1 Corporate Integrity Department 2016 Volunteer Services Compliance Training
2 CoxHealth is: An organization rich in traditions, history and integrity An organization whose mission is to improve health of the communities we serve An organization that recognizes it is only as good as its Board, employees, medical staff, volunteers and the companies that we select to do business with Therefore we select those individuals and companies carefully And train everyone annually on the importance of compliance and the culture at CoxHealth
3 Let s start out with meeting your President and Chief Executive Officer and Corporate Compliance Officer
4 Meet Steven D. Edwards, your President & CEO for CoxHealth Meet Betty Breshears, VP & Corporate Compliance Officer for CoxHealth We are proud of our long tradition and commitment to quality care. Our success is a testimony to the dedication of our employees, medical staff, volunteers and board members to improve the lives of others.
5 Why is Compliance training important at CoxHealth? It is important to advise employees of the Federal and State Laws and Regulations that govern practices at CoxHealth you can not follow the rules if you do not understand the rules.
6 Why is Compliance Important at CoxHealth? In Order To : Meet the federal and state regulations that govern healthcare practices Prevent fraud, waste and abuse Detect, correct and prevent errors that might result in a violation
7 Compliance and all related policies apply to Everyone doing business with CoxHealth Physicians All Staff Volunteers Vendors Contractors Board
8 How does CoxHealth address compliance with all the rules and regulations?
9 Through its employees, medical staff members, board members, volunteers and vendors all of you are working diligently every day to do the right thing in your work, in how you conduct yourselves and in your working relationships. Thank you!
10 CoxHealth has two core policies that make up the compliance program Corporate Compliance Program: Structure of compliance administered by the Corporate Integrity Department to prevent and correct errors in health care Code of Business Conduct and Ethics: Defines work rules and behaviors for those who work at CoxHealth
11 Code of Business Conduct and Ethics
12 CoxHealth Code of Business Conduct and Ethics Addresses CoxHealth s expected behaviors for employees, volunteers, medical staff members, students and Board Members. Conduct business practices in compliance with all applicable laws and regulations Conduct yourself with Compassion, Respect and Integrity Set an example for others by modeling these behaviors and standards at all times
13 CoxHealth Code of Business Conduct and Ethics The policy covers many of CoxHealth s business practices and standards, this training will list a few of those business practices Please review the policy when you complete the Code of Conduct certification portion of this training
14 CoxHealth Code of Business Conduct and Ethics Access to care: Patients have access to medically necessary care regardless of race, color, religion, sex, ethnic origin, age, disability, financial status, source of payment or ability to pay All company records shall be accurate: For example: - Patient medical records - Financial-accounting records - Human Resource Records - Patient Registration Records
15 CoxHealth Code of Business Conduct and Ethics Maintain Safe Work Environment At CoxHealth we strive to adhere to OSHA standards Staff are trained on how to properly dispose of medical waste and hazardous materials Appropriate Billing, Charging & Coding for services Accurate documentation for services provided Medically unnecessary services shall NOT be provided and/or billed. To do so would be considered a false claim.
16 CoxHealth Code of Business Conduct and Ethics Compliance with Antitrust Laws: Sharing of price, cost or profit information with competitors or from one vendor to another is inappropriate. Confidentiality: We must maintain the confidentiality of all patient records and other company documents. Gifting from Patients: It is inappropriate for employees to accept a personal gift from a patient
17 CoxHealth Code of Business Conduct and Ethics Protect CoxHealth Corporate Assets: Do not use for personal use, unlawful purposes Unbiased decision making At CoxHealth we do not accept or solicit gifts, bribes, kickbacks, gratuity or other forms of payments to influence a business decision Political Activity & Contributions CoxHealth encourages all employees to vote and be active in politics if they so choose; however, the activity must be on personal time Be sure not to hang political signs/pictures in your workspace or discuss candidates during work time
18 CoxHealth Code of Business Conduct and Ethics Conflict of Interest Policies Using your position to: Get a personal benefit Refer a service to a relative, or Receive payment, gift or improper entertainment in exchange for a contract, or purchase from CoxHealth is inappropriate
19 CoxHealth Code of Business Conduct and Ethics Clear and Honest Marketing: All marketing and advertising is intended to be truthful so as not to mislead. All use of CoxHealth logos and advertisements must be approved by the Marketing and Planning Department. Cooperation with Government Officials: CoxHealth will fully cooperate with regulatory officials.
20 CoxHealth Code of Business Conduct and Ethics Harassment/Discrimination and Disruptive Behavior Are all prohibited at CoxHealth and should be immediately reported Harassment can be in the form of: Creating an uncomfortable work environment Heckling or bullying a co-worker Inappropriate sexual comments Discrimination can be: Based on race, color, religion, sex, ethnic origin, age, disability or financial status is prohibited Hiring practices, promotions or delivery of healthcare For additional information please see the full policy on the intraweb
21 CoxHealth Code of Business Conduct and Ethics Disruptive Behavior interferes with patient care Staff generally will not report concerns if they re afraid of getting yelled at or made to feel their question is inappropriate Affects overall employee morale Causes high staff turnover Undermines productivity
22 CoxHealth Code of Business Conduct and Ethics Report disruptive behavior when someone is Criticizing caregivers in front of a patient Belittling or berating others Use of profanity or disrespectful language Racial, ethnic or socioeconomic slurs Raising your voice or yelling or shouting in a hostile manner
23 CoxHealth Code of Business Conduct and Ethics Patient Rights: Patients have the right to considerate care that protects their dignity and privacy. The patient s right to choose, be involved in their care, practice their religion and beliefs will be respected. Ethical Concerns: The Corporate Integrity Department coordinates ethical reviews (patient and business issues)
24 CoxHealth Code of Business Conduct and Ethics A work environment free from retaliation: Retaliation against any person who reports a in good faith, is strictly prohibited. If anyone believes they have been or are being, retaliated against they should immediately contact the Corporate Integrity Department at or the Legal Department at
25 CoxHealth Code of Business Conduct and Ethics Violations of the Code of Business Conduct and Ethics Will Result in Disciplinary Action The standards contained in the Code of Conduct are important, and therefore any violation will subject the offender to some form of discipline.
26 Your actions and work ethic have created the excellent reputation CoxHealth enjoys in this community. Help us maintain that reputation by always doing the right thing!
27 Corporate Compliance Program
28 Corporate Compliance Program The Purpose of the Compliance Program: Establish a mechanism to detect, correct and prevent errors which could result in violations of the CoxHealth policies or of a federal and state law or regulation governing health care
29 Corporate Compliance Program The Compliance Programs is governed by the following policies: Corporate Compliance Program The seven requirements of a Compliance Program Code of Business Conduct and Ethics Which includes HIPAA, Privacy and Security Prohibition of False Claims Detection of Individuals and Entities Listed for Exclusion
30 The Office of Inspector General recommends 7 core requirements for an effective Compliance Program These 7 requirements are part of the CoxHealth Corporate Compliance Program
31 OIG requirements Designate a Corporate Compliance Officer and have a structure for compliance Your System Corporate Compliance Officer is Betty Breshears who develops, implements and monitors the compliance program and appoints compliance managers for the entities Betty also serves as the compliance officer for HPS, Home Support, Oxford and Cox HealthPlans Betty can be reached at or at
32 OIG requirements Designate a Corporate Compliance Officer and have a structure for compliance The Structure for CoxHealth is the Corporate Integrity Department and Compliance Committees. The Corporate Integrity Department includes: Betty Breshears, Compliance Officer Abby Welytok, Assistant Compliance Officer Angela Hoffman, Compliance Manager Cortney Freeman, Compliance Manager Dawn Frank, HIPAA Privacy and Security Officer
33 OIG requirements Designate a Corporate Compliance Officer and have a structure for compliance The Committees are: Board of Directors Compliance Committee Executive Compliance Committee CMS Newsletter and Billing Compliance Committee Home Support/HPS Compliance Committee Oxford Compliance Committee Contract Compliance Committee CoxHealth Branson Compliance Committee CoxHealth Monett Compliance Committee HIPAA Compliance Committee
34 OIG requirements - Establish Open Lines of Communication How does CoxHealth meet this element? By establishing a Hotline for reporting suspected concerns without fear of retaliation By keeping the calls confidential you DO NOT have to leave your name By educating staff they can report to anyone in management, speak directly to the Corporate Compliance Department or the Legal Department HOTLINE: (COX-LAWS) Toll free: Your call can be anonymous
35 OIG requirements- Provide Education and Training How does CoxHealth meet this element? Compliance training is provided to all new employees, volunteers, medical staff and board members. Annual compliance training is provided to the same groups
36 OIG requirements- Conduct Internal Audit and Monitoring How does CoxHealth meet this element? Develop an annual audit plan Conduct risk assessments of current practices at CoxHealth Conduct audits on billing, coding and documentation to ensure compliance with the Medicare and Medicaid regulations and other applicable laws Conduct audits as part of an investigation Departments monitor practices for compliance such as: HIM monitors coding HR monitors the exclusion list Each department monitors billing for their area
37 OIG requirements- Establish a Disciplinary Action Plan For Non- Compliance Policies state that members of CoxHealth will be disciplined for: Not attending annual training Not reporting a known concern Retaliation against others who report an issue in good faith is prohibited.
38 OIG requirements- Investigate & Resolve Issues of Concern & Make Refunds As Appropriate How does CoxHealth meet this element? Each compliance concern is investigated thoroughly and a file is opened Identity of the person reporting the concern is NOT disclosed Data is evaluated and interviews are conducted as appropriate Resolution is determined and implemented Written report is placed in the file with back-up documentation Corrective action is taken if necessary as follows: Self-reporting and refunding a government agency Disciplining staff Modifying policies/procedures Providing education Follow-up to ensure correction and compliance continues
39 OIG requirements- Investigate & Resolve Issues of Concern & Make Refunds As Appropriate Investigations undertaken are often coordinated with other departments Human Resources Guest Services Patient Financial Services Health Information Management Legal Department Audit and Compliance
40 OIG requirements- Establish Policies for a Corporate Compliance Program How does CoxHealth meet this element? By developing the following policies which are available on the intranet. These policies are reviewed annually and updated as needed. Corporate Compliance Program Code of Business Conduct and Ethics Prohibition of False Claims Law Compliance with Stark & Anti-Kickback Statute Detection of Individuals and Entities Excluded from Government Programs l Program policies are available on the intranet
41 Another policy that addresses State and Federal Fraud and Abuse is Prohibition of False Claims Policy
42 Prohibition of False Claims This policy defines the Federal False Claims Act, the State False Claims Act, Whistleblower Provisions and Protections Against Retaliation.
43 Prohibition of False Claims State/Federal imposes a civil liability on any person who knowingly submits, or causes to be submitted a false or fraudulent claim A provider who violates the False Claims Act may be fined: Federal - $11,000 per false claim Up to triple damages for the billed amount State - $5,000 $10,000; plus 3 times amount of damages
44 Prohibition of False Claims Whistleblower A suit brought by an individual on behalf of the United States government is called a qui tam action. A qui tam relator, often referred to as a whistleblower is someone who has first hand knowledge of an issue and reports that to the government. Generally, the issue is a suspected violation of a law, rule, regulation and/or a direct threat to public interest fraud, health, safety violations and corruption are just a few examples
45 False Claims Act Environment Free From Retaliation Retaliation is an act designed to cause harm, get even, or get back at another person Retaliation against any person who reports a concern to the Corporate Integrity Department, in good faith, is strictly prohibited Report any concerns you might have with retaliation to the Corporate Integrity Department, anyone in management or call the hotline at
46 Detection of Individuals and Entities Listed for Exclusion Policy This policy requires CoxHealth to verify that all employees, medical staff members, board members and vendors doing business with CoxHealth have not been excluded from participation in Government Programs.
47 Congratulations! You have completed your 2016 Volunteer Services Compliance Training Remember it is everyone s responsibility to report concerns about a violation of a State, Federal or CoxHealth policy. Thank you for all you do for CoxHealth and our patients