MEDICAL STAFF CREDENTIALING POLICY Please read carefully

Transcription

1 I. Pre-Application & Application: MEDICAL STAFF CREDENTIALING POLICY Please read carefully Pre-Application is provided to the applicant. After forms are completed and documentation obtained, all information will be submitted to Medical Staff Services for primary source verification of documentation. Please note: The credentialing process is entirely dependent upon the length of time it takes to receive verification of education, licensure, references, affiliations, certifications, etc. The burden of proof in all respects is on the applicant. The Medical Staff Office will make at least two attempts to obtain verifications. However, the applicant may be called upon to obtain required documentation/verifications, if references, etc., are not received in a timely manner. Processing of Pre-Application will be delayed if complete addresses are not provided and any of the below documentation is missing. Required Documentation Completed Pre-Application Completed Verification of Professional Liability form for each malpractice carrier for the past five (5) years. Feel free to make copies of enclosed form if necessary. Copy of all Malpractice Certifications (showing limits & expiration) Completed Pre-Application Malpractice Claims/Suits History Form (if applicable) Copy of Medical School (Professional) Diploma Copy of ECFMG Certificate (as applicable) Copy of Internship Certificate Copy of Residency Certificate Copy of Board Certification & Recertification Copy of Sub-Specialty Board Certification & Recertification Copy of ALL licensure or license numbers and states where issued DEA Certificate (if original is sent, a copy will be made and returned to you) Copy of current, chronological Curriculum Vitae A clear, current professional photograph (for ID badge within hospital) A Copy of Government Issued Picture ID (driver s license, etc.) A Pre-application fee of $ (due at the time the Pre-Application is submitted) *** An Application Fee of $ will be charged when formal application is granted. Both are non-refundable. Current PPD results (If positive, provide recent chest x-ray results) Case logs/volumes for the past 2 years for privileges requested When the Pre-Application is determined to be complete (all requested documents furnished and Pre-Application completed and returned), at least three (3) interviews will be scheduled by the applicant - one with the Department Chief, one with the Chief of Staff and one with the Chief Executive Officer of Bayfront Health-Punta Gorda. Medical Staff Services will provide the applicant with contact names and telephone numbers. 1

2 MEDICAL STAFF CREDENTIALING POLICY PAGE 2 II. The Committee and Departmental Approval Process: The Joint Conference Committee: After all references are verified by primary source verification, the Pre-Application is forwarded to the Joint Conference Committee for review. This Committee usually meets each month. No pre-application will be taken to the Joint Conference Committee until it is determined to be complete in all respects. This includes, but not limited to, all requested documentation, letters, verified references, proof(s) of insurance, current DEA, Florida license, and completed interviews. Due process is not available if the decision of the Joint Conference Committee is not to provide the would-be applicant with a full application. The applicant will be notified in writing of the decision of the Joint Conference Committee. Formal Application and Departmental Review: After the Joint Conference Committee meets and the Pre-Application is approved, a Request for Formal Application for Medical Staff membership and clinical privileges is forwarded to the applicant together with a copy of the Medical Staff Bylaws, and other documents to be signed and returned. The applicant must complete ALL questions and/or requests - date, sign and return all material to Medical Staff Services. An Application Fee of $ is required. The Application will be reviewed by the appropriate Department Chief, who will make a recommendation to the Credentials Committee for both the Application and requested privileges. The Credentials Committee The Credentials Committee meets monthly, to review the file, the Department Chief s recommendation, and requested privileges. Should the recommendation be adverse, the applicant will be notified in writing and given reasons for an adverse decision. The adverse recommendation will proceed to the Medical Executive Committee. The Medical Executive Committee The Medical Executive Committee meets monthly. The applicant will be duly notified in writing of the status of the application. Should the recommendation of the Executive Committee be adverse, the applicant will be notified in writing and will be entitled to due process as described in the Bylaws. The Board of Trustees Recommendations involving Medical Staff credentialing are made to the Board of Trustees by the Executive Committee. The Board of Trustees usually meets quarterly; therefore, the Executive Committee of the Board of Trustees meets on a monthly basis. 2

3 PRE-APPLICATION FOR MEDICAL STAFF APPOINTMENT AND CLINICAL PRIVILEGES Please attach recent photo here INSTRUCTIONS: Please print all information clearly! If the existing space is insufficient, attach additional sheets and reference the question being answered. Please enclose a recent photograph and Curriculum Vitae. INCOMPLETE PRE-APPLICATIONS WILL BE RETURNED FOR COMPLETION. Please fill in all blanks. PERSONAL DATA Last Name First Name Middle Name Maiden Name List of all names under which you were enrolled, licensed, or also known as: Social Security Number Birth Date Birth Place Date of Pre-application Office Address 1 Telephone City State Zip Code Office Address 2 Telephone City State Zip Code Residence Address Telephone City State Zip Code Marital Status: (circle one) S M D W Spouse Name: Answering Service Number FAX Number Beeper Number Cell Phone Number Citizenship If not a US citizen, please indicate type and status of your Visa Expiration Date Tax ID Number Address: NPI#: STAFF CATEGORY AND DEPARTMENT Please indicate the staff category and department to which you wish to be appointed, as well as specific clinical privileges you would like to exercise: STAFF CATEGORY CLINICAL SERVICE/DEPARTMENT (Ex. Active, Courtesy, Consulting) (Ex. Internal Medicine/Medicine, General Surgery/Surgery, etc) 3

4 Bayfront Health-Punta Gorda - Pre-application for Medical Staff Appointment and Clinical Privileges BOARD CERTIFICATIONS AND CERTIFICATES Names of specialty boards by which you are certified: Specialty Name Date Certified Expiration Date Recertified? Date of Recert. Expiration Date Subspecialty Name Date Certified Expiration Date Recertified? Date of Recert. Expiration Date Are you Board Qualified? Yes No If Yes, Date of Exam If not certified, it must be less than 5 years since your last medical schooling session. If more than 5 years since last medical school session and not board certified, you are ineligible for Medical Staff privileges. If 5 years or less since last medical schooling session, state your intent with respect to becoming certified on a separate sheet. GROUP/PRACTICE NAME AND INFORMATION Group/Practice Name: When you unavailable, please indicate below what member of our staff will provide coverage to your patients: Name Address Specialty AFFILIATIONS List all present and previous affiliations and Medical Staff memberships in chronological order, beginning with the most recent dates (include assistantships and appointments). All time periods must be accounted for. Full Dates of Affiliation Facility Name Address/Phone/Fax Department and Status Held *Please indicate your primary admission facility(s). If more space needed, please attach additional sheets with full information. 4

5 Bayfront Health-Punta Gorda Pre-application for Medical Staff Appointment and Clinical Privileges AFFILIATIONS (Cont d) 1. Have your membership or clinical privileges ever been voluntarily or involuntarily limited, reduced, suspended, or relinquished, or have you ever lost your clinical privileges at another health care facility? Yes No 2. Has your pre-application for appointment to the medical staff of any other health care facility ever been denied? Yes No 3. Have you voluntarily or involuntarily resigned from the medical staff of any health care facility? Yes No If the answer to any of the above questions is YES, please attach a sheet with detailed information. Branch of Service: Title: Type of Discharge: Bases where service was held: MILITARY SERVICE Dates: Highest Rank: Reserve Status: MEDICAL LICENSES AND DEA CERTIFICATION Please list all medical licenses held, both active and inactive. State License Number Profession Expiration Date DEA Registration Number Expiration Date Medicare Number Medicaid Number Does your DEA Number reflect schedules 2, 2N, 3, 3N, 4 and 5? Yes No If the answer is NO, please explain: NOTE: A copy of DEA certificate and all licenses, active and inactive, must be included in this pre-application. Please answer each of the following questions: 1. Have any disciplinary actions ever been initiated and/or are pending against you by any state licenser board? Yes No 2. Has your license to practice medicine in any states ever been denied, limited, suspended, revoked, placed on probation, or voluntarily/involuntarily relinquished? Yes No 3. Have you ever been suspended, sanctioned, or otherwise restricted from participating in any private, federal or state health insurance program (for example, Medicare or Medicaid)? Yes No 4. Have you ever been the subject of an investigation by any private, federal, or state agency concerning your participation in any private, federal or state health insurance program? Yes No 5. Has your DEA Number ever been limited, suspended, revoked, or voluntarily/involuntarily relinquished? Yes No 6. Have you ever been a defendant in a criminal proceeding? Yes No 7. List participation in any private health insurance program: If the answer to any of the above questions is YES, please attach a sheet with detailed information. 5

6 Bayfront Health-Punta Gorda Pre-application for Medical Staff appointment and Clinical Privileges EDUCATION Type Name of Institution Full Mailing Address Degree Dates Attended From To Medical School Undergraduate College or University From To If medical or other processional school was not in the United States, Canada or Puerto Rico, please attach a copy of ECFMG certificate. ECFMG Certificate Number: Date of Certificate: INTERNSHIPS Institution Name Dates Attended Program Director Type if Internship Full Mailing Address If more than one internship was begun or completed, please supply the same information on a separate sheet and attach. RESIDENCIES Institution Name Dates Attended Department Chairman/Program Director Type of Residency Full Mailing Address Institution Name Dates Attended Department Chairman/Program Director Type of Residency Full Mailing Address If more than two residencies were begun or completed, please supply the same information on a separate sheet and attach. FELLOWSHIPS Institution Name Dates Attended Department Chairman/Program Director Type of Fellowship Full Mailing Address If more than one fellowship was begun or completed, please supply the same information on a separate sheet and attach. 6

7 Bayfront Health-Punta Gorda Pre-application for Medical Staff Appointment and Clinical Privileges TEACHING APPOINTMENTS Institution Name Affiliation Dates Department Chairman Type of Appointment Full Mailing Address If more than one teaching appointment was begun or completed, please supply the same information on a separate sheet and attach. During your internship, residency, fellowship or teaching appointment (as is applicable): a.) were you ever disciplined, suspended, placed upon probation, formally reprimanded or asked to resign? Yes No b.) have you has to leave for 30 or more consecutive days? Yes No If YES, please attach a sheet with detailed information. Name of Society PROFESSIONAL SOCIETIES Dates of Membership Name of Society Dates of Membership Name of Society Dates of Membership Have you ever been denied membership or renewal thereof, or been subject to disciplinary proceedings in any professional organization? Yes No If YES, please attach a sheet with detailed information. Present Insurance Mailing Address INSURANCE Company Type of Policy Dates of Coverage Policy Number Claim/Aggr Limit Retroactive Date / List all insurance carriers for the past 5 years: Past insurance 1 Company Type of Policy Dates of Coverage Policy Number Claim/Aggr Limit Mailing Address Retroactive Date / Past Insurance 2 Company Type of Policy Dates of Coverage Policy Number Claim/Aggr Limit Mailing Address Retroactive Date / 7

8 Bayfront Health-Punta Gorda Pre-application for Medical Staff Appointment and Clinical Privileges INSURANCE (Cont d) Please list other insurance carriers on separate sheet if space is needed for additional carriers. Please make sure to complete a Consent to Verify Professional Liability form for each insurance company listed. Has your professional liability insurance coverage ever been terminated by action of an insurance company? Yes No Have you ever been denied professional liability insurance coverage or rated in a higher than average risk class for your professional specialty? Yes No If the answer to either of the above questions is YES, state when and by what company: LEGAL ACTIONS 1. Have any professional liability claims or suits ever been filed against you? Yes No 2. Have any professional liability claims or suits been filed against you which are presently pending? Yes No 3. Have any judgements been made against you in a professional liability case(s) or claim(s), or have you entered into any settlements? Yes No If the answer to any of the above questions is YES, please complete the attached malpractice claims/suits history form. HEALTH STATUS 1. Are you able to perform the functions relevant to the privileges you have requested? Yes No If answer is NO, please provide additional information. INTERRUPTION OF PRACTICE 1. Has your medical practice been interrupted or discontinued for any reason, voluntarily or involuntarily, for more than three (3) weeks since you began your practice of medicine? Yes No If the answer to the above question is YES, please provide additional information of reason and duration of interruption. REFERENCES List at least three professional references, which have personal knowledge and can evaluate your performance. Please provide current and complete address for each. Pre-applications will be returned for incomplete information. Name Mail Address Telephone/Fax Number 8

9 CONTINUING EDUCATION On a separate sheet of paper, list all Continuing Medical Education credits for the past 2 years OR attach a copy of your certificates of attendance/participation; or I ATTEST I HAVE OBTAINED THE REQUIRED CME CREDITS FOR MAINTENANCE OF MY FLORIDA LICENSE AND THAT THE MAJORITY OF THESE CREDITS ARE RELATED TO MY SPECIALTY AND ARE AVAILABLE UPON REQUEST. CONFIDENTIALITY OF INFORMATION ACKNOWLEDGEMENT I understand that all information pertaining to patients, employees, facility business, and/or physicians is confidential and prohibited from disclosure, and that this confidentiality is protected from disclosure by law. Furthermore, I understand that any information pertaining to patients obtained through use of, or access to, reports, or an automated data processing system is similarly confidential and it is protected from disclosure by the same statutes. I understand that I am prohibited from making and disclosure of such information without the appropriate consent of the person to whom the information pertains and hereby agree to maintain the confidentiality of such information. I understand that if I should breach this confidentiality, I will be subject to disciplinary action up to and including termination of medical staff membership and clinical privileges. I further understand that could be subject to legal action. Applicants Signature Date Be sure to include these required documents Completed Verification of Professional Liability form for each malpractice carrier for the past five (5) years. Feel free to make copies of enclosed form if necessary. Copy of all Malpractice Certifications (showing limits & expiration) Completed Pre-Application Malpractice Claims/Suits History Form (if applicable) Copy of Medical School (Professional) Diploma Copy of ECFMG Certificate (as applicable) Copy of Internship Certificate Copy of Residency Certificate Copy of Board Certification & Recertification Copy of Sub-Specialty Board Certification & Recertification Copy of ALL licensure or license numbers and states where issued DEA Certificate (if original is sent, a copy will be made and returned to you) Copy of current, chronological Curriculum Vitae A clear, current professional photograph (for ID badge within hospital) A Copy of Government Issued Picture ID (driver s license, etc.) A Pre-application fee of $ (due at the time the Pre-Application is submitted) *** An Application Fee of $ will be charged when formal application is granted. Both are non-refundable. Current PPD results (If positive, provide recent chest x-ray results) Case logs/volumes for the past 2 years for privileges requested 9

10 Bayfront Health-Punta Gorda Pre-application for Medical Staff Appointment and Clinical Privileges APPLICANT S CONSENT AND RELEASE I hereby apply for medical staff appointment and clinical privileges as requested in this pre-application and, whether or not my pre-application is accepted, I acknowledge, consent, and agree as follows: As an applicant for appointment, I have the burden for producing adequate information for proper evaluation of my qualifications. I also agree to update the hospital/health plan with current information regarding all questions contained in this pre-application as such information become available and any additional information as may be requested by the hospital/health plan or its authorized representatives. Failure to produce any such information will prevent my pre-application for appointment from being evaluated and acted upon. Information given in or attached to this pre-application is accurate and complete to the best of my knowledge. I fully understand and agree that as a condition to making this pre-application, any misrepresentations or misstatements in, or omission from it, whether intentional or not, shall constitute cause for automatic and immediate rejection of this pre-application, resulting in denial of appointment and clinical privileges. In the event that appointment or privileges have been granted prior to the discovery of such misrepresentation, misstatement or omission, such discovery may result in immediate termination of such appointment pr privileges. I accept the following conditions: A.) B.) C.) I extend immunity to, and release from any and all liability, the hospital/health plan, its authorized representatives and any third parties, as defined in Subsection C below, for any acts, communications, recommendations or disclosures involving me; performed, make, requested or received by this hospital/health plan and its authorized representatives to, from or by any third party, including otherwise privileged or confidential information, relating, but not limited to, the following: 1.) pre-applications for appointment or clinical privileges, including temporary privileges; 2.) periodic reappraisals; 3.) proceedings for suspension or reduction of clinical privileges or for denial or revocation of appointment, or any other disciplinary action; 4.) summary suspensions; 5.) hearings and appellate reviews; 6.) medical care evaluations; 7.) utilization reviews; 8.) any other hospital/health plan, medical staff, department, service, or committee activities; 9.) matters or inquiries concerning my professional qualifications, credentials, clinical competence, character, mental or emotional stability, physical condition, ethics or behavior; and 10.) any other matter that might directly or indirectly impact or reflect on my competence, on patient care or on the orderly operation of this or any other hospital/health plan or health care facility. I specifically authorize the hospital/health plan and its authorized representatives to consult with any third party who may have information, including other privileged or confidential information, bearing on my professional qualifications, credentials, clinical competence, character, mental or emotional stability, physical condition, ethics, behavior or any other matter bearing on my satisfaction of the criteria for continued appointment to the medical staff, as well as to inspect or obtain any and all communications, reports, records, statements, documents, recommendations and/or disclosures of said third parties relating to such questions. I also specifically authorize said third parties to release said information to the hospital/health plan and its authorized representatives upon request. The term hospital/health plan and its authorized representatives means the hospital/health plan corporation and any of the following individuals who have any responsibility for obtaining or evaluation my credentials, or acting upon my pre-application or conduct in the hospital/health plan: the members of the hospital/health plan s Board and their appointed representatives, the Chief Executive Officer or his designees, other hospital/health plan employees, consultants to the hospital/health plan, the hospital/health plan s attorney and his/her partners, associates or designees, and all appointees to the medical staff. The term third parties means all individuals, including appointees to the hospital/health plan s medical staff, and appointees to the medical staffs of other hospitals/health plans or other physicians or health practitioners, nurses or other government agencies, organizations, associations, partnerships and corporations, whether hospital/health plans, health care facilities or not, from whom information has been requested by the hospital/health plan or its authorized representatives or who have requested such information from the hospital/health plan and its authorized representatives. I acknowledge that (1) medical staff appointment and clinical privileges at this hospital/health plan are not a right; (2) my request will be evaluated in accordance with prescribed procedures defined in the hospital/health plan and medical staff bylaws, rules and regulations; (3) all medical staff recommendations relative by my pre-application are subject to the ultimate action of the hospital/health plan Board whose decision shall be final; (4) if appointed, my appointment and clinical privileges shall be provisional; (5) I have the responsibility to keep this pre-application current by informing the hospital/health plan, through the Chief Executive Officer, of any change in the areas of inquiry contained herein; and (6) appointment and continued clinical privileges remain contingent upon my continued admission, treatment and continuous care and supervision of patients for whom I have responsibility, and acceptable performance of all responsibilities related thereto, as well as other factors that are relevant to the effective and efficient operation of this hospital./health plan. Appointment and continued clinical privileges shall be granted only on formal pre-application, according to hospital/health plan and medical staff bylaws, rules and regulations, and upon final approval of the hospital/health plan Board. I have received and had an opportunity to read a copy of the medical staff bylaws and such hospital/health plan policies and directives as are applicable to appointees to the medical staff, including the bylaws and rules and regulations of the medical staff presently in form. I specifically agree to abide by all such bylaws, policies, directives and rules and regulations as are in force, and as they may hereafter be amended, during the time I am appointed or reappointed to the medical staff of exercise clinical privileges at the hospital/health plan. If appointed or granted clinical privileges, I specifically agree to (1) refrain from fee-splitting or other inducements relating of patient referral; (2) refrain from delegating responsibility for diagnoses or care of hospitalized patients to any other practitioners who is not qualified to undertake this responsibility or who is not adequately supervised; (3) refrain from deceiving patients as the identity of any practitioner providing treatment or services; (4) seek consultation whenever necessary or required; (5) abide by generally recognized ethical principles applicable to my profession; (6) provide continuous care and supervision as needed to all patient in the hospital/health plan for whom I have responsibility; and (7) accept committee assignments and such other duties and responsibilities as shall be assigned to me by the hospital/health plan Board and medical staff. All information submitted by me in this pre-application is true and complete to the best of my knowledge. A photo static copy of this original statement constitutes my written authorization and request to release any and all documentation relevant to this pre-application. APPLICANT S PRINTED NAME APPLICANT S SIGNATURE DATE 10

11 RECOMMENDATIONS DEPARTMENT CHAIRPERSON o Recommend as requested o Recommend with modifications/conditions o Recommend be deferred o Recommend denial Comments: APPLICANT DO NOT COMPLETE, FACILITY USE ONLY Department Chairperson Signature Date CREDENTIALS COMMITTEE CHAIRPERSON o Recommend as requested o Recommend with modifications/conditions o Recommend be deferred o Recommend denial Comments: Credentials Committee Chairperson Signature Date MEDICAL EXECUTIVE COMMITTEE CHAIRPERSON o Recommend as requested o Recommend with modifications/conditions o Recommend be deferred o Recommend denial Comments: Medical Executive Chairperson Signature Date BOARD OF TRUSTEES o Approved as requested o Approved with modifications/conditions o Appointment deferred o Appointment denial Comments: Board of Trustees Chairperson Signature Date Applicant Name: Specialty: 11

12 CONSENT TO VERIFY PROFESSIONAL LIABILITY I, the undersigned insured, authorize my current/former professional liability insurance carrier to send BAYFRONT HEALTH-PUNTA GORDA verification of my professional liability coverage showing the dates, amounts of coverage and any limits in coverage, and a listing of any and all claims made a Name of Insurance Carrier Name of Policyholder Address of Ins. Carrier Policy Number Coverage Dates CURRENT INSURANCE CARRIER, ONLY: BAYFRONT HEALTH PUNTA GORDA is to hereinafter be notified of the amount of my coverage and any future changes in my insurance status. Date Signature of Insured Printed Name of Insured NOTE: Please provide separate, completed consent for each insurance carrier for the past five years. Please copy this form if necessary. 12

13 Confidentiality of Information Acknowledgement I understand that all information pertaining to patients, employees, facility business, and/or physicians is confidential and prohibited from disclosure, and that his confidentiality is protected from disclosure by law. Furthermore, I understand that any information pertaining to patients obtained through use of, or access to, reports, or automated data processing systems is similarly confidential and it protected from disclosure by the same statutes. I understand that I am prohibited from making any disclosure of such information without the appropriate consent of the person to whom the information pertains and hereby agree to maintain the confidentiality of such information. I understand that if I should breach this confidentiality, I will be subject to disciplinary action up to and including termination. I further understand that I could be subject to legal action. Signature Date Print Name (Please print clearly) 13

14 BAYFRONT HEALTH-PUNTA GORDA Punta Gorda, Fl Telephone: (941) Fax: (941) PRE-APPLICATION MALPRACTICE CLAIMS/SUITS HISTORY FORM APPLICANT: Please attach additional pages if necessary. 1. The following professional liability claims or suits have been filed against me: Name of Insurance Carrier: Policy Number: Date of Claim: Details of Claim: 2. The following professional liability claim(s) or suit(s) have been filed against me and are currently pending : Name of Insurance Carrier: Policy Number: Date of Claim: Details of Claim: 3. The following judgments have been made against me in a professional liability case(s) or claim(s): Name of Insurance Carrier: Policy Number: Date of Claim: Details of Claim: 4. I have entered into the following settlement(s): Name of Insurance Carrier: Policy Number: Date of Claim: Details of Claim: Signature: Date: 14

15 Background Inquiry Authorization I, authorize Punta Gorda HMA, Inc. dba Bayfront Health-Punta Gorda to conduct a background investigation on myself including, but not limited to consumer credit history, criminal conviction history, driving history, National Practioner Data Bank information, and prior employment. I further understand that information may be requested from various Federal, State, and other agencies, which may maintain records concerning my past activities. I authorize without reservation, any person or agency to furnish the above information to: Bayfront Health-Punta Gorda Medical Staff Office 809 East Marion Avenue Punta Gorda, FL (941) Fax (941) I authorize that a photocopy or facsimile of my signature below may be used to obtain information. I further understand that to aid in the proper identification of my file or records, I am providing the following information. Name: Any prior names, maiden name, nickname or aliases: Social Security Number: Date of Birth: Drivers License: State of Issue: Physician License: State of Issue: Current Address: Previous Address: I, by signature below, authorize and request release of any and all documentation requested, by photostatic copy of this original statement. Date Printed Name Signature 15

16 BAYFRONT HEALTH-PUNTA GORDA CONFLICT OF INTEREST DISCLOSURE For (Print Name Clearly) Do you or a Family Member have an actual or potential Conflict of Interest as defined by the Medical Staff Conflict of Interest Policy? No Yes If yes, please specify in detail: STATEMENT OF COMPLIANCE WITH THE CONFLICT OF INTEREST POLICY I am expected to comply with the Hospital s Conflict of Interest Policy. To the best of my knowledge and belief, I am in compliance with the Conflict of Interest Policy and have disclosed any known or potential Conflicts of Interest. I have a continuing responsibility to comply with the Conflict of Interest Policy, and I will promptly disclose any information required to be disclosed under the Policy. Signature: Print Name: Date: 16

17 I. Compliance Program Introduction Bayfront Health-Punta Gorda has developed and implemented a Compliance Program that is designed to deter, detect, and prevent fraud, abuse, and mistakes. Examples of potential fraud, abuse, and mistakes include the following: 1. Billing for goods or services that were not provided. 2. Billing for goods or services that are not documented or not sufficiently documented. 3. Billing for goods or services that were not medically necessary. 4. Providing a referral source anything of value in exchange for referrals. 5. A financial relationship between a hospital and a referring physician, physician group, or immediate family member of a referring physician, without a written agreement. 6. Paying a referring physician, physician group, or immediate family member of a referring physician above fair market value for services rendered. 7. Charging a physician less than fair market value rent for space or equipment. Written Standards, Policies, and Procedures The Compliance Program structure and requirements are set forth in the Compliance Manual and Compliance Policies and Procedures. Both of these documents are available on the hospital intranet at hma-info.com. In addition, a paper copy of the Compliance Manual can be obtained from the Director of Human Resources, Faye Peraza. Oversight Dalizza Marques is the Hospital Compliance Officer responsible for making sure that the Compliance Program has been implemented and is operating in accordance with the requirements of the Compliance Manual and Compliance Policies and Procedures. The Hospital Compliance Officer works in conjunction with a Divisional Compliance Officer Susan Stephens and reports to the Vice President of Compliance on all compliance related matters. Training In order to successfully deter, detect, and prevent potential fraud, abuse, and mistakes, it is critical that all individuals working in the hospital, including medical staff members, are aware of the existence, purpose, elements, and requirements of the Compliance Program. Consequently, we have developed this Compliance Program Overview Certification to introduce and/or remind you of the elements and requirements of Bayfront Health-Punta Gorda s Compliance Program. In addition, you may contact the Hospital Compliance Officer, Dalizza Marques - (941) , at anytime should you have any questions or concerns. Audits Each year, a risk assessment is performed to identify risk areas that can be proactively monitored and audited. A Compliance Work Plan is developed based upon the risk assessment and the Compliance Work Plan describes the mandatory internal and external auditing and monitoring activity. Significant portions of the Compliance Work Plan audits relate to validating that services are adequately documented and medically necessary. In addition, all financial relationships with physicians, physician groups, and immediate family members of physicians are audited to verify that any transfer of remuneration is pursuant to a written agreement that is supported by evidence that the financial relationship is fair market value. Anonymous Reporting Mechanisms As part of Bayfront Health-Punta Gorda s Compliance Program, we have contracted with an outside vendor to provide a mechanism, the Compliance Helpline, for associates to anonymously report suspected misconduct 24/7. The Compliance Helpline number is: All matters reported through the Compliance Helpline are ed to the Vice President of Compliance for the hospital s parent company. The Vice President of Compliance reviews the reports and determines the appropriate person to investigate the concern. In addition, associates can also anonymously report suspected misconduct by sending their concerns to a confidential post office box at the following address: Health Management Associates, P.O. Box , Naples, Florida Similar to communications through 17

18 the Compliance Helpline, all communications through the P.O. Box are reviewed by the Vice President of Compliance and then forwarded for investigation. Investigations All reports of suspected misconduct must be entered into the hospital s compliance log and investigated. The Hospital Compliance Officer will oversee all investigations and is responsible for involving when necessary, legal counsel and/or subject matter experts. If the Hospital Compliance Officer cannot perform the investigation due to a conflict, then the Vice President of Compliance will determine who will conduct the investigation. If the investigation reveals fraud, abuse, or mistakes, then these conclusions must be reported to the Vice President of Compliance and an appropriate corrective action plan must be established to address all noted deficiencies. Conclusion The success of our Compliance Program depends on each and every Bayfront Health-Punta Gorda associate helping to establish and maintain a culture that is focused on our mission of providing compassionate high quality healthcare services that improve the quality of life for our patients, physicians, and communities that we serve and showing zero tolerance for illegal, unethical, or otherwise inappropriate behavior. II. HIPAA Program To be in compliance with the HIPAA regulations, all healthcare providers should be knowledgeable about Health Management Associates HIPAA policies and procedures. Key Message Points Relating to HIPAA compliance include: The HIPAA Privacy Rule establishes national standards to control the use and disclosure of what is known as Protected Health Information (PHI). PHI is any health information that is collected from the patient or created or received by a health care provider or facility that relates to the past, present or future physical or mental health or condition of a patient that could potentially identify that individual. Unsecured PHI: All PHI we deal with is unsecured. Paper records are unsecured. Secured PHI: PHI is secured only if it is encrypted by NIST standards or has been destroyed. Disclosure: PHI brought outside the organization The Privacy Rule gives patients the right to: Receive a Privacy Notice Inspect and get a copy of their PHI Amend their PHI if incorrect Request restrictions on disclosures of PHI Request alternative means of communication Obtain accounting of non-routine disclosures of PHI The obligation of the hospital s workforce and medical staff is to: Use or disclose PHI only for work related purposes Limit uses and disclosures to the minimum necessary to achieve those work purposes Exercise reasonable caution to protect PHI under their control Understand the HIPAA policies and follow them Try to remedy any privacy problems or to report them to the Privacy Officer of Bayfront Health-Punta Gorda. The Privacy Officer is Dalizza Marques, who can be reached at (941) Recognize that the hospital will not retaliate or discriminate against any patient, member of the workforce, or medical staff member who exercises their right to express a privacy or other HIPAA concern Do not: Throw PHI in the trash or leave on the copier use a shredder or dispose of paper-based PHI in the secured trash receptacles located throughout the facility 18

19 Share your password to any computer system. Your password is your key and you will be held responsible for others that view information. Use your personal cell phone or camera to take pictures of patient s body parts, X-rays, or other PHI. Be aware that: Audits are done regularly to see who accessed PHI in our systems. Every associate, physician, and VIP admitted to the hospital will have their account reviewed for inappropriate access. The Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH Act) empowers individual State Attorneys General to investigate and recover damages from INDIVIDUALS in federal court (anti-snooping measure). The new law mandates civil monetary penalties for certain violations and can include fines and jail time for the INDIVIDUAL. The HITECH Act also requires written notification to patients (as of 9/23/09) of inappropriate access of their unsecured PHI and notification to the Federal Government and local media if 500 or more patients are affected. o Exceptions from notifying the patient or Federal Government about breaches: Breaches that were not intentional and did not disclose information outside of the facility. (Note outside the facility includes HIPAA information found in the facility by a non-employee or individual covered by our HIPAA policy.) If a stolen laptop is protected by encryption software approved by the Federal Government. Physicians/AHPs and students are expected to follow facility policies concerning privacy and security. The HIPAA and HITECH regulations provide a range of penalties for non-compliance depending on the context of the violation and the offender s intent. For individuals who knowingly release information inappropriately, the penalties could include jail time, loss of licensure, and/or significant financial penalties. 19

20 Compliance and HIPAA Program Certification I have received and read the Medical Staff Compliance and HIPAA Program Overview and have had the opportunity to ask questions, request a copy of the Compliance Manual, and discuss the Compliance and HIPAA Programs with the Hospital Compliance Officer and Privacy Officer Dalizza Marques. I am aware that as a member of Bayfront Health-Punta Gorda s medical staff, I agree to report even suspected HIPAA issues and suspected misconduct to the Hospital Compliance/Privacy Officer, Dalizza Marques, or through one of the anonymous reporting mechanisms. Unless otherwise noted below, I do not have knowledge of any illegal, unethical, or otherwise inappropriate conduct at Bayfront Health- Punta Gorda. Physician Signature Date Print Physician Name 20

21 PHYSICIAN MEDICARE & CHAMPUS CERTIFICATION NOTICE TO PHYSICIANS: Medicare and Champus payment to hospitals is based in part on each patient's principal and secondary diagnoses and the major procedures performed on the patient, as attested to by the patient's attending physician by virtue of his or her signature in the Medical Record. Anyone who misrepresents, falsifies, or conceals essential information required for payment of Federal Funds, may be subject to fine, imprisonment, or civil penalty under applicable Federal Laws. I,, the undersigned, acknowledge having received the above notice. Legal Signature Date (Print Name Clearly) (Legal signature means that which you would normally use on documents such as a will, checks, etc. Initials are not acceptable.) 21

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