Purpose Components Examples of Non-Compliance Applicable Laws & Regulations Responsibilities & Management

Transcription

1 Purpose Components Examples of Non-Compliance Applicable Laws & Regulations Responsibilities & Management

2 The purpose of a Compliance Program is To reduce the risk or error or fraud Designed to ensure that all employees, administration, medical staff & vendors know & follow federal, state laws and regulations in their respective areas.

3 The Four E s Educate on the legal risks & consequences of certain business & clinical practices Encourage-seek advice & conduct business activities according to law & ethical standards conduct Enable- allows us to investigate, prevent, & deter criminal activity; to comply with federal, state & local laws; to provide and document all appropriate care and services Enforce-ensures all employees comply with internal polices & procedures.

4 A government investigation of a health care institution can come about at any time. It can also be triggered by: Unfavorable analysis of billing practices-such as double billing or unbundling (the practice of billing a single service as a series of separate procedures) Whistle-blower complaints someone in the organization sees something wrong (i.e. a violation of federal or state law) and blows the whistle by calling attention to it Patient complaints -such as an alleged HIPAA violation. Note: You can call the Hotline to report violations

5 THE SEVEN ELEMENTS

6 The Medical Center s Code of Conduct along with its polices and procedures must be adhered to at all times. They are required to be distributed and readily available to all.

7 Provided by: Senior Management Board of Governors Compliance Committee Thomas Flynn, the Chief Compliance Officer who is responsible for implementing plan activities.

8 Designed to communicate: Our Code of Conduct Your role as an employee How to complete required initial and ongoing educational programs.

9 The use of evaluation techniques such as audits to monitor compliance and reduce incidents including the establishment and maintenance the confidential and anonymous hotline Establish a system to prevent & respond to allegations of improper or illegal activities. Examples: Patient record review Billing audits Quality review of business processes.

10 Investigation Remediation Disciplinary action, if required for any and all employees who violate the code of conduct including administrators, medical staff and vendors.

11 Non-Compliance can occur at any time: Billing errors occur due to ignorance of the law or policy i.e. duplicate or incorrect billing Fraud is committed by falsifying, altering, or padding information to make underserved money on a claim i.e. upcoding, unbundling, forgery, & kickbacks Note: Incorrect billing or coding may be unintentional, but can be considered fraud Ignorance of the law or policy is NOT an acceptable defense to a government investigation!

12 Workplace conduct is governed by HUMC policy and is part of our compliance program. Be aware of our policy regarding issues like: Conflict of Interest Harassment or workplace violence Policy against accepting gifts for any reason.

13 Government prosecution efforts have been achieved by existing law and regulations. Medicare regulations describe the minimum standards of patient care and billing procedures for participation in the Medicare program. Some laws: Federal False Claims Act NJ Healthcare Claims Fraud Act The Stark Act Anti-kickback Statutes Mail and Wire Fraud.

14 The Federal False Claims Act allows for courts to penalize anyone who submits a fraudulent bill or false claim to the government Penalties: Up to $10,000 per claim plus triple damages for the billed amount.

15 NJ HealthCare Claims Fraud Act- you can be suspended or lose your healthcare license if convicted of healthcare claims fraud Penalties: Jail time of up to ten years and fines of $150,000, or 5 times the amount of the claim.

16 Prohibits physicians from referring patients to facilities where they or an immediate family member has a financial interest or ownership Penalties: Payment denied Refund of money $15,000 per improper claim & $10,000 per for failure to report Exclusion from Medicare/Medicaid program.

17 Prohibits individuals and corporations from offering kickbacks or accepting kickbacks from anyone doing business with the government. Certain arrangements may be excluded from these laws Penalties: $25,000 fine or imprisonment for up to five years Exclusion in Medicare/Medicaid programs.

18 Prohibits using the U.S. Postal Service or electronic communications as part of a scheme to defraud the government Penalties: Fines up to $250,000 Can include 30 years in prison!!!

19 This patient anti-dumping law requires all Medicare participating hospitals with emergency rooms to provide emergency services (medical screening and stabilization) regardless of the patients ability to pay or whether they have insurance Penalties: $50,000 per violation for hospitals with more than 100 beds and possible exclusion from Medicare/Medicaid program.

20 Protects the Security and Confidentiality of Patient Information Avoid placing patient information in view of other patients or family members (i.e. sign-in sheets, waiting rooms, or visible computer displaying patient information) Restrict conversations to only the necessary information required for patient care especially in the hallways & elevators where the general public may be. You may be fined $10,000 and sentenced one year in prison for disclosing patient information to someone who is not privileged to know such information.

21 You have an affirmative duty to report any perceived violation or non-compliance to your supervisor. HUMC policy and both state and federal law protects individuals who report violations. Always follow the chain of command for reporting If you are dissatisfied with the outcome when reporting alleged misconduct or if you want to report without your identity being known dial the Hotline Calls are handled in strict confidence and all allegations will be investigated.