Corporate Compliance. Other Important Compliance Topics

Transcription

1 Corporate Compliance & Other Important Compliance Topics Revised

2 What is Corporate Compliance? Corporate Compliance means we strive to follow all the rules and regulations required of us as an organization, that we make ethical decisions, and that we behave in an ethical way. There are more than 35 regulatory agencies that have oversight of MCMH.

3 What Are Our Responsibilities? Do the right thing. Treat our patients and each other with respect. Ensure your conduct reflects the hospital s values. Learn the rules and regulations of your area. Seek help when you are unsure of the right course of action. Report any concerns regarding Corporate Compliance.

4 Why Do We Comply With These Rules? We want to meet the highest standards of business and professional ethics. Because we have a responsibility to our patients, the government, and the communities we serve. We want to avoid fines and other penalties.

5 The Corporate Compliance Committee The Corporate Compliance Committee is responsible for overseeing the compliance program and reviewing any compliance concerns. However, Corporate Compliance is the responsibility of everyone in the Organization!

6 What kinds of activities fall under compliance?

7 Compliance Activities Performing narcotic counts. Making sure all unscheduled ED patients have a medical examination. Completing an EMTALA (COBRA) form for transfers. Following Joint Commission standards. Properly billing for services that are medically necessary. Maintaining patient confidentiality electronically, verbally and in writing

8 To Report a Corporate Compliance Concern You may Call the Corporate Compliance Officer, Mary Storm, from our consulting firm at Send a confidential memo to the Corporate Compliance Officer: Hall, Render, Killian, Heath & Lyman Attn: Mary Storm, MCMH Compliance Officer 210 W Big Beaver Rd Suite 1200 Troy, MI Anonymously call the Hotline at or Discuss the issue with your supervisor or another member of management.

9 Other Important Compliance Topics

10 The False Claims Act Pertains to Any person who knowingly presents, or causes to be presented: A false or fraudulent claim for payment or approval, Knowingly makes, uses, or causes to be made or used a false record or statement to get false and fraudulent claims paid, Conspires to defraud the Government by getting false claims paid or Knowingly makes, uses, or causes to be made or used a false record or statement to conceal, avoid or decrease an obligation to pay or transmit money or property to the federal government.

11 False Billing is a Serious Offense! When claiming payment for the Hospital or Professional Services, we have an obligation to our patients, third party payers, and the state and federal governments to exercise diligence, care and integrity and to accurately describe the service we provided.

12 Your Responsibility The right to bill the Medicare and Medicaid program carries a responsibility that must not be abused. We are committed to maintaining the accuracy of every claim we process and submit. Many people throughout the organization have responsibility for entering charges and procedure codes. Each person is expected to comply with applicable rules and report any compliance concerns. Any individual who is ineligible to participate in federal healthcare programs is also not eligible for MCMH employment.

13 Examples of False Claims Include: Claiming reimbursement for services not rendered. Double billing ; Filing duplicate claims. Upcoding to more complex procedures than were performed or documented. Including inappropriate or inaccurate costs on the Hospital cost report. Falsely indicating a provider attended a procedure or that services were otherwise given in a manner they were not. Billing for a length of stay longer then medically necessary. Billing for care that does not meet the standard of care.

14 Examples of False Claims Include (Cont.) Billing for services or items that are not medically necessary. Failing to provide medically necessary services or items. Billing excessive charges. Unbundling using 2 or more billing codes instead of one inclusive code. Routinely waiving patient co-payments. When part of a test was not done due to technical problems and is billed as a complete test or procedure. Billing for new equipment and giving the patient used equipment.

15 Reporting Any false, inaccurate, or questionable claim should be reported immediately to: A Supervisor, Corporate Compliance Officer (Mary Storm) or The Compliance Hotline

16 False Claims Act (FCA) Whistleblower Protection The FCA also provides that private parties may bring action on behalf of the US Government (Whistleblowers known as Qui Tam Relators) and allows them to share in a percentage of proceeds from the action or settlement. The FCA provides protection to whistleblowers from demotion, discharge, suspension, threatening, harassment or any other manner of discrimination of terms and condition of employment. The State of Maine also has a Whistleblowers Protection Act.

17 Penalties for Violating the FCA A provider or supplier who violates the false claims rule is guilty of a felony. Fines as high as $25,000 and five years in prison. The hospital may be excluded from Medicare and Medicaid programs. Civil monetary claims against the person who submits a false claim. Triple damages and up to $10,000 for each false claim.

18 Ethics Any employee, medical staff member, patient, or family member may make a referral to the Ethics Committee by - Calling the CNO/COO - Calling the anonymous Compliance Hotline at Speaking with a department manager or senior leader.

19 Sentinel Events The State of Maine requires that each hospital report Sentinel Events. Examples of Sentinel Events include: - Any unanticipated death - Major permanent loss of function caused by a medical error - Wrong site surgery - Stage III or IV pressure ulcer acquired after admission - Patient suicide while in the hospital -Abduction of a patient of any age The complete list is in the MCMH Sentinel Event policy.

20 Sentinel Events Reporting Sentinel Events helps all hospitals learn how to prevent the events in the future. MCMH must annual attest that all Sentinel Events were reported. You can alert the hospital to a potential Sentinel Event by talking to your supervisor or calling the anonymous Compliance hotline

21 Conclusion Compliance is an important part of how we do our jobs! False billing is a serious offense! Report any concerns regarding Corporate Compliance to: - A Supervisor, - The Corporate Compliance Officer, Mary Storm or - The Compliance Hotline