S02 - Attch - D.7. Compliance and Business Integrity Program Policy.pdf

36C26322R0024 D.7. Compliance and Business Integrity Program Policy

Department of Veterans Affairs Policy DIR-018 Nebraska-Western Iowa Health Care System October 16, 2017

Compliance & Business Integrity (CBI) Program Policy

1. BACKGROUND: The Veterans Health Administration (VHA) expects that its business operations and health information practices will be known in government and in industry as consistently complying with applicable standards and achieving the highest levels of business integrity. Compliance and Business Integrity (CBI) programs exist at all levels of the organization.

a. VHA’s business and health information units generate transactions which in the aggregate are material to VHA financial reporting. Revenues generated via first- and third-party billing activity are essential to fund health care services for veterans;

payments to non-VA sources of health care are significant expenditures for the system.

VHA’s business and health information units also rely on the clinical coding and other data the accuracy of which is essential for both business and clinical purposes.

b. CBI is an oversight and management process, woven into the fabric of routine operations to assure that business, health information and related clinical transactions occur in operational environments which accurately and reliably initiate, authorize, record, process, and report transactional data to ensure that management will be able to prevent or detect errors in transactions and on financial statements and other significant management reports.

2. PURPOSE: This directive establishes the framework for a Compliance and Business

Integrity (CBI) Program at VA-Nebraska Western Iowa Health Care System (VA-NWIHCS) which supports the operations of the organization’s mission and vision through a Medical Center-wide compliance program.

3. POLICY: The policy of VA-NWIHCS is that its business activities and health information practices will be conducted in accordance with all laws, regulations, and industry standards which apply and will maintain the highest level of professional and ethical standards in the conduct of its clinical and administrative operations. These standards can be achieved and sustained only through the actions and conduct of all staff of VA-NWIHCS

a. Compliance is actual and meaningful adherence to the requirements of any law, regulation, or industry standard applicable to the business activity or health information practice in question.

b. Business integrity is more than just technical or minimal compliance with the laws and regulations which apply to a business activity or health information practice. It means actions which not just comply fully with the letter of a particular law, rule or standard, but in addition can be characterized as the actions of an organization as above-board, ethical, and without the intent or effect of being false or misleading.

4. SCOPE: The scope of the CBI program is oversight of the business operations and health information practices of VA-NWIHCS. The scope of the CBI program does not include oversight of:

a. Clinical aspects of care and matters related to the clinical quality of that care, as to which the Office of Quality and Performance, the Office of Patient Safety, the Medical Inspector, the Office of Patient Care Services, the Office of Nursing, the Office of Clinical Logistics, and the National Center for Ethics in Health Care have primary program and oversight accountability.

b. The clinical and educational aspects of graduate medical education and training of clinical professionals, as to which the Office of Academic Affiliations has primary program and oversight accountability.

c. The clinical aspects of human subjects research as to which the Office of Research and

Development has primary program accountability and as to which the Office of Research Oversight has oversight responsibility. Within VA-NWIHCS, these activities are the responsibility of the Associate Chief of Staff for Research in conjunction with the Research Compliance Officer (RCO).

Note: It is recognized that in each of these areas, there will be overlap between the management of these areas and the business operations and health information practices which result. In these instances of overlap, leadership of clinical, education, research, and CBI program offices must coordinate their activities to meet individual program office needs and to compliment each others’ programs.

5. STRUCTURE AND RESPONSIBILITY:

a. Managers of operational units which engage in business operations and health information practices are primarily responsible for ensuring that all business operations and health information practices within their respective operations are being conducted in continuing compliance with the laws, regulations and standards which govern those activities, the reasonable expectations of VHA’s business partners, and the highest standards of business integrity.

b. The Compliance and Business Integrity Officer (CBI Officer) is delegated the day-to-day operational responsibility for the CBI program and for coordinating CBI activities for the Medical Center.

1) The CBI Officer will report to the Medical Center Director.

2) The CBI Officer will have resources, authority, and autonomy to conduct CBI activities, and is specifically delegated full authority to access all documents or information necessary to conduct CBI activities, regardless of whether that information is confidential or non-disclosable to the public or VHA employees generally.

3) The CBI Officer will not conduct any CBI activity in any situation where the Officer has personal or organizational interests which conflict, or might be perceived to conflict, with their CBI responsibilities.

a) When a situation arises where an actual or apparent conflict might be said to conflict, the CBI Officer in conjunction with the Associate Director will inform the Director in writing of all pertinent facts and either, (a) state that a conflict exists, or (b) ask the Director to determine in writing that a conflict does not exist.

b) In situations where a conflict is found to exist, the VISN 23 CBI Officer will be informed in writing and will be requested to designate a CBI Officer from another VAMC within the VISN to perform the duties of the CBI Officer.

6. PROCEDURES:

a. The following procedures are adopted:

1) Attachment A: Compliance Committee.

2) Attachment B: Training and Education Policy

3) Attachment C: CBI Communications Policy

4) Attachment D: Enforcement and Discipline Policy

5) Attachment E: Monitoring Policy

6) Attachment F: Auditing Policy

7) Attachment G: Investigation and Response Policy

8) Attachment H: Annual Review of CBI Program Effectiveness

b. The CBI Officer and Compliance Committee will coordinate the preparation of an annual formal CBI Risk Assessment which will be used to identify business processes to be monitored, the business processes and health information practices to be audited, and the areas to be the subject of focused training and education. The Risk Assessment will include:

1) A description of the risk identified,

2) The basis for identifying areas of identified risks, including assessment of:

a) The VA OIG Summary Report of Combined Assessment Program Reviews at Veterans Health Administration Medical Facilities,

b) JCAHO Reviews, and the HHS OIG Work Plan.

c) Results from VA-NWIHCS or VISN 23 monitoring activities and auditing activities.

3) A rating of the risk (for prioritization purposes) and

4) A plan to mitigate or minimize each risk other than those categorized as minimal, which includes:

a) Business process redesign, including documentation of standard operating procedures.

b) Training and Education.

c) Enhanced, focused, and repeated monitoring or audits to confirm the effectiveness of the mitigation plan.

7. REFERENCES:

a. VHA Directive 1030, Compliance and Business Integrity (CBI) Program, July 31, 2006

b. VHA Handbook 1030.01, Compliance and Business Integrity (CBI) Program Administration, July 31, 2006

c. Compliance And Business Integrity (CBI) Program Standards, VHA Handbook 1030.02, November 8, 2010

d. VHA Handbook 1030.04, VHA Compliance & Business Integrity (CBI) Help Line, June 9, 2009

e. VHA Compliance And Business Integrity Screening Procedures Of Government Sanctions Lists (GSL) For Individual And Entity Exclusions VHA Handbook 1030.05, July 14, 2011

f. VHA Directive 2005-039; Compliance and Business Integrity Program VHA Handbook 1030.06, August 26, 2011 HHS OIG Compliance Program, Guidance for Hospitals, 63 Federal Register (FR) 8987

(February 23, 1998) HHS OIG Compliance Program Guidance for Nursing Facilities, 65 FR 14289 (3/16/2000)

g. HHS OIG Compliance Program Guidance for Individual and Small Group Physician Practices, 65 FR 59434 (10/5/2000).

h. HS OIG Compliance Program Guidance for Third Party Medical Billing Companies, 63

FR 70138 (12/18/1998).

i. HHS OIG Provider Self-Disclosure Protocol, 63 FR 58399 (10/30/1998).

j. HHS OIG and American Health Lawyers Association, “Corporate Responsibility and

Corporate Compliance: A Resource for Health Care Boards of Directors, June 2003.

HHS OIG Supplemental Compliance Program Guidance for Hospitals, 70 FR 4858 (January 31, 2005) Public Law 107–174, Notification and Federal Employee Antidiscrimination and Retaliation Act of 2002, also known as the NO FEAR Act;

Standards for Internal Control in the Federal Government; Government Accountability Office (GAO); November 1, 1999; available at: http://www.gao.gov/special.pubs/ai00021p.pdf;

Standards of Ethical Conduct for Employees of the Executive Branch at:

http://www.usoge.gov/ethics_docs/publications/reference_publications/rfsoc_02.pdf

United States Sentencing Commission, Sentencing Guidelines, Chapter 8, Sentencing of Organizations at: http://www.ussc.gov/2004guid/CHAP8.pdf;

VA Handbook 0700, Administrative Investigations, located at:

http://www1.va.gov/vapubs/viewPublication.asp?Pub_ID=82&FType=2

VHA Directive 2011-041 Refund Policy;

CPAC Guidebooks

CPAC RNB Monitoring Policy, P-000-08-02 http://www.gao.gov/special.pubs/ai00021p.pdf http://www.usoge.gov/ethics_docs/publications/reference_publications/rfsoc_02.pdf http://www.ussc.gov/2004guid/CHAP8.pdf http://www1.va.gov/vapubs/viewPublication.asp?Pub_ID=82&FType=2

CPAC, Clinic Monitoring, P-000-09

CPAC, Service Connection and Special Authority Eligibility Validation Review Process, P-007-01-

CPAC, First- and Third-Party Billing on Non-VA Care, SOP-000-003

8. RESCISSIONS: DIR-018 dated April 14, 2014

9. FOLLOW-UP RESPONSIBILITY: CBI Officer is responsible for follow up of this policy.

10. CONCURRENCES:

AFGE (Omaha, Lincoln, Grand Island) Business Office Finance Office

COS

Associate Director

11. KEY WORDS: Compliance

/es/

B. DON BURMAN, MHA

Director

Attachment A

COMPLIANCE COMMITTEE

1. PURPOSE: This policy establishes a Compliance and Business Integrity (CBI) Committee at VA-NWIHCS to assist in the design and implementation of CBI program activities. The Committee serves in an advisory role to senior leadership regarding the CBI function.

2. BACKGROUND.

a. The Guidelines of the United States Sentencing Commission defines the characteristics of an effective compliance program. Among these is the need for organizational boards and leadership to be knowledgeable about the content and operation of the compliance and ethics program, and the need to exercise reasonable oversight with respect to the implementation and effectiveness of the compliance and ethics program. Recent revisions to the Sentencing Commission Guidelines make clear that all management and leadership shares responsibility with the compliance officer for leading the organization to achieve compliance and ethical behavior.

b. Veterans Health Administration (VHA) Directive 1030, July 31, 2006, Compliance and Business Integrity Program, establishes CBI Committees at the facility and VISN level, as well as a national Compliance Advisory Board (CAB).

3. POLICY: It is the policy of VA-NWIHCS that a Compliance Committee will be established to provide guidance to local leadership as to whether the organization’s business operations and health information practices are being conducted in accordance with applicable laws, regulations and industry standards and the highest standards of business integrity.

4. ACTION.

a. Facility Director. The Facility Director is responsible for establishing the CBI Committee and:

1. Appointing appropriate members of the Committee.

2. Reviewing and approving minutes and recommendations.

3. Delegating necessary authority to the CBI Committee to complete its functions.

4. Providing overall CBI Program oversight.

b. CBI Officer. The CBI Officer is responsible for:

1. Serving as the Chair or co-Chair of the CBI Committee.

2. Ensuring minutes of the CBI Committee are provided to the Director for review, discussion, and approval.

3. Developing the agenda prior to each meeting.

4. Providing reports at each CBI Committee meeting describing the actions and initiatives of the CBI program.

5. Providing or arranging to provide education to CBI Committee members regarding its role and CBI oversight functions through training and education refresher courses.

6. Soliciting guidance and advice from the CBI Committee regarding the activities and direction of the CBI program.

c. CBI Committee.

1. At a minimum, membership must include the senior-most officers responsible for the revenue cycle and purchased care operations, Health Information Management (HIM), the Chief Financial Officer, Union Representative and may include other services with operational responsibility for CBI program elements, such as Human Resources, Quality Management, and other services as needed.

1. The CBI Committee will meet monthly, and may meet on an ad hoc basis at the call of the Chair or co-Chair if an issue needs immediate attention.

2. The Committee will establish documented standards and processes for executing its compliance oversight responsibilities. These standards and processes will include:

a. The Committee will assist in developing and/or reviewed the facility’s Risk Assessment, Monitoring Plan, Auditing Plan and Training and Education Plan

b. CBI Officer, in concert with the Compliance Committee, reviews referrals from other VAMC programs and functions that influence business integrity.

c. The CBI Officer will inform the Committee of investigations, program reviews, external inspections or other recurring or episodic program assessment efforts that involved CBI issues.

d. The Committee will review the results of all revenue cycle quality monitoring, CBI-related audits and investigations.

3. The following may be standing agenda items at every Compliance

Committee meeting.

a. Review of and updates to Risk Assessments, Training and Education Plans, Monitoring Plans, and Auditing Plans.

b. Review of referrals from other VAMC programs and functions.

c. Review of results of investigations, program reviews, external inspections or other recurring or episodic program assessment efforts.

d. Review of results and findings of all compliance-related business quality monitoring, audits, investigations, fact-finding efforts, progress and outcomes of CBI Action Plans.

e. Review of results of Training and Education programs.

f. Review of results of Government Sanctions List GSL, LEIE screening and Background checks.

g. Review of CBI Supporting Indicators.

h. Review of CIRTS entries with length of activity as well as more detailed reports when necessary.

i. Review of rates and causes for nonpayment of MCCR billings.

j. Review of High-Value refund requests as defined by VHA

Directive 2005-039.

k. Review of results of investigations regarding misconduct related to compliance.

l. Review of CBI Policies.

4. The Committee’s minutes will be forwarded to:

a. The VA-NWIHCS Director who will sign them to show they are reviewed.

b. The VISN CBI Officer will be promptly informed of issues of significant importance or compliance issues.

5. At least once each calendar quarter, the committee will provide a written report regarding CBI program activities to the Executive Leadership Board (ELB) of NWI.

6. On an annual basis, the Committee will provide a written report to the

VA-NWIHCS Director on significant work performed during the year and upcoming focus areas.

Attachment B

COMPLIANCE TRAINING AND EDUCATION

1. PURPOSE: This policy establishes policy for training and education in support of the Compliance and Business Integrity initiatives within the VA-NWIHCS.

2. POLICY. The following policies govern all CBI-related training:

a. CBI awareness training will be provided for all new employees within 60 days of hire and recurrent CBI awareness training will be provided to all employees on an annual basis. CBI awareness training will cover at least the following subjects:

1. The VHA CBI program, the necessity of integrity in all business operations, and the importance of these to the Center’s mission.

2. Applicable laws and regulations.

3. The CBI Helpline.

b. Job-specific compliance and business integrity training will be provided to all employees on an annual basis. Job-specific training covers, as appropriate to the job function, clinical documentation and documentation standards.

c. Volunteers assisting in revenue cycle operations or health information practices will receive the same initial and recurrent CBI training as the employees with whom they work.

d. Employees of independent contractors engaged in revenue cycle activities will be required by contract to receive initial and annual recurrent CBI awareness and job-specific training approved by the CBI Officer.

e. Targeted education will be provided to affected employees, volunteers, and contractor’s employees based on monitoring results, audit results, the Risk Assessment, or after a compliance exception is detected.

f. Regional Counsel will be invited to participate in, or approve the content of, education involving government ethics and conflicts of interest.

g. A system will track the education each employee receives.

h. The effectiveness of the training will be evaluated.

i. Training will be conducted pursuant to a formal Training and Education Plan which is reviewed and approved by the Compliance Committee. The Plan will:

1. Provide, with respect to each CBI training and education program:

a. The target audience or employee group.

b. The syllabus, i.e., a detailed discussion of the content to be taught.

c. The method of education (e.g., lecture, video, web-based, etc.)

d. The timing, frequency or scheduling of the program.

e. The methods of tracking the education each employee receives, and

f. The methods for evaluating the effectiveness of the training.

2. Provide for job-specific CBI training and education for at least the following categories of employees, volunteers, or contractors:

a. Who enter, review, or validate clinical codes.

b. Who produce, review, or monitor the quality of billings for clinical goods or services or copayments related to clinical goods or services.

c. Who process any other activity related to the revenue cycle, including patient registration, insurance identification and verification, accounts receivable, claims appeals or reconsiderations.

d. Physicians and Residents.

e. Clinical providers other than physicians as indicated by the risk assessment or auditing and monitoring results.

f. Executive Management.

g. Clinical Department Heads and Supervisors.

h. Compliance Committee Members.

i. Employees engaged in contracting for or administering contracts for clinical services.

Attachment C

CBI COMMUNICATIONS POLICY

1. PURPOSE: This policy establishes policies related to communication involving matters relating to Compliance and Business Integrity initiatives within the VA-NWIHCS.

2. POLICY. The following are policies of VA-NWIHCS:

a. The following items will be communicated to the executive leadership and managers of each department identified for focused compliance activity:

1. The Risk Assessment

2. The Training and Education Plan

3. The Monitoring and Auditing Plan

4. Any compliance risks identified throughout the year, as well as the plan to mitigate that risk.

b. The CBI Officer will be involved in entrance and exit interviews conducted by the VA OIG, SOARS, JCAHO, any health benefit plan or third party payor, or other agency which evaluates business compliance or health information practices.

c. The facility will use employee exit interviews to ask business integrity related questions and will immediately advise the CBI Officer of any allegations of lack of compliance or business integrity.

d. Clinical providers will be informed of changes to documentation standards which may affect coding or billing.

e. Managers of all business operations will immediately forward to the CBI Officer copies of any correspondence that suggests significant or systemic deficiencies in patient registration data, clinical documentation, coding, billing, refunds, or overpayments.

f. The CBI Officer will be promptly informed of issues of significant importance or compliance exceptions.

g. The CBI Officer will receive reports of monitoring by internal business units.

h. The CBI Officer will have ready access to assistance from Regional Counsel and will consult with Counsel when serious compliance exceptions are suspected or detected.

i. CBI Posters will be displayed in employee and other appropriate areas such as patient waiting areas, break rooms, revenue office, etc.

j. The CBI Officer may be a member of the following multidisciplinary committees:

1. VISN Compliance Committee.

2. MCCR or Revenue Committee

3. HIMS Committee

Attachment D

CBI ENFORCEMENT, DISCIPLINE and RECOGNITION POLICY

1. PURPOSE: This policy establishes policies related to the enforcement of standards relating to Compliance and Business Integrity initiatives within the VA-NWIHCS, recognition of those employees who identify compliance and business integrity issues, and discipline of those employees and managers who fail to comply with these policies.

2. POLICY. The following are policies of VA-NWIHCS:

a. All employees are required to understand and comply with the laws, regulations, and industry standards which apply to their job functions and to perform those functions with the highest standards of business integrity.

b. Managers of business functions are to operate their programs in compliance with the laws, regulations and industry standards which apply to those functions and with the highest standards of business integrity.

c. Performance standards for managers and employees of business functions will measure both quantity and quality of work performed, the compliance of that work with the laws, regulations and industry standards which apply, and whether the work was performed in accordance with the highest standards of business integrity.

d. Managers and supervisors will be expected to adequately train employees in compliance and business integrity matters. Failure to train employees in matters pertaining to compliance and business integrity, or failure to use reasonable diligence to adequately detect, disclose, and correct noncompliance with applicable laws, regulations or industry standards could lead to discipline.

e. Employees are to receive appropriate recognition when they identify compliance or business integrity issues.

f. There will be no retaliation or adverse action of any kind against any employee who identifies or reports a compliance or business integrity issue to management, to the CBI Officer, or through the CBI Helpline.

g. Actual or possible violations of law are to be reported to the Inspector General and other proper authorities as required by 38 CFR 1.201.

h. All employees, all without-compensation (WOC) employees, all volunteers, and all contractors will be screened against the HHS OIG List of Excluded Individuals and Entities (LEIE) at the time of employment or engagement and monthly thereafter.

Attachment E

CBI MONITORING POLICY

1. PURPOSE: This policy establishes policies related to the monitoring of operations within the VA-NWIHCS to assist in confirming that business operation and health information practices are conducted in accordance with applicable laws, regulations and industry practices or to identify where they do not, so that causes for noncompliance can be identified and resolved.

2. POLICY. The following is the policy for VA-NWIHCS:

a. Process owners, i.e., operational units responsible for all steps in the revenue cycle including health information practices, will routinely monitor the accuracy of all output from each of those steps to assure such data is accurate and complies with all applicable laws, regulations and industry standards. The following steps in the revenue cycle will be routinely monitored:

1. Patient registration.

2. Insurance identification and verification.

3. Utilization review, precertification of benefits, preauthorization of services.

4. Clinical documentation.

5. Clinical coding.

6. First Party Billing.

7. Third Party Billing.

8. Accounts Receivable posting.

9. Accounts Receivable decreases, write-offs and terminations.

10. Reasons for claims denials and denial patterns.

11. Overpayments and Refunds.

b. In addition to monitoring the output from each of the steps of the revenue cycle, business process and health information practices owners will monitor additional aspects of the revenue cycle or other business operations or health information practices:

1. as indicated by the facility’s Risk Assessment,

2. as indicated by results of monitoring or auditing,

3. as indicated by external to the facility (e.g., communications from veterans or payors) of deficiencies in the quality or accuracy of the output from any element of the revenue cycle, and

4. Conflicts of interest in the purchasing of non-VA care.

c. Monitoring activity will be conducted in accordance with formal Monitoring Plans which will be reviewed by the Compliance Committee and approved by the Director.

Monitoring plans will:

1. Be based on a documented and consistently applied statistical sampling methodology sufficient to produce reliable data on which management decisions can be based.

2. Contain a detailed discussion of the following elements:

a. A description of each monitor;

b. The frequency (which will be not less frequently than monthly)1 with which the monitor will be conducted;

c. The business process owner which will conduct the monitor;

d. A description of the data to be monitored;

e. The manner in which the data will be sampled for review;

f. The statistical confidence and precision of the results of the monitoring, and a discussion showing how that confidence and precision is calculated;

3. A definition of the standards for determining accuracy of the sampled data;

4. The minimum accuracy standard for the business output, which in the case of revenue cycle data will not be less than 95 per cent;

5. An explanation of how monitors will be conducted and who would conduct them.

6. The reporting format and list of recipients of monitoring reports.

d. Monitoring results will be reported to the supervisors of the business process and health information practices owners and to the CBI Officer.

e. The CBI Officer will provide oversight of the Monitoring process and be in a position to advise facility leadership whether Monitoring is conducted by process owners as required by the policy and whether Monitoring results:

1. Are sufficient to provide reliable information as to whether business output is accurate, complies with all applicable laws, regulations and industry standards; and

2. Is reliable data on which management decisions can be based.

Attachment F

CBI AUDITING POLICY

1. PURPOSE: This policy establishes policies related to the auditing of operations within the

VA-NWIHCS to assist in confirming that business operation and health information practices are conducted in accordance with applicable laws, regulations and industry practices or to identify where they do not, so that causes for noncompliance can be identified and resolved.

2. POLICY: The following is the policy for VA-NWIHCS:

a. The CBI Officer will perform or manage audits of the accuracy of all output from each of the steps in the revenue cycle including health information to assure such data is accurate and complies with applicable laws, regulations and industry standards.

The following steps in the revenue cycle will be audited:

1. Patient registration.

2. Insurance identification and verification.

3. Utilization review, precertification of benefits, preauthorization of services.

4. Clinical documentation.

5. Clinical coding.

6. First Party Billing.

7. Third Party Billing.

8. Accounts Receivable posting.

9. Accounts Receivable decreases, write-offs and terminations.

10. Reasons for claims denials and denial patterns.

11. Overpayments and Refunds.

b. In addition to auditing the output from each of the steps of the revenue cycle, the CBI Officer will perform or manage audits of additional aspects of the revenue cycle or other business operations:

a. As indicated by the facility’s Risk Assessment.

b. As indicated by the results of monitoring or the results of auditing.

c. As indicated by data or information from sources external to the facility of deficiencies and the quality or accuracy of the output of any element in the revenue cycle, and

d. Conflicts of interest in the purchasing of non-VA care.

c. Auditing activity will be conducted in accordance with formal Audit Plans which will be reviewed by the Compliance Committee. Audit Plans will:

a. Be based on, but need not strictly comply with, Generally Accepted Government

Audit Standards.

b. Be based on documented and consistently applied statistical sampling methodologies sufficient to produce reliable data on which management decisions can be based.

c. Contain:

1. A description of each audit;

2. The frequency (which will be not less frequently than annually) with which the audit will be conducted;

3. The personnel or contract resource which will conduct the audit;

4. A description of the data to be audited;

5. The manner in which the data will be sampled for review;

6. The statistical confidence and precision of the results of the audit, and a discussion showing how that confidence and precision is calculated;

7. A definition of the standards for determining accuracy of the sampled data;

8. The minimum accuracy standard for the business output, which in the case of revenue cycle data will not be less than 95 per cent;

9. The reporting format and list of recipients of monitoring reports.

d. Audit results will be reported to the supervisors of the business process owners and to the Compliance Committee.

Attachment G

CBI INVESTIGATION AND RESPONSE POLICY

1. PURPOSE: This policy establishes policies related to the investigation of allegations or concerns that business operations within the VA-NWIHCS, including health information practices, are not being conducted in accordance with applicable laws, regulations and industry practices and the resolution of causes of any findings of noncompliance.

2. POLICY: The following is the policy for VA-NWIHCS:

a. The CBI Officer will conduct a fact-finding review whenever the CBI Officer receives credible information from any source, including CIRTS, that any of the facility’s business activities may not be conducted in accordance with applicable laws, regulations or industry standards or the highest standards of business integrity;

b. The CBI Officer will develop a process for conducting such inquiries and the timelines during which fact-finding is to be performed;

c. The CBI Officer will make an initiating entry into the CIRTS system at the start of any inquiry and will track progress toward conclusion of the inquiry in CIRTS until completion.

d. Every effort be made to protect a reporting individual’s identity (if requested and applicable), while at the same time individuals bringing information forward will be warned that this might not always be possible.

e. If during fact-finding the CBI Officer comes to a conclusion that a criminal act may have occurred or that waste, fraud or abuse has occurred, the CBI Officer will immediately suspend fact-finding (which may impair investigation by the VA Inspector General) and working with facility executive leadership, will inform the Inspector General in accordance with 38 CFR 1.201.

f. At least the following documentation will be maintained about each CBI fact-finding inquiry which is conducted:

1. Background and allegations.

2. Description of the fact-finding which was conducted.

3. Copies of documents reviewed.

4. Copies of all interview notes.

5. Results of the fact finding and copies of all reports.

6. Corrective action plan as implemented if needed.

7.

g. The results of all fact-findings conducted by the CBI Officer will be reported, with appropriate detail, to the Compliance Committee.

h. If during fact-finding the CBI Officer comes to a conclusion that a formal Board of Investigation is needed, the CBI Officer will so inform the facility Director and will be a resource to the Director in determining whether a formal Board should be convened.

i. The CBI Officer will be a member of, or act as a consultant to, Administrative Boards of Investigation within the facility when the subject matter involves compliance and business integrity issues.

j. Compliance and business integrity issues which are found or detected during a formal

Board of Investigation at VA-NWIHCS will be referred to the CBI Officer for follow up and remediation.

k. If a determination is made by informal fact finding or through a formal investigation or otherwise of noncompliance with any applicable law, regulation or industry standard, or that business activities were conducted inconsistent with the highest standards of business integrity; then

1. prompt corrective action will be taken to remedy the identified transactions

(including making refunds of overpayments, if any), and

2. root cause analysis will occur to assess affected business systems which will be corrected as necessary to assure that they are sufficient in the ordinary course of business to prevent noncompliance from occurring, to detect noncompliance when it occurs, and correct non-complying transactions and the causes for such noncompliance.

Attachment H

Annual Review of CBI Program Effectiveness

1. PURPOSE. This policy establishes procedures regarding the Annual Review of CBI Program Effectiveness at Nebraska-Western Iowa Health Care System.

2. POLICY: The following policy is the policy of the Nebraska-Western Iowa Health Care System.

A. The organization will demonstrate a written review of the effectiveness of the CBI program on a fiscal year basis.

B. After the review of the effectiveness has been concluded, the CBI Officer will author a report for the senior-most executive and the CBI Committee detailing.

• The performance of the program, including all work completed:

• the results of the risk assessment, and the contents of the program’s various planning documents This report is to include a description of how future CBI program activities will mitigate current compliance risks and failures.