Compliance Program Assessment Results

Compliance Program Assessment Results

The Bureau of Compliance (BOC) in the New York State Office of the Medicaid Inspector General (OMIG) conducts assessments of Required Providers’ compliance programs. The chart below identifies the frequency (on a percentage basis) of Insufficiencies that were cited by BOC during compliance program reviews completed from January 2015 through June 30, 2017. The higher the percentage the more frequent the Insufficiency was observed. An “Insufficiency” is defined to be any failure to meet any requirement under an Element.

A Required Provider is defined in 18 New York Codes, Rules, and Regulations (NYCRR) Part 521 as:

(a) persons subject to the provisions of Article 28 or 36 of the New York State Public Health Law;

(b) persons subject to the provisions of Article 16 or 31 of the New York State Mental Hygiene Law; or

(c) other persons, providers, or affiliates who provide care, services, or supplies under the Medical Assistance Program or persons who submit claims for care, services, or supplies for or on behalf of another person for which the Medical Assistance Program is or should be reasonably expected by a provider to be a substantial portion of their business operations.

(What constitutes a “substantial portion of business operations” is defined in 18 NYCRR Section 521.2.)

Required Providers’ compliance programs shall meet the requirements established in 18 NYCRR 521.3 (c), which contains eight elements. 18 NYCRR 521.3(a) sets forth that Required Provider’s compliance programs shall be applicable to:

(1) billings;
(2) payments;
(3) medical necessity and quality of care;
(4) governance;
(5) mandatory reporting;
(6) credentialing; and
(7) other risk areas that are or should with due diligence be identified by the provider.

OMIG’s Compliance Program Assessment Form can assist Required Providers to assess whether their compliance program is meeting the regulatory requirements. The eight elements and their corresponding requirements on the Self-Assessment Form are the same as those used by BOC when it conducts compliance program assessments.

The following chart identifies the frequency (on a percentage basis) that a particular compliance requirement was determined by BOC to be an Insufficiency. The percentages reported are for January 2015 through June 30, 2017. The higher the percentage the more frequent the Insufficiency was observed.

NOTE: On the following chart, some requirements include multiple components. If BOC finds a failure in any one component of a requirement, the whole requirement is considered Insufficient.

 

Requirement

Insufficiency Percentage

 

 

Element 1: Written policies and procedures

 

1.1

Do you have written policies and procedures in effect that describe compliance expectations as embodied in a code of conduct or code of ethics?

3%

 

1.2

Do you have written policies and procedures in effect that implement the operation of the compliance program?

9%

 

1.3

Do you have written policies and procedures in effect that provide guidance on dealing with potential compliance issues for all of the following groups:

a. employees; and
b. others?

“Others” for purposes of this requirement should be defined to include all those individuals that are not employees that are subject to the Compliance Program.  This includes, but may not be limited to:  executives, governing body members, appointees, and persons associated with the provider

24%

 

 

Element 2: Designate an employee vested with responsibility

 

2.1

Has a designated employee been vested with responsibility for the day-to-day operation of the compliance program?

7%

 

2.2

Are the designated employee’s (referred to in 2.1) duties related solely to compliance?

NA

 

2.3

Are the compliance responsibilities satisfactorily carried out?

31%

 

2.4

Does the designated employee (referred to in 2.1) report directly to the entity's chief executive or other senior administrator?

1%

 

2.5

Does the designated employee (referred to in 2.1) periodically report directly to the governing body on the activities of the compliance program?

13%

 

 

Element 3: Training and education

 

3.1

Is periodic training and education on compliance issues, expectations and the compliance program operation provided to all of the following categories of affected individuals:

a. employees;
b. executives;
c. governing body members; and
d. persons associated with the provider?

Also define the timing of the periodic training, and identify any categories of affected individuals that do not receive training and education, if any.

55%

 

3.2

Is compliance training part of the orientation for all of the following categories of affected individuals:

a. employees;
b. executives;
c. governing body members; and
d. persons associated with the provider?

Also define when orientation occurs, and any categories of affected individuals that do not receive orientation, if any.

47%

 

 

Element 4: Lines of communication to the responsible compliance position

 

4.1

Are there written policies and procedures that identify how to communicate compliance issues to appropriate compliance personnel?

7%

 

4.2

Are there lines of communication to the designated employee referred to in item 2.1 that allow compliance issues to be reported and which are accessible to all of the following categories of affected individuals:

a. employees;
b. executives;
c. governing body members; and
d. persons associated with the provider?

Also identify any categories of affected individuals who do not have access to the lines of communication identified.

12%

 

4.3

Is there a method for anonymous and confidential good faith reporting of potential compliance issues as they are identified for all of the following categories of affected individuals:

a. employees;
b. executives;
c. governing body members; and
d. persons associated with the provider?

Also identify any categories of affected individuals who do not have access to the lines of communication identified.

47%

 

 

Element 5: Disciplinary policies to encourage good faith participation

 

5.1

Do disciplinary policies exist to encourage good faith participation in the compliance program by all of the following categories of affected individuals:

a. employees;
b. executives;
c. governing body members; and
d. persons associated with the provider?

Also identify any categories of affected individuals not covered by the policies.

23%

 

5.2

Are there policies in effect that articulate expectations for reporting compliance issues for all of the following categories of affected individuals:

a. employees;
b. executives;
c. governing body members; and
d. persons associated with the provider?

Also identify any categories of affected individuals not covered by the policies.

4%

 

5.3

Are there policies in effect that articulate expectations for assisting in the resolution of compliance issues for all of the following categories of affected individuals:

a. employees;
b. executives;
c. governing body members; and
d. persons associated with the provider?

Also identify any categories of affected individuals not covered by the policies.

29%

 

5.4

Is there a policy in effect that outlines sanctions for failing to report suspected problems for all of the following categories of affected individuals:

a. employees;
b. executives;
c. governing body members; and
d. persons associated with the provider?

Also identify any categories of affected individuals not covered by the policy.

8%

 

5.5

Is there a policy in effect that outlines sanctions for participating in non-compliant behavior for all of the following categories of affected individuals:

a. employees;
b. executives;
c. governing body members; and
d. persons associated with the provider?

Also identify any categories of affected individuals not covered by the policy.

4%

 

5.6

Is there a policy in effect that outlines sanctions for encouraging, directing, facilitating or permitting non-compliant behavior for all of the following categories of affected individuals:

a. employees;
b. executives;
c. governing body members; and
d. persons associated with the provider?

Also identify any categories of affected individuals not covered by the policy.

21%

 

5.7

Are all compliance-related disciplinary policies fairly and firmly enforced?

Also list all policies in effect that support your answer and Identify circumstances where compliance-related discipline was enforced.

8%

 

 

Element 6: A system for routine identification of compliance risk areas

 

6.1

Do you have a system in effect for routine identification of compliance risk areas specific to your provider type?

Also reference documents in which you’ve identified your risk areas.

17%

 

6.2

Do you have a system in effect for self-evaluation of the risk areas identified in 6.1, including internal audits and as appropriate external audits?

Also reference any documents in which you have identified compliance work plans and/or audit plans.

15%

 

6.3

Do you have a system in effect for evaluation of potential or actual non-compliance as a result of audits and self-evaluations identified in 6.2?

Also reference documents that outline your system for evaluating the cause of compliance problems.

19%

 

 

Element 7: A system for responding to compliance issues

 

7.1

Do you have written policies and procedures that provide guidance on how potential compliance problems are investigated and resolved?

7%

 

7.2

Is there a system in effect for responding to all of the following:

a. compliance issues as they are raised; and
b. as identified in the course of audits and self-evaluations?

Also reference documents that outline your system for responding to actual or potential compliance issues.

12%

 

7.3

Is there a system in effect for correcting compliance problems promptly and thoroughly?

23%

 

7.4

Is there a system in effect for implementing procedures, policies and systems as necessary to reduce the potential for recurrence?

12%

 

7.5

Is there a system in place for identifying and reporting compliance issues to the NYS Department of Health or the NYS Office of Medicaid Inspector General?

31%

 

7.6

Is there a system in place for refunding Medicaid overpayments?

Also identify examples of prior refunds of Medicaid overpayments.

9%

 

 

Element 8: A policy of non-intimidation and non-retaliation

 

8.1

Is there a policy of non-intimidation and non-retaliation for good faith participation in the compliance program, including but not limited to reporting potential issues, investigating issues, self-evaluations, audits and remedial actions, and reporting to appropriate officials as provided in Sections 740 and 741 of the New York State Labor Law?

Both non-intimidation and non-retaliation must be present.

44%