Michael Holper, Jim Finnegan

Approaches to Compliance EducationAndi Bosshart, Michael Holper, Suzan W. New

Organizing for Compliance in Large Health Systems

Glenna JacksonMedStar Health

Mindy HattonAmerican Hospital Association

Michael C. HemsleyCatholic Health East

Organizing for Compliance at the System Level: Factors in Analyzing the Necessary/Desirable Program Structure

• Legal Rationale: The degree to which the system legal structure increases/decreases system exposure for operating unit compliance features

• Business/Operational Integration Rationale: The degree to which operational integration and uniformity impacts on system wide risk and program uniformity

• Program Management Rationale: The degree to which corporate culture and resources impact on program management; from Confederations to Federalism to Central Control

HCCA Industry Immersion:Large Health Systems

Glenna JacksonVice President, Compliance

– Integrated Delivery System• Washington, DC/Baltimore• Not for Profit

- 7 hospitals • Franklin Square Hospital• Georgetown University Hospital• Good Samaritan Hospital• Harbor Hospital• National Rehabilitation Hospital• Union Memorial Hospital• Washington Hospital Center

MedSTAR helicopter at the Pentagon--September 11, 2001

Integrated Delivery System• 1000+ physicians• Research Institute• Home Health• DME• Nursing Homes• Transport

COMPLIANCE DIRECTORS COMPLIANCE COMMITTEES

Franklin SquareHospital

Georgetown

Good SamaritanHospital

Harbor HospitalCenter

NationalRehabilitation

Hospital

Union MemorialHospital

WashingtonHospitalCenter

HospitalCompliance

MedStar VNAHome Health

MedStar ManorLamond Riggs

Center forAmbulatory

Surgery

MedStarEnterprises

Central BusinessOffice

DiversififedBusinesses

BaltimoreSkilled Nursing

LaboratoryCompliance

MedStarTransport

MedStarPhysician Partners

MedStar ResearchInstitute

Vice PresidentCompliance

Glenna Jackson

Compliance Committees

• Periodic Meetings-Monthly/Quarterly• Annual Business Plans• Quarterly Activity Reports• Compliance Director Presentations• Annual Conference

– Compliance Director Recognition

Responsibility

Compliance Committees

Corporate Compliance

A&C Committee

Board

Centralized• Plan & Policies• Audits

– Doc & Code– CMS inquiries– DME– Home Health– Lab– Medical Records– Research

Decentralized• Plan & Policies

– Adapt central plans and policies to entities

• Audits– Medical Records– CMS Inquiries

Federalist System

Federalist SystemCentralized• Hotline

– Staff Hotline– Track Calls/Responses– Report to Management

• Discipline– Corporate HR

Decentralized• Hotline

– Research issues– Responses to

Compliance– Process Improvement

• Discipline– Local HR– Union Issues

Federalist SystemCentralized• Training

– Design– Scheduling– eLearning– Stand-Up– Self-Learning Packets

Decentralized• Training

– Specialty-specific– Entity-specific– Business-unit-specific

Federalist SystemCentralized• Communications

– Brand/Logo– Posters, Giveaways– Compliance Newsletter

Decentralized• Communications

– Entity/Facility Newsletters

– Health Fairs

HCCA Industry Immersion

Sarbanes-Oxley and Not-for-profit HospitalsMelinda Reid Hatton

Vice President AHA

• The role of independent directors• Executive compensation and loans• New disclosure requirements

• Financial condition• Financial statements and controls

• Codes of ethics, business conduct and conflict of interest

Sarbanes-Oxley Reforms:

New Rules for Independent Directors

• What’s “independent”?• Free of relationships that might

influence decision-making

• Oversight activities• Independent director only governancecommittees

audit, nominating, governance & compensation

• Audit Cmte• Responsible for hiring, firing and

oversight of auditors• Prohibited from receiving compensation

other than fees and expenses• Nominating Cmte

• Responsible for identifying criteria for board candidates and evaluation of directors

• Corporate Governance Cmte• Prepares and recommends governance

guidelines, including director qualifications and duties

• Recommends appropriate ethics and codes of conduct

• Compensation Cmte• CEO and senior executive compensation

including performance goals

• Executive Compensation• Threat of bonus or reward pay back for

restated results owing to misconduct or failure to adhere to financial reporting standards

• Prohibition against loans or extensions of credit to directors and senior officers

$ Split dollar life insurance?

Disclosure Requirements• CEOs & CFOs expected to “stand

behind” accuracy of financial disclosures with a certification of accuracy

• Codes of Conduct and Ethics• Public companies expected to adopt ethics

code for CFO and other senior officers• Waiver of conflict-of-interest policy must

be reported

Sarbanes-Oxley Act of 2002:

A Compliance Officer’s Analysis for Action

Michael C. Hemsley, EsquireGeneral Counsel and Vice PresidentCorporate Compliance Catholic Health East

As functionally responsible for the operation of a corporate program to detect and deter

criminal/wrongful conduct, how does a Compliance Officer analyze Sarbanes and

incorporate relevant provisions into the Corporate Compliance Program?

Initial Reaction• Applicable to Publicly Traded Companies

(“Issuers”)• Not applicable to Not for Profit (“NFP”)... yet• Suggest Monitor Industry Practices

– Evolving SEC Regulations– State Legislative Initiatives (i.e., NY)– Capital Market Expectations– Extract and apply reasonable corporate

governance concepts from Act

Governance

Control Activities

Control Activities

SarbanesTitle I Public Company Accounting

Oversight Board• Creates Board to oversee the audit of public companies;

establish standards for audit reports; registration requirements and disciplinary standards and procedures for registered public accounting firms (RPAs)

• “Issuer” - Not Applicable• “NFP” - Not Applicable

Title IIAuditor Independence

Addresses limits on RPA scope of non-audit engagements, staffing and auditor reporting

As proscriptive of RPAs rather than Issuers, no action required but informative.

Title IIICorporate Responsibility Action Required/Recommended

SEC 301: Public Company Audit Committee•Review/Revise Committee Charter re: Authority, Composition, ReportingProcedures, Committee Education;•Establish CCO role in complaint process required for “Issuer” AuditCommittees (include financial irregularities within hotline scope?)SEC 302: Corporate Responsibility for Financial Reports•Assure, monitor and review quarterly CEO/CFO certifications re filedfinancial reports. Topics include management’s evaluation of theeffectiveness of internal controls, disclosure of significant changes ordeficiencies in internal controls or fraud•Participate in a “Disclosure” or other Committee with responsibility forconsidering the materiality of information and disclosure obligations;SEC 303: Prohibition on Improper Influence on Conduct of Audits•Ensure incorporation into Code of Conduct or relevant policy, DocumenteAudit Committee annual inquiry of auditors.

Title IV Enhanced Financial Disclosures

Action Required/Recommended (cont’d)SEC 402: Enhanced Conflict of Interest Provisions• Suggest annual verification of compliance with director and

officer extraordinary loan prohibitions

SEC 404: Management Assessment of Internal Controls• Suggest review of annual management assessment for notable

program related items (see SEC 302)

SEC 406: Code of Ethics for Senior Financial Officers • Evaluate/Revise current Code of Conduct to meet requirements

Title V Analyst Conflicts of Interest N/A

Title VI Commission Resources and Authority N/A

Title VII Studies and Reports N/ABut a source for future regulatory expansion (i.e., Credit Rating Agencies)

Title VIII Corporate and Criminal Fraud Accountability

Reinforcement of need for existing policies, i.e.:Record Management and Investigation Response Policies (See, i.e., 802 Criminal Penalties for Altering Documents and §1102 Tampering with a Record or Otherwise Impeding an Official Proceeding)

Catholic Health EastResponse to Sarbanes

• Board Compliance and Audit Committee Charter Expansion

• Recommended for adaption and adoption by Regional Health Corporation (RHC) Audit Committees

• Addresses:– Member qualifications– Authorities– Communication with and reporting of auditors– Limits on non-audit service

CHE External Auditor Policy• Structure: System Wide Auditor; Engagement oversight

and reporting to CHE and each RHC Audit Committee• Communication: Annual Auditor Meeting with CHE and

each RHC Board; minimum semi-annual meeting with Audit Committee Chair direct access to audit partner

• Services: Limitation on non-audit services with pre-approval of non-audit engagements in excess of $100,000; quarterly review of RHC non-audit engagements

• Recommended for adoption by RHC Audit Committees

CHE Quarterly Stewardship Representations Policy

• Certifications from System CEO/CFO and from RHC CEO and CFO, co-signed by Divisional EVP – Certifications address 14 areas including:

• Internal Controls (limited)• Fraud and Conflicts of Interest• Corporate Compliance Program

Approaches to Risk Assessments

Andi BosshartCommunity Health Systems

Michael HolperTrinity Health

Jim FinneganHCA

Governance

Control Activities

Control Activities

ComplianceProgram &

Infrastructure

ComplianceProgram &

Infrastructure

The solution to the “weakest link” isa compliance program andinfrastructure to measure andmonitor the effectiveness andalignment between corporategovernance and business unit /functional control activities toprovide a basis for certification.

Community Health Systems Compliance Risk Assessment Program

Corporate Compliance OfficerCorporate Compliance Workgroup• “Subject Matter Experts”• Develop and create policies and tools Facility Compliance Committee and Chair• Perform audits• Follow instructions from corporate compliance


Written policies and proceduresCode of ConductTraining and education• MC Strategies Knowledge Deployment

System• EduCode


Computerized auditing and monitoring (“CAM”)• Systematic process for hospitals to self-audit

potential risk areas• Automated reporting mechanism• Focus audits of limited risk issuesEligibility Screening Process• SanctionCheck—internet based screening tool for

comparison against the OIG and GSA websites


Confidential Disclosure Program• 1-800-495-9510• Direct contact with Compliance Officer• Investigation by appropriate source• Follow-up with caller

Annual Planning and Risk Assessments

HCCA 2003 Annual Compliance InstituteIndustry Immersion: Large Health Systems

April 27, 2003Michael R. Holper,

Vice President Organizational Integrity & Audit Services

• Third largest Catholic health system in U.S.

• Operations in 7 states• Revenues of $4.8 billion in

2002• $230 million in community

benefits• Approximately 50,000

employees• 10,000 physicians• 45 owned and managed

hospitals, 342 outpatient clinics, LTC, home health, hospice and other serivces

• Formed in May 2000 through merger of Mercy Health Services and Holy Cross Health System

Trinity Health Management Framework

“3 Box Model” Management Framework• Responsibility for operations rests with local Member

Organizations which are also accountable for results• Trinity Health provides certain fiduciary and oversight

services via a System-wide, coordinated approach– Organizational Integrity Program– Insurance and risk management– Legal

• Trinity Health has/will standardize/centralize a limitednumber of services where strong rationale exists directly tied to achievement of mission and strategic objectives– Supply chain management– Certain common information systems

Organizational Integrity Program - Roles and Responsibilities

TrinityOIAS

LIO

THGeneralCounsel

THCEO

MOCEO

OI Corporate Committee

Local IntegrityCommittee

TH OI & Audit

Committee

Local Board

TH OI Council


• Local Responsibilities– Local Integrity Officers

• Responsible for local program implementation and operation of OIP• Member of senior management with direct reporting to CEO• Provides reports to local Board of Directors or delegated committee• Participant on Trinity Health Organizational Integrity Council

– Local Integrity Committees• Assist LIO in implementation and operation of the OIP within the

Member Organization• Chaired by LIO• Responsibilities include input to annual risk assessment and

identification of local OIP priorities– Policy development– Education and training– Auditing and monitoring


• Corporate Supporting Resources– Organizational Integrity and Audit Services responsible for

compliance and internal audit services within Trinity Health– Organizational Integrity resources include Director, 6 Managers and

5 specialists with diverse specialty backgrounds and experience• HIM/coding• Physician services• Post-acute care• Legal/Regulatory• PFS/CDM

– OI Managers assigned to Member Organizations to provide support to local OIP activities

– Additional Audit Services staff with financial and IS audit backgrounds

• Sarbanes-Oxley• Contract reviews• HIPAA

Annual Work Plan Objectives• Identify risks impacting Trinity Health and its

Member Organizations– Regulatory/compliance– Financial/operational– Information systems

• Formally assess and prioritize identified risks• Allocate available department resources to the

highest identified priorities• Establish department Work Plan for upcoming year

based on priorities

Identifying Risks

• Our collective knowledge and experience• Industry information and resources• Ask our customers

– Governance– Corporate management– Member Organization management

• Ask others with knowledge of Trinity Health and industry– External audit firm

Annual Risk Assessment• Risk assessment evaluation templates developed

for:– Organizational Integrity– Financial/Operational– Information Systems

• Organizational Integrity risk assessment evaluation tool updated annually based on:– DHHS Office of Inspector General Work Plan– Recent federal and state enforcement activities– DHHS OIG Compliance Guidance– OIAS experience within Trinity Health

Risk AssessmentEvaluation Tool-Example

Risk Assessment Criteria• Use numerical assessment scale 1(low)-5 (high)• Relative financial materiality of the area to the

organization;• Current regulatory/compliance risks impacting the

area;• Assessed strength/weakness of the control and

operating environment, including prior OIAS or industry experience;

• Internal and external factors beyond the control of the organization– New regulations– New payment systems– Key stakeholder interest– Regulatory enforcement activities

Risk Assessment ProcessDevelop RA tools and distribute to LIOs

and Local Integrity Committees(January)

Obtain LIO and Local Integrity Committee input (February/March)

Finalize RAs and Complete OIAS Work Plan (April/May)

Note: Trinity Health is a 6/30 fiscal year end

Annual Planning Database• All OIAS personnel utilize internally developed Access database

application for annual planning and project administration

Annual planning application

Annual Planning Database• OIAS personnel input information on potential projects, scope/objectives,

staff resources, timing and risk rating

Annual Work Plan Development• Education

– Computer-Based Training system support and administration– HIPAA education development– Integrity Tribune

• Program Development– Toolkits, compliance guidance

• Clinical trials/research• Relationships with pharmaceutical and medical supply companies• ESRD

– System-wide Projects • Automated coding monitoring and reporting system• System vendor for background checks/screenings

• Audit and Monitoring Projects

Annual Work Plan - Consolidated Report

Annual Work Plan - Member Organization Report

Work Plan Status Reporting

Risk Assessments -Lessons We Are Learning

• Educational value of risk assessments• Limited resources require us to prioritize!• Risk Assessment Factors

– Necessarily judgmental, but basis for selection of overall risk factor must be supportable;

– Use of comments/notes field to indicate basis for evaluation when not obvious;

• Cannot have all “5”s• Does it make sense at the end of the day?• Allow for the unexpected

– 20-25% of hours set-aside for special projects– Continued re-evaluation of risk throughout the year with re-

prioritization of projects

Program Assessment

Jim FinneganManager, Ethics and Compliance

Program [email protected]

Compliance Process Reviews

• Purpose of Reviews• Process Overview• Reporting• 2003 Program Goals

Purpose of Reviews• Assess the performance and level of

engagement of the facility’s Ethics and Compliance Officer (“ECO”).

• Provide the ECO with guidance and examples of best practices.

• Communicate one-on-one with individual ECOs and become more familiar with program issues.

Process Overview

• Program Assessment Team – Manager– Compliance Process Reviewers (2)

• Legal Background• Audit Background/Former ECO

– Administrative Assistant

Process Overview• Pre-Review Preparation

– Scheduled 2 months in advance by the Compliance Process Reviewer

– Documents requested from facility– Internal resources reviewed

• Facility E&C Committee Meeting Minutes• ECO Evaluation• Ethics Line Cases• Internal Audits• ECO Quarterly Reports

Process Overview• Agenda

– Day One• ECO Introduction and Facility Tour (1 Hr.)• ECO Interview (4 Hrs.)• Document Review/Testing (1 Hr.)• Employee Interviews (2 Hr.)

– Day Two• ECO Interview Continued (3 Hrs.)• Document Review/Testing (1 Hr.)• Prepare for Exit Conference (1 Hr.)• Exit Interview with ECO (1 Hr.)

Process Overview

• Facility Tour– Facility

• Ethics and Compliance Posters

– Emergency Department/Labor and Delivery• EMTALA Signage

– Nursing units• Patient Confidentiality• Informal Employee Interviews

Process Overview• ECO Interview

– One-on-one• Reviewer• ECO

– Checklist– Decision Tree Analysis

• Gauge ECO’s level of knowledge • Involve Department Heads if ECO’s level of

knowledge is determined to be insufficient in any one area

Process Overview• Checklist

– 26 Topics– Approximately 300 discussion points

• Answer tracker• Remarks column

– Reviewer prompts– Tests– Available resources

Process Overview• Checklist Topics

– Distribution of Code and Related Training– Health Information Management– Conducting Investigations– Corporate Integrity Agreement– EMTALA– Professional Service Agreements– Medical Office Building Leases– HIPAA– Monitoring Controlled Substances

Process Overview• Tests

– Personnel files • Signed Code of Conduct acknowledgement cards• Proof of background check• Proof of OIG/GSA exclusion list screen

– Physician files • Proof of OIG/GSA exclusion list screen

– Local Vendors • Proof of OIG/GSA exclusion list screen

– Overpayment Tracking Log• Ensure refunding is occurring within 30 days of

identification

Process Overview• Tests (continued)

– Professional Service Agreements• Proper execution• Multiple Medical Directorships

– Business Courtesies• Appropriate Monitoring

– Monitoring of Controlled Substances• Existence of facility policy• Required elements• DEA 222s Log

Reporting

• Executive Summary• Report of Findings• Corrective Action Plan Grid• Quality Control Questionnaire

Reporting• Executive Summary

– Provided to the ECO’s Manager– Approximately 3 pages– ECO Assessment

• Rated 1 (Poor) to 5 (Excellent)

– Special Commendations– Important Issues– Explanation of rating system

Reporting

• Report of Findings– Provided to the ECO and the ECO’s manager– Length varies– Acknowledgement of well-managed areas– Opportunities for improvement (Exceptions)– Recommendations

Reporting• Corrective Action Plan Grid

– Exceptions– Root cause(s)– Operational corrective action– Responsible individual– Projected completion date– Actual completion date– Submitted to Program Assessment team by

ECO for approval

Reporting

• Quality Control Questionnaire– Provided to the ECO– Assessment tool

• Process• Reviewer

– Feedback reviewed by Program Assessment team

• Continuous improvement

2003 Program Goals• Conduct 40 Facility Reviews

– Evenly Distributed Among HCA Groups and Divisions

• Seek, gather, and disseminate determined “Best Practices” to facilities

• Issue Summary of Findings Report to SVP, Ethics, Compliance, & Corporate Responsibility on a Quarterly Basis

• Issue Annual Report of Findings to SVP, Ethics, Compliance, & Corporate Responsibility

• Improve Communication of Discovered Issues within E&C Department

Approaches to Compliance Education

Andi BosshartCommunity Health Systems, Inc.

Michael HolperTrinity Health

Suzan W. NewBaylor Health Care System

Community Health Systems Compliance Education Program

Presented by:Andi Bosshart, RHIA, AVP

Community Health Systems, Inc.

Training and Education• MC Strategies Knowledge Deployment System• Subject Matter Experts design job-specific

training materials for deployment at each facility• Training is mandatory for those involved with

coding, billing, or the delivery of patient care• Training must occur within specified timeframes• Individuals with a certain job code must complete

the training• Job codes are standard across all 72 facilities

Training and Education

• KDS enables tracking of training status of all enrolled employees

• Employees and physicians are auto-enrolled based upon job position code

• Facilities and Corporate Management may generate reports

• Performance evaluations based solely upon completion of mandatory training

Compliance EducationHCCA 2003 Annual Compliance Institute

Industry Immersion: Large Health Systems

April 27, 2003Michael R. Holper

Vice President Organizational Integrity & Audit ServicesTrinity Health

• Third largest Catholic health system in U.S.

• Operations in 7 states• Revenues of $4.8 billion in 2002• $230 million in community

benefits• Approximately 50,000

employees• 10,000 physicians• 45 owned and managed

hospitals, 342 outpatient clinics, LTC, home health, hospice and other services

• Formed in May 2000 through merger of Mercy Health Services and Holy Cross Health System


“3 Box Model” Management Framework• Responsibility for operations rests with local Member

Organizations which are also accountable for results• Trinity Health provides certain fiduciary and oversight services via

a System-wide, coordinated approach– Organizational Integrity Program– Insurance and risk management– Legal

• Trinity Health has/will standardize/centralize a limited number of services where strong rationale exists directly tied to achievement of mission and strategic objectives– Supply chain management– Certain common information systems


• Education, in general, is not an area where Trinity Health has decided to standardize/centralize support services

• Approach to date has been to provide support, tools, systems in response to Member Organization needs– “Develop once, implement many times” approach– Member Organizations have option to utilize support

resources or purchase/develop their own• Member Organization’s are accountable for outcomes - e.g.

delivery of compliance education to employees• Compliance education and training resources is an area of

support often requested by Member Organizations

Approach to Compliance Education• General Compliance Training

– Trinity Health Organizational Integrity Program video– Presentation materials for OIP employee orientation – Standards of Conduct - employees– Standards of Conduct - medical staff – Posters, newsletters and other communication materials

• Allow Member Organizations opportunity to customize materials – Name of Member Organization – Name and contact information of Local Integrity Officer– Personalized introduction by CEO

• Develop annual update materials in similar manner and distribute to Local Member Organizations

Example Education and Communication Materials

Approach to Compliance Education• Substantive Education

– Education content specifically targeted to employees based on job functions

• For compliance education,Trinity Health has offered a computer-based training (CBT) system (CompliStar) for use of all Member Organizations– Licensed through PricewaterhouseCoopers (PWC) and

Catholic Health Association (CHA)– Developed by PWC in collaboration with CHA and other

large Catholic health care systems– Currently used by approximately 25 Catholic health care

systems – 34 compliance courses currently offered, including 6 HIPAA

courses

CompliStar ComplianceEducation Courses

Introduction to Healthcare Regulatory EnvironmentManagement Responsibilities in the Healthcare Regulatory EnvironmentCustomer ServiceNursing DocumentationHome Health/HospiceSkilled NursingPatient Financial ServicesAdmitting & RegistrationMedical Records Management HIM Coding ComplianceHIM General ComplianceMedical Records - Compliance ManagementLab AdministrationLaboratory Processing of OrdersLaboratory Medical NecessityLaboratory Coding/Pricing

Allied Services - CardiologyAllied Services - RadiologyAllied Services - TherapiesAllied Services - DialysisPhysician Documentation - Family Practice/Internal MedicinePhysician Documentation -CardiologyPhysician Documentation -NephrologyPhysician Documentation -Psychiatry

• Physician Documentation - Surgery• Physician Documentation -

Anesthesia• Physician Documentation - OBGYN• Physician Coding• HIPAA - Core• HIPAA - Clinical• HIPAA - Patient Records

Computer-Based Training

Computer-Based Training• Trinity Health Support to Member Organizations for

CompliStar– Payment of vendor license and maintenance fees– Initial batch registration of all employees – Initial assignment of course requirements based on job

responsibilities– Monthly updates from Human Resource Management

Systems to vendor– Training of local system administrators at each Member

Organization for• Revisions to course assignments• Self-registration of new employees• Management tracking and reporting

CBT -Lessons We Are Learning• Rapid development of CBT vendors, products and

curriculum • Other identified needs for CBT within Trinity Health

– Joint Commission Accreditation– OSHA – Information system implementations

• Flexibility – Have not mandated use of one CBT system – Currently 4 CBT systems in use within Trinity Health– Development of compliance curriculum that can be

delivered in multiple systems• Desire to develop more internal courses for delivery via CBT

– HIPAA policies and procedures– Develop once, implement many times approach

CBT -Lessons We Are Learning• Need for consistent platform for delivery of CBT to facilitate:

– Employee access to CBT (sign-on, user id, passwords, etc.)– Consolidated tracking and reporting of all employee

education requirements– Maintenance of employee information in multiple systems

• Internet/computer access for employees• Employee experience with Internet/computer-based training• Curriculum reading and comprehension levels• Human Resources policies for non-exempt personnel• Registration and maintenance of employee information

– 4 Human Resource Management Systems in Trinity Health must link with CBT systems

Other Compliance Education

• Significant portion of Organizational Integrity & Audit Services Annual Work Plan is dedicated to compliance education– Education provided as part of all audits performed by

OIAS– Education provided to functional councils

• HIM, Lab, Radiology, Pharmacy, Physician Networks, Medical Affairs

– Compliance program guidance and toolkits developed for specific risk areas

• Co-sponsored coding education and certification courses within Trinity Health– 4-5 day intensive courses conducted in regional locations– Examination administered 30 days following completion– Trinity Health pays cost of consultant’s travel, meeting

Leveraging Internet ASP Architecture for the Compliance Program

Presented by:Suzan W. New

Director, Corporate Compliance

• 9 Acute Care Hospitals• 1 Rehabilitation Hospital• Pediatric Specialty

Hospital• Adult Specialty Hospital• Research Institute• 300 Employed Physicians• ASC Joint Ventures• Heart Hospital Joint

Venture

Fiscal Year 2002 Statistics:• 74,195 admissions (including newborns)• 11,455 babies born • 227,258 emergency department visits • 444,581 outpatient visits • 1,906 licensed beds • 14,000+ employees • 2,414 physicians (300 employed physicians)• $337.3 million, total long-term debt • $1.6 billion, total assets • $1.2 billion, total operating revenue • $133 million in community benefits

BHCS Compliance Program Structure

CorporateCompliance

Officer

BHCSBoard ofTrustees

BHCS CEO

BHCS CFO

•Affiliate/Joint Venture •Billing Compliance•Biohazardous Materials•Business Ethics•Charity Care•Clinical Ethics•Coding Compliance•Donor Restricted Compliance•Education•EMTALA•Government Relations

•HIPAA•Human Resources•JCAHO•Laboratory•Managed Care•Physician Contracting•Physician Practice Compliance•Research/Clinical Trials•Utilization Management•Vendor Relationships

EntityComplianceCoordinator

CorporateComplianceCommittee

EntityComplianceCommittee

Office ofCorporate

Compliance

EntityPresident

EntityComplianceCoordinatorsCommittee

Compliance Subgroups

Compliance Program Tools

ASP Architecture• Web Education

– Learning– Event/classroom scheduling and registration– Documentation– Employee Performance Management Tool– Policy Implementation Tool

• Physician Time and Effort Reporting

• Research Time and Effort Reporting

• Conflicts of Interest Disclosure Process

• Compliance EthicsLine Case Tracking

Web EducationSelection of On-Line Education Driven by Need for Compliance Education

• Billing Compliance Committee looking for education curriculum

• Recognized HFMA Compliance@Work Curriculum for a broad audience

• MC Strategies was web vendor

• After further study of the needs of other high risk compliance areas, full curriculum of WebInservice was licensed

Web Education

Learning

• Annual Compliance Education• HIPAA Education and Policy Implementation• Physician Practice Education • Research Credentialing• Custom education for employees in the Revenue Cycle• Education for other high risk compliance areas• Custom education plan for Financial Services• Other Policy Implementation

Web EducationTarget Audiences/Strategic Uses

• All employees 14,000+• Board Members• Employed Physicians• Revenue Cycle Staff• Finance Staff• Research Staff• Medical Staff Members• Business Associates

Web EducationAdministration for

E-Learning

• Assign lessons• Create modules• Grant administrative

access• Monitor completion

of lessons • Generate reports

Web Education

Various types of reports can be generated

Web Education• Module report -

Compliance 2002– 7 lessons

• 5 code of conduct

• 1 compliance program

• 1 violations and penalties

• Monitors compliance with education requirements

Web EducationAdministration for Events Management

• Administrator sets up classes for face to face training for registration by individual employees

Web Education

Lesson Plan/Transcript

• Documents e-learning and completed classroom instruction

Awarded ToNEW, SUZAN W

By

MC Strategies/WebInservice For the completion of:

Compliance Management: HIPAA Standards for Electronic Transactions On: 07-26-2001

0.25 hours

New Employee Orientation• Shifting face to face topics to on-line

training– Back Safety– Epidemiology (job specific)– JCAHO Competencies– OSHA Competencies– Code of Conduct

• Introduction to Compliance Program will continue to be introduced face to face

Research Staff Credentialing

• Mandatory for Principle Investigator Credentialing– No studies approved after January 1, 2003

without proof of credentialing

– NIH education – public information repurposed for WebInservice lessons and utilized in credentialing

HIPAA Education• Combination of HFMA HIPAA lessons and Baylor Custom

Lessons for education and policy implementation• Corporate Compliance has coordinated all education activities

with HIPAA Subgroup Chairs• Custom lessons have been developed by subject matter experts

of HIPAA Subgroups• Lesson development

– PowerPoint presentation for face to face training– PowerPoint presentation repurposed for web training by MC

Strategies– Target audiences for each of the subjects identified by HIPAA

Subgroups• Classroom training will be documented in the learning

management system• Corporate Compliance Education Subgroup

– Representative from each entity – Coordination/planning for implementation at each facility

Policy Implementation• Develop custom web lesson related to policy

with link to policy

• Add policy alone to lesson plan with certification required to pass lesson

• Examples of policies for implementation:– HIPAA Policies– Nonretaliation Policy– Billing Policies

Physician Time and Effort Reporting

• Very structured “front-end” physician contracting process

• Contract management using MediTract

• Need for “back-end” time and effort reporting process

• Worked with MediTract to develop TERMS – Time and Effort Record Management Service

Physician Time and Effort Reporting • Numerous

sorting/ searching options

• Will only see time-sheets authorized by administrator

• Identify relevant parties to contract

Research Time and Effort Reporting

• Current process is very manual

• MediTract is working with Baylor Research Institute to develop tool very similar to TERMS

• Track hours of anyone working on a research project

• Actual activities will be logged (no preset categories)

• Two levels of reporting– Actual Hours– Percentages of Time

• Goal is to link to payroll system

Conflicts of Interest Disclosure Process• Current process primarily conducted via e-mail with

completed disclosure forms stored in MediTract’s TractManager System

• Future Disclosure Process– Custom web lesson will be developed for conflicts of interest policy

with link to TractManager– Disclosure form will be accessed via the internet through

TractManager– Disclosure statement must be completed on-line. All requested

information must be provided to be able to save/submit disclosure statements

– Automatic e-mail reminders will be sent to those not completing disclosure statements

– TractManager will flag disclosure statements with any “yes” answers

– Numerous sorting options– Variety of reports can be generated

Large Health System Compliance Focus Group Immersion ......Large Health System Compliance Focus...

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