The U.S. Department of Health and Human Services' (HHS) and the Office of Inspector General (OIG) believe that an effective compliance program can significantly reduce fraud, waste and abuse. In addition, prosecutors may not pursue a criminal action against organizations that have an effective compliance program. Consequently, implementing an effective compliance program could minimize the consequences resulting from a violation of the law. Generally, the OIG will look to the effectiveness of the compliance program as a factor when determining the level of sanctions, penalties, and/or exclusions to be imposed on the provider.
In addition to reducing the risk of criminal and civil liabilities and sanctions, compliance programs offer many other benefits. Primarily, a compliance program fulfills the provider's legal duty to ensure that it is not submitting false or inaccurate claims to government and private payors. Equally important, a compliance program helps a provider fulfill its care-giving mission to residents and patients and the community. It improves quality of care and operations because it assists the provider to identify weaknesses and to improve upon internal systems and business office management. Furthermore, an effective compliance plan and program concretely demonstrates to employees and the community at large the provider's strong commitment that it is honest and ethical in its corporate conduct. In addition, it helps provide a more accurate view of employee and contractor behavior relating to fraud and abuse.
A compliance program reduces the likelihood of wrongdoing, aids in the early detection of issues, and establishes a structure for internal reporting and investigation. In addition, it helps prevent criminal activity and illustrates a lack of intent to perform unlawful acts; thus, in cases where the government uncovers fraud, it shows that reasonable efforts have been made by management to prevent and detect any misconduct that occurs within the entity. By initiating immediate and appropriate corrective action; and through early detection and reporting, you can minimize the loss to the government from false claims, and thereby reduce your exposure to civil damages and penalties, criminal sanctions, and administrative remedies, such as program exclusion.
Quality risk management supports a scientific and practical approach to decision making. It provides documented, transparent, and reproducible methods to accomplish steps of the quality risk management process based on current knowledge about assessing the probability, severity, and, sometimes, detectability of the risk. Quality risk management should be integrated into existing operations and documented appropriately.
Quality assurance can be characterized as a focus on current outcomes, with a retrospective (look-back) view of "what happened." Often, this is done out of a need to ensure compliance and proper follow-up of identified issues. While the scope of a quality assurance committee may include such actions as conducting a root cause analysis and developing action plans, current regulations do not require any specific or formal improvement processes to be used.
On the other hand, performance improvement can be thought of as a system that makes things better. Unlike quality assurance, which focuses on compliance, performance improvement focuses on "systems issues" that cause poor outcomes. Skilled Nursing Facilities must develop and implement a Quality Assurance Performance Improvement Program in 2014.
Why should you attend: Skilled Nursing Facilities (SNF) face complex challenges that require new and coordinated approaches by the quality, compliance and risk management teams. A survey finding of immediate jeopardy could be followed by a wrongful death lawsuit, attorney general investigation, professional licensure actions, 'qui tam' civil lawsuit or criminal enforcement action. SNF leadership won't want to miss this insightful presentation that will review the key strategies and tactics necessary to evaluate and update current program efforts to maximize outcomes, while minimizing the typical program 'gaps' that leave SNFs vulnerable to the 'perfect storm' that churns up complex issues tied to quality, compliance and risk management.
Areas Covered in the Session: