Prepared by: The Office of Corporate Compliance & HIPAA Administration

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1 Gwinnett Health System s Annual Education 2014 Corporate Compliance: Our Commitment to Excellence Prepared by: The Office of Corporate Compliance & HIPAA Administration

2 Objectives After completing this Computer-Based Learning (CBL) module, you should be able to: Define compliance. Describe the GHS Code of Conduct and Associate Handbook, including: The topics they cover, and Where to obtain a copy of each. Define the role of the Office of Corporate Compliance & HIPAA Administration. List examples of ethical behavior. Describe how the Fraud, Waste, and Abuse Laws apply at GHS. List associate responsibilities for compliance. List the ways to report any concern. Describe the GHS nonretaliation policy and your rights and protection.

3 Compliance Education Compliance education is required for: All newly hired associates during general orientation, All associates annually, and Associates in some areas that require additional education depending on their role at GHS.

4 What is Compliance? Compliance in the workplace means following the rules, regulations, and laws set forth by the government and GHS policies and procedures. Compliance is being ethical and honest in everything you do. Examples include: Obeying the law. Following GHS policies and procedures. Responding appropriately when you discover errors. Timely reporting when you have concerns. Understanding the constant changes in healthcare: Rules and regulations. Coding and billing. Payments or reimbursement. Medicare and Medicaid Coverage rules.

5 Corporate Compliance Program The Corporate Compliance Program is how we promote and monitor compliance at GHS. The program includes the seven elements of an effective compliance program defined by the U.S. Federal Sentencing Guidelines. The seven elements were developed to assist organizations in creating a Compliant Environment.

6 The Seven Elements 1. Designation of a Chief Compliance Officer/Compliance Committee/Compliance Program. 2. Develop written standards of conduct and policies and procedures. 3. Provide regular compliance training and education for all associates. 4. Have effective and open lines of communication to receive anonymous complaints and to allow complaints from associates without fear of retaliation, such as a hotline. 5. Auditing and monitoring to identify potential problem areas. 6. Prevention and process improvement to remedy any opportunities found within the system that have the potential to lead to a violation. 7. Enforcement and disciplinary actions to respond to allegations of wrongdoing and to enforce disciplinary action against those who have violated the Code of Conduct and GHS polices and procedures.

7 Compliance Resources Compliance resources: GHS Code of Conduct GHS Associate Handbook GHS policies and procedures The GHS Corporate Compliance Program, Policy # Annual compliance education Corporate Compliance intranet web site Compliance Hotline: Directly contact the Compliance Office

8 GHS Code of Conduct Our Code of Conduct is GHS s written commitment to compliance. It covers a variety of topics, including: Referral relationships. Vendor relationships. Conflicts of interest. Billing and coding. Reporting compliance concerns. Workplace conduct. Patient quality of care. Patient and associate safety. Confidentiality.

9 GHS Associate Handbook Our Associate Handbook: Is a companion resource to the Code of Conduct. Explains how GHS complies with employment-related laws and regulations. Provides guidance about GHS: Human Resources policies and procedures. Employment, benefits, and pay practices. Expectations for proper workplace conduct. ASSOCIATE HANDBOOK Revision Date: June 2007 February 2008

10 GwinnettWork Resources The GHS Code of Conduct and the Associate Handbook are available on GwinnettWork under Associate Resources. 1. Click on Associate Resources from the menu on the left. 2. Click on Code of Conduct or Associate Handbook from the Associate Resources menu link to access these resources.

11 GHS Policies and Procedures Know and understand the policies and procedures in your area. Ask when you aren t sure of the correct way to do something, or if something doesn t seem right. GHS policies and procedures are available on GwinnettWork. 1. Go to the menu tabs at the top of the GwinnettWork page and click on policies. 2. Find the policy by a keyword search or by policy number. 11

12 Intranet Compliance Web Site Compliance resources and Compliance team member contacts are also available on the Corporate Compliance intranet web site. The Corporate Compliance intranet web site is available on GwinnettWork. To access it: Go to the menu tabs at the top of the GwinnettWork page and click on departments/teams. Then, scroll down and click on Corporate Compliance. Or, use the following intranet web address: atecompliance/default.aspx

13 The Value of Participation You are the key to a successful compliance program. Help make GHS stronger by: Participating in: Policy development. Department meetings. Town hall meetings. Other opportunities to learn about our healthcare system. Your professional association. Communicating effectively and professionally with management, physicians, and co-workers. Asking questions! Remember: You are the key to our success!

14 Have a Concern? Any associate can report a concern. Managers typically offer the best and quickest response to situations. If you are not comfortable talking to your manager, or feel a concern is not being addressed, contact: The Office of Corporate Compliance & HIPAA Administration, or The associate relations director in Human Resources. You can report any concern at any time to the Compliance Hotline at

15 The Compliance Hotline The Compliance Hotline is a toll-free number operated by an outside vendor, not by GHS associates. You can call any time, from anywhere. You do not have to say who you are. The call is not recorded. The hotline provides you with a report number and a PIN number. You can use these numbers to follow up and get additional information. The Office of Corporate Compliance & HIPAA Administration investigates all issues and responds to the caller via the outside vendor.

16 GHS Non-Retaliation Policy GHS has a strict non-retaliation policy for any associate who reports a problem. You will not be fired or sanctioned in any way for reporting a concern in good faith, even if it turns out there isn t a problem. However, you cannot avoid discipline by reporting an incident in which you are involved. You will not be fired or sanctioned for reporting an unresolved quality of care concern to: The Joint Commission (JC), Centers for Medicare and Medicaid Services (CMS), or A state agency. Retaliation is not tolerated and subject to discipline up to and including termination.

17 Additional Reporting Options If a concern has not been resolved internally through internal reporting options, the Compliance Hotline, and/or the chief compliance officer you can also report a concern to: The Joint Commission (JC), Centers for Medicare and Medicaid Services (CMS), and Government enforcement entities: The Office of Inspector General (OIG) of the Department of Health and Human Services, Department of Justice (DOJ).

18 Reporting Quality Concerns You may report internal quality or safety concerns to your manager, and to other departments, by using any of the following tools as appropriate: Patient/Visitor Variance Report, Form # 1836 report of unusual or unexpected patient or visitor event or patient care concerns. Medication Error Information Form # report of actual or potential medication variance. Fall Variance Report, Form # report of actual or potential patient fall. OHNO! report of associate illness or injury. Hazard Tracker Report Form # report environmental safety concerns.

19 Fraud, Waste, and Abuse Laws Fraud, Waste, and Abuse (FWA) Laws include the: False Claims Act, Anti-Kickback Statute, Physician Self Referral Statute, Exclusion Statute, and Civil Monetary Penalties Law. The government requires FWA training for all new associates and FWA training for all associates on an annual basis.

20 Fraud, Waste, Abuse, cont d Fraud Healthcare fraud refers to receiving or obtaining a benefit by an intentional misrepresentation or concealment of material facts. Waste Waste includes incurring unnecessary costs as a result of deficient management, practices, or internal controls. Abuse Abuse is similar to fraud but there is no evidence that the act was intentional. Abuse includes excessive or improper use of government resources.

21 Examples of Fraud Billing for services or supplies not furnished. Duplicate billing: Billing for services already covered by another claim. Unbundling: Billing separately for services that should be a single service. Billing for services not supported by documentation in the medical record. Falsely reporting diagnoses or procedures to maximize or increase payment. Falsifying information on records. Offering or accepting bribes, payment or incentives in exchange for healthcare referrals.

22 Examples of Abuse Providing services that are not medically necessary. Providing services that do not meet professionally recognized standards. Providing services that are not fairly priced.

23 False Claims Act Prohibits the submission of false or fraudulent claims for payment to Medicare and Medicaid. Fines for False Claims Act violations can be up to three times the program s loss, plus $11,000 per claim. You can be punished if you act with deliberate ignorance or reckless disregard of the truth. This means you cannot hide your head in the sand and avoid liability.

24 Anti-Kickback Statute Prohibits asking for, offering, or receiving anything of value in exchange for referrals of federal healthcare program business. The Anti-Kickback Statute applies to both payers and recipients of kickbacks. Just asking for or offering a kickback could violate the law. A kickback can be anything of value, not just cash! As a GHS associate, you may not ask for, offer or take anything of value in exchange for patient referrals.

25 Anti-Kickback Statute, cont d GHS does not pay or offer to pay anyone for patient referrals. This includes: Colleagues, Colleagues include GHS officers, associates, medical and affiliated staff, volunteers, vendors, agents, and anyone else affiliated with GHS or those with whom you have professional contact. Physicians, and Other persons or entities.

26 Physician Self-Referral Statute The Physician Self-Referral Statute is sometimes called the Stark Law. Stark prohibits physicians from referring Medicare or Medicaid patients to entities for designated health services where they have a financial relationship, unless an exception applies. Financial relationships covered by this law include ownership/investment interests, as well as compensation relationships. This law applies to physician financial relationships and those of their immediate family members.

27 Exclusion Statute Under the Exclusion Authorities, individuals and entities can be excluded from participation in the federal healthcare programs. Some refer to exclusions as a financial death sentence because excluded persons and entities may not receive payment for treating any Medicare and Medicaid beneficiaries. GHS conducts routine exclusion checks. GHS does not employ, grant or renew privileges to, or contract with, any individual or entity who is under sanction or excluded from participation in federal healthcare programs.

28 Civil Monetary Penalties Law Penalties range from $10,000 to $50,000 per violation. The government may seek civil monetary penalties for a wide variety of fraudulent and abusive conduct in addition to: Exclusion from the Medicare and Medicaid program, Criminal conviction, and Jail time.

29 Whistleblower Provisions State and federal governments permit private citizens to file lawsuits on behalf of the government when fraud is suspected. This is the qui tam or whistleblower provision. GHS does not retaliate against any associate who files a qui tam action or other lawful acts such as assisting in a False Claims Act investigation. GHS encourages associates to report suspected fraud internally so that we can investigate and immediately correct any problems.

30 Laws and Regulations GHS has policies and procedures in place to promote compliance with all applicable federal, state, and local laws and regulations set forth by the: Department of Health and Human Services Office of Inspector General (OIG). Federal Drug Administration (FDA). Environmental Protection Agency (EPA). Centers for Medicare and Medicaid Services (CMS). Drug Enforcement Agency (DEA). Department of Community Health (Georgia Medicaid). Office for Civil Rights (OCR).

31 Charging, Billing, Coding GHS is committed to honesty, accuracy and integrity in all its charging, billing, coding and documentation activities. GHS associates must assure that documentation in the medical record supports the services billed to any payor. GHS can bill only for services ordered, provided and documented.

32 Charging, Billing, Coding, cont d Charging for a service that is not ordered, provided or documented in the record is inappropriate. It is not acceptable to fix the record to make it match the bill. Falsifying medical records is grounds for disciplinary action up to and including termination. See GHS Discipline Policy (HR ). See GHS Charging, Coding and Billing Compliance Policy #

33 Protection of Property All goods and items purchased by GHS are the property of GHS. Any item taken from GHS, without appropriate authorization to sell, donate or for personal use, no matter the cost or value of the item, is considered theft. Theft is prohibited by: GHS Code of Conduct. Georgia state law. GHS does not tolerate theft of any kind and involves the police when necessary to resolve property theft.

34 Environmental Laws GHS maintains, administers and disposes of hazardous drugs in a manner which protects associates and patients. GHS is compliant with EPA requirements. It is a violation of Safety Policy to dispose of hazardous drugs in a manner not identified in the policy. If an associate witnesses the improper administration or disposal of hazardous drugs, the associate has an obligation to report the incident to a supervisor immediately.

35 Harassment and Retaliation Harassment is prohibited by: HR policy The Associate Handbook. The Code of Conduct. Retaliation for reporting a concern or violation of a policy is prohibited by: The Complaints and Grievances Policy, HR policy The Code of Conduct.

36 To Report any Concern Use one of the following options to report: Speak to your manager immediately. Call: Chief Compliance and Privacy Officer Compliance Manager Compliance Analyst Compliance Hotline

37 Congratulations! Compliance is our ongoing commitment to do the right thing for our patients and GHS. You have completed this CBL module. Proceed to take the Corporate Compliance Test.

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