VHA and VISN 21 Compliance

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VHA and VISN 21 Compliance Business Integrity
(CBI) Program

• Mandatory Training for Contractors
• 
  Prepared March 2007

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Compliance Officers

• Jane Dutton Morris, MHA
• Compliance Specialist, Sierra Pacific Network
• [phone]
• Jane.Dutton2_at_.va.gov
• Yvonne Brooks, CCP
• Compliance Officer
• VA San Francisco Medical Center
• [phone] Ext. 4398
• Yvonne.Brooks_at_med.va.gov
• Caroline Chaderjian, MHA
• Compliance Officer
• VA Palo Alto Health Care System
• [phone] Ext. 63315
• Caroline.Chaderjian_at_va.gov
• Patty Almond, RHIT, CPC
• Compliance Officer

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Compliance Officers- continued

• Patricia Moran, RHIT CPC
• Compliance Officer
• VA Northern California Health Care System
• [phone]
• Patricia.Moran_at_va.gov
• Peggy Ashcraft
• Compliance Officer
• VA Sierra Nevada Health Care System
• [phone]
• MargaretPeggy.Ashcraft_at_med.va.gov
• Craig Oswald, MHA
• VA Pacific Islands Health Care System
• [phone]
• Craig Oswald_at_med.va.gov

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VHA Definition of Compliance

• Compliance is an oversight process which
  requires employees and contractors to conduct
  administrative and clinical duties in an honest,
  ethical and professional manner.
• Behavior that is not consistent with ethical
  business practices places Veterans Health
  Administration (VHA) facilities at risk for
  penalties, negative publicity and loss of public
  trust.

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VHAs Compliance Program

• Currently the VHAs Compliance Business
• Integrity program focuses on the
• REVENUE CYCLE to include the following
• business operations
• 1) Patient registration intake
• 2) Medical documentation
• 3) Coding for medical procedures visits
• 4) Billing for services provided
• 5) Collections from insurance companies

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Purpose of VHA Compliance Program

• Ensure business operations comply with relevant
  laws, rules and regulations
• Promote ethical practices and standards of
  excellence in patient care
• Help VHA maintain the publics trust.

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Effective Compliance Program

• An Effective Compliance Program Has 7 Elements
• 1. Designating Compliance Officer Committee
• 2. Written Policies and Procedures
• 3. Education and Training
• 4. Auditing and Monitoring
• 5. Reporting Mechanisms
• 6. Investigation and Remediation
• 7. Disciplinary Action

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Medical Documentation, Coding Billing by
Contractors

• Physicians or healthcare providers are
  responsible for completely and accurately
  documenting patient care services.
• Coders are responsible for assigning and
  validating procedural diagnostic codes based on
  provider documentation.
• Billers are responsible for generating timely,
  accurate and appropriate bills based on veterans
  eligibility and the service provided.
• Accurate and complete services reduce the
  negative
• consequences associated with fraud and maximize
• reimbursement from insurance companies
• which, in turn, allows
• VHA to provide more services to our patients.

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Open Lines of Communication
The VA has a Reporting Mechanism called CBI
Helpline The telephone number for the CBI
Helpline is 1-866-842-4357
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CBI Helpline- continued

• The CBI Helpline is available Monday
  through Friday from 800 to 4300, EST. Anyone
  internal or external to the VA (this includes
  employees, patients or contractors) may call the
  CBI Helpline number to report potential
  compliance failures.
• The caller may remain anonymous.

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HIGH RISK AREA

• A high risk area is a clinical or business
  activity that may be
• unethical, illegal, a conflict of interest or in
  violation of national and
• local policies procedures.
• Employees and contractors should
• Be aware of high risk areas concerning VHA
• Not engage in fraud or abuse against VHA
• Take appropriate actions- report all
  potential
• compliance failures to the VHA
  facility Compliance
• Officer and/or the CBI Helpline.

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EXAMPLES of High Risks

• Fraudulent Coding Up-coding (using higher
  codes) to get higher
• reimbursement from 3rd party insurance companies.
• Erroneous Billing Billing for services not
  provided to the patient
• Billing for Services Provided by Residents
  (physicians in training) without
• adequate supervision by a credentialed physician.
• Providing Medically Unnecessary Services
  Providing services that the
• patient does not need or may cause the harm to
  the patient.
• Failure to Report a Suspected Compliance
  Violation knowing about a
• potential compliance failure and not reporting it.

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EXAMPLES of High Risks (continued)

• Failure to Exert Due Diligence Contracting with
  individuals or
• companies that have a propensity to engage in
  illegal activities.
• Kickback Soliciting or receiving payment / gifts
  in return for referring a
• patient to another healthcare provider or for
  conducting business with a
• certain entity.
• Appearing on the OIG Sanction List Sanctioned
  individuals, entities,
• contractors listed on the Office of inspector
  Generals (OIG) Exclusionary
• List Database cannot receive payments from any
  federal healthcare
• programs for services furnished.

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Identifying Reporting High Risk Areas

• STEP 1 Ask yourself some key questions
• Does the action fit with the organizations
  values?
• Would you feel good about yourself if you did it?
• Would you be comfortable discussing this with
  your family and friends?
• If you answer no to any of these questions, you
  should go to the next step.
• STEP 2 Discuss your concern with the
  facility Compliance Officer and/or call the CBI
  Help-Line at 1-866-842-4357

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Federal Employee and Contractor
Responsibilities

• 1. Contractors should not offer gifts to federal
  employees and federal employees should not accept
  gifts from entities that do business or are
  attempting to do business with the organization
• 2. Federal employees should excuse themselves
  from activities in which they might have a
  financial interest
• 3. Federal employees must remain impartial in
  conducting official duties.

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SUMMARY

• Compliance is Everybodys Responsibility
• Know who the Compliance Officers are
• and how to contact them
• Follow your own best instincts
• Do your job ethically legally
• Be honest in all business transactions/ and
  contracts / awards.