Compliance Plan

Table of Contents

Compliance Policy

1. Policies and Procedures and Standards of Conduct
2. Compliance Program Oversight
3. Education and Training
4. Lines of Confidential Communication
5. Discipline and Enforcement of Compliance Standards
6. Auditing and Monitoring
7. Response to Compliance Issues

COMPLIANCE POLICY

Purpose

Metropolitan Center for Mental Health (MCMH) is committed to providing services of the highest quality and to being in full compliance with all federal, state and local laws and regulations.  As part of that commitment, MCMH has adopted this Compliance Plan and the Standards of Conduct as the basis of its efforts in fostering an organizational culture that promotes responsible and honest conduct, transparency in all business transactions, and adherence to the laws and regulations of the government oversight agencies and funders.

For purposes of this Policy, the term “Affected Individuals” includes all Metropolitan Center for Mental Health Staff (hereafter referred to as “Affected Individuals”).  

I. Policy

It has been and continues to be the policy of MCMH to comply with all applicable Federal, State, and local laws and regulations, and payer requirements. It is also the Organization’s policy to facilitate the prevention of improper or illegal activities, to provide mechanisms to detect any violations of laws and regulations and work to prevent, detect, and investigate issues related to fraud, waste, and abuse. To ensure this, MCMH has established this Compliance Plan and commits to maintaining an effective Compliance Program.

II. Commitment

MCMH is, and will remain, committed to our responsibility to conduct our business affairs with integrity based on sound ethical and moral standards. We will hold all Affected Individuals to these same standards.

MCMH is committed to maintaining and measuring the effectiveness of our Compliance Program and Standards of Conduct through monitoring and auditing systems reasonably designed to detect noncompliance by Affected Individuals.

MCMH is committed to the prevention of improper or illegal activities and to provide mechanisms to detect noncompliance, including but not limited to, any violations of laws and regulations, healthcare program requirements, the Standards of Conduct and MCMH’s policies and procedures.  MCMH is committed to the prompt investigation and resolution of reported or detected noncompliance.

MCMH is committed to the performance of regular, periodic compliance audits by internal and/or external auditors who have expertise in Federal and State healthcare statutes, regulations, and healthcare program requirements.

III. Responsibility

All Affected Individuals shall acknowledge that it is their responsibility to report any instances of suspected or known noncompliance to their immediate supervisor, the Chief Executive, or the Compliance Officer without fear of retaliation, retribution, or intimidation. Failure to report known noncompliance or making reports that are not in good faith will be grounds for disciplinary action, up to and including termination of employment, contract, assignment, or appointment. Reports related to harassment or other workplace-oriented issues will be referred to Human Resources.

IV. Policies and Procedures and Standards of Conduct

MCMH will communicate its compliance standards and policies through required training and communication initiatives and distribution of this Compliance Plan and the Standards of Conduct to all Affected Individuals.

V. Compliance Officer and Compliance Committee

MCMH has appointed a Compliance Officer who is responsible for the overall operation of the Compliance Program. A Compliance Committee works with the Compliance Officer to implement and maintain an effective Compliance Program.

VI. Discipline/Enforcement

This Compliance Plan will be consistently enforced through appropriate disciplinary mechanisms including, if appropriate, discipline of Affected Individuals responsible for failure to detect and/or report noncompliance.

VII. Organization Response

Detected noncompliance, discovered through any mechanism, such as compliance auditing procedures and/or confidential reporting of noncompliance, will be responded to in an expedient manner. MCMH is dedicated to the resolution of such matters and will take all reasonable steps to prevent further similar violations, including any necessary modifications to the Compliance Plan and policies and procedures.

VIII. Due Diligence

MCMH will, at all times, exercise due diligence with regard to background and professional license investigations for all Affected Individuals.

IX. Non-Retaliation, Non-Intimidation, and Whistleblower Protections

MCMH will not take any retaliatory action against an Affected Individual who, in good faith, reports actual or suspected noncompliance or illegal activities or for good faith participation in the Compliance Program.

MCMH will not take any retaliatory action against an employee if the employee discloses certain information about the Organization’s policies, practices, or activities to a regulatory, law enforcement, or other similar agency or public official. Protected disclosures are those that assert that the Organization is in violation of a law that creates a substantial and specific danger to the public health and safety; or that constitute healthcare fraud under the law; or that assert that the employee, in good faith, believes constitutes improper quality of care.

Compliance Program: Key Elements

Element 1: Policies and Procedures and Standards of Conduct

To support the operation of MCMH’s Compliance Program, policies and procedures are established to provide direction to Affected Individuals and address the following components of the Compliance Plan:

• Conflict of Interest
• Reporting and investigation of noncompliance
• Non-retaliation and non-intimidation
• False Claims Act and Whistleblower protections
• Compliance Program education and training
• Auditing and monitoring
• Billing errors and overpayments
• Kickbacks and business courtesies
• Discipline for noncompliance or failure to report
• Responding to governmental investigations

All Affected Individuals are expected to be familiar with and knowledgeable about the Compliance Program Policies and Procedures.  The Policies can be accessed at MCMH’s Resource toolkit.

The Standards of Conduct serves as a foundational document that describes the Organization’s fundamental principles and values, and commitment to conduct its business in an ethical manner. The Standards of Conduct provides Affected Individuals with guidance on requirements for conduct related to their employment, contract, assignment or association with MCMH.

When any person knows or reasonably suspects that the expectations in the Standards of Conduct and the Compliance Program have not been met, this must be reported to the immediate supervisor, a member of Management, the Compliance Officer, member of the Compliance Committee, or the Chief Executive so that each situation may be appropriately dealt with. The Compliance Officer may reached at (332) 267-0730.  The Chief Executive can be reached at (212) 362-8755. Reports may be made in person; by phone, fax, mail, or email; or anonymously by placing a complaint in the Compliance Box at all three MCMH locations.

Element 2:  Compliance Program Oversight

I. The Role of the Compliance Officer

The Chief Executive and Board of Directors of the Organization designate Carla Lewis-Peters as the Compliance Officer.

The Compliance Officer has primary responsibility for Compliance Program development, implementation, monitoring, and evaluation for effectiveness.

Reporting Relationship

The Compliance Officer has direct lines of communication to the Chief Executive, the Board of Directors, the Compliance Committee, and the Organization’s legal counsel.

Role and Responsibilities

The Compliance Officer’s primary responsibilities include:

• Overseeing and monitoring the adoption, implementation, and maintenance of the Compliance Program;
• Developing and implementing Compliance Program policies and procedures and Standards of Conduct;
• Reviewing and revising, periodically, the Standards of Conduct, the Compliance Program, and policies and procedures as changes occur within MCMH, and/or in the law, regulations, or governmental and third-party payers.
• Evaluating the effectiveness of the Compliance Program, policies and procedures, and Standards of Conduct.
• Developing, implementing, and monitoring the annual Compliance Work Plan.
• Reporting, no less frequently than quarterly, to the Board of Directors, Chief Executive, and Compliance Committee on the progress of implementation of the Compliance Program.
• Assisting the Chief Executive, Senior Leadership, Management, and the Compliance Committee in establishing methods to improve MCMH’s quality of service and to reduce vulnerability to fraud, abuse, and waste.
• Developing, coordinating, and participating in a multifaceted educational and training program that focuses on the elements of the Compliance Program and seeks to ensure that all Affected Individuals, consistent with roles and any associated risk areas, are knowledgeable of, and comply with, pertinent Federal and State standards and MCMH’s Standards of Conduct.
• Ensuring that excluded individuals and entities are not employed or retained by the Organization.
• Directing MCMH’s internal audits established to monitor effectiveness of compliance standards and the Compliance Program.
• Independently investigating and acting on matters related to compliance, including the flexibility to design and coordinate internal investigations (e.g., responding to reports of problems or suspected violations) and any resulting corrective action with all departments, providers, and sub-providers, agents, and, if appropriate, independent contractors.
• Coordinating internal investigations and implementing corrective action(s).
• Developing policies and programs that encourage managers and employees to report suspected fraud and other improprieties without fear of retaliation.
• Providing guidance to Management, medical/clinical program personnel, and individual departments regarding policies and procedures and governmental laws, rules, and regulations.
• Maintaining a reporting system, including an anonymous means to report, and responding to concerns, complaints, and questions related to the Compliance Program.
• Overseeing efforts to communicate awareness of the existence and contents of the Compliance Program.
• Ensuring that independent contractors and contractors (recipient service provision, vendors, billing services, etc.) are aware of the requirements of MCMH’s Compliance Program.
• Acting as a resourceful leader regarding regulatory compliance issues. Actively seeking up-to-date material and releases regarding regulatory compliance issues.
• Continuing the momentum of the Compliance Program and the accomplishment of its objectives.

II. The Structure, Duties, and Role of the Compliance Committee

The Compliance Committee is appointed by the President of the Board of Directors and Chief Executive to advise and assist the Compliance Officer with the implementation of the Compliance Program. The Compliance Committee reports directly to the Chief Executive and Board of Directors.  

The Compliance Committee will meet on a regular basis, but not less than quarterly. Meeting minutes will be maintained by the Compliance Officer.

The Compliance Committee is responsible for the following:

• Analyzing the regulatory environment where MCMH does business, including legal requirements with which it must comply.
• Reviewing and assessing existing policies and procedures that address risk areas for possible incorporation into the Compliance Program.
• Reviewing and monitoring Compliance Program training and education to ensure that they are effective and completed in a timely manner.
• Ensuring that the Organization has effective systems and processes in place to identify Compliance Program risks, overpayments, and other issues and has effective policies and procedures for correcting and reporting such issues.
• Working with departments to develop standards and policies and procedures that address specific risk areas and to encourage compliance according to legal and ethical requirements.
• Coordinating with the Compliance Officer to ensure that the written policies and procedures and Standards of Conduct are current, accurate, and complete.
• Developing internal systems and controls to carry out compliance standards, Standards of Conduct, and policies and procedures.
• Coordinating with the Compliance Officer to ensure communication and cooperation by Affected Individuals on compliance-related issues, internal or external audits, or any other function or activity.
• Developing a process to solicit, evaluate, and respond to complaints and problems.
• Monitoring internal and external audits to identify issues related to non-compliance.
• Implementing corrective and preventative action plans and follow-up to determine effectiveness.
• Ensuring the development and implementation of an annual Compliance Work Plan.
• Advocating for sufficient funding, staff, and resources to be allocated to the Compliance Officer to carry out duties related to the Compliance Program.
• Ensuring that the Organization has appropriate systems and policies in place that effectively identify risks, overpayments, and other areas of concerns including fraud, waste, and abuse.
• Monitoring and evaluating the Organization’s Compliance Program for effectiveness at least annually and making recommendations for necessary modifications to the Compliance Program as applicable.
• Developing and implementing a Compliance Committee Charter. The Charter will outline the Compliance Committee’s duties and responsibilities, membership, designation of a chairperson and frequency of meetings.  The Charter will be reviewed and updated annually.

III. Delegation of Substantial Discretionary Authority

Any employee or prospective employee who holds, or intends to hold, a position with substantial discretionary authority for the Organization is required to disclose any name changes and any involvement in non-compliant activities including healthcare-related crimes. In addition, the Organization performs reasonable inquiries into the background of such applicants, all prospective employees, the Chief Executive and other senior administrators, Board members, interns, contractors, and vendors.

The following resources may be queried when conducting screening:

1. The System for Award Management (SAM) available on the SAM website. The URL address is: https://www.sam.gov
2. HHS/OIG List of Excluded Individuals and Entities. The URL address is: http://exclusions.oig.hhs.gov/
3. Medicaid Exclusions | Office of the Medicaid Inspector General. The URL address is: https://omig.ny.gov/medicaid-fraud/medicaid-exclusions‍
4. Licensure and disciplinary record with NYS Office of Professional Medical Conduct (Physicians, Physician Assistants) (the URL address is http://www.health.state.ny.us/nysdoh/opmc/main.htm) and/or New York State Department of Education (other licensed professionals) (the URL address is http://www.op.nysed.gov/opsearches.htm).  

Element 3: Education and Training

I. Expectations

Education and training are critical elements of the Compliance Program. All Affected Individuals are expected to be familiar with and knowledgeable about MCMH’s Compliance Program and have a solid working knowledge of their responsibilities under the Compliance Program. Compliance Program Policies and Procedures and Standards of Conduct will be communicated to all Affected Individuals through required participation in training programs.

II. Training Topics – General

All Affected Individuals shall participate in training on the topics identified below:

• MCMH’s Compliance Plan;
• Standards of Conduct and other related written guidance;
• Federal False Claims Act;
• New York False Claims Act;
• Whistleblower Protections;
• Risk areas and organizational experience;
• The role and responsibilities of the Compliance Officer and the Compliance Committee;
• Communication channels (name of Compliance Officer, reporting mechanisms, anonymous reporting mechanism);
• MCMH’s expectations for reporting known or suspected fraud, waste, and abuse; illegal or unethical acts; actual or suspected violations of Federal or State laws and regulations; actual or suspected violations of the Standards of Conduct, the Compliance Program, and MCMH’s policies and procedures; improper acts in the delivery or billing of services; and other wrongdoing (collectively referred to as “compliance concerns”) and how the Organization responds to such reports including the investigation process and corrective actions;
• MCMH’s disciplinary policy and standards;
• Prevention of fraud, waste, and abuse; and
• Non-retaliation and non-intimidation policy.

All Affected Individuals will complete the Compliance Program training no less frequently than annually.

MCMH will maintain an annual training plan.  The training plan will, at a minimum, outline the subjects or topics for compliance training and education, the timing and frequency of the training, which Affected Individuals are required to attend, how attendance will be tracked, and how the effectiveness of the training will be periodically evaluated. The training plan will be reviewed by the Compliance Officer and Compliance Committee and updated as needed, but at minimum on an annual basis.  

III. Topics – Targeted

In addition to the above, targeted training will be provided to all managers and any other employees whose job responsibilities include activities related to compliance topics, such as documentation of services and coding and billing procedures.  Managers shall assist the Compliance Officer in identifying areas that require specific training and education.

IV. Orientation

As part of their orientation, each Affected Individual shall receive a written copy of the Compliance Plan and Standards of Conduct and be provided access to Compliance Program Policies and Procedures.

V. Attendance

All education and training relating to the Compliance Plan will be verified by attendance and a signed acknowledgement of receipt of the Compliance Plan and Standards of Conduct.

Attendance at compliance training sessions is mandatory and is a condition of continued employment / contract / appointment / assignment with the Organization.

Element 4:  Lines of Confidential Communication

I. Expectations

Open lines of communication between MCMH’s Management, the Compliance Officer, and each Affected Individual subject to this Compliance Plan are essential to the success of MCMH’s Compliance Program and commitment to comply with all applicable laws and regulations and the prevention of Medicaid or Medicare fraud, waste, and abuse.

All Affected Individuals must report compliance concerns.  Failure to report is deemed misconduct and a violation of this requirement.

Every Affected Individual has an obligation to refuse to participate in any wrongful course of action and to report the actions according to the procedure listed below.

II. Reporting Procedure

If an Affected Individual witnesses, learns of, or is asked to participate in any activities that are potentially in violation of this Compliance Plan and/or Standards of Conduct, he or she should contact the Compliance Officer, immediate supervisor, a member of the Management Team, or a member of the Compliance Committee. Reports may be made in person; by mail, phone, or email; by calling a telephone line dedicated for the purpose of receiving such notification (212) 362-3937; or by emailing information to the attention of the Compliance Officer at compliance@metropolitancenter.com.  The Compliance Officer may be reached by calling (332)-267-0730.  Affected Individuals may also anonymously report to the Compliance Officer by placing a complaint in the Compliance Box at all three MCMH locations.

Upon receipt of a question or concern, any supervisor, officer, or director shall document the issue at hand and report to the Compliance Officer. Any questions or concerns relating to potential non-compliance by the Compliance Officer should be reported immediately to the Chief Executive.

The Compliance Officer or designee shall record the information necessary to conduct an appropriate investigation of all complaints. If the Affected Individual was seeking information concerning the Standards of Conduct or its application, the Compliance Officer or designee shall record the facts of the inquiry and the nature of the information sought and respond as appropriate.

III. Protections

MCMH shall, as much as is possible, protect the anonymity or identity of the Affected Individual who reports a compliance concern or raises a question about MCMH’s Compliance Program and Standards of Conduct.  Strict confidentiality regarding the reporting of compliance concerns will be maintained unless the matter is subject to a disciplinary proceeding, referred to, or under investigation by Federal, State, or local law enforcement, or disclosure is required during a legal proceeding.

IV. Policy of Non-Retaliation and Non-Intimidation

MCMH will not take any retaliatory action against an Affected Individual who, in good faith, reports a compliance concern, as defined by this Plan or for good faith participation in the Compliance Program, including but not limited to:

• Reporting potential issues;
• Investigating issues;
• Self-evaluations;
• Audits;
• Remedial actions; and
• Reporting to appropriate officials as provided in sections 740 and 741 of the New York State Labor Law.

Any threat of retribution, retaliation, or intimidation against a person who acts in good faith pursuant to their responsibilities under the Compliance Plan is acting against MCMH’s Compliance Policy.  Discipline, up to and including termination of employment, contract, appointment, or assignment, will result if such retribution, retaliation or intimidation is proven.

Affected Individuals who believe they have been subject to retribution, retaliation and/or intimidation for reporting a compliance concern or for good faith participation in the Compliance Program shall report the actions to the Compliance Officer who shall conduct an investigation into the allegation in accordance with Element 7 of this Compliance Plan (Response to Compliance Issues).

V. Guidance

Any Affected Individual may seek guidance about the Compliance Plan or Standards of Conduct at any time by following the reporting mechanisms outlined above.

Element 5: Discipline and Enforcement of Compliance Standards

I. Disciplinary Action – General

Affected Individuals who fail to comply with MCMH’s Compliance Program and Standards of Conduct, or who, upon investigation, are found to have committed illegal or unethical acts or violations of applicable Federal and State laws and regulations, the Compliance Program, the Standards of Conduct, or the Organization’s policies and procedures, will be subject to appropriate disciplinary action, up to and including termination of employment, contract, assignment, or appointment with the Organization.

When the determination is made that a compliance violation occurred involving a contractor or vendor, the Compliance Officer will notify the Chief Executive and work collaboratively to determine and execute the appropriate corrective action.

The Organization will apply progressive discipline consistent with the violation. Examples of the disciplinary action that may be taken in accordance with the nature and scope of the infraction include but are not limited to: (a) verbal counseling or warning; (b) counseling with written warning; (c) retraining; (d) reassignment or demotion; (e) suspension without pay; and (f) termination of employment, contract, assignment, or appointment.  The Organization will consider intentional or reckless behavior as being subject to more significant discipline.

The following actions will result in more significant disciplinary action:

• Authorization of or participation in actions that violate Federal or State laws, regulations, the Compliance Program, Standards of Conduct, or any related policies and procedures;
• Failure to comply with the Organization’s policies governing the prevention, detection, or reporting of fraud and abuse;
• Falsification of records;
• Submitting or causing to submit a false claim;
• Failure to report a violation by a peer or subordinate;
• Failure to cooperate in an investigation; and
• Retaliation/intimidation against an individual for reporting a possible violation or participating in an investigation.

Any discipline will be appropriately documented in the Affected Individual’s file, along with a written statement of reason(s) for imposing such discipline.  Such documentation will be considered during an employee’s regular and promotional evaluations.

The Compliance Officer will maintain a written record of all disciplinary actions taken against Affected Individuals related to non-compliance and violations, including verbal warnings, and will reference these records when necessary to ensure consistency in application of disciplinary measures.  The Compliance Officer will provide a report on disciplinary actions taken to the Compliance Committee and the Board of Directors.

II. Disciplinary Action – Supervisory

Managers and supervisors will be disciplined for failure to adequately instruct their subordinates or failure to detect noncompliance with applicable policies and procedures and legal requirements where reasonable diligence on the part of the manager or supervisor would have led to the earlier discovery of any problems or violations and would have provided the Organization with the opportunity to correct them.

Element 6: Auditing and Monitoring

I. Internal Audits

Ongoing evaluation is critical in detecting non-compliance and will help ensure the success of MCMH’s Compliance Program. An ongoing auditing and monitoring system, implemented by the Compliance Officer and in consultation with the Compliance Committee, is an integral component of MCMH’s auditing and monitoring systems.

On an annual basis, the Compliance Officer, in conjunction with the Chief Executive, Senior Management, and Compliance Committee, will develop an audit plan based on an organizational risk assessment.

This ongoing auditing and monitoring will evaluate at minimum, the following risk areas:

• Billings;
• Payments;
• Ordered services;
• Medical necessity;
• Quality of care;
• Governance;
• Mandatory reporting;
• Credentialing;
• Contractor, subcontractor, agent, or independent contract oversight;
• Review of contracts and relationships with contractors, specifically those with substantive exposure to government enforcement actions;
• Review of documentation and billing relating to claims made to Federal, State, and third-party payers for reimbursement;
• Compliance training and education;
• Effectiveness of the Compliance Program: and
• Other risk areas that are or should reasonably be identified by the Organization through its organizational experience

The audits and reviews will examine the Organization’s compliance with specific rules and policies through on-site visits, personnel interviews, general questionnaires (submitted to employees and contractors), and record reviews.

Results of all auditing and monitoring activities will be reported to the Compliance Committee and Board of Directors.

II. Compliance Plan Integrity

Additional steps to ensure the integrity of the Compliance Plan will include:

• The Compliance Officer will be notified immediately in the event of any visits, audits, investigations, or surveys by any Federal or State agency or authority, and shall immediately receive a photocopy of any correspondence from any regulatory agency charged with licensing the Organization and/or administering a Federally or State-funded program or county-funded program with which the Organization participates.
• Establishment of a process detailing ongoing notification by the Compliance Officer to all appropriate personnel of any changes in laws, regulations, or policies, as well as appropriate training to assure continuous compliance.

Element 7:  Response to Compliance Issues

I. Violation Detection

MCMH maintains a formal confidential and anonymous compliance reporting process to encourage the reporting of any compliance concerns.  Affected Individuals must promptly report any compliance concerns to Compliance Officer, the immediate supervisor, a member of Management, or a member of the Compliance Committee.  Service recipients, vendors, and any party conducting business with MCMH may report compliance concerns to the Compliance Officer through the confidential or anonymous reporting process.

As part of its Compliance Program, MCMH will ensure that all reports of compliance concerns are immediately and objectively investigated and resolved promptly.  Such investigations may be conducted by the Compliance Officer, members of the Compliance Committee, other employees or external parties as indicated or recommended by the Compliance Officer, the Chief Executive or legal counsel.

The Compliance Officer will take immediate measures to secure relevant evidence or documentation and will ensure the confidentiality of any information obtained from a report, interview or through an investigation, unless otherwise required by law.

Unless a potential conflict of interest exists, the Compliance Officer will inform the Chief Executive of any pending investigations. The Compliance Officer or Chief Executive will arrange to retain legal counsel, as deemed appropriate.

II. Reporting

The results of the investigation and remedial actions will be communicated confidentially to the Chief Executive, members of the Board of Directors, and other employees based on a need-to-know basis.  The Compliance Officer shall report to the Compliance Committee regarding each investigation conducted unless conducted under attorney privilege.

At the conclusion of an investigation involving legal counsel, they shall issue a report to the Compliance Officer, Chief Executive, and Compliance Committee summarizing their findings, conclusions, and recommendations and will render an opinion as to whether a violation of the law has occurred.  The report will be reviewed with legal counsel in attendance.  Any additional action will be on the advice of counsel.

III. Rectification

If the Compliance Officer, in consultation with legal counsel, identifies credible evidence or credibly believes that a State or Federal law, rule, or regulation has been violated, the Compliance Officer will promptly report such violation to the appropriate governmental entity, where such reporting is otherwise required by law, rule, or regulation.

If the Organization identifies that an overpayment was received from any third-party payer, the appropriate regulatory (funder) and/or prosecutorial (attorney general/police) authority will be appropriately notified with the advice and assistance of counsel.

It is the Organization’s policy to not retain any funds received from overpayments. Overpayments will be reported and refunded to Medicaid and Medicare in accordance with the appropriate self-disclosure protocols and any required time frames.

In instances where it appears that an affirmative fraud may have occurred, appropriate amounts shall be returned after consultation and approval by involved regulatory and/or prosecutorial authorities.  Systems shall also be put in place to prevent such overpayments in the future.

IV. Record keeping

Regardless of whether a report is made to a governmental agency, the Compliance Officer shall maintain a record of the investigation, including copies of all pertinent documentation.  The Compliance Officer will organize the information so that the Organization can determine if an infraction occurred.  The Compliance Officer will securely maintain all notes of the interviews, all evidence and review of documents as part of the investigation file.  This record will be considered confidential and not released without the approval of the Chief Executive or legal counsel.