Chief Compliance Case Study

Compliance 360 has identified a number of areas which it can augment healthcare organizations to improve the audit process for Joint Commission audits. The program intuitively links contractors to regulations as evidence of compliance and monitors risk trends to

Aaron, you have demonstrated knowledge of Department policies and procedures and pose questions when concerns arise. You have demonstrated an understanding and practice of HIPAA laws as is evident in your ability to remain confidential with all investigations despite ongoing inquiries from those that are not authorized including Reporters and various family members. Aaron, you have demonstrated knowledge of the Department’s goals and also Division programs as evidenced by your investigative plans including requests for HCBS, assistance with Medicaid applications and reinvestigations, and care plan or provider changes. Many of these cases required follow up after case closure which you completed thoroughly. Throughout your hotline investigations,

Regulators work from set regulation of standards. These regulations allow setting defined standards and setting parameters for organizations to maintain compliance (Dlugacz, 2006). The Joint Commission (TJC) is a private non-profit organization whose mission is to continuously improve the safety and standards of care .TJC develops standards of care in collaboration with national experts to ensure quality standards of care are met , through data collection and

In Michigan, the Office of the Inspector General (OIG) was created in 1972 by the Michigan Department of Health and Human Services to help maintain accountability in efficient and appropriate administration of HHS programs (OIG, 2013). The OIG investigates alleged fraud in these programs as well as reviewing policies and procedures and recommending improvements in ways to counteract and detect fraud. In addition, OIG monitors compliance with reimbursement regulations. OIG provides guidance documents for compliance programs for various types of providers to use to develop compliance programs in their facilities. The compliance plans include development of policies, including those for accurate coding, internal monitoring and auditing, naming of a compliance officer, and appropriate training (Peden, 2012).

A typical day in the office includes auditing claims, sending claims to insurance companies, and working denials. Auditing claims is making sure what the physician coded for is documented and that the codes are correct. Each day I review the physician 's documentation against the codes they put into our system for their patient’s visit. At times when the documentation does not match what is coded, I query the physician and ask them to re-review their assessment and documentation. Below in the section, “Issues and How They Were Resolved” is a couple of examples of when the physician was contacted. I audit multiple claims a day and it is important that each one is suitable before it is sent to the insurance company.

of Health and Human Services and three of its managers, Allison Zinn, Emilee Hudson and Zoe

Tara informed me that she has over 20 years of experience in the behavioral health field. Tara stated she started out working at a home health agency that worked with the geriatric population. Tara is a Behavioral Health Technician, and holds a High Needs Case Manager position with Southwest Network. Tara explained that Southwest Network provided counseling services, medication management, and various behavioral health services to adults and children. In Tara’s role she works primary with children with high behavioral needs. Tara main role as a case manager is to be the liaison for the agency in regards to the behavioral health services with the child’s team or family. Tara explains although she does not do the initial assessments she with the clients she does complete annual assessments to determine if the services the child is receiving are appropriate; while making changes if necessary. Tara explained Southwest Network is funded by Mercy Maricopa Integrated Care (MMIC). MMIC makes the determination on if and when a client will receive services. If there is a case where a child is having major behaviors Tara can complete an assessment and request for a behavioral coach. MMIC is able to approve or deny the request based off the data Tara provides to them. Subsequently, if a child is not doing well in their home and the family or team is looking at a high level of inpatient care this too has to be approve. Tara would submitted a packet with supporting documentation to MMIC. MMIC again as the ability to approve or deny this request. Tara is also responsible for filing appeals when cases are denied for services. Tara would work with the child’s family or team to ensure the child is getting the services they need to be able to function within their daily

Requirements: Confirmed Veterans contact information Confirmed Veterans release date Confirm the facility has the secured equipment needed to conduct a hearing Confirm a test recording can be conducted prior to the scheduled hearing date Confirmed facility’s contact information to include POC title, and a phone number Conformation of VSO representation Requests to speak to VSO prior to hearing with VLJ Question: Should we put a return within a certain time frame date?

Jamison Consultants Behavioral Health Center offers Medicaid-supported behavioral wellbeing administrations – empowering those with Medicaid to have entry to an expansive scope of psychological wellness and substance misuse administrations. These administrations are regularly discriminating for some

To enhance my research, investigative, and analytical skills I enrolled in several courses in Talent Connection to improve my ability to review suspicious activity cases, provide a summary, and recommend action to management. I enrolled in Compliance Risk Assessment, Compliance Reporting and Administration, Audit Skills, Compliance Monitoring and Testing, and GLCR Learning Days.

Young?s behavioral perspective would be describe as an authority- compliance (9,1) on the Leadership Grid. According to Northouse, authority ?compliance is an all task approach that is not reasonable when changing the painting department at the hospital. Young?s new behavioral perspective is now Team management (9,9) on the Leadership Grid. Team management is refers as a leader who is ? stimulates participation, acts determined, gets issues out the open, makes priorities clear, follow through, behaves ?own ?mindedly, and enjoys working(Northouse,2016,p.77). He demonstrates three qualities: acts determined, makes priorities clear, and enjoying working. Young showed acts determined by doing a four month in-depth analysis on cost of painting services (Northouse, 2016). Making priorities clear by designing the department, changing policies and procedures and changing job performance expectations. Young allowed himself and his subordinates to work as a unit. Rewarding his team with an appreciation dinner has proven Young now operating in team management style .Team leadership style approach has led to a 92% customer satisfaction rate (Northouse, 2016).

When I worked as the Behavioral Health Quality Coordinator for Arizona State Medicaid, my Department was responsible for providing quality measures requirements to health plans. We were also responsible for evaluating the data submitted and the effectiveness of these measures. Health plans that did not meet these quality measures were issued corrective action plans or sanctions.

I would like to express my concern addressing the importance of emotions in the workplace culture that I believe we should remain aware of. I am concerned about a recent situation with Bob Sanderson and it is being handled. Unless there is additional information I am unaware of or documentation relating to this matter, my expression of concern is that by Bob’s supervisor telling him that he may not express any negative emotion in any way either verbally or nonverbally, that a mistake is being made. I, therefore, do believe this needs immediate action taken.

A solution focused compliance executive with experience in internal controls, policy & procedures, audits, investigations, monitoring, within public and non-profit organizations. Manage ethics and compliance, fraud, waste & abuse programs, and regulatory mandates. Well versed in ethics and compliance requirements, OIG, OMIG, Medicaid, Medicare, SOX, HIPAA, PhRMA, FCPA, Anti-kickback, Stark, HITECH, 340B DME, FERPA, and OSHA. Expert at assessing, monitoring and implementing programs. Manage global compliance and privacy programs. Recognized for being proactive in areas related to compliance education and training, and being reactive to developments in regulatory and governance environments. Highly adept in identifying gaps and/or risk exposure

Ability to review audit documentation, perform analysis, validate and document potential risk to determine course of appropriate corrective action and/or make recommendations