**Compliance and Business Integrity (CBI)**

**FY 2008 Denver Medical Center & NHCU/Pueblo NHCU/All CBOCs**

**["We say what we do, and we do what we say."]{.underline}**

**[WHAT IS COMPLIANCE?]{.underline}**

A process that demonstrates whether or not our VISN/Facility bases our
actions on laws, regulations, and our own policies, and if not, detects
and resolves those situations or processes.

**[WHAT IS BUSINESS INTEGRITY?]{.underline}**

"Doing things right, and doing the right things."

**[Compliance starts with our first contact with
veterans.]{.underline}**

Compliance means that each veteran experiences our commitment to these
values:

**Trust**

**Respect**

**Excellence**

**Compassion**

**Commitment**

[Areas of Concern to the CBI Program:]{.underline}

> **Documentation Registration Coding**
>
> **Billing Sanctions List Self-Referrals**

**[Healthcare fraud]{.underline} is against the law! Fraud occurs when
someone:**

-   intentionally submits false claims

-   Makes someone else submit false claims

**[Examples of health care fraud]{.underline} are:**

-   billing for services not actually performed

-   falsifying a patient's diagnosis to justify tests, surgeries, or
    other procedures that are not medically necessary

-   billing for a more costly service than the one actually received

-   accepting kickbacks for patient referrals

**Some [patients commit fraud]{.underline} by:**

-   filing claims for services or medications not received

-   using someone else\'s coverage or insurance card

**Documentation**

......is the provider\'s record of care (the patient\'s chart).

-   Most funding (1st party, 3rd party, VERA) is based on this
    documentation

-   Improper documentation or lack of documentation can lead to coding
    and billing errors.

**[Poor documentation]{.underline} or an inadequate note**

> results in NO CODES (no encounter)
>
> which results in NO BILL
>
> which results in NO REVENUE

**Registration**

.....is the process of receiving patients and their demographic
information.

**[Incorrect registration]{.underline} data can lead to:**

-   incorrect billing,

-   ineligible care, and

-   the inability to contact the patient with important information.

**Coding**

-   The process that converts documented descriptions of medical,
    surgical, diagnostic services, and care into numeric codes before
    writing the bill.

-   The wrong code means the wrong price goes on the bill.

**Billing**

-   The process of putting the cost on the bill and sending it to the
    correct person.

-   When the cost is wrong, or when the bill is sent to the wrong
    person, it can lead to wrong payments by the veteran or their
    insurance company.

**Sanctions List**

-   A list kept by the government of those people or companies who have
    defrauded the government in the past.

-   These people or companies are not allowed to be employed by or
    contract with VA or other agencies.

**Self-referrals**

-   VHA healthcare providers may not refer patients in a way that will
    financially benefit the provider.

-   VHA healthcare providers may not refer patients to their own private
    practice outside of the Veterans Health Administration and collect
    payments from VHA or the patient.

**[WHY Have a Compliance Program?]{.underline}**

-   Provides internal monitoring to:

Prevent fraud

Identify problem processes or situations

Work with employees to correct problem processes or situations

Educate employees in best practices and standards of excellence related
to the way we do business

-   Prevents costly failures such as:

Loss of revenue due to improper documentation, coding, billing

Loss of credibility when mistakes are made that appear to be fraud

Waste of limited government resources

**CBI Program Elements**

**An effective CBI program has seven elements:**

(1) Designation of a Compliance Officer and Compliance Committee

(2) Written compliance policies to promote commitment and to guide the
    monitoring process

(3) Education and Training programs

(4) Open Lines of Communication

(5) Auditing and Monitoring

(6) Enforcement and Discipline

(7) Investigation and Remediation

**Reporting**

**If you recognize a compliance issue, you should ask yourself:**

Does the action comply with laws and regulations?

Is it consistent with written policies?

Does it fit with our published values?

Would I feel good about doing this activity?

Would I feel good if my friends, family, or the community found out
about this?

**Every employee has a duty to report potential compliance failures!**

-   **Discuss your concern with your supervisor.**

-   **If you are not comfortable discussing with your supervisor,
    discuss with a higher level manager.**

-   **If you are not comfortable discussing with supervisor or higher
    level manager, discuss your concern with the Compliance & Business
    Integrity Officer at your facility.**

-   **You may call the CBI helpline directly.**

**[Know your Compliance Officers:]{.underline}**

**VISN 19: Susan Curtis ..........................(303)756-9279**

**Eastern Colorado: Jackie Albright ............(303)393-5176 or**

**Jim Schmelzer............\...(719)553-1050**

**Salt Lake City: Jane Montmeny...............(801)582-1565, ext. 1610**

**Montana: Marilyn Frize.........................(406)874-5610**

**Sheridan: Cynthia Edwards..................\...(307)672-1965**

**Cheyenne: Lisa Adamson.....................\...(307)778-7550, ext.
7933**

**Grand Junction: Terri Gossett...............\...(970)242-0731, ext.
2210**

**[CBI Helpline]{.underline}**

**1(866)VHA-HELP (1-866-842-4357) or e-mail vaww.chaco.va.gov/cbi**

**The helpline is to receive questions and reports of potential
non-compliance related to any matter relating to the integrity of the
VA.**

**The caller can remain anonymous. Information submitted is not
confidential or else the situation could not be examined. Your name will
not be used as the source of information for the compliance inquiry.**

**All calls are researched.**

**No employee will be penalized for raising an issue or concern. If you
think you are being retaliated against for reporting, you need to report
that, too.**

**Case Study 1**

T.C. works in the VAMC laundry. John, his neighbor, works in the Patient
Accounts section. At a neighborhood cook-out, John tells T.C. that Bob,
another neighbor, has not paid his VA hospital bills and is being
referred to a collection agency. What should T.C. do?

**Advice:** T.C. should remind John that he should not be discussing
this matter as soon as he starts to mention it. This is a breach of
patient privacy and confidentiality. T.C. had no "need to know" this
information. This breach of privacy could be reported to supervisors,
the Privacy Officer, the Compliance Officer, or the Compliance Helpline.

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**Case Study 2**

A.K. is a clerk at the VA Medical Center. She notices that Dr. Smith is
marking all his visits as "service-connected" for all veterans having
any level of service-connection, so they won't have to pay a co-pay. She
has heard several patients "remind" Dr. Smith to do this. What should
A.K. do?

**Advice:** Co-payments are mandated by law. They are one way to help
fund ongoing health care for veterans. A.K. should notify the area
supervisor of this practice, and if it does not change, A.K. should call
the facility Compliance Officer or the CBI Helpline.

**Case Study 3**

L.S. is a social worker in the rehabilitation department. Dr. Jones
asked L.S. to refer all of his discharged patients to a specific medical
equipment company that you know is owned by his family. What should L.S.
do?

**Advice:** Dr. Jones may be in violation of conflict of interest laws.
This should be reported. Discuss with the area supervisor and/or the
Chief of Staff. Finally, L.S. could call the facility Compliance Officer
or the CBI Helpline.

**Case Study 4**

H.K. works in Accounts Receivable. His friend, Robert, was a recent
in-patient who had extensive surgery. H.K. knows that Robert is in
recent financial difficulty and may be eligible for an increase in his
eligibility. Because of that, H.K. did not charge him for his co-pay for
his follow-up MRI. Can H.K. get into trouble for this?

**Advice:** Yes, H.K. would be in trouble. The patient must apply for an
eligibility change and the determination will not be made by the same
person who does the billing. This favoritism could be considered a
fraudulent or abusive billing practice. All patients are not being
treated equally according to the laws and policies of the VHA. The
supervisor should be notified. If reporting assistance is needed, the
facility Compliance Officer should be contacted.

**Compliance programs assure veterans, employees, and the public that
VHA follows the rules!**