AppleCare General Compliance Training

Transcription

1 AppleCare 2013 General Compliance Training

2 Goals After completing this course, you will understand: The Principles of Ethics and Integrity and the Compliance Plan How to report a suspected or detected noncompliance Compliance policies regarding Conflict of Interest, Privacy, Accuracy of Records, Required Training, & Government Employees Consequences of violating the Principles of Ethics and Integrity Laws governing conduct in the Medicare Program 2

3 Training Agenda Overview Required Topics: 1. Description of Compliance Program Compliance Program (Standards of Conduct & Compliance Policies) Commitment to business ethics and compliance with all Medicare program requirements Personal Accountability 2. How to ask compliance questions, request clarification, or report suspected or detected noncompliance. Confidentiality, anonymity, non-retaliation 3. Requirement to report actual or suspected Medicare program noncompliance or potential FWA 4. Examples of reportable noncompliance 3

4 Training Agenda 5. Disciplinary Guidelines 6. Required Compliance and FWA Training 7. Government Employees 8. Conflicts of Interest 9. Privacy, Data, & Accuracy Privacy Data Use Accuracy of Records 10. Monitoring and Auditing 11. Medicare Program Laws Resources Attestation 4

5 Overview The Centers for Medicare & Medicaid Services (CMS) requires annual General Compliance training for organizations providing health, prescription drug or administrative services to Part C Medicare Advantage (MA) or Part D Prescription Drug Plan (PDP) enrollees on behalf of a health plan. This includes first-tier, downstream and related entities that support Medicare Advantage and Part D plans. AppleCare is considered a first tier, downstream, and/or related entity (FDR). Additionally, section 6401 of the Healthcare Reform Law providers and suppliers shall, as a condition of enrollment, establish a compliance program that contains certain core elements established by HHS in consultation with OIG within particular industries or categories. 5

6 Overview Compliance is Everyone s responsibility! As an individual who provides health or administrative services for Medicare enrollees, every action you take potentially affects Medicare enrollees, the Medicare program, or the Medicare trust fund. AppleCare is committed to following all applicable laws, regulations and guidance that govern these programs. 6

7 1. Compliance Program Description Compliance Program (Standards of Conduct & Compliance Policies) AppleCare s compliance policies and procedures are outlined in the Compliance Plan and the Principles of Ethics & Integrity: Your Guide to Business Conduct ( Principles ). These Principles provide the standards of conduct and reinforce our dedication to compliance with Federal and State law, Medicare Program requirements, along with sound ethical and business practices. AppleCare will provide access to the Principles and Compliance Plan to each employee and all providers/suppliers and other individuals or entities performing functions or services related to AppleCare activities. These individuals must sign the Principles of Ethics & Integrity Attestation Statement reflecting their understanding of and agreement to abide by the Principles. 7

8 1. Compliance Program Description The AppleCare Compliance Program: Describes personal accountability and compliance expectations as embodied in the Principles; Provides guidance on dealing with suspected, detected or reported compliance issues; Identifies how to communicate compliance issues to appropriate compliance personnel; Includes a policy of non-intimidation and non-retaliation for good faith reporting 8

9 1. Compliance Program Commitment Description Honesty and integrity are core values of our organization. Our commitment to these values has helped us earn a reputation as an organization that health care providers and health plans can engage in solid, long term business arrangements. In order to create a workplace which values commitment to honesty, fairness and compliance with the law and Medicare program requirements, individuals must be familiar with and abide by the AppleCare standards of conduct, the Principles of Ethics and Integrity ( Principles ). 9

10 1. Compliance Program Personal Accountability Description All of us are personally accountable for our decisions and actions. We each must follow a course of conduct that preserves and enhances AppleCare s reputation for honesty and integrity. To do so, it is critical that we understand the laws, company policies and contractual obligations that apply to our specific area. We should never misuse our authority, whether for personal interests or to the detriment of AppleCare. It is your obligation to comply with the law, the Principles, and all applicable Company policies and contractual obligations. 10

11 2. Asking Questions & Reporting Noncompliance Ethics Do the Right Thing! Act Fairly and Honestly Adhere to high ethical standards in all that you do Report suspected violations Comply with the letter and spirit of the law As of part of the Medicare program, it is important that you conduct yourself in an ethical and legal manner. It s about doing the right thing! 11

12 2. Asking Questions & Reporting Noncompliance How to ask compliance questions, request compliance clarification or report suspected or detected noncompliance: Talk to your manager about any questions you may have and any action you believe may violate these Principles, the law, company policies or any contractual obligation. If you are not comfortable talking with your manager or you have already done so and you think the problem has not been completely resolved, please contact: A more senior manager The Human Resources department A member of the executive management team The Compliance Officer The Ethics & Compliance hotline (877) Can be used for anonymous reporting 12

13 2. Asking Questions & Reporting Noncompliance Confidentiality, anonymity, non-retaliation: Anonymous reports can be made to the Ethics & Compliance hotline at (877) To the extent possible, the company will take reasonable precautions to maintain the confidentiality of those who report an integrity or compliance concern. Retaliation in any form against an individual who, in good faith, reports a suspected violation of these Principles or provides information related to such reports, Company policies, the law or contractual obligations, is prohibited. 13

14 3. Requirement to report Everyone is required to report violations of the Principles and suspected noncompliance. Your Duty to Report Misconduct To protect AppleCare s reputation as well as your personal reputation you must promptly report illegal or unethical conduct to an appropriate company representative. Failure to report suspected violations violates these Principles of Ethics and Integrity and can lead to discipline. If you encounter what you believe to be a potential violation, speak up. Speaking up is not only the right thing to do, it s required. Making malicious or purposely false reports also violates the Principles and will result in disciplinary action up to and including termination. 14

15 4. Examples of reportable noncompliance Some examples of reportable noncompliance that you might observe: Billing for services not rendered Entering false information into a medical record Physician soliciting payment for a referral Using a patient/member/customer s financial information for personal gain Accessing protected heath information outside of work responsibilities/without a need to know Providing misleading information to an auditor Providers giving patient names and contact details to Sales Agents Providers offering anything of value to patients to select them as their provider 15

16 5. Disciplinary Guidelines No employee is ever authorized to commit, or direct another employee to commit an unethical or illegal act. In addition, employees cannot use a contractor, agent, consultant, broker, distributor or other third party to perform any act not allowed by law, these Principles, any company policy or any applicable contractual obligation. The goal of the Principles is to promote proper conduct and avoid the need for discipline. However, all violations of the law, the Principles, company policies and contractual obligations will be taken seriously and may result in retraining and/or disciplinary actions, up to and including termination. In addition, employees who commit criminal or illegal acts may face immediate termination and possible legal action. 16

17 6. Required Compliance and FWA Training Attendance and participation in compliance and FWA training programs AppleCare commitment to compliance requires training of employees and all providers/suppliers and other individuals or entities performing functions or services related to AppleCare and Medicare Advantage Part C & D programs. Individuals will receive compliance training appropriate to the requirements of their position upon hire or contracting and annually thereafter. 17

18 7. Government Employees There are very strict rules about what may be offered to government employees. The rules depend on the nature of the relationship between AppleCare and the government employee. If the government employee is a contract officer for a contract we have or are seeking, the rules are very strict. In that case very little, if anything, can be offered to the person. In some cases, you may not even be able to offer beverages or food during a meeting. If the person is a member of a legislative staff, you may be able to offer meals or entertainment without breaking the law but you need to make sure you strictly follow any restrictions that apply. If you have regular contact with government employees, you must know and carefully follow the rules that apply to those employees. 18

19 8. Conflicts of Interest Business decisions and actions must be based on the best interests of AppleCare and not personal interests or relationships. Relationships with prospective or existing suppliers, contractors, customers, competitors or regulators must not affect your independent and sound judgment on behalf of AppleCare. Avoid any situation that causes or appears to cause a conflict of interest with AppleCare s interests. Possible conflicts of interest may include: Gifts, favors, travel and entertainment Board Memberships Employment and Activities Outside of AppleCare Family Members - Doing business or competing with Investments and Other Financial Opportunities Additional details on these Conflicts of Interest can be found in the Principles. 19

20 8. Conflicts of Interest Disclosures The best way to avoid a conflict of interest is to disclose any relationships others might misinterpret. This includes any relationships with other employees, customers, suppliers and competitors. You should raise questions about possible conflicts of interest and disclose these kinds of situations to your manager or the Ethics & Compliance hotline as they arise. If you have any questions about whether a situation is a conflict of interest, consult with your manager. Of course, you or your manager may consult the Human Resources department, or the Ethics & Compliance hotline (877)

21 9. Privacy, Data, & Accuracy Maintaining the privacy and security of personal information that we collect, use or that is entrusted to our care is an essential, supportive component of AppleCare s mission and its commitment to integrity and ethical behavior. Protect Personal Information Managing an individual s personal information respectfully, responsibly and in accordance with all applicable domestic and international laws builds trust individualby-individual, serves our business objectives and fosters enduring relationships with our stakeholders. Protect Privacy, Ensure Security Understand the rules regarding personal information that you use and have access to in your day-to-day responsibilities. Fulfill the obligations of your job. When accessing or using personal information in your job, take care of it! Use only the minimum amount of information you need to do your job. Keep it private; keep it secure! 21

22 9. Privacy, Data, & Accuracy Allowable Use of Medicare Beneficiary Information Obtained from CMS CMS restricts the use of Medicare data to those purposes directly related to the administration of the Medicare managed care and/or outpatient prescription drug benefits for which they have contracted with CMS to administer. Plan sponsors agree not to use that information to develop, market, or operate lines of business unrelated to their Medicare plan operations. CMS-provided data includes information provided by beneficiaries in the course of their enrollment in a Medicare plan as well as data obtained solely as a result of access to CMS systems granted to the contracting organization or sponsor because it is a Part C, Part D, PACE or section 1876 cost plan contractor. Except in cases in which the enrollee gave information as part of a commercial relationship prior to enrollment in the Medicare plan, the contracting organization or sponsor was only given the information on the application as a result of the contract with CMS. 22

23 9. Privacy, Data, & Accuracy of Company Records Accuracy AppleCare needs correct information and reliable records to make sound business decisions and to submit reports to customers and governmental agencies. You must be complete, accurate and honest when recording, reporting and retaining company information. This includes business records involving quality, safety and personnel, as well as time, expense and other financial records. 23

24 10. Monitoring and Auditing Auditing and monitoring may be performed utilizing any of the following: Unannounced internal audits or "spot checks ; Examination of the performance of the compliance plan including review of training, the compliance issues log (e.g. Hotline log), investigation files and certifications for receipt of standards of conduct; Review of areas previously found non-compliant to determine if the corrective actions taken have fully addressed the underlying problem; Access to existing audit resources, relevant personnel, and relevant areas of operation by both internal and independent auditors. 24

25 11. Medicare Program Laws Laws that govern Compliance and conduct in the Medicare program Social Security Act: Title 18 Code of Federal Regulations*: 42 CFR Parts 422 (Part C) and 423 (Part D) CMS Guidance: Manuals HPMS Memos CMS Contracts: Private entities apply and contracts are renewed/non-renewed each year Other Sources: OIG/DOJ (fraud, waste and abuse (FWA)) HHS (HIPAA privacy) State Laws: Licensure Financial Solvency Sales Agents * 42 C.F.R (b)(4)(vi) and (b)(4)(vi) 25

26 11. Medicare Program Laws For more information on laws governing the Medicare program and Medicare noncompliance, or for additional healthcare compliance resources please see: Title XVIII of the Social Security Act Medicare Regulations governing Parts C and D (42 C.F.R. 422 and 423) Civil False Claims Act (31 U.S.C ) Criminal False Claims Statute (18 U.S.C. 287,1001) Anti-Kickback Statute (42 U.S.C. 1320a-7b(b)) Stark Statute (Physician Self-Referral Law) (42 U.S.C. 1395nn) Exclusion entities instruction (42 U.S.C. 1395w-27(g)(1)(G)) The Health Insurance Portability and Accountability Act of 1996 (HIPAA) (Public Law ) (45 CFR Part 160 and Part 164, Subparts A and E) OIG Compliance Program Guidance for the Healthcare Industry: 26

27 Resources Ethics & Compliance hotline (877) Can be used for anonymous reporting Human Resources department Tawnya Rybarczyk Director, Human Resources (714) Compliance Officer ACIS & ACO Sean Heath (952) AppleCare Medical Group Jim Brown (714)

28 Attestation of Training Completion You have completed the General Compliance Training requirement for calendar year 2013 You must sign the training attestation sheet and give it to Human Resources! 28

29 Attestation of Training Completion 2013 General Compliance Training I attest that I have completed this course, understood the information presented and acknowledge that I am required to follow the guidelines outlined in this course. I agree and understand that I am to abide by the principles of the training program and if I violate those principles it can result in disciplinary action, up to and including termination of employment or contract. Should I have questions regarding these topics, I will contact my manager for clarification. Signature: Date: Print Name: Title: 29