MHACG Corporate Compliance Plan

Corporate Compliance Plan

The Mental Health Association of Columbia-Greene Counties (MHACGC) has adopted a Corporate Compliance Plan. This Corporate Compliance Plan (hereafter referred to as the “Plan”) is being adopted in accordance with industry standards relative to the maintenance of such Plans.

STATEMENT OF VALUES

We are committed to providing quality, relevant, and accessible services to children, families, and adults who are affected by emotional disturbance and mental illness. We believe that those we serve all have potential and deserve our respect. We believe that those we work with have the ability, to varying degrees, to recover, and that it is our job to help them with this process. We are here to assist people in the process of change, not to ‘change them’. We believe that society in general is better off when it is able to embrace and accept people with disabilities. This is why we provide community education and legislative advocacy. This is also why we use ‘people first language’ (e.g. “people with mental illness” not “the mentally ill”). This philosophy is key to our work and it is important that all staff work with this in mind.

CORPORATE COMPLIANCE OFFICER

A Corporate Compliance Officer (CCO) has been designated by the Agency. The Corporate Compliance Officer is responsible for overseeing the Corporate Compliance Committee; reviewing agency policies and procedures, and recommending changes or new policies and procedures; overseeing administration of agency risk assessment relative to Compliance issues and recommending changes in procedures as a result of Risk Assessment; developing and implementing internal audit procedures relative to Corporate Compliance issues; maintaining a library of regulations, agency policies and procedures; overseeing the implementation of the Corporate Compliance training program, including conducting of training sessions for staff; investigating matters related to Corporate Compliance issues, including hotline reports, and employee, consumer, and/or payor complaints; developing and implementing an employee feedback loop which encourages employees to report potential problems without fear of retaliation.

The Corporate Compliance Officer chairs the Corporate Compliance Committee, and reports to the committee as well as the Executive Director. The Corporate Compliance Officer also reports to the board as necessary or requested, and no less than annually.

The Corporate Compliance Officer’s Job Description is included as an appendix to this Plan.

CORPORATE COMPLIANCE COMMITTEE

The Corporate Compliance Committee (“Committee”) consists of members from top Management and assists the Corporate Compliance Officer in implementing the Corporate Compliance Plan. The Committee consists of the Executive Director, the Fiscal Director, the Human Resources Coordinator, the Division Directors and a member of the Board of Directors.

The Committee works with the CCO to carry out each aspect of the Plan, and helps the CCO develop and implement policy and action plans relative to the Corporate Compliance Plan.

The Committee will be responsible for ensuring:

Orientation and training of staff on issues relative to Compliance;
Orientation and training of outside consultants on issues relative to Compliance;
Coordinating with Human Resources the efforts on employee background checks, credentialing, and disciplinary policy regarding compliance;
Coordinating internal audits and monitoring activities as prescribed by the Compliance Plan;
Independently acting on and investigating matters related to Corporate

Compliance including hotline reports, and consumer or payor complaints;

Developing and implementing employee feedback loops which encourage employees to report potential problems without fear of retaliation;
Monitoring and oversight of the Compliance Plan; and
Updating the Compliance Plan on a regular basis to reflect changes in the organizations risk profile, and applicable laws and regulation.

WRITTEN POLICIES AND PROCEDURES

A Code of Ethics/Code of Conduct has been written which details expected employee behavior covering various areas. In addition, the Employee Personnel Handbook and Policies and Procedures Manuals for each program detail procedures expected to be followed by employees.

Policies and Procedures Manuals of Certified Programs have been recently reviewed using a Risk Assessment Tool explicitly developed to assist in Corporate Compliance Planning. New Policies and Procedures have been developed as a result of this Risk Assessment.

Policies and Procedures Manuals have also been developed for the agency’s non-certified programs, during the year 2001. In addition, a fiscal Policies and Procedures Manual is also being developed which will detail a variety of fiscal functions.

These various Policies and Procedures Manuals will be reviewed at least every other year.

New Programs will be expected to complete their Policies and Procedure Manuals within the first year of operations. After six months, Policies and Procedures relating to Admission Procedures, Target Populations, Discharge Procedures, and Services Definitions, should be completed. After the first year, the remaining elements of the Manual should be completed. The Manual will be placed in the Quality Assurance Committee’s schedule for Policies and Procedure Manual review.

AUDITING AND MONITORING

Audit procedures have been developed to ensure that billing of third party payors will not occur until specific expectations have been met. The Corporate Compliance Officer is responsible for conducting Corporate Compliance oriented pre-billing audits. This explicitly refers to programs which receive an Operating Certificate from the New York State Office of Mental Health and bill Medicaid.

In the Residential Programs, the Program Directors audit each billing sheet prior to submission for billing. The Program Directors seek to reconcile the progress note written for the service being billed. The Corporate Compliance Officer audits the process, also ensuring treatment plans and authorizations are up to date. Reports are submitted to Program Directors and the Residential Division Director and remedial work is required when all required information is not in the chart. The Corporate Compliance Officer reviews billing reports and remedial work with the Program Directors and the Division Director.

In the Continuing Day Treatment Program and the Intensive Psychiatric Rehabilitation Treatment Program, the Corporate Compliance Officer audits charts prior to billing. Progress notes, Treatment Plans, and Reviews must all be up to date and signed by the physician (in the CDT) and authorizations signed by a referring clinician (in the case of IPRT) must be in the chart prior to billing being submitted. Reports are provided to the Program Directors and remedial work is required prior to billing. The Corporate Compliance Officer reviews billing reports and remedial work with Program Directors and the Division Director prior to billing.

In the Intensive Case Management/Supportive Case Management (ICM/SCM) Program, the Corporate Compliance Officer audits charts prior to billing, seeking the following: Authorization to receive ICM/SCM Services are documented via existence of SPOA minutes admitting consumer to ICM/SCM Program; Case Management Assessments are performed within fifteen days of admission, and reviewed within six months; Case Management Plans were developed within thirty days of admission; documentation of at least two face to face visits per consumer, and an aggregate of at least 88 face to face contacts for the ICM/SCM team.

Other audit procedures such as Utilization Review procedures are detailed in program specific Policies and Procedures Manuals.

TRAINING AND EDUCATION

In addition to a formalized Agency orientation program, and a formalized ongoing training and education program, a formalized training and education program on the agency’s Corporate Compliance Plan is conducted on an annual basis. The Corporate Compliance Officer and Committee are responsible for conducting these training programs. All new hires will be trained regarding the Program at orientation or within thirty days of hire.

CONFIDENTIAL COMMUNICATION

The agency will maintain an “open door” policy towards employees, especially in areas concerning Corporate Compliance, and questions pertaining to the agency’s stance relative to the Plan, or Code of Conduct/Code of Ethics. Any communication brought to the attention of the Corporate Compliance Officer, especially relative to possible violations of the Plan, or Code of Conduct/Code of Ethics will be kept in strictest confidence. All communications of this nature will be investigated thoroughly and fairly.

Employees may communicate with the CCO in any fashion they are comfortable with, including telephone, written communications and e-mail. Face to face communications are also welcome.

Employees who wish to anonymously report suspected violations of the Plan or Code of Conduct/Code of Ethics must submit their complaint in writing and may use the Agency’s Anonymous Drop Box. The Drop Box is located in the Staff Lounge at the Agency’s main office, 713 Union St., Hudson, NY 12534. Anonymous complaints may also be mailed to the Corporate Compliance Officer, at the above address.

MHACGC will make every effort to maintain, within the limits of the law, the confidentiality of the identity of any individual who reports possible misconduct. There will be no retribution or discipline for anyone who reports a possible violation in good faith. Any employee who deliberately makes a false accusation with the purpose of harming or retaliating against another employee will be subject to discipline. Abuse of the use of the Anonymous reporting system will likewise result in disciplinary action.

RESPONDING TO OFFENSES AND
DEVELOPING CORRECTIVE ACTION

As mentioned in the previous section, all communications involving allegations of employee misconduct relative to the Corporate Compliance Plan and the Code of Ethics/Code of Conduct will be investigated by the Corporate Compliance Officer swiftly, thoroughly and fairly. All communications will be kept confidential to the degree possible while conducting the investigation. If employee misconduct is detected, corrective action will be taken. This will include a series of progressive steps, depending upon the seriousness of the offense. Training or re-training will be the first course of action taken for minor offenses. Steps of progressive discipline will be taken with each subsequent offense as outlined in the Employee Personnel Handbook, and the Code of Ethics/Code of Conduct.

Violators of the Agency’s Corporate Compliance Plan and Code of Ethics/Code of Conduct will be subject to disciplinary action. The precise discipline utilized will depend on the nature, frequency and severity of the violation and may result in any of the following disciplinary actions:

Verbal warning
Written warning
Suspension
Terminiation
Restitiution

ENFORCEMENT OF STANDARDS

Standards of conduct as set forth in the Agency’s Personnel Manual, Code of Conduct/Code of Ethics, and the various program’s Policies and Procedures Manuals will be communicated to employees via orientation, training and education, and other means of agency communications, including staff meetings, and supervisory sessions. The agency will consistently and appropriately enforce standards through its system of employee discipline.

Disciplinary procedures will follow a progression of steps as follows: verbal warning, written warning, suspension, termination and restitution.

COMPLIANCE OVERSIGHT

MHACGC follows a clear and systematic process of delegating responsibility and maintaining accountability regarding all aspects of Corporate Compliance. The level and scope of responsibility for overseeing, correcting and reporting compliance issues is described below:

The Board of Directors- has ultimate responsibility for oversight of the Corporate Compliance Plan.

Compliance Committee-A Committee with reporting responsibilities to the
Board of Directors, this committee is comprised of the Corporate Compliance Officer, the Executive Director, the Fiscal Director, the Human Resources Coordinator, the Division Director of each Services Division and a member of the Board of Directors. The Corporate Compliance Officer reports to the Board of Directors on a periodic, invitational basis. The Compliance Officer will however report to the Board of Directors no less than annually. The Executive Director reports to the Board of Directors and acts as liaison to the Board on a regular basis.

The Corporate Compliance Officer-reports to the Committee on a regular basis and coordinates with the Committee implementation of the Corporate Compliance Plan.

The Executive Director- Through supervision, the Executive Director reviews any written reports, and remains apprised of implementation issues as they arise.

Director of Quality Assurance/Corporate Compliance Officer- Designated as Corporate Compliance Officer. The Corporate Compliance Officer is responsible for the development and implementation of the Plan. This includes coordinating the various functions such as auditing, staff training, reporting, following up with investigations, including recommendations for corrective action. The Corporate Compliance Officer chairs the Corporate Compliance Committee, and guides it through its activities and responsibilities.

Human Resources Coordinator- works closely with the Executive Director and Corporate Compliance Officer in assuring that the Plan addresses and is consistent with laws, regulations and standards which bind the agency. The Human Resources Coordinator also plays a primary role regarding the personnel issues which arise relative to compliance. This would include (but not necessarily be limited to) issues relating to employee discipline as a result of compliance investigations.

Division Directors- are responsible for assuring that the Plan is implemented in each program area they supervise.

Program Directors- have day to day responsibility assuring that the Agency Plan is implemented in their respective program areas.

Direct Service Personnel- have the responsibility to assure that all documentation and billing is completed according to the standards and processes established in the Agency’s Corporate Compliance Plan.

REGULATORY ACCESS

The Mental Health Association of Columbia-Greene Counties (MHACGC) will obtain timely and relevant regulations governing those programs which are governed by regulations. Currently, those regulations pertain to the New York State Office of Mental Health (OMH) regulations governing Licensed Residential Programs, (Part 595), Outpatient Programs (Parts 585 and 587) Supportive and Intensive Case Management (Parts 504 and 506), and Incident Management (Part 524). Regulations governing Medical Assistance Payments for these programs will be kept in the Corporate Compliance Library, as well.

The agency retains the MMIS Provider’s manual. Regular updates and bulletins are maintained by the billing officer, and the Corporate Compliance Officer.

The OMH Regulatory documents will be obtained through the agency’s subscription to Westlaw Group. Westlaw distributes manuals, with updates to the various regulations as they occur. Updates are manually inserted by the Executive Secretary. The manual and updates include regulations to all OMH regulated programs. Updated Regulatory information will also be searched via the internet, where OMH maintains on-line versions of their regulations. This is available at http://www.omh.ny.state.us. The Corporate Compliance Officer will periodically search the OMH web site for updated regulations.

In addition, the Corporate Compliance Regulations Library will include all Provider Procedures Manuals relating to billing Medicaid and any other Federal Program the Agency may bill for services, Provider Procedures Manuals of any other Third Party Payor the agency may bill for services, the Agency’s Fiscal Policies and Procedures Manual, and Policies and Procedures Manuals of each program operated by the agency.

This library of regulations will be kept in a Regulations Library maintained by the Corporate Compliance Officer.

As new information enters the agency, all information pertaining to OMH and Medicaid regulations will be directed to the Corporate Compliance Officer. The Corporate Compliance Officer will distribute relevant information to Division Directors as necessary. Division Directors will in turn distribute information, as relevant to Program Directors. The Corporate Compliance Committee may also review new regulatory information, as necessary.

Retention of Outdated Versions: Outdated versions of regulations will be maintained as long as there are records available which pertain to those outdated regulations. For example, if the regulations of a certified program changes, but we are required to maintain individual medical records for seven years, regulations which pertain to those records relative to the time frame involved will be kept until no such records exist. The Corporate Compliance Officer will be responsible for storage of outdated regulations.

Licensure Rules

Licensure Rules are governed by OMH Regulations, Medicaid regulations, the New York State Office of Professional Licensing, and standards governed by the specific Profession. MHACGC will monitor licensure rules as governed by OMH and Medicaid Regulations by following the procedures as outlined in the section covering the Regulatory Documents Library. Information from the New York State Education Department, Office of Professional Licensing will be obtained and maintained in the same library.

All Licensed Professionals will be responsible for obtaining and maintaining their licenses and certifications, providing documentation of theses licenses and certifications, and maintaining the validity of these licenses and certifications. Copies of most recent licenses and certifications will be maintained by the Human Resource Department, in each individual Personnel Folder.

Professional Standards and Codes of Ethics from the various Professional Associations represented by MHACGC staff will be maintained by the Corporate Compliance Officer.

Labor and Human Resource Regulations

The Human Resources Coordinator will maintain a library relating to labor regulations that are relevant to our agency.

The Human Resources Coordinator and the Corporate Compliance Officer will be responsible for maintaining the most current information and updated rules and regulations regarding wage and hour standards. This includes necessary Federal and State Regulations as they pertain to wage and hour standards, as well as other regulations pertinent to the operation of the Human Resources Department.
A separate file for all codes, bulletins and correspondence relative to the operations of Human Resources and payroll will be maintained by the Human Resources Coordinator.

The Human Resources Coordinator will monitor all sites to ensure that they are in compliance with Federal and State posting requirements. The Human Resources Coordinator will also be responsible for ensuring that appropriate management personnel are apprised of new information regarding labor laws, as it becomes available.

The above documents will be maintained by the Human Resources Coordinator and will be maintained in a library in conjunction with the Corporate Compliance Library.

The Human Resources Coordinator and the Corporate Compliance Officer will also be responsible for ensuring compliance with Federal Occupational Safety and Health Administration (OSHA) regulations. A library of OSHA materials will be maintained in the Corporate Compliance Library as well. Each work site is responsible for maintaining their own Exposure Control Plan. However materials relating to complying with OSHA regulations will be maintained in the Corporate Compliance Library.

The Human Resources Coordinator will also maintain Federal and State Guidelines such as information pertaining to Worker’s Compensation, NYS Disability, the Family Medical Leave Act, and other information required of a Human Resources Department.
In addition, the Human Resources Library will include updates provided by a Personnel Management Law firm as they are produced and distributed.

Background checks are required for all employees hired by the Mental Health Association of Columbia-Greene Counties. The Human Resources Coordinator and the Division Director of the Division doing the hiring are jointly responsible for seeing that all personnel files are maintained in accordance with federal, state, licensure, and accreditation regulations and standards.

All employees are presented with a Personnel Manual. The Manual consists of two parts. The Manual outlines all employment regulations and standards, as well as the agency’s Code of Conduct/Code of Ethics. All employees are requested to sign an acknowledgement of receipt of the Manual and Code of Conduct/Ethics. The means of reporting any infractions is outlined in the Manual.

All new employees are required to attend a full day orientation. The Program will include an overview of the agency and its programs, selected trainings, and a brief discussion regarding the Personnel Policy and the Agency Code of Conduct/Code of Ethics.

The Continuous Quality Improvement Committee puts together a calendar of training events on an annual basis. This training schedule incorporates the various mandatory training events as well as training events that are pertinent (although not necessarily mandatory) to the various programs.

The Human Resources Coordinator conducts an exit interview with each employee voluntarily terminating employment with MHACGC. Each employee is provided with an exit interview questionnaire. The employee is given the opportunity to address any areas of concern s/he may have regarding the agency at this interview. All exit interviews are kept confidential.

INVESTIGATIONS OF THE AGENCY AND THE PROCESSING OF SUBPOENAS, COURT ORDERS AND WARRANTS

Subpoenas and other requests for information from attorneys, courts, governmental agencies and investigators are very serious matters that must be handled properly with the advice of counsel, as needed. When a staff member receives a subpoena or other requests for information, he or she should contact his or her supervisor immediately. The Division Director and Corporate Compliance Officer should also be immediately notified.

Subpoenas need to be addressed in different ways depending upon the party that issued the subpoena. Where a subpoena is issued by the Deputy Attorney General for Medicaid Fraud, the United States Department of Health and Human Services Office of the Inspector General, the Federal Bureau of Investigations, District Attorneys, or another investigative agency or prosecutor, the Executive Director and the Compliance Officer should be notified immediately and counsel should be consulted. Counsel will then discuss options for response with the agency.

If an investigator appears at the agency, staff should obtain the name, agency and telephone number of the investigator. Staff should notify the Executive Director and the Corporate Compliance Officer immediately. Staff should provide no records without the express consent of senior management.

In all cases, no subpoenaed document should ever be altered or destroyed. No documents should ever be created to comply. Any document to be given to an investigative agency should be bates-stamped and copied. An inventory of all materials produced should be kept.

ACCESS TO RECORDS BY CONSUMERS
AND OTHER QUALIFIED PRESONS

This policy applies to all programs operated by the Mental Health Association of Columbia-Greene Counties (MHACGC) which are funded, regulated, or otherwise governed by the New York State Office of Mental Health, where Medical, Clinical, Rehabilitation or other programmatic records are maintained. This policy was written pursuant to Section 36.16 of the New York State Mental Hygiene Law of 1972.

“Qualified Persons” is defined as any adult consumer, parent or guardian of a child, parent, spouse or adult child of an adult consumer where parent, spouse or adult child is authorized pursuant to law, rule or regulation to provide consent and has consented.

Such Qualified Persons may request access to clinical records. This request must be in writing, addressed to the Program Director of the Program in question. The request may be for a review of the record, or parts of the record. Any inspection of a clinical record shall be limited to that information which is relevant in light of the reason for such inspection. The Agency must respond within ten days.

The Record in question will be reviewed by the practitioner, and supervisory personnel if requested by practitioner. Request for review may be denied based on the determination that such access would cause substantial or identifiable harm to the consumer, and/or have a detrimental effect on the practitioner’s professional relationship with the consumer, or on the care and treatment of consumer or on the relationship of consumer with parent, child, or spouse.

In determining that access to records would cause harm, or have a detrimental effect, the practitioner may consider the following: (i) the need for and the fact of continuing care and treatment; (ii) the extent to which the knowledge of the information contained in the record may be harmful to the health and safety of the consumer or others, (iii) the extent to which the record contains sensitive information disclosed in confidence to the practitioner or staff members by family members, friends, or others persons, (iv) the extent to which the record contains sensitive information disclosed to the practitioner or staff member by the consumer which would be injurious to the consumer’s relationships with other persons except where the consumer is requesting information concerning him or herself.

In the event of a denial of access, the Qualified Person shall be notified of the denial, as well of their right to obtain without cost, a review of the denial by a clinical records review committee. If such a request is made, the Agency shall begin a review within ten days of receipt of written request. An ad hoc committee shall be composed, which would include at minimum the Division Director of the Program in question, and the Director of Quality Assurance. This ad hoc committee shall consist of at least three members, and no more than five.

In the event that no denial is made, the Agency shall provide opportunity for the Qualified Person to review the record within ten days of request.
The Practitioner or Primary staff member may request the opportunity to review the information with the Qualified Person, but such review may not be a prerequisite for furnishing the record.

The Agency may make available for in-house inspection the original record or a copy.

Subject to the above provisions, the agency may furnish upon written request of a Qualified Person within a reasonable time a copy of the record which the Qualified Person is authorized to inspect. The Agency may impose a reasonable charge for costs associated with copying, however not to exceed seventy five cents per copy. Inability to pay shall not be reason to deny access to copies of records.

Health Insurance Portability and AccountabilityAct (HIPAA)

Under the Privacy Regulations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) a consumer of MHACGC services has the right to review his/her case record for the purpose of requesting amendment or correction to the case record.

The above procedures apply in making a request to view a case record. The individual making a request for amendment or correction should likewise make such request in writing. The Primary Clinician, or Case Manager will review the Case Record in light of the request and will make such correction or amendment if that is determined to be the appropriate response, or will notify the requestor in writing as to why the request is denied, should that be determined to be the appropriate course of action.

The person making the request will be notified of the decision within ten (10) working days of the original request.

When the decision regarding a request for amendment or correction of a case record has to be made by a third party, (i.e., Clinician at Mental Health Center, or Psychiatrist at Continuing Day Treatment Center) the primary staff member will assist the consumer in making the request to the appropriate party.

Under the Privacy Regulations of HIPAA, a consumer of services has the right to request an accounting of whom the Mental Health Association of Columbia-Greene Counties has shared their confidential information with. This does not include programs within the Agency, or other agencies identified in MHACGC’s General Consent Form as information being shared within the context of Treatment, Payment or Healthcare Operations. However, this does pertain to any information shared for which an Authorization Form was completed and signed by the consumer.

The Mental Health Association of Columbia-Greene Counties has the right to charge reasonable fees for reproduction costs associated with multiple requests for such information within one year.

CASE RECORD RETENTION, STORAGE AND DISPOSAL POLICY

The Mental Health Association of Columbia-Greene Counties, Inc., (MHACGC) will retain Case Records and dispose of records in accordance with policies as set forth by the New York State Office of Mental Health (OMH) and Medicaid Rules.

As per New York State OMH policy, full case records will be kept for ten years after last contact. Discharge Summaries and Face Sheets will be kept for 25 years after last contact.
Referral information on those not accepted into residential or clinical program will be kept for three years.

Case Records on individuals actively receiving services will be stored in metal file cabinets, which will be kept locked. Standards of confidentiality will be maintained as per Program Policies and Procedures. When individuals are discharged, records will be closed out and kept locked in metal cabinets in storage situations reserved for closed out case records. Referral information on individuals not accepted will be stored in similar fashion.

Records will be maintained centrally in a storage facility as designated by the Agency. Every six months, Program Directors will be responsible for collecting records which are over five years old. They will be collected centrally, stored and organized according to Division, Program, function, etc. Keys will be stored centrally and kept by the Corporate Compliance Officer.

The Central Storage Facility designated by the Agency is Accountable Storage, located at 4071 Route 9, Hudson, NY.

Records which are under audit, investigation or litigation will be kept separately under lock and key and under the management of the Corporate Compliance Officer.

When appropriate time elapses, records will be shredded by staff, using the Record Storage Catalogue Form. This form tracks when a record should be put in storage, and when they should be destroyed. The Catalogue Form will be maintained by the Program Supervisor and the Corporate Compliance Officer.

CONTRACTING

MHACGC will enter into contracts in accordance with its Mission Statement and Purpose under its Articles of Incorporation.

Contracts will be renegotiated, renewed, and/or terminated under the terms of each specific contract. Each contract will define parameters regarding renegotiation, renewal and termination.

Requests for Proposals will be responded to according to the following logic: MHACGC will respond to Requests for Proposals for programs and/or services which meet the Agency’s mission statement and Purpose under its Articles of Incorporation.

Staff involved in a contracted program or service will receive training and briefings as to their responsibilities under each contract. Staff will be retrained as appropriate.

A review of each contract will be conducted to ensure regulatory compliance.

Contracts are reviewed by executive staff and senior program staff. These reviews are conducted to review the following:

Excessive compensation is not paid, or provided for services performed;

That there are no direct or indirect payments made for referrals;

Fee splitting does not occur;

Free or discounted services are not provided to professionals, independent contractors, employees, board members, agents or referral sources;

Country club fees, gifts or payments for other personal expenses are prohibited;

Travel payments are made in accordance with the agency’s personnel policies;

Extraordinary employee benefits or benefit payments are not made.

All Board members and staff must disclose any ownership, investment or compensation relationship or interest they may have with any entitiy or person doing business with or negotiating to do business with MHACGC. A fiscal schedule reports all payments made within these arrangements. MHACGC will take all steps to avoid engaging in business arrangements in which any board member or staff member has an ownership, investment or compensation relationship or interest.

The Fiscal Director will maintain all documents relating to contracts entered into by the Agency. The Fiscal Director will obtain and maintain original copies of contracts, all revisions, amendments and updates, and will retain outdated versions as per agency policy and in accordance with General Accounting Principles. These documents will be located within the Fiscal Department, as designated by the Fiscal Director.

Annual Audits are conducted by our outside Auditing Firm which includes auditing contracts, as well as other required documents. Audit of these documents include audits for regulatory compliance.

Audit results are reviewed by the Management Team, including the Director of Quality Assurance/Corporate Compliance Officer.
Monitoring of contract negotiations and the dissemination of contractual requirements within the agency are performed by management and senior program staff, in accordance with time frames pursuant to each individual contract.

BILLING AND CODING

Billing occurs according to procedures developed by the particular payor sources. Procedure Manuals are maintained by the Billing Department. Medicaid billing occurs according to the procedures outlined in the Medicaid Procedure Manual. The Medicaid Manual includes federal and state regulatory requirements. Other billing procedures will be incorporated in the finance procedure manual that is maintained by the Fiscal Director.

Fiscal staff are oriented to billing and coding procedures upon hire. Retraining occurs as necessary. Clinical staff are oriented and retrained as to their clinical medical records duties as per the Policies and Procedures manuals of each respective program.

Timing and process of determining enrollment, eligibility and benefits is determined by the Policies and Procedures delineated in the relevant payor manual.

Billing for services in the Medicaid program occurs according to the receipt of authorizations and reauthorization for services. Initial authorization for services are obtained prior to services being rendered. Obtaining these authorizations is the responsibility of Program Directors in IPRT and Supervised Community Residences, and program staff in the Apartment Program. Reauthorizations are obtained in accordance with Medicaid rules and OMH Regulations in each of these programs. Authorizations for services provided by Supervised Community Residences are obtained by a Psychiatrist, and are reauthorized every six months. For the Apartment Program, authorizations are also obtained by a Psychiatrist and reauthorizations are obtained every year. Authorizations for services for IPRT are obtained by a licensed Mental Health Professional, and the authorization lasts for the duration of the IPRT group. Obtaining these reauthorizations is the responsibility of the same staff.

In our Continuing Day Treatment Program, the Psychiatrist’s signature on the treatment plan acts as authorization for services.

Covered services and limits, as well as frequency of services are determined by clinical judgment in the case of the CDT. This clinical judgment is guided by Medicaid rules and OMH regulations. IPRT is a predetermined set of services, which is also guided by Medicaid rules and OMH regulations. In residential programs, frequency of services is also determined by Medicaid rules and OMH guidelines.

Determination of whether a consumer has met benefit limits is determined by each program’s Utlilzation Review Protocols. These protocols are described earlier in this document and are further defined by each program’s Policies and Procedures Manual.

The Medicaid Provider Manual clearly states rules pertaining to concurrent multiple services for the same or different providers, either ongoing or on day of transfer. MHACGC follows all applicable billing practices relating to billing for different services on the same day.

The coding system for charges is also predetermined by Medicaid. MHACGC uses the DSM IV diagnostic codes.

Medicaid rules determine which services can be provided by staff according to credentials and licensure. MHACGC follows these guidelines and bills for services accordingly.

The finance procedure manual will have procedures for monthly spend downs. There will never be financial incentives to patients who receive our services.

Written polices relative to conducting audits of the required charge sheets are found earlier in this document. In the Residential programs, billing forms are audited by the Program Directors prior to billing. These are the only programs in which billing sheets are submitted from the program to the Billing Department. The Corporate Compliance Officer audits the process. In the Continuing Day Treatment Program and IPRT, the Corporate Compliance Officer audits the program’s charts prior to billing. Results of these audits are reported to staff, and Program Directors, with responses due. These responses are reported to the Corporate Compliance Committee.

Consumers of COPS services are not refused service due to inability to pay. Medicaid rules, and OMH regulations prohibit such a practice. Consumers of other services are not refused service due to inability to pay so long as the program is able to maintain fiscal viability. The Agency has a sliding fee scale available for those who are not eligible for Medicaid, or other insurance. The consumer’s face sheet shows the benefits he/she receives and is used to determine their fee when using the sliding fee scale. Financial assistance is uniformly enforced.

All consumers in certified programs receive an explanation of benefits which relate to the agency’s programs in which they are enrolled. Policies governing the dissemination of these explanations of benefits are detailed in each certified program’s Policies and Procedures Manuals. (CDT, IPRT, and Residential Policies and Procedures Manuals). These notifications are done in accordance with OMH Rules and Regulations, where applicable.

Procedures for processing all denied and pended claims are delineated in the Agency’s Finance Procedure Manual. This includes review of charges, verification of documentation, correction protocols, and appeals process.

Procedures for identifying and refunding overpayments are delineated in the Agency’s Finance Procedure Manual. This includes the audit procedures utilized to verify the agency’s billing for services rendered.

BUSINESS OPERATIONS RECORD SAFEKEEPING

As an agency operating several licensed Mental Health Programs, and operating within current practice standards and guidelines, MHACGC maintains policies and procedures governing a broad array of practice areas. MHACGC maintains polices and procedures governing Confidentiality and Releasing of Information, Consumer Access to Records, Storage and Retention of Records, Charting Procedures, Responding to Subpoenas, handling records under audit, Grievance Procedures, General Rules of Conduct, Protocols for Reporting Suspected Criminal Activity, and Reporting of Child Abuse and Neglect, among others. These areas are covered in either Program Policies and Procedure Manuals, the Agency Personnel Manual, or the Agency Code of Conduct/Code of Ethics.

Quality Assurance Policies and Procedures are found in the Agency’s Quality Assurance Policies and Procedures Manual. The Agency’s Quality Assurance Program is guided by a Continuous Quality Improvement (CQI) Committee. This committee meets on a regular basis, and minutes are kept in a file labeled “Quality Assurance” in the “Quality Assurance” file. The Quality Assurance Manual addresses such areas as Incident Management, Utilization Management, administration of Consumer Satisfaction Surveys,
Education and Training, as well as other areas traditionally considered under the umbrella of Quality Assurance.

Incident reports, and Incident Management are governed by OMH Rules and Regulations Part 524 which govern all Certified OMH Programs. Incident Management Policies and Procedures are covered by CDT Policies and Procedures Manual Section VI “Incidents”, IPRT Policies and Procedures Manual Section VI “Incidents”, and Residential Policies and Procedures Manual, Section 2 “Quality Assurance-Incident Management.” Incident Management Procedures are also located in the Agency’s Quality Assurance Manual.
In addition, each program’s Policies and Procedure Manual, whether a certified program or not contains procedures governing Incident Management.

Clinical Program Policies and Procedures are located within the Policies and Procedures Manuals of the Clinical Programs: CDT Policies and Procedures Manual, and IPRT Policies and Procedures Manual. These manuals cover such areas as charting procedures, intake procedures, and Utilization management.

Policies and Procedures governing training and education records, and personnel records can be found within the Agency’s Personnel Policies.

Procedures detailing the following Fiscal functions are found in the Agency’s fiscal Policies and Procedure’s Manual: Financial Report and Tax Returns; Billing Records; Accounts Payable Records; and Banking Accounts.

Requests from third party payors and auditors, as well as financial records under audit are maintained by the Fiscal Director.

I hereby acknowledge receipt of the Mental Health Association of Columbia Greene Counties’ Corporate Compliance Plan and Code of Conduct/Code of Ethics, and HIPAA 101.

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