# Presentation: 828898

## VHA and VISN 21 Compliance & Business Integrity (CBI)  Program

**Mandatory Training for Contractors**
-                                              **Prepared: March 2007 **

**Notes:**
VHA and VISN 21 Compliance & Business Integrity (CBI) ProgramMandatory Training for ContractorsPrepared Jan. 2006

## Compliance Officers

**Jane Dutton Morris, MHA**
**Compliance Specialist, Sierra Pacific Network **
**(707) 562-8377**
** **_[Jane.Dutton2@.va.gov](mailto:Jane.Dutton2@.va.gov)_
** **
**Yvonne Brooks, CCP****    **
**Compliance Officer **
**VA San Francisco Medical Center**
**(415) 221-4810 Ext. 4398**
- _[Yvonne.Brooks@med.va.gov](mailto:Yvonne.Brooks@med.va.gov)_
**Caroline Chaderjian, MHA**
**Compliance Officer**
**VA Palo Alto Health Care System **
**(650) 493-5000 Ext. 63315**
_**Caroline.Chaderjian@va.gov**_
**Patty Almond, RHIT, CPC****    **
**Compliance Officer **
**VA Central California Health Care System **
**(559) 225-6100 Ext. 5581**
_**Patricia.Almond@va.gov**_
**       **

**Notes:**
Compliance Officers:Jane Dutton MorrisYvonne BrooksCaroline ChaderjianPatty Almond

##    Compliance Officers- continued

**     ****Patricia Moran,**** ****RHIT CPC **
**     ****Compliance Officer **
**     ****VA Northern California Health Care System **
**     ****(707)437-1905**
**     **_[Patricia.Moran@va.gov](mailto:Patricia.Moran@va.gov)_
**     ****Peggy Ashcraft**
**     ****Compliance Officer **
**     ****VA Sierra Nevada Health Care System**
**     ****(775)328-1212**
**     **_**MargaretPeggy.Ashcraft@med.va.gov**_
**     ****Craig Oswald****, MHA**
**     ****VA Pacific Islands Health Care System**
**     ****(808)433-0103**
**     **_**Craig Oswald@med.va.gov**_

##   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.
**	**

##  VHA’s Compliance Program

**Currently the VHA’s 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

## 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 public’s trust.

##  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

##  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.**

##   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**

##         CBI Helpline- continued

**         **The CBI Helpline is available Monday  through Friday from 8:00 to 4:300, 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.

## 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.

##   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.

##  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 General’s (OIG) Exclusionary
- List Database cannot receive payments from any federal healthcare
- programs for services furnished.

## Identifying & Reporting High Risk Areas

_**STEP 1**_**: Ask yourself some key questions**** **
- Does the action fit with the organization’s 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

##       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.

## SUMMARY

**Compliance is Everybody’s 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.**