KNOCK KNOCK Managing Audits and Compliance Robert Saenz

KNOCK…. . KNOCK “Managing Audits and Compliance” Robert Saenz, President VIP Medical Consulting 1

Current Epidemic “Dilly” “Miss Emma” “Good Fellas” “Mary Jane”

Robert Saenz Graduate of both the U. S. Border Patrol Academy & the FBI National Academy. 20 years investigating federal crimes with the Department of Justice. Prior Field Director for the U. S. Congress working on legislative issues related to Federal & Healthcare law. Currently, PRESIDENT of VIP Medical Consulting www. vipmedicalonline. com (210) 643 -4300

For Every One Death From Prescription Drug Misuse 32 Emergency 9 Treatment dept visits admissions for abuse 1 Death 161 People who Misuse/abuse 461 Non-medical users CDC Vital Signs: Overdoses of Prescription Opioid Pain Relievers in the U. S. 1999 -2008 Atlanta, GA: Centers for Disease Control and Prevention, November 2011.

“DUE DILIGENCE” Thorough Initial Exam “Specialist” Consult Drug Tox Screen Signed Patient Agreement State PDMP Check 5

DEA AUDIT and Chart Review • Overdose of a Patient • New Patient Eval. • Patient/Employee Sells • Patient Agreement • Pharmacist • State PDMP • Whistleblower • Drug Screen 6

Dr. Albert Yeh • • Dr Yeh wrote over 6000 prescriptions in 1 yr 11 separate DEA undercover visits Brief History and Physical Pain in My Toe What has worked for you before? X-Ray /MRI but no Drug Screen NO PDMP PA follow ups vs MD 7

DEA vs. Dr Yeh Since Dr. did not Act in Good Faith and in Accordance with Generally Accepted Medical Standards, this leads to arrest and seizure based on : • Racketeering (Dishonest/ Organized Crime) • Money Laundering (Dirty Money) • Billing Fraud (Deception) • Drug Dealing (self explanatory) 8

Medical Board Reviews It is a Battle of “Documentation” • “Were The Prescribing Guidelines followed” – Face to Face physical examination – Prevention of diversion – Assessment of Benefit of opiates or Benzos – Adjustment of treatment according to risk – Periodic Review and Notes delineating progress – Adequate and accurate record keeping 9

HEALTHCARE HISTORY 101 • 1965 Medicare was created • 1970 Kickbacks rampant • 1975 HEW (Health, Education, Welfare) • 1980 Pres. Reagan “Waste Fraud & Abuse” 10

Deterrence or Terror • 1981 -1991 OIG Richard Kusserow 11

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) establishes the Health Care Fraud and Abuse Control Program HCFAC or “The Program” TODAY…………… 30 Federal Agencies investigating Health. Care FBI OIG DEA HEAT

OIG Strategic Work Plan 2016 -2017 With the Affordable Health Care Act known as Obama Care on the rocks and TRUMP Care on the Horizon sputtering as well and the Medicare program in financial jeopardy, the 2016 -2017 OIG work plan may be more important today. More federal agencies are investigating Medicare fraud and abuse than ever before, with a “zero tolerance expectation” of physicians https: //oig. hhs. gov/: Strategic work plan 13

“HEAT” TASK FORCE Created On May 20, 2009 Increased tools and resources, Sustained focus by senior level leadership Cabinet level commitment to prevent and prosecute health care fraud • HEAT jointly led by Deputy Attorney General and HHS Deputy Secretary • Comprised of top level agents, prosecutors, attorneys & auditors • • 14

ANTI KICKBACK • Prohibits Outright Bribes • Prohibits INDUCEMENT – Items or Services 15

7 STANDARDS OF SAFE HARBOR • IN WRITING SIGNED BY • COMPENSATION SET IN BOTH PARTIES ADVANCE (FAIR MARKET VALUE) • COVER SPECIFIC • NOT INVOLVE SERVICES BY THAT INVOLVE CONTRACTOR PROMOTION OF • SET SCHEDULE , LENGTH BUSINESS SERVICES AND EXACT CHARGE FOR PART TIME • SERVICES DO NOT EXCEED REASONABLY • SPAN AT LEAST 1 YEAR NECESSARY 16

Elements of Compliance • 1. Establish compliance standards by developing a code of conduct and writing policies and procedures. • 2. Assign compliance monitoring to a designated compliance officer. • 3. Conduct comprehensive training and education on practice ethics, policies and procedures. https: //oig. hhs. gov/authorities/docs/cpglab. pdf 17

THANK YOU ! VIP MEDICAL CONSULTING www. vipmedicalconsulting. com 18