Hilton Head, South Carolina
Project Experience

Clinical and Financial Compliance

Laff Associates has worked with compliance attorneys in accordance with multiple Corporate Integrity Agreements (CIA) in Texas, California, Arkansas and Nevada for successful resolution. Sanctioned compliance reviews for health care systems with multiple site providers have included multi-office national providers and statewide organizations with 12-15 in-state branches.

  • As requested, compliance projects have been initiated with a review of the existing compliance plan. If an adequate compliance plan is not in place, Laff Associates has assisted in the development of an appropriate plan.
  • All compliance projects incorporate the use of statistically valid random sampling techniques and specified confidence and error rates. Specified time periods were identified by the corporate integrity agreement. The number of clinical records audited in every project was specific to the error rate and confidence level required by the CIA or the project requirements.
  • A review of all relevant processes was performed to determine that they achieved the required compliance objectives and desired results.
  • An onsite audit of all relative financial and clinical information was performed. Audit findings were analyzed and a detailed report was provided. A partial sample of compliance activities for completed projects include;
    • Billing review
      • Payors
      • Patient
      • Co-Pay billing requirements
      • Coding accuracy
      • Compliance with CMS, Medicaid or other billing regulations
      • Credit balances
    • Payroll
      • Employee hours, visits and salaries are validated
      • Contract services rates and actual time worked vs. time paid
    • Documentation of visits and all care initiated
      • Physician orders
      • Medical necessity
      • Delivery of appropriate level of care
        • Compliance with admission and discharge criteria
        • Compliance with clinical practice standards
        • Under-utilization of services
    • Marketing activities
      • Anti-kickback
        • Referral practices
        • Patient selection or de-selection by diagnosis
        • Relationships with medical directors, discharge planners, extended care facilities, assisted living and independent living communities
        • Unwritten "deals" or reciprocal arrangements
  • Tools and processes have been developed to assist organizations with standards compliance of the Medicare Conditions of Participation and other regulatory compliance issues.
  • Educational presentations were provided to staff and management regarding newly recommended processes to ensure ongoing compliance.

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