Ethics and Compliance Training

Transcription

1 Ethics and Compliance Training Revised 12/2011

2 Dear Fellow Employee: West Tennessee Healthcare (WTH) entered into a Corporate Integrity Agreement (CIA) for a period of five years with the Office of Inspector General (OIG) of the Department of Health and Human Services on November 26, This agreement, along with payments to the Medicare program, was the result of a six-year cooperative process in which we worked with government representatives to resolve allegations of improper billing. The allegations involved billing for non-emergency ambulance transportation at Jackson-Madison County General Hospital and geriatric-psychiatric services at Milan General Hospital. The CIA requires that we actively demonstrate our commitment to compliance with applicable regulations, including the Medicare program. One of the requirements is that we provide general compliance training to providers of patient care services and those who are involved in billing and coding processes. The training will cover topics such as: the requirements of the CIA, the WTH Code of Conduct, WTH s Ethics and Compliance Program, and applicable WTH Compliance Policies and Procedures. You will be required to complete a test and sign a certification at the end of this training module. It is very important that you complete this training. This initial training will take you approximately 1 ½ hours to complete. If, at any time during the completion of the training, you have a question regarding any of the training topics, please contact the WTH Compliance Officer at or the Compliance Office at , and someone will be glad to assist you with your question.

3 Training Objectives To provide information on the requirements of the WTH Corporate Integrity Agreement (CIA) To provide information regarding the WTH Code of Conduct and what it means to employees To provide information about WTH s Ethics and Compliance Program, including the anonymous reporting tools To provide information on WTH Compliance Policies and Procedures To test on the knowledge provided in this module and to obtain certification that training has been provided

4 WTH Corporate Integrity Agreement What is a Corporate Integrity Agreement (CIA)? The Office of Inspector General of the Department of Health and Human Services often negotiates these agreements with health care providers as a part of a settlement of an investigation in order to ensure the integrity of Federal health care claims billed by the provider. Under a CIA, health care providers agree to certain compliance-related obligations for the term of the agreement. What is the term of the agreement? We have entered into the Corporate Integrity Agreement for five (5) years. What will we have to do to comply with this agreement? The training you are currently completing is just one requirement under the CIA. As you continue in the training materials, you will read about the numerous requirements of our CIA as well as the penalties that can be assessed on the organization for non-compliance.

5 WTH Corporate Integrity Agreement Requirements WTH must maintain a Compliance Officer for the term of this CIA. The WTH Vice President/Compliance Officer is Amy Griffin. WTH must maintain a Compliance Committee. WTH has several compliance committees throughout the health system. The Ethics and Compliance Committee is a subcommittee of the System Quality PLUS Committee. There is also a Billing Compliance Committee which focuses on issues related to billing federal health care programs. There are many departments who also have their own compliance committees. For more information, please contact the Compliance Office at WTH must maintain and distribute its Code of Conduct. WTH must implement and maintain policies and procedures regarding the operation of the WTH Ethics and Compliance Program.

6 WTH Corporate Integrity Agreement Requirements WTH must provide at least 1 ½ hours of initial general compliance training to those who provide direct patient care services and those who perform billing and coding functions. WTH must provide specific training regarding accurate coding and submission of claims, policies and procedures, documentation, and the personal obligation of each individual involved in the claims submission process to ensure that claims are accurate. WTH must engage an auditor each year to perform reviews to assist us in assessing and evaluating our billing and coding practices. The auditor will review a sample claims relating to ambulance transportation and also another sample of all paid Medicare claims submitted by JMCGH. If the error rate is less than 5%, no more additional auditing is required; however, is the error rate is 5% or greater, the auditor must perform an audit on a larger sample of claims and must perform a systems review of the billing and coding process. The auditor will also perform a cost report review.

7 WTH Corporate Integrity Agreement Requirements Each individual that receives training is required to certify, in writing, that he or she has received the required training. You will be able to print your training certification later in the training. Any overpayments identified must be repaid within 30 days. WTH must maintain an anonymous reporting system and emphasize our non-retaliation policy. WTH must screen all officers, trustees, employees, and contractors, and agents to determine if they are ineligible to participate in Federal health care programs. WTH must notify OIG within 30 days after discovery of any ongoing investigation or legal proceeding known to WTH conducted or brought by a governmental entity or its agents involving an allegation that WTH has committed a crime or has engaged in fraudulent activities.

8 WTH Corporate Integrity Agreement Requirements WTH must report to the OIG within 30 days any substantial overpayments or any matter that a reasonable person would consider a probable violation of criminal, civil, or administrative laws applicable to any Federal health care program. WTH must report the change in location of any departments of JMCGH, and any sale, closure, and establishment of a new business unit related to the furnishing of items or services that may be reimbursed by Federal health care programs no later than 30 days after the date of the event. WTH must submit an Implementation Report to the OIG no later than 150 days after the effective date of the CIA including evidence of compliance of all the above requirements. WTH must also submit an Annual Report with the status of WTH s compliance activities for each year.

9 SUMMARY A CIA is an agreement between the OIG and a health care provider as part of a settlement of a Federal health care program investigation. Our settlement was related to allegations of improper billing for ambulance transportation at JMCGH and geriatric-psychiatric services at MGH. The CIA requires WTH to have a Compliance Officer, a Compliance Committee, written standards of conduct, a comprehensive training program, and mandatory reporting. WTH must engage an outside auditor to perform claims reviews and cost report reviews. WTH must submit regular reports to the OIG regarding our compliance activities including information on the individuals who were trained and an explanation of any exceptions.

10 West Tennessee Healthcare Code of Conduct The WTH Code of Conduct is a guide for the conduct expected of WTH employees while carrying out their daily activities within the appropriate ethical and legal standards Approved by the WTH Board of Trustees in Applies to all members of the WTH Workforce including officers, trustees, employees, physicians, contractors, and agents.

11 WTH Code of Conduct STANDARDS OF CONDUCT 1. Treatment of Patients Our mission is to provide high quality, compassionate health care to all of our patients. You are expected to treat all patients with dignity, respect, and courtesy, and to provide care that is safe, necessary, and appropriate. You are to comply with applicable rules, regulations, and policies. These include requirements that you: Not discriminate in the admission, transfer or discharge of patients or in the care we provide based on race, color, religion, sexual orientation, or national origin. Involve patients in all aspects of their care and obtain informed consent as required. Ensure the accuracy of all clinical documentation. In any circumstance where you have a question about whether the quality or patient safety commitments are being fully met, you are obligated to raise this concern through appropriate channels until it is satisfactorily addressed and resolved.

12 WTH Code of Conduct STANDARDS OF CONDUCT 2. Accreditation and Surveys WTH workforce members must deal with all accrediting and external agency survey bodies in a direct, open, and honest manner. In preparation for or during a survey or inspection, WTH colleagues must never conceal, destroy, or alter any documents, lie, or make misleading statements to the agency representative. WTH colleagues must never attempt to cause another colleague to fail to provide accurate information or obstruct, mislead, or delay the communication of information or records relating to a possible violation of law.

13 WTH Code of Conduct STANDARDS OF CONDUCT 3. Financial Relationships and Business Courtesies WTH employees must comply with laws that restrict giving anything of value to physicians or accepting anything of value from vendors, designed to influence referrals or purchases. You should not give or offer to give anything of value to induce the referral of patients or federal health care program business. Any entertainment or gift involving referral sources must be in accordance with the Business Courtesies Policy, MGB You may never solicit a gift or accept cash or cash equivalents.

14 WTH Code of Conduct STANDARDS OF CONDUCT 4. Federal Health Care Program Billing Requirements WTH workforce members must prepare and submit bills that are truthful, accurate, and complete and that comply with Federal health care program or private payer requirements. WTH workforce members must include truthful and complete information in medical records to promote accurate billings. Workforce members or agents of WTH may not knowingly present or cause to be presented claims which are false, fictitious, or fraudulent. All clinical and administrative staff are expected to be knowledgeable about billing requirements applicable to their particular departments. Areas in which staff should be knowledgeable include coverage, medical necessity for standards for billing, accurate coding of diagnoses and procedures, and documentation requirements. If you have a question about appropriate documentation or procedures, you are expected to ask your department director or other appropriate individual.

15 WTH Code of Conduct STANDARDS OF CONDUCT 5. Accuracy of Documentation WTH workforce members must prepare accurate documents and records and retain them in accordance with WTH policy. Each WTH workforce member is responsible to ensure that records are available to defend our business practices and actions. No one may alter or falsify information on any record or document. Medical and business documents must be retained in accordance with law and our Record Retention Policy, MGB Never tamper with records or remove or destroy them prior to the specified date in the Record Retention Policy.

16 WTH Code of Conduct STANDARDS OF CONDUCT 6. Confidentiality of WTH Business Information WTH workforce members are expected to keep our patients protected health information and WTH business information confidential. Each workforce member is responsible for maintaining the privacy and security of our patient s protected health information in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Workforce members will ONLY access patient information that is necessary for their job responsibilities. Confidential information must never be shared with others outside WTH or your department unless the individuals have a legitimate need to know this information and have agreed to maintain the confidentiality of the information.

17 WTH Code of Conduct STANDARDS OF CONDUCT 7. Electronic Media and Security Requirements WTH workforce members are expected to use all communication systems, including but not limited to computers, electronic mail, Intranet, Internet access, telephones, and voice mail, primarily for business purposes and in accordance with WTH policies and procedures. All communications systems are the property of the organization; users should assume that these communications are not private. WTH workforce members may not use internal communication channels or access to the Internet at work to view, post, store, transmit, download, or distribute any threatening materials, knowingly, recklessly, or maliciously false materials, obscene materials, or anything constituting or encouraging a criminal offense, giving rise to civil liability, or otherwise violating any laws. Only assigned user IDs shall be used and should not be shared. Portable devices and removable media, such as laptops, USB drives, CDs and external hard drives should be secured at all times. These devices may require encryption in accordance with WTH policy if protected health information is permitted and present on the device.

18 WTH Code of Conduct STANDARDS OF CONDUCT 8. Conflicts of Interest A conflict of interest may occur if your outside activities or personal interests influence or appear to influence your ability to make objective decisions in the course of your job responsibilities. It is your responsibility to ensure that you remain free of conflicts in the performance of your responsibilities at WTH. If you have any question about whether an outside activity might constitute a conflict of interest, you must obtain approval from your supervisor. See the Conflict of Interest Policy, MGB 7175.

19 WTH Code of Conduct STANDARDS OF CONDUCT 9. Controlled Substances You must ensure the proper handling of controlled substances and medical supplies. Some of the substances in the organization are governed and monitored by regulatory organizations and must be administered by physician order only. These items are to be handled properly and only by authorized individuals to minimize risks to WTH and to patients. If you become aware of the diversion of drugs from the organization, you should report the incident immediately. 10. Diversity and Equal Employment Opportunity You must comply with all laws, rules, and regulations relating to non-discrimination in all personnel actions. WTH is committed to providing an equal opportunity work environment where everyone is treated with dignity, respect, and courtesy.

20 WTH Code of Conduct STANDARDS OF CONDUCT 11. Harassment and Inappropriate or Disruptive Behavior Appropriate behavior toward co-workers and patients is defined in our Quality PLUS Principles, which emphasize love and respect for all people. Workforce members have the right to work in an environment free from all forms of discrimination and conduct which can be considered harassing, coercive, or disruptive. We do not tolerate harassment by anyone based on race, color, creed, sex, religion, national origin, sexual orientation, citizenship status, age, or disability. Any form of sexual harassment, including sexual advances, requests for sexual favors, unwelcome or offensive touching, and other verbal, graphic, or physical conduct of a sexual nature, is strictly prohibited. Harassment also includes incidents of workplace violence. If you witness inappropriate behavior, it should be reported to your supervisor, Human Resources, the Medical Affairs office, or the Compliance Office.

21 WTH Code of Conduct STANDARDS OF CONDUCT 12. Health and Safety You are expected to comply with laws, rules, regulations, and policies to promote a safe workplace. Our policies have been developed to protect you from potential workplace hazards. It is important for you to notify your supervisor of any workplace injury or any situation presenting a danger of injury so that timely corrective action may be taken to resolve the issue. 13. Relationships with Subcontractors and Suppliers You should select subcontractors and suppliers in a fair and reasonable manner. Our selection of subcontractors, suppliers, and vendors is made on the basis of objective criteria including quality, technical excellence, price, delivery, adherence to schedules, service, and maintenance of adequate sources of supply. We do not communicate to a third party confidential information given to us by our suppliers. We do not disclose contract pricing and information to any outside parties.

22 WTH Code of Conduct STANDARDS OF CONDUCT 14. Substance Abuse and Mental Acuity You are required to report to work free of the influence of alcohol and illegal drugs. Reporting to work under the influence of any illegal drug or alcohol; having an illegal drug in your system; or using, possessing, or selling illegal drugs during working hours or while on WTH property may result in immediate termination. We may use drug testing as a means of enforcing this policy. If you have questions about prescription medications you may be taking, consult with your supervisor or Employee Health.

23 WTH Code of Conduct STANDARDS OF CONDUCT 15. Ineligible Persons WTH does not contract with, employ, or bill Federal health care programs for services rendered by ineligible persons. Ineligible persons are individuals or entities that are excluded or ineligible to participate in Federal health care programs; suspended or debarred from Federal government contracts; or that have been convicted or a criminal offense related to the provision of healthcare items or services. WTH routinely searches the Office of Inspector General s and General Services Administration s lists for such excluded and ineligible persons. If you become an ineligible person, you are required to report this information to WTH immediately.

24 WTH Code of Conduct STANDARDS OF CONDUCT 16. License and Certification Renewals WTH does not allow any workforce member, independent contractor, or privileged practitioner to work without valid, current licenses or credentials. WTH workforce members, independent contractors, and privileged practitioners in positions which require professional licenses, certifications, or other credentials are responsible for maintaining the current status of their credentials and shall comply at all times with federal and state requirements applicable to their respective disciplines. Each workforce member, contractor, or practitioner must have evidence of current and valid licensure, certification, registration, accreditation, or credential as required by their position description. WTH may require evidence of current licensure or credential status.

25 WTH Code of Conduct STANDARDS OF CONDUCT 17. Research, Investigations, and Clinical Trials WTH facilities follow the highest ethical standards in full compliance with federal and state laws and regulations in any research, investigations, and/or clinical trials conducted by our physicians and professional staff. Our facilities first priority is always to protect the patients and human subjects and respect their rights during research, investigations, and clinical trials. Refusal of a potential subject to participate in a research study or the voluntary withdrawal of his or her participation in an existing study will not compromise his or her access to other services to which he or she is otherwise entitled. A patient s voluntary informed consent to participate in a clinical trial is documented and retained in accordance with WTH policies. Any WTH facility or colleague engaging in human subject research must do so in conjunction with IRB approval, if applicable at that facility, and must be consistent with WTH policies and procedures.

26 WTH Code of Conduct STANDARDS OF CONDUCT 18. Environmental Compliance WTH workforce members must understand how job duties may impact the environment, adhere to all requirements for the proper handling of hazardous materials, and immediately alert supervisors to any situation regarding the discharge of a hazardous substance, improper disposal of hazardous and medical waste, or any situation which may be potentially damaging to the environment. 19. Government Relations and Political Activities WTH workforce members must comply with all federal, state, and local laws governing participation in government relations and political activities. No use of corporate resources, including , is appropriate for personally engaging in political activity. A colleague may participate in the political process on his or her own time and at his or her own expense but must never give the impression that they are speaking on behalf of or representing WTH in these activities. Colleagues cannot seek reimbursement for any personal contributions.

27 WTH Code of Conduct COMPLIANCE PROGRAM RESOURCES Each WTH workforce member has an individual responsibility for reporting any activity that appears to violate applicable laws, rules, regulations, including suspected violations of any Federal health care program requirements, and WTH policies and procedures. Employees who fail to report violations may be subject to disciplinary action. We encourage employees to follow the chain of command in reporting issues; however, if this is uncomfortable or inappropriate, another option is to discuss the situation with another member of management or the Compliance Office. WTH has available and encourages the use of, the telephone Compliance Hotline ( INFORM or ) and a website located at these systems were established for reporting suspected violations. You may report anonymously and your issue will be investigated. We have mechanisms in place to communicate with you anonymously and to let you know the results of the investigation. There is no retaliation for reporting a possible violation in good faith. See the Compliance Issue Reporting Policy, MGB 7160, for more information.

28 WTH Code of Conduct SUMMARY 1. Act in Accordance with Published Standards. These include the Code of Conduct, WTH policies and procedures, and federal and state regulations, including Federal health care program requirements. 2. Uphold the Highest Standards of Ethics and Integrity. We expect you to set the ethical tone for the organization. 3. Learn the Standards that Apply. Familiarize yourself with the rules and standards that apply to your department. 4. Report and Detect Wrongdoing. We expect you to report violations of the Code and Federal health care program requirements, and we provide mechanisms for you to do so anonymously. You have a duty to detect conduct that is unlawful and WTH prohibits retaliation against those who make a good faith report. 5. Governmental enforcement. If you fail to comply with Federal health care program or other legal requirements, you may be subject to enforcement action by the government. The precise nature of such enforcement action will depend on the violation at issue but may include financial penalties, repayments to Federal health care programs, imprisonment, exclusion from participating in Federal health care programs, disciplinary actions by medical licensing agencies, or other actions. 6. Discipline by WTH. Employees who fail to meet these obligations may also face disciplinary action up to and including termination. 7. Evaluations. WTH evaluates every employee s conformance to the Code of Conduct and the Ethics and Compliance Program. That evaluation is reflected in the employee s annual performance evaluation.

29 West Tennessee Healthcare Ethics and Compliance Program This program was established in recognition of WTH s responsibility to our patients, staff, physicians, other healthcare providers, payers, and the community we serve. The purpose of this program is to discourage and prevent fraud, abuse, and unethical behavior in our health care organization, to stop such behavior, and to prevent the reoccurrence of such violations. Ethics and Compliance is one of the WTH System Goals along with High Quality Healthcare, Compassionate Customer Service, Financial Strength, Employee Satisfaction, and Community Value.

30 WTH Ethics and Compliance Program BENEFITS Reduction in negative publicity Reduction in fines and external audits Helps to deter fraud and abuse within the organization Helps to improve operational guidelines Demonstrates that the organization wants to be a good community partner Change in organizational culture Know you are doing things right PENALTIES FOR NON-COMPLIANCE Negative Publicity Civil Monetary Penalties Damages Exclusion from Federal health care programs Imprisonment

31 WTH Ethics and Compliance Program PENALTIES FOR VIOLATIONS Federal False Claims Act: The federal False Claims Act prohibits knowingly submitting (or causing to be submitted) to the federal government a false or fraudulent claim for payment or approval. It also prohibits knowingly making or using (or causing to be made or used) a false record or statement to get a false or fraudulent claim paid or approved by a state Medicaid program, the federal government, or its agents, such as a carrier or other claims processor. Civil penalties can be $5,500 to $11,000 per claim plus up to three times the government s damages. Tennessee Medicaid False Claims Act: The TN Medicaid False Claims Act prohibits knowingly submitting (or causing to be submitted) to the state a false or fraudulent claim for payment under the Medicaid program (Tenncare). Civil penalties can be $5,000 to $25,000 per claim plus up to three times the state s damages.

32 WTH Ethics and Compliance Program PROTECTIONS Employees of WTH and others working for or on behalf of WTH must report potential violations of law. WTH prohibits retribution or retaliation against anyone who reports a suspected violation in good faith. The federal False Claims Act and the Tennessee Medicaid False Claims Act also prohibit retaliation against an employee who investigates, files, or participates in an action relating to the potential submission of false claims.

33 Standards and procedures Oversight WTH Ethics and Compliance Program ELEMENTS OF OUR PROGRAM Reporting: Compliance Hotline ( INFORM), direct call to Compliance Office, or visit the website at Education and training Monitoring and auditing Response and prevention Enforcement and discipline Risk assessment

34 WTH Ethics and Compliance Program COMPLIANCE ISSUE REPORTING One of the most important elements of our WTH Ethics and Compliance Program is the ability for you to report concerns anonymously without fear of retaliation. We have many reporting methods you can choose from: Report to your supervisor Report to another level of management following the chain of command Report directly to the Compliance Office by calling or ing Report anonymously using the Compliance Hotline Report anonymously using the website at The Compliance Hotline number is INFORM ( ) Your call will be answered by an individual 24 hours per day, 7 days per week, 365 days per year. You will be asked a series of questions by the Hotline service rep, but you do not have to provide your name if you choose to remain anonymous. You will be assigned an issue number and will be able to call back in order to receive information from the individual investigating your report or to receive updates on the resolution of your issue.

35 WTH Ethics and Compliance Program WEB-BASED REPORTING You may also visit our new website to report an issue. Go to

36 WTH Ethics and Compliance Program WEB-BASED REPORTING Click Submit a New Report

37 WTH Ethics and Compliance Program WEB-BASED REPORTING Read the list of issue types and choose the primary issue type for the issue you want to report by clicking on that category.

38 WTH Ethics and Compliance Program WEB-BASED REPORTING Complete the fields in Red. If you do not feel comfortable providing your name, click the box that says I do not wish to provide my name.

39 WTH Ethics and Compliance Program WEB-BASED REPORTING Once you have completed the information, click Submit Report at the bottom of your screen.

40 WTH Ethics and Compliance Program WEB-BASED REPORTING You will be assigned a report number and you will have your own PIN number that will enable you to return to the website to receive updates on the status of your report. Simply go back to and click on Follow Up on an Existing Report.

41 WTH Ethics and Compliance Program POLICIES AND PROCEDURES All WTH Compliance Policies and Procedures are located in the Management Guidebook on the WTH Intranet. Additionally, you will find detailed policy information in the remaining Ethics and Compliance Training lessons in the WTH Online Education System which have been assigned to you. These written policies include the following: WTH Code of Conduct Billing and Coding Compliance Compliance Issue Reporting Compliance and Ethics Program Discipline Policy Governmental Investigations Non Retaliation Policy Notification Regarding Certain Investigations or Legal Proceedings Reportable Events Civil Rights/Nondiscrimination

42 WTH Ethics and Compliance Program Compliance Office Contacts WTH Vice President/Compliance Officer Amy Griffin Office Location: JMCGH Administration 620 Skyline Drive Jackson, TN Phone: Fax:

43 WTH Ethics and Compliance Program Compliance Office Contact Information Location: WTH Building, 1804 Hwy 45 Bypass, Suite 502, Jackson, TN Phone: Fax: Administrative Secretary WTH Privacy Coordinator Mariette Lauze Julie Shoaf, MBA, CHP Phone: Phone: Billing Compliance Analyst/RAC Coordinator Compliance Auditor Patricia Puckett, EJD, RHIA, CHC, CCP Lorraine Kail, RN Phone: Phone: Compliance Auditor Safety Engineer Dianne Wilkinson, RHIT Shane Ashby, JD, CSP Phone: Phone: MedSouth Medical Center Jackson-Madison County General Hospital

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