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February 15, 2012

Measuring the Effectiveness of a Compliance Program: OMIG Style

As you may know, over the course of the last year, the New York State Office of the Medicaid Inspector General (OMIG) has issued guidance for providers regarding how OMIG would evaluate the effectiveness of a compliance program. OMIG now requires providers to certify the effectiveness of their compliance programs during December of each year. In recent months, OMIG has been conducting an increased number of "effectiveness reviews," where it contacts a provider who is supposed to have an effective compliance program, and requires them, sometimes on an expedited basis, to complete the relevant OMIG effectiveness questionnaire and provide other documentation to the compliance effectiveness review team. A site visit may occur, which includes interviews of board members, management and staff and can last a week.

OMIG's effectiveness questionnaire requires yes/no answers, evidence of compliance and statements of action items for improvements. OMIG has stated, "During the course of the . . . focused review, providers may be asked to complete a Compliance Program Assessment Tool (Tool) and return it to OMIG's Bureau of Compliance." As such, it behooves every provider with a compliance program to complete this document in a meaningful and thorough way. The advantages of completing the tool voluntarily in advance of an OMIG review are many, including: 1) the opportunity to be proactive in improving your compliance program, prior to any OMIG review; 2) the opportunity to give the questionnaire the time it deserves, rather than completing it under the tight time frame provided by OMIG; 3) giving your agency the best opportunity to provide to OMIG, should it request completion of the tool, a thorough and complete response; and 4) assisting your agency to provide the "evidence" of a working compliance program, as OMIG requires.

OMIG has gone on to state, "OMIG believes that it is a best practice for Medicaid providers to perform, at a very basic level, an annual self-assessment of the effectiveness of their compliance programs. Compliance officers, chief executives and governing boards should use self-assessment, along with other measurements, to objectively assess the strengths and weaknesses of their compliance programs. A Medicaid provider's self assessment will be one measure available to OMIG when reviewing the effectiveness of a provider's compliance program. OMIG may ask Medicaid providers for evidence of their self assessment as part of routine audits, routine investigations or routine Compliance Program effectiveness reviews. . . . Once the Provider Self Assessment Tool is completed, OMIG recommends that the compliance officer share the responses on the tool with the provider's senior management and governing board."

OMIG has stated that the purpose of its review is to educate providers and give guidance on best practices for effective compliance programs. OMIG seeks to ensure that providers have an implemented plan; not merely a document that sits on a shelf. To show a fully functional plan, providers must have documentation proving the plan's effectiveness. OMIG will request documentation from the provider in key areas, including: employee records confirming the receipt of the code of conduct; compliance training materials, participant sign-in sheets and pre-test and post-test results; compliance logs and investigation reports and results; employee disciplinary records; compliance risk area assessments; internal/external audits and corrective action taken; reports of intimidation and retaliation and outcome and resolution thereof; quality of care complaints/mandatory reporting information; and incidents of repayment of overpayments and self-disclosure. Having a plan and providing training is not enough; there must be evidence that the plan is used and implemented. The self-assessment tool will help providers achieve this goal.

Given the importance of the self-assessment tool, Hiscock & Barclay has developed an entrance questionnaire and has been working with providers on site or by phone to complete the tool. Hiscock & Barclay sends the questionnaire in advance and then spends four to six hours with the compliance officer and any other relevant staff to work on the questionnaire. We also review questionnaires and provide comments for clients who perform the review on their own. We are also experienced in working with clients undergoing an effectiveness review.

For further information, please contact Melissa M. Zambri, Margaret Surowka Rossi, or any member of the Health Care and Human Services Practice Area.

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