Compliance

This Agenda will consist of the following points of review:

1. Review of Consumers’ EHR Charts
2. Quality of Care
3. Billing of Treatment Services
4. Clinic Staff Education
5. Review of IT Systems
6. Clinic Staff Credentialing
7. ICS Business Practices
8. Allegations of Fraud
9. Annual Report to ICS’s Board of Directors
10. New Business

The Compliance Program will address each of these issues in the following manner with the following designated staff:

1. Review of Consumer’s EHR Charts

Such continuous reviews will be the fundamental task of the Compliance Officer.  This Officer will randomly sample charts as well as focus on particular clinicians for specific reason including: past problematic performance by the clinician; clinician is a new employee of ICS; a Unit Director has asked the Officer to review a certain clinician’s chart; etc.  In addition, the Officer will follow up on any flagged billing category previously cited in NYS OMIG or other audits.  To date, only once such category exists for ICS: clearly differentiating consumers with identical names.

The Compliance Officer will continuously communicate findings to the appropriate Unit Director for corrective action by the clinician.

2. Quality of Care

This is in the purview of each of the three clinic’s Utilization Management and Special Review Committees.  As a result, at the quarterly Compliance Committee Meeting, each of such clinic’s Unit Directors will furnish a summary of the past three months meetings and underscore any striking problems as well as the remediation of such.  In addition, they will detail any reports made to ACS or APS and the outcome of such.

If an issue arises (Untoward Event; Medical Necessity dilemma; etc.) in one of the clinics that needs to be brought immediately to the attention of the Compliance Committee, a special Compliance Committee Meeting (in between quarterly Compliance Committee Meetings) will be held to address this issue of note.

3. Billing of Treatment Services

ICS’s Fiscal Department will designate a staff person to attend quarterly Compliance Committee meetings and provide a report on any significant fiscal issues that have arisen in the past three months that pertain to billable clinical services.  In addition, this fiscal report will delineate all of the following:  instances of double billing; examples of billing for the wrong person or service; and overpayments by Medicaid, Medicare, or insurance companies. Documentation of corrected billing will be provided, and in the case of overpayments, proof that ICS has instructed the paying entity to recoup such an overpayment will be submitted to the Compliance Committee.

4. Clinic Staff Education

On an annual basis, the Compliance Officer will meet (in person or virtually) with all employees of the three clinics and detail the elements of ICS’s Compliance Program.  As a central component of this Staff Education initiative, the Officer will focus especially on NYS OMIG’s aforementioned genesis: the prevention of fraud.  Accordingly, an anonymous manner of reporting possible fraud via phone, letter or email will be presented. This information will also be posted on ICS’s website. Additionally, the Compliance Officer will remind all employees that ICS’s Whistleblower Policy safeguards any reporting employee from retaliation and intimidation.

This Education component will also inform staff members of the organization’s risk areas; the workings of the Compliance Committee; the process that will be followed in cases of suspected fraud; and the organization’s disciplinary posture toward such.

It should be noted that as a small community-based organization that has spent decades building trust among its neighborhood resident participants, ICS has zero tolerance for any staff member engaged in fraud. Accordingly, such a member will be dismissed immediately if allegations prove to be true, and if indicated, ICS will cooperate with the authorities to pursue criminal charges.

5. Review of ICS IT Systems

The Compliance Officer will meet with ICS’s IT Consultant on an annual basis to ensure that ICS’s computer and software systems remain password and firewall protected; and that they comply with all HIPPA requirements and regulations.

6. Clinic Staff Credentialing

At the quarterly meetings of the Compliance Committee, each clinic Unit Director will provide a report confirming that all clinic staff have received necessary clearances (e.g., Fingerprinting; Justice Center; Exclusion Lists; ACS; etc.) and have become, or remain, appropriately licensed and credentialed; and, if applicable, have completed the appropriate number of required continuing education or specialty trainings.

7. ICS Business Practices

An ICS Fiscal Department representative will report at the quarterly Compliance Committee meetings that ICS has not engaged in nefarious business practices including paying, bartering, or offering inducements for client referrals; engaging in false advertising; requesting and/or accepting kickbacks; or in general, proceeding in a manner deemed illegal or unethical by local, state or federal laws and regulations.

8. Allegations of Fraud

The Compliance Officer will respond immediately to any allegation of fraud and launch a thorough investigation. The results of the Officer’s findings will be reported verbally to ICS Executive Director as quickly as possible so immediate action can be taken. This will be followed by a written report to be submitted to, and attendance at a meeting with, ICS’s Board of Directors.  Simultaneously, any required external official, entity, or regulating body will be notified in writing as mandated.

Once resolved, a corrective action plan will be implemented and will be reviewed and monitored by the Compliance Office on a quarterly basis for a full year following the infraction.

9. Annual Report to ICS’s Board of Directors

The Compliance Committee Office will report to the Board in person or virtually on an annual basis to offer an update on ICS’s Compliance Program and summarize findings relevant to the agenda items noted above.

10. New Business

Government regulations are continuously evolving, so the proposed Compliance Program Agenda will be expanded and amended to respond to new regulations, foci, developments, etc. as needed. Additionally, this Policies and Procedures manual will be reviewed annually.