Adopted August 4, 2008
Revised November 6, 2009
Revised February 14, 2012
Revised February 14, 2013
Revised February 14, 2014
Revised January 5, 2015
Revised February 10, 2016
Revised December 27, 2016
Revised December 12, 2019
Reviewed March 2020
Reviewed and Revised January 28, 2021
Creating opportunities for individuals with I/DD, to celebrate personal abilities and to encourage success.
Creating Opportunities. Celebrating Abilities. Encouraging Success.
TABLE OF CONTENTS
- Expected Conduct
- The Eight Elements of Compliance
- Purpose of this Document
- WRITTEN POLICIES AND PROCEDURES
- Periodic Review
- OVERSIGHT AND MANAGEMENT OF THE PROGRAM
- Board of Directors Audit and Compliance Committee
- Chief Compliance Officer 7
- Chief Compliance Officer Duties
- Chief Compliance Officer Authority
- Chief Compliance Officer Reports
- Compliance Oversight Committees
- Compliance Oversight Committees Member Duties
- Agency Directors and Managers
- TRAINING AND EDUCATION
- Initial Education
- Subsequent Retraining—General
- Job-Specific Training
- Evolving Regulatory Training
- Types of Training
- Amount of Training
- Failure to Comply
- Communication with Employees
- Compliance Helpline
- Intimidation & Non-Retaliation
- ENFORCEMENT THROUGH DISCIPLINE
- AUDITING, MONITORING, AND SCREENING
- Reimbursement-Related Reviews
- New Employees and Applicants
- Vendors and Contractors
- RESPONDING TO OFFENSES AND DEVELOPING CORRECTIVE ACTIONS
- Possible Criminal Activity
- Other Non-Compliance
- Voluntary Disclosures
- Reports by Chief Compliance Officer
- Response to Governmental Inquiries
Agencies and departments of the U.S. Government have identified a number of instances of fraud, abuse, and waste in federally-funded health care programs including Medicare and Medicaid. The Board of Directors and Lochland’s administration and management recognize the seriousness of the issues raised by the Government and recognize that failure to comply with applicable laws and regulations could threaten Lochland’s continuing participation in service coordination, residential and day habilitation, community habilitation and respite services.
The Board, therefore, has directed Lochland to undertake an integrity program in order to continue the commitment to high standards of conduct, honesty, and reliability in its business practices. This integrity program is called a Compliance Program (the “Program”). The primary purpose of the Program is to make a sincere effort to prevent, detect, and correct any fraud, abuse, or waste at Lochland in connection with federally funded health care programs and private health plans. In order to accomplish this goal, the Program strives to create a culture that promotes understanding of and adherence to applicable federal, state, and local laws and regulations. To be effective the Compliance Program should be a continuously evolving effort to meet the changing regulatory landscape.
The Program describes the expected conduct of all Lochland employees, Board members, volunteers, student interns and contractors including:
- Directors: individuals appointed to serve as a member of the Lochland Board of Directors, including Emeritus Directors.
- Employees: the executives, managers, and staff as well as any other person or individual hired on a full, part-time, per diem or seasonal basis and receiving compensation by Lochland.
- Volunteers: those individuals assisting Lochland on an unpaid basis.
- Students: individuals in pursuit of a degree interning with Lochland.
- Contractors: an entity with whom Lochland has a written agreement to provide health care items or services, perform billing or coding functions, or monitor health care provided by Lochland.
There are several parts to the Program, each of which is important. The essential policies, procedures, and initiatives that define an effective, robust Program are included herein and constitute the Lochland Compliance description.
The Eight Elements of Compliance
Lochland believes that an effective compliance program must have eight basic elements as first described by the U.S. Sentencing Commission Guidelines:
- Written policies and procedures;
- A designated compliance officer and a compliance committee;
- Effective training and education;
- Effective lines of communication;
- Disciplinary policies to encourage good faith compliance program participation;
- A system to routinely identify compliance risk areas;
- A system for responding to compliance issues as they arise;
- A policy of non-intimidation and non-retaliation for good faith participation.
Element 1: Written Policies & Procedures
- Code of Conduct
- Minimum Standards
- Program Implementation
- Employee Guidance
- Investigative Process
Element 2: Compliance Officer and Committee
- Must be an Employee
- Compliance Officer Responsibilities
- Appropriate Workload
- Reporting Relationships
- Board Interaction
Element 3: Training & Education
- Initial and annual refresher Compliance training for all employees and Board of Director members, as well as periodic training as deemed necessary
Element 4: Open Lines of Communication
- Culture encouraging reporting
- Anonymous Helpline
- Reports to Compliance Officer
Element 5: Disciplinary Policies
- Active Participation
- Mandatory Reporting
- Consistent Enforcement at All Levels in Organization
Element 6: Identification of Compliance Risk Areas
- Risk Assessments
- Corrective Action
Element 7: Responding to Compliance Issues
- Prompt Investigation
- Proper Mandatory Reporting
Element 8: Non-intimidation and Non-retaliation
- Protect Whistleblowers, Employees and Compliance Officer
Purpose of this Document
This document describes these eight basic elements as they fit within Lochland and details the fundamental principles, values, and operational framework for compliance within the agency. It articulates the organization’s commitment to compliance and the goals to which the organization strives.
Throughout the document, words and phrases such as “shall”, “should”, and “strive to” are used to describe the organizational framework of the Lochland compliance program and the basic responsibilities of employees. The program description is designed to be accompanied by more specific policies that detail expected behavior and plans that detail compliance goals and objectives.
Nothing in this document shall (i) constitute a contract of or agreement for employment; (ii) modify or alter in any manner any employee’s at-will employment status; or (iii) modify any rights of employees outlined in the Lochland School Employee Handbook. Any part of the program may be changed or amended at any time by the Board of Directors without notice to any employee.
WRITTEN POLICIES AND PROCEDURES
An effective compliance program should define the expected conduct of its employees through the establishment of written, dynamic policies and procedures. Within Lochland these policies and procedures begin with the mission statement and the service standards which provide a framework. This conduct is more specifically defined in Lochland’s policy and procedures, Code of Conduct and Ethical Standards Handbook as well as the Employee Handbook to address the specific risk areas of Lochland.
To effectively manage known risks, adherence to policies and procedures should be reviewed on an ongoing basis by Lochland’s management. In addition, newly identified risks should result in the promulgation of new policies and procedures or revisions to old ones as well as action plans, where necessary, to address those risks.
Policies and procedures will be clearly communicated to employees in such a manner that they are capable of integrating them into their daily operations. Methods for accomplishing this will include administrative notification, training of policies and procedures through read and sign and/or face-to-face training, along with inclusion in employee handbooks, position descriptions or performance evaluations.
OVERSIGHT AND MANAGEMENT OF THE PROGRAM
Board of Directors Audit and Compliance Committee
The Board of Directors Audit and Compliance Committee (the “Compliance Committee”) is established, in part, for the purpose of assisting the administration in the oversight of Lochland’s regulatory compliance and business ethics. The purpose, authority, composition, duties, and responsibilities of this Committee are fully described in the Committee Charters.
Chief Compliance Officer
The Board of Directors Audit and Compliance Committee of Lochland shall appoint an administrative employee (the Chief Compliance Officer or CCO) as the executive in charge of the continued development, implementation, and operation of the Program. The performance of the duties and responsibilities of the CCO shall be reviewed at least annually by the Board of Directors Audit and Compliance Committee.
Chief Compliance Officer Duties: The CCO’s primary responsibilities set out in the job description shall include:
- Overseeing and monitoring the implementation of the Compliance Program in conjunction with the Compliance Oversight Committee.
- Reporting on a regular basis to the Board of Directors, the Executive Director (ED), and the Compliance Oversight Committee on the progress of implementation.
- Assisting the Board, the ED, and the Compliance Oversight Committee in establishing methods to improve Lochland’s efficiency and quality of services, and to reduce Lochland’s vulnerability to fraud, abuse, and waste.
- Periodically revising the Compliance Program as required by changes in the law as well as policies and procedures of government.
- Developing, coordinating, and participating in an educational and training program that focuses on the elements of the Compliance Program, and seeks to ensure that all individuals to whom the program is extended are knowledgeable of, and comply with pertinent federal and state standards.
- Coordinating personnel issues with the Human Resource Director to ensure criminal backgrounds have been checked with respect to all employees and independent contractors, as applicable.
- Assisting in coordinating internal compliance reviews and monitoring activities, including annual or periodic reviews of programs and audits.
- Investigating and acting on matters related to compliance, including the flexibility to design and coordinate internal investigations (e.g., responding to reports of problems or suspected violations) and any resulting corrective action with all Lochland programs, providers, and sub-providers, agents and, if appropriate, independent contractors.
- Developing policies and programs that encourage managers and employees to report suspected fraud and other improprieties without fear of retaliation.
Chief Compliance Officer (Chief of Compliance and Strategy) Authority: The CCO shall have direct access to the CEO and the Chairperson of the Board of Directors Audit and Compliance Committee. The CCO shall have access to all documents and information relevant to compliance activities, including but not limited to resident records, billing records, contracts, and written arrangements, or agreements with others.
Chief Compliance Officer Reports: The CCO shall make written and/or oral reports on compliance activities including reports on complaints received from employees, investigations, audits, and monitoring to the Board of Directors Audit and Compliance Committee, ED, and the Compliance Oversight Committee on a regular basis. Reports to the Board shall be at least quarterly or more often as necessary or advisable.
Compliance Oversight Committee (COC)
To assist the CCO in promoting the effectiveness of the Compliance program and striving to create a culture that promotes understanding of and adherence to applicable federal, state, and local laws and regulations, Lochland has established the Compliance Oversight Committee (COC). The CCO has designated members of the COC, who serve as the focal point for compliance activities.
Compliance Program management is executed through the COC under the guidance of the CCO. The Compliance Program’s financial support is the responsibility of the business office and the agency.
The CCO is responsible for oversighting the educating of Lochland employees about regulatory changes that impact the work done at the agency. The ED or COO is responsible for reviewing documentation, billing, and coding throughout the agency to ensure compliance with regulatory requirements.
Compliance Oversight Committee Member Duties: The COC, which includes employees of Lochland’s senior management, shall promote the effectiveness of the Compliance Program by performing the leadership functions identified below:
- Understand the legal/compliance requirements of Lochland in order to identify and assess risks to prioritize Program initiatives.
- Recommend, develop and help to implement policies, procedures and controls that reflect preferred practices to address identified risks.
- Identify and promote training relevant to general compliance as well as training responsive to specific risk areas.
- Evaluate the performance of the Compliance Program including the systems for communicating, evaluating and responding to complaints and other compliance matters.
- Help identify potential instances of non-compliance and potentially of waste, fraud and abuse at Lochland.
- Assist in adjudicating identified compliance issues and implementation of corrective action plans.
- Ensure the ongoing enforcement of compliance policies and procedures and, if required, provide direction regarding disciplinary actions for repeated violations.
- Encourage a culture of compliance throughout Lochland.
- Collaborate with the CCO and attend monthly meetings of the COC.
- Assist in drafting billing guidelines.
- Address compliance issues and bring them to the attention of the CCO.
Agency Directors and Managers
In order to create a culture supportive of compliance and ethics, the directors, managers, chairs, and/or administrators of all departments shall be responsible for:
- Participating in the identification of risks in each department;
- Developing and maintaining agency compliance policies and procedures that support applicable Medicaid and Office for People with Developmental Disabilities (OPWDD) laws and regulations;
- Ensuring each new employee receives initial compliance training within 30 days of hire and all employees complete required training as it is assigned;
- Providing or arranging for training for all employees to implement these policies and procedures;
- Taking all measures reasonably necessary to ensure compliance with Lochland’s policy and procedures, and applicable laws and regulations by:
- Monitoring the employee adherence to established policies and procedures.
- Reporting and encouraging employees to report suspected violations to the COC, CCO or the anonymous Compliance Helpline as well as any member of Lochland’s Board of Directors.
- Investigating suspected violations in conjunction with the COC.
- Initiating appropriate disciplinary action in the event of a confirmed violation.
- Implementing post-audit corrective action plans.
TRAINING AND EDUCATION
Rules and regulations relating to delivery of healthcare are complex. The consequences of failure to comply with these requirements, particularly in areas of coding and billing of federal healthcare claims can be severe.
Sometimes conduct undertaken with good intentions, but with inadequate knowledge, may violate applicable laws and regulations.
Training is required by the federal and state governments and considered to be a necessity at Lochland in order to provide employees with the knowledge and skills to carry out their responsibilities in compliance with all requirements. Proper and continued training and education of employees at all levels is, therefore, a significant element of Lochland’s Compliance Program. Adherence to and promotion of the program shall be a factor in evaluating the performance of employees, including supervisory, managerial, and administrative personnel.
The CCO and COC strive to ensure training and education for all Lochland employees, contractors, and agents includes the dissemination of written policies and procedures regarding:
- The Federal False Claims Act
- The New York State False Claims Act
- The specific statutory and regulatory provisions named in section1902(a)(68)(A) of the Social Security Act
- Other applicable state, civil or criminal laws and state and federal whistleblower protections
- Information regarding Lochland’s policies and procedures for detecting and preventing waste, fraud, and abuse
The CCO strives to ensure all new employees participate in Corporate Compliance training during orientation and receive the Employee Handbook. Code of Conduct and Ethical Standards training will be conducted within the first 120 days of employment. New employees will receive Lochland’s Code of Conduct and Ethical Standards Handbook upon participating in the training. In combination, these training sessions provide the new employee with an introduction to the compliance program, giving them a sense of its importance in Lochland’s culture. In particular, employees will be introduced to the Compliance Helpline, the CCO, and Lochland’s policy and procedures. The Code of Conduct and Ethical Standards Handbook and Employee Handbook should include specific discussion of the laws described in the agency’s written policies, the rights of employees to be protected as whistleblowers, and a specific discussion of Lochland’s policies and procedures for detecting and preventing fraud, waste, and abuse.
Corporate Compliance training, available in a variety of formats, provides education about fraud, waste, and abuse laws, and the importance of proper coding and billing. It also provides detailed information on the complaint or reporting process, highlights non-retaliation and other important policies, and demonstrates Lochland’s commitment to integrity in its business operations and compliance with applicable laws and regulations.
Subsequent Retraining – General
Periodically, but at least annually, employees and Board of Director members should be retrained on Lochland’s Compliance Program including the fraud, waste, and abuse laws as they relate to the claim development and submission process and Lochland’s business relationships; relevant federal and state requirements; how to identify and report potential violations of policy or law; and the consequences both to Lochland and to individuals for failing to comply with applicable laws and regulations. The purpose of this training is to emphasize the importance of the Compliance Program and Lochland’s commitment to honesty and integrity in its business dealings. Additional training would be provided whenever warrented.
Financial and other administrative management personnel should receive training applicable to their role. For finance personnel, these areas include submission of cost reports, disposition of credit balances, charity and bad debt policies and requirements, tax-exempt status and billing procedures.
Evolving Regulatory Training
As new regulations are implemented, the CCO and COC should be consulted to assist in interpretation and implementation, including the development of policies and procedures.
Types of Training
Training and education may occur in sessions with individual employees, in mandatory in-service meetings, incorporated into special or regular staff meetings, or in some other effective manner. Training and education may consist of live presentations, videos, question-and-answer sessions, written material, and/or web-based sessions. Training includes participation in both in-house or external workshops and seminars.
Amount of Training
All employees need not have the identical amount of training and education, nor should the focus of training and educational efforts be the same for all employees. Targeted training and education should be provided to employees whose actions may affect the accuracy of claims submitted to the government. The actual amount of training should reflect necessity, an analysis of risk areas, or areas of concern identified by Lochland or a regulatory oversight agency, Lochland’s compliance experience, and the results of periodic audits or monitoring.
The CCO strives to ensure training provided to each member is documented. Appropriate documentation shall include the date and a brief description of the subject matter of the training activity or program. Documentation is important and should be retained on file for a minimum of seven (7) years.
Failure to Comply
Failure to comply with training requirements or to attend scheduled training sessions of each program area may result in disciplinary action.
There should be periodic evaluations of training and education programs to determine, and if necessary improve, the value, effectiveness, and appropriateness of any such program.
Lochland strives to ensure open, two-way communication lines between all employees, persons associated with the agency, senior management, management and members of the Board of Directors to allow compliance issues to be reported. This open communication is essential to maintaining an effective compliance program. It increases Lochland’s ability to identify and respond to compliance problems and reduces the potential for fraud, abuse and waste. Without help from employees it may be difficult to learn of possible compliance issues and make necessary corrections.
At any time employees should be free to request information or education. Employees should be able to seek clarification or advice from the CCO or COC in the event of any confusion or question regarding any element of the program or any Lochland policy or procedure related to the program. The CCO or COC will strive to document questions and their responses and, if appropriate, share them with other employees for informational and educational purposes.
Communication with Employees
In compliance with the Social Security Act and through a variety of communication methods, Lochland strives to maintain open two-way channels of communication between all employees and members of Lochland’s Board of Directors. This communication may include information on policies, Lochland’s policy and procedures, guidelines, and/or changes in the law. Communication methods can include one-on-one conversations, mailings to individuals, education sessions or small-and large-group meetings.
Employees who are aware of or suspect acts of fraud, abuse, waste or violations of the standards of conduct have a fiduciary duty to notify Lochland of such activities, including giving Lochland reasonable time to investigate and to respond to such allegations. Having knowledge of inappropriate conduct and choosing not to report it is, in itself, a violation of Lochland’s policy and procedures. Lochland strives to establish and maintain several independent reporting paths for a person to report fraud, waste, or abuse so that such reports cannot be diverted by supervisors or other personnel:
- Persons covered by this policy who suspect a violation of the federal or state False Claims Provisions are expected to notify Lochland via their supervisors or other managers in the chain of command (to the extent they are not involved).
- Individuals who feel management is not responding (or management may be involved), may express their concerns to a staff person from the COC or anonymously to the Compliance Helpline.
- Individuals who feel the COC member or the Compliance Helpline is not responding may address their concern directly with the CCO or any member of Lochland’s Board of Directors.
- Lochland will strive to investigate all allegations individuals bring forward and will make every attempt to correct those found to be true and prevent future occurrences.
- Individuals who feel nothing is being done to address their concerns have the right to report their suspicions to the appropriate government agency.
Lochland’s Compliance Helpline operates 24-hour, 365-day and may be reached at (315) 789-1857. This line may be used anonymously at any time, day or night. The phone number of the Helpline is published in various places throughout Lochland and employees will be reminded of the number and of their duty to report actual or suspected wrongdoing. Employees are encouraged to use the Helpline. Employees may also call the hotline of the Office of Inspector General of the Department of Health and Human Services at 1-800HHS-TIPS (1-800-447-8477) or the New York State Office of the Medicaid Inspector General at (1-518-473-3782).
The COC strives to provide appropriate feedback regarding resolution of reported issues. Such feedback may include reports through the anonymous helpline system, confidential meetings, and a variety of confidential communications.
The CCO will strive to treat all reports confidentially, to the extent possible under applicable law. However, there may be a time when an individual’s identity may become known or have to be revealed if governmental authorities become involved or in response to a subpoena or other legal proceedings.
Intimidation & Non-Retaliation
The COC strives to ensure that there will be no intimidation of or retaliation against any person who in good faith reports acts or suspected acts of fraud, abuse, or waste; violations or suspected violations of the standards of conduct; or other wrongdoing or misconduct. However, an employee who makes an intentional false report or a report not in good faith may be subject to disciplinary action.
The CCO will strive to maintain a record of reports received detailing violations of the program, the standards of conduct, or relevant laws or regulations. The CCO will periodically furnish a summary of such reports to the ED, the Compliance Oversight Committees, and the Board of Directors Audit and Compliance Committee.
ENFORCEMENT THROUGH DISCIPLINE
In addition to possible disciplinary action mentioned elsewhere in the program description, policies have been developed to encourage good faith participation in the Compliance Program by all affected individuals, including policies that articulate expectations for reporting compliance issues and assist in their resolution. These policies should outline sanctions for:
- Failing to report suspected problems
- Participating in non-compliant behavior
- Encouraging, directing, facilitating, or permitting non-compliant behavior
- Failing to perform any obligation or duty required of employees relating to compliance with the program or applicable laws or regulations
- Failure of supervisory or management personnel to detect non-compliance with applicable policies and legal requirements and the program, where reasonable diligence on the part of the manager or supervisor would have led to the discovery of any violations or problems
The COC strives to ensure that any disciplinary action follows Lochland’s existing disciplinary policies and procedures. Discipline should be fairly and firmly enforced.
AUDITING, MONITORING, AND SCREENING
Lochland strives to ensure that the agency’s Compliance Program is effective. An important element of this effort is identifying and correcting any deficiencies in Lochland’s business processes. Identification efforts should include built-in monitoring systems, and periodic small reviews conducted by employees of the Business Office, as well as larger, more formal reviews and/or audits conducted by the Continuous Improvement department.
The Compliance Officer/Director of Continuous Improvement department on at least monthly basis will review documentation, coding, billing, and reimbursement to ensure accuracy. In the event of the CO’s absence, the CCO will complete these tasks. Additionally, the CCO and CO will ensure all billing practices are accurate and allowable in accordance with Medicare/Medicaid laws, regulations, and policies. Some such non-allowable services would include when a resident is hospitalized, on vacation for more than 14 days annually, without staff services, no services rendered, inaccurate documentation for services, when being provided another Medicaid allowable service, incarcerated, etc.
Lochland, under the direction of the CCO, strives to conduct periodic reimbursement-related reviews and audits. By way of example, these reviews might include claims submitted to Medicare, Medicaid and other federal health payors, as well as the claims development and submission process. They might include the work of billers as well as risk areas identified by the US Department of Health and Human Service Office of Inspector General (DHHS OIG) or fiscal intermediaries. Reviews and audits might also cover Lochland’s relationship with third party contractors, and compliance with laws governing kickback arrangements.
Access: Auditors and reviewers shall have access to all necessary documents including those related to claim development and submission, resident records, e-mail and the contents of computers and electronic storage devices. Auditors and reviewers shall at all times bear in mind confidentiality requirements.
Action: The CCO will be notified of the results of all audits performed by agencypersonnel, consultants, or government auditors that identify potential compliance issues. Further action, if any, by the CCO with respect to any deviation or discrepancy revealed by an audit will be taken under the provisions of Section VII.
Documents: All audits shall be thoroughly documented. Area directors shall respond to audit reports in writing to the CCO within 30 days of the report. Such documents shall be maintained in the permanent files of the CCO and adequately secured.
Screening: Lochland strives to conduct a reasonable level of screening to ensure that it does not employ or contract with ineligible persons. All employees, Board of Directors, contractors, merchants and medical providers utilized on behalf of Lochland require a review of the Medicaid Excluded Provider Lists via the internet through www.omig.state.ny.us and www.oig.hhs.gov websites.
Lochland’s Financial Executive Assistant will maintain a master list of frequently used (at least monthly) contractors, merchants and medical providers and complete a review of the Excluded Provider Lists by the end of each month. The master list will be reviewed by Compliance Oversight Committee on a quarterly basis. Vendors will be added or deleted from the list. If there are changes the master list will be distributed each quarter to all managers for reference when making purchases, attending medical appointments, etc.
When a contractor, merchant or medical provider is not on the master list, the manager is required to complete a review of the Medicaid Excluded Provider Lists via the internet prior to use. The results of the Excluded Provider Review are to be printed and attached to the Requisition form. The medical staff will complete the Excluded Provider Review for medical providers prior to use for those providers used less than monthly. When a requisition form is not completed Medical staff will print the Excluded Provider Review results and document the name of the person for the appointment or purchase, date and time of appointment when applicable and send to the Financial Executive Assistant.
If the Excluded Provider Review reveals that the contractor, merchant or medical provider is on the Excluded Provider list, Lochland staff will not use that entity and report the results to the CCO and ED immediately.
New Employees and Applicants: Lochland shall conduct an OPWDD required background investigation of all new employees, or applicants for employment. This investigation is of primary importance for those employees who will have discretionary authority to make decisions that may materially impact the Medicare/Medicaid claim development and submission process. The purpose of the background investigation is to determine whether any such employee or applicant has been (i) convicted of a criminal offense related to healthcare or (ii) listed by a federal agency as debarred, excluded, or otherwise ineligible for federal program participation.
Providers: A similar reasonable background investigation shall be undertaken for providers who do or will possess an individual Medicare or Medicaid provider number. Such providers also are periodically screened.
Employees and Contractors: Employees and contractors shall be screened monthly to determine whether they have been disbarred or excluded by a federal agency.
Prohibition: It is the goal of Lochland not to hire or retain an employee in a position which has or will have discretionary authority to make decisions or whose job functions may materially impact the Medicare/Medicaid claim development and submission process if such prospect or employee has been convicted of a crime related to healthcare or has been excluded or debarred. Lochland also strives not to contract with any person or entity that has been so convicted, excluded, or debarred, and will attempt to terminate its contract arrangements with any such person or entity, subject to legal constraints such as damages for breach of contract. Lochland strives to make reasonable and prudent efforts not to submit any claims for service ordered or furnished by any person or entity, including physicians, excluded from participation.
RESPONDING TO OFFENSES AND DEVELOPING CORRECTIVE ACTIONS
Violations of Lochland’s compliance program, failures to comply with applicable Federal and State law, and other types of misconduct threaten an agency’s status as a reliable, honest, and trustworthy provider, capable of participating in Federal healthcare programs. Lochland strives to ensure that all allegations of failure to comply are promptly and thoroughly investigated and that there is a prompt and appropriate response to all government inquiries.
Investigations: Lochland strives to ensure that all issues reported to managers and supervisors, the COC, and the helpline are promptly and thoroughly investigated under the guidance of the CCO. The goals of an internal investigation include:
- Discovering facts and circumstances related to allegations of legal or regulatory noncompliance.
- Discovering all relevant facts, including those that are both incriminating and non-incriminating.
- Assessing the significance of the facts discovered to determine whether the conduct was illegal or legal but in violation of Lochland’s policies and procedures.
- Recommend both disciplinary actions and corrective actions.
Managers or directors who receive a report of a suspected violation are expected to report the allegation to the CCO or member of the Board of Directors for prompt investigation. Reports of violations might include any reasonable indication of violations of the program, the Code of Conduct, Lochland’s policies and procedures, or applicable law or regulation by employees or others within their supervision.
In undertaking investigations, the CCO may consult with the respective manager, director, or administrator who has responsibility for the program area. The CCO may also utilize other Lochland employees (consistent with appropriate confidentiality), outside attorneys, outside accountants and auditors, or other consultants or experts for assistance or advice.
An investigation by the CCO shall be preliminary to the initiation of disciplinary proceedings. If there is reasonable cause to believe a violation exists, the CCO or respective manager or director, shall initiate a formal complaint against the employee. The adjudication of such complaint shall proceed in accordance with the applicable policies and procedures of Lochland.
Process: The CCO, or his or her designee, may conduct interviews with any Lochland employee and with other persons; may review any Lochland document including but not limited to those related to the claim development and submission process, resident records, e-mails, and the contents of computers and electronic storage devices; and may undertake other processes and methods as the CCO deems necessary.
Documentation: The CCO may prepare a report which (i) defines the nature of the situation or problem (ii) summarizes the investigation process (iii) identifies any person(s) whom the investigator believes to have acted deliberately or with reckless disregard or intentional indifference, particularly toward the Medicare/Medicaid laws, regulations, and policies, and (iv) if possible, estimates the nature and extent of the resulting overpayment by the government or another entity.
Responses: Lochland strives to respond promptly and appropriately to the discovery of possible criminal activity as well as the discovery of other non-compliant activity.
Possible Criminal Activity: In the event an investigation reveals or uncovers what appears to be criminal activity on the part of any employee, the following actions shall be taken:
- All billing involved in the situation or problem shall be reviewed until such time as appropriate corrections are made.
- A summary of the results of the investigation shall be sent for appropriate disciplinary action to the direct supervisor of the implicated employee, as well as to the ED and Board of Directors. Pending disciplinary action, any such employee may be removed from any position with oversight of or impact upon the claims development and submission process.
- Federal, State, and/or local agencies shall be notified as deemed appropriate by legal counsel, the CCO, ED and Board of Directors.
Other Non-Compliance: In the event the investigation reveals claims development and submission problems, which does not appear to be the result of criminal activity on the part of any employee, the following action shall be taken:
- If duplicate payments have been made by Medicare/Medicaid or other healthcare program or excessive payments made because of coding or other Lochland errors or mistakes (i) the defective practice or procedure will be corrected as quickly as possible; (ii) the duplicate or improper payments will be calculated and repaid to the appropriate payor or fiscal intermediary; and (iii) a program of education will be undertaken with appropriate employees to prevent future similar problems.
- If no duplicate or excessive payments have been made because of Lochland errors or mistakes (i) the defective practice or procedure will be corrected as quickly as possible; (ii) a program of education will be undertaken with appropriate employees to prevent future similar problems.
- A summary of the results of the investigation shall be sent for appropriate disciplinary action, if any, to the ED as deemed appropriate.
Voluntary Disclosures: Voluntary self-disclosures will be guided by the New York State Office of Medicaid Inspector General Compliance Alert 2014-01, Self-Disclosure, in conjunction with outside counsel.
Reports by Compliance Officer: The CCO periodically shall furnish information (bearing in mind issues of confidentiality) about such investigations to the ED, the Compliance Oversight Committee (COC), and the Board of Directors Audit and Compliance Committee.
Response to Governmental Inquiries: Federal agencies have available a number of investigation tools including search warrants, subpoenas, and civil investigation demands. Actions also may be brought against Lochland to exclude it from participating in Medicare/Medicaid if Lochland fails to grant immediate access to agencies conducting surveys or reviews. It is, therefore, the policy of the Lochland to cooperate with and properly respond to all governmental inquiries and investigations.
Process: Employees, who receive a search warrant, subpoena, or other demand or request for investigation, or who are approached by a federal agency, should attempt to identify the government representative. They should also immediately notify their supervisor, the ED, and CCO.
Employees should request the government representative to wait until the ED, CCO or his or her designee arrives before conducting any interview or reviewing documents. The CCO in consultation with the ED and as necessary, outside legal counsel, is responsible for coordinating Lochland’s response to warrants, subpoenas, inquiries, and investigations by federal agencies. If appropriate, Lochland also may provide legal counsel to employees. Documents: Lochland’s response to any warrant, subpoena, investigation, or inquiry must be complete and accurate. No employee shall alter, destroy, or mutilate any document or record or alter, delete, or download any material from any computer, word processor, disk, or tape, except in accordance with Lochland’s records retentions policies. If a document is required to be retained, it must be preserved in its original form.