2014 Annual Training. Table of Contents. Click on 'home' key to return to Table of Contents from any location

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1 2014 Annual Training Table of Contents Common Terms & Abbreviations p. 2 HIPAA Privacy and Security pp Medicare Fraud, Waste, and Abuse pp Medicare General Compliance pp Code of Conduct pp Cultural and Linguistic Competency pp Special Needs Plans (SNP) pp Click on 'home' key to return to Table of Contents from any location

2 Common Terms & Abbreviations HIPAA: Health Insurance Portability & Accountability Act PHI: Protected Health Information Medicare Part C: Medicare Advantage Plan; Health plan options approved by Medicare and are run by private companies MAO / MA: Medicare Advantage Organization / Medicare Advantage FWA: Fraud, Waste, and Abuse CMS: Centers for Medicare and Medicaid Services Sponsor: Medicare Advantage Health Plan Enrollee: Medicare Advantage Beneficiary FDR: First Tier, Downstream, Related Entity C.F.R.: Code of Federal Regulations Beneficiary: The name for a person who has health care insurance through the Medicare or Medi-Cal/Medicaid program CMP: Civil Monetary Penalties Remuneration: an amount of money paid to someone for the work that person has done OIG: Office of the Inspector General U.S.C.: United States Code P.L.: Public Law IPA: Independent Practice Associations IOM: Medicare Internet-Only Manual HPMS: Health Plan Management System HHS: Health and Human Services LGBT: Lesbian, gay, bisexual, and transgender Ask Me 3 : Patient education program designed to improve communication between patients and health care providers, encourage patients to become active members of their health care team, and promote improved health outcomes. SNP: Special Needs Plans MOC: Model of Care C-SNP: Chronic Conditions Special Needs Plans D-SNP: Dual Eligible Special Needs Plans I-SNP: Institutional Special Needs Plans LTC: Long Term Care Facility ICF: Intermediate Care Facility ALF: Assisted Living Facility SNF / NF: Skilled Nursing Facility / Nursing Facility 2

3 H I P A A HIPAA Do The Right Thing! 3

4 HIPAA Privacy Rule HIPAA stands for the Health Insurance Portability and Accountability Act of Healthcare providers, health plans and healthcare clearinghouses called covered entities are required by law to follow the Rule. Some healthcare professionals are still unclear about what the Rule requires them to do to safeguard patient information. Misinterpretations affect the quality of patient care. 4

5 HIPAA Review: Disclosure Protected Health Information (PHI) is any personal information oral, recorded, on paper or sent electronically about a patient s physical or mental health, healthcare services or payment. A name and address, social security number, or even physician notes are PHI. PHI needs to be protected. Think minimum limit the use and disclosure of PHI, inside & outside of your facility, to the minimum except when it comes to treatment. Healthcare providers need access to the entire record to provide quality care 5

6 HIPAA Review: Disclosure Use and disclosure of PHI is permitted for payment, claims billing, or to obtain & review services for coverage of medical necessity and the day-to-day operations necessary for healthcare delivery. PHI use and disclosure is permitted for incidental uses like physicians talking to patients in semi-private rooms or waiting room sign-in sheets. You re permitted to use or disclose a patient s PHI when that person requests or authorizes it with a few exceptions: You re not permitted to use or disclose PHI when it comes to psychotherapy notes about private counseling sessions or information that can be used in litigation. You re not permitted to use or disclose PHI if it could endanger the health or safety of the patient, staff or anyone else. 6

7 When Patient Authorization isn t Required To control and prevent disease Report victim abuse Law enforcement Coroners, tissue / organ donations HIPAA review 7

8 Patient Agreement (not written authorization) required for use and disclosure of PHI: Patient directory or inform agencies during disaster relief efforts. To inform family, caregivers or other identified persons involved in the patient s care or payment, or notify them on patient location, general condition, or death. For non-responsive patients, follow your facility rules. Your facility rules may differ from state or federal rules. The key question is if it s in the best interest of the patient to disclose or use information. Privacy official is a resource for any issues you don t understand. 8

9 Patient Authorization: The following requires a signed authorization form for use & disclosure of PHI Psychotherapy notes about private counseling sessions Marketing Exceptions include Informing patients about services like smoking cessation classes or specialists Informing on services such as discounts for prescription drugs 9

10 Patient Authorization Forms Authorization forms include a description of the PHI, who will use or disclose it and if disclosure will result in financial gain for the covered entity. Forms also include the patient s right to revoke authorization, how he or she can do so, a signature, date of signing and expiration date. After the expiration date, you re required to get a new authorization. Make sure the patient receives a copy of the form. 10

11 Patients Privacy Rights The Rule gives patients the right to choose how their PHI is used. Facility privacy practices should be displayed at the site of service and posted on a website. Patients can have PHI communicated to them by alternate means and at alternative locations. Patients can request inspection and amendment of PHI, obtain copies and make unlimited requests. You have the right to ask that requests be made in writing. If you believe the information could cause harm to the patient, or endanger staff or anyone else, you do not have to agree. If you do deny access to PHI, you are required to give the patient a written explanation of the reason and a description of how to lodge complaints. 11

12 Patient Representatives Patients who can t exercise their rights can pre-designate or have a court appointed Patient Representative. A designated Personal Representative can exercise all the rights that apply to the patient and can have full medical authority to make all healthcare decisions. Or, a Personal Representative may only have power of attorney regarding use of artificial life support and only have the right to the PHI needed to make that decision. Generally parents can access and control the PHI of their minor children. Exceptions include when state law overrides parental control. Examples include HIV testing of minors without parental permission or in cases of abuse, or when parents have agreed to give up control of their minor child. 12

13 Privacy Solutions Guarding sensitive information is just as important as guarding a life. In many cases, patient families have had difficulties obtaining information about their loved ones due to misinterpretation of HIPAA. To add to the confusion, states have rules in addition to Federal privacy laws. State laws take precedence over HIPAA rules if they provide greater privacy protections or for the reporting of disease or injury, child abuse, birth, death or for public health surveillance, investigation or intervention. 13

14 Know the facts about HIPAA requirements. Get familiar with your state laws and your facility rules. Ask for help. Privacy Solutions Make every effort to comply. Do the right thing when deciding to use or disclose confidential health information. People are counting on you! 14

15 Medicare Part C Fraud, Waste, and Abuse (FWA) Training Developed by the Centers for Medicare & Medicaid Services Issued: February,

16 Why Do I Need Training? Every year millions of dollars are improperly spent because of fraud, waste, and abuse. It affects everyone. F W A Including YOU. This training will help you detect, correct, and prevent fraud, waste, and abuse. YOU are part of the solution. 16

17 Objectives and Requirements The Social Security Act and CMS regulations and guidance govern the Medicare program, including part C. Part C sponsors must have an effective compliance program which includes the following objectives: Meet the regulatory requirement for training and education Provide information of the scope of FWA Explain obligation of everyone to detect, prevent, and correct FWA Provide information on how to report FWA Provide information on laws pertaining to FWA 17

18 Where Do I Fit In? As a person who provides health or administrative services to a Part C enrollee you are either: Part C Sponsor (Health Plan) Employee First Tier Entity Examples: Provider group, a Claims Processing Company or contracted Sales agent Downstream Entity Example: contracted specialist Related Entity Example: Entity that has a common ownership or control of a Part C Sponsor 18

19 What are my responsibilities? You are a vital part of the effort to prevent, detect, and report Medicare non-compliance as well as possible FWA. FIRST you are required to comply with all applicable statutory, regulatory, and other Part C requirements, including adopting and implementing an effective compliance program. SECOND you have a duty to the Medicare Program to report any violations of laws that you may be aware of. THIRD you have a duty to follow your organization s Code of Conduct that articulates your and your organization s commitment to standards of conduct and ethical rules of behavior. 19

20 An Effective Compliance Program Is essential to prevent, detect, and correct Medicare noncompliance as well as fraud, waste and abuse. Must, at a minimum, include the 7 core compliance program requirements. (42 C.F.R and 42 C.F.R ) 20

21 Prevention How Do I Prevent Fraud, Waste, and Abuse? Make sure you are up to date with laws, regulations, policies. Ensure you coordinate with other payers. Ensure data/billing is both accurate and timely. Verify information provided to you. Be on the lookout for suspicious activity. 21

22 Policies and Procedures Every sponsor, first tier, downstream, and related entity must have policies and procedures in place to address fraud, waste, and abuse. These procedures should assist you in detecting, correcting, and preventing fraud, waste, and abuse. Make sure you are familiar with your entity s policies and procedures. 22

23 Detection Understanding Fraud, Waste and Abuse In order to detect fraud, waste, and abuse you need to know the Law 23

24 Criminal Fraud Knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program; or to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by or under the custody or control of, any health care benefit program. 18 United States Code 1347 What Does That Mean? Intentionally submitting false information to the government or a government contractor in order to get money or a benefit. 24

25 Waste and Abuse Waste: overutilization of services, or other practices that, directly or indirectly, result in unnecessary costs to the Medicare Program. Waste is generally not considered to be caused by criminally negligent actions but rather the misuse of resources. Abuse: includes actions that may, directly or indirectly, result in unnecessary costs to the Medicare Program. Abuse involves payment for items or services when there is not legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment. 25

26 Differences Between Fraud, Waste, and Abuse There are differences between fraud, waste, and abuse. One of the primary differences is intent and knowledge. Fraud requires the person to have an intent to obtain payment and the knowledge that their actions are wrong. Waste and abuse may involve obtaining an improper payment, but does not require the same intent and knowledge. 26

27 Report Fraud, Waste, and Abuse Do not be concerned about whether it is fraud, waste, or abuse. Just report any concerns to your compliance department or your sponsor s compliance department. Your sponsor s compliance department area will investigate and make the proper determination. 27

28 Indicators of Potential FWA Now that you know what fraud, waste, and abuse are, you need to be able to recognize the signs of someone committing fraud, waste, or abuse. The following slides present issues that may be potential fraud, waste, or abuse. Each slide provides areas to keep an eye on, depending on your role as a sponsor or other entity involved in the Part C program. 28

29 Key Indicators: Potential Beneficiary Issues Does the prescription look altered or possibly forged? Is the person receiving the service the actual beneficiary (identity theft)? Does the beneficiary s medical history support the services being requested? 29

30 Key Indicators: Potential Provider Issues Does the provider write for diverse drugs or primarily only for controlled substances? Is the provider performing unnecessary services for the member? Is the provider s diagnosis for the member supported in the medical record? Does the provider bill the sponsor for services not provided? 30

31 Key Indicators: Potential Manufacturer Issues Does the manufacturer promote off label drug usage? Does the manufacturer provide samples, knowing that the samples will be billed to a federal health care program? 31

32 Key Indicators: Potential Sponsor Issues Does the sponsor offer cash inducements for beneficiaries to join the plan? Does the sponsor lead the beneficiary to believe that the cost of benefits are one price, only for the beneficiary to find out that the actual costs are higher? Does the sponsor encourage/support inappropriate risk adjustment submissions? 32

33 How Do I Report Fraud, Waste, or Abuse? Reporting Fraud, Waste, and Abuse Everyone is required to report suspected instances of fraud, waste, and abuse. Your sponsor s Code of Conduct and Ethics should clearly state this obligation. Sponsors may not retaliate against you for making a good faith effort in reporting. Every MAO sponsor is required to have a mechanism in place in which potential fraud, waste, or abuse may be reported by employees, first tier, downstream, and related entities. Each sponsor must be able to accept anonymous reports. When in doubt, call the Compliance Department. 33

34 Correction Once fraud, waste, or abuse has been detected it must be promptly corrected. Correcting the problem saves the government money and ensures you are in compliance with CMS requirements. How Do I Correct Issues? Once issues have been identified, a plan to correct the issue needs to be developed. Consult your compliance officer or your sponsor s compliance officer to find out the process for the corrective action plan development. The actual plan is going to vary, depending on the specific circumstances. 34

35 Laws You Need to Know About The following slides provide very high level information about specific laws. For details about the specific laws, such as safe harbor provisions, consult the applicable statute and regulations concerning the law. 35

36 Civil Fraud Civil False Claims Act Prohibits: Presenting a false claim for payment or approval; Making or using a false record or statement in support of a false claim; Conspiring to violate the False Claims Act; Knowingly concealing or knowingly and improperly avoiding or decreasing an obligation to pay the Government. 31 United States Code

37 Civil False Claims Act Damages and Penalties The damages may be tripled. Civil Money Penalty between $5,000 and $10,000 for each claim. Criminal Fraud Penalties If convicted, the individual shall be fined, imprisoned, or both. If the violations resulted in death, the individual may be imprisoned for any term of years or for life, or both. 18 United States Code

38 Anti-Kickback Statute Prohibits: Knowingly and willfully soliciting, receiving, offering or paying remuneration (including any kickback, bribe, or rebate) for referrals for services that are paid in whole or in part under a federal health care program (which includes the Medicare program). 42 United States Code 1320a-7b(b) Anti-Kickback Statute Penalties: Fine of up to $25,000, imprisonment up to five (5) years, or both fine and imprisonment. 38

39 Stark Statute (Physician Self-Referral Law) Prohibits a physician from making a referral for certain designated health services to an entity in which the physician (or a member of his or her family) has an ownership/investment interest or with which he or she has a compensation arrangement (exceptions apply). 42 United States Code 1395nn Stark Statute Damages and Penalties Medicare claims tainted by an arrangement that does not comply with Stark are not payable. Up to a $15,000 fine for each service provided. Up to a $100,000 fine for entering into an arrangement or scheme. 39

40 Exclusion No Federal health care program payment may be made for any item or service furnished, ordered, or prescribed by an individual or entity excluded by the Office of Inspector General. 42 U.S.C. 1395(e)(1) 42 C.F.R

41 HIPAA Health Insurance Portability and Accountability Act of 1996 (P.L ) Created greater access to health care insurance, protection of privacy of health care data, and promoted standardization and efficiency in the health care industry. Safeguards to prevent unauthorized access to protected health care information. As an individual who has access to protected health care information, you are responsible for adhering to HIPAA. 41

42 Consequences of Committing Fraud, Waste, or Abuse The following are potential penalties. The actual consequence depends on the violation. Civil Money Penalties Criminal Conviction/Fines Civil Prosecution Imprisonment Loss of Provider License Exclusion from Federal Health Care programs 42

43 Medicare Part C General Compliance Training Developed by the Centers for Medicare & Medicaid Services Issued: February,

44 Why Do I Need Training? 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. C O M P L I A N C E 44

45 Training Objectives To understand the organization s commitment to ethical business behavior To understand how a compliance program operates To gain awareness of how compliance violations should be reported 45

46 Where Do I Fit in the Medicare Program? Medicare Advantage Organization Independent Practice Associations (First Tier) Provider Groups (First Tier) Health Services/Hospital Groups (First Tier) Call Centers (First Tier) Providers Radiology Hospitals Mental Health (Downstream) (Downstream) (Downstream) (Downstream) Providers (Downstream) Providers (Downstream) 46

47 Background CMS requires Medicare Advantage Sponsors (Health Plan) to implement an effective compliance program. An effective compliance program should: Provide guidance on how to handle compliance questions and concerns Provide guidance on how to identify and report compliance violations Articulate and demonstrate an organization s commitment to legal and ethical conduct 47

48 Compliance Prevents noncompliance A culture of compliance within an organization: Detects noncompliance Corrects noncompliance 48

49 Compliance Program Requirements At a minimum, a compliance program must include the 7 core requirements: 1. Written Policies, Procedures and Standards of Conduct; 2. Compliance Officer, Compliance Committee and High Level Oversight; 3. Effective Training and Education; 4. Effective Lines of Communication; 5. Well Publicized Disciplinary Standards; 6. Effective System for Routine Monitoring and Identification of Compliance Risks; and 7. Procedures and System for Prompt Response to Compliance Issues 42 C.F.R (b)(4)(vi) and (b)(4)(vi); Internet-Only Manual ( IOM ), Pub , Medicare Managed Care Manual Chapter 21; IOM, Pub , Medicare Prescription Drug Benefit Manual Chapter 9 49

50 Compliance Training CMS expects that all Sponsors will apply their training requirements and effective lines of communication to the entities with which they partner. Having effective lines of communication means that employees of the organization and the partnering entities have several avenues through which to report compliance concerns. 50

51 Ethics Do the Right Thing! Act Fairly and Honestly Comply with the letter and spirit of the law As a 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! Adhere to high ethical standards in all that you do Report suspected violations 51

52 How Do I Know What is Expected of Me? Standards of Conduct (or Code of Conduct) state compliance expectations and the principles and values by which an organization operates. Contents will vary as Standards of Conduct should be tailored to each individual organization s culture and business operations. Everyone is required to report violations of Standards of Conduct and suspected noncompliance. An organization s Standards of Conduct and Policies and Procedures should identify this obligation and tell you how to report. 52

53 What Is Noncompliance? Noncompliance is conduct that does not conform to the law, and Federal health care program requirements, or to an organization s ethical and business policies. Conflicts of Interest Credentialing Appeals and Grievance Review Beneficiary Notices Claims Processing Medicare Part C High Risk Areas* HIPAA Ethics *For more information see the Documentation Requirements Quality of Care Medicare Managed Care Manual on 53

54 Noncompliance Harms Enrollees Delayed Services Denial of Benefits Without programs to prevent, detect, and correct noncompliance there are: Difficulty in using providers of choice Hurdles to care 54

55 Noncompliance Costs Money Noncompliance affects EVERYBODY! Without programs to prevent, detect, and correct noncompliance you risk: Higher Premiums Higher Insurance Copayments Lower profits Lower benefits for individuals and employers Lower Star Ratings 55

56 I m Afraid to Report Noncompliance There can be NO retaliation against you for reporting suspected noncompliance in good faith. Each Sponsor must offer reporting methods that are: Confidential Anonymous Non- Retaliatory 56

57 How Can I Report Potential Noncompliance? Employees of an MA Sponsor Call the Medicare Compliance Officer Make a report through the Website Call the Compliance Hotline FDR Employees Talk to a Manager or Supervisor Call Your Ethics/Compliance Help Line Report through the Sponsor Call the Sponsor s compliance hotline Make a report through Sponsor s website Call Medicare Beneficiaries 57

58 What Happens Next? After noncompliance has been detected It must be investigated immediately And then promptly correct any noncompliance Correcting Noncompliance Avoids the recurrence of the same noncompliance Promotes efficiency and effective internal controls Protects enrollees Ensures ongoing compliance with CMS requirements 58

59 How Do I Know the Noncompliance Won t Happen Again? Once noncompliance is detected and corrected, an ongoing evaluation process is critical to ensure the noncompliance does not recur. Monitoring activities are regular reviews which confirm ongoing compliance and ensure that corrective actions are undertaken and effective. Auditing is a formal review of compliance with a particular set of standards (e.g., policies and procedures, laws and regulations) used as base measures. Monitor/ Audit Correct Prevent Report Detect 59

60 Know the Consequences of Noncompliance Your organization is required to have disciplinary standards in place for non-compliant behavior. Those who engage in non-compliant behavior may be subject to any of the following: Mandatory Training or Re-Training Disciplinary Action Termination 60

61 PREVENT Compliance is EVERYONE S Responsibility!! Operate within your organization s ethical expectations to PREVENT noncompliance! DETECT & REPORT If you DETECT potential noncompliance, REPORT it! CORRECT CORRECT noncompliance to protect beneficiaries and to save money! 61

62 What Governs Compliance? Social Security Act: Title 18 Code of Federal Regulations*: 42 CFR Part 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) HHS (HIPAA Privacy) State Laws: Licensure Financial Solvency Sales Agents *42 C.F.R (b)(4)(vi) and (b)(4)(vi) 62

63 Additional Resources 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: 63

64 C O D E O F Our Principles of Ethics & Integrity C O N D U C T 64

65 What is a Compliance Plan and Code of Conduct? The Compliance Plan and Code of Conduct are formal statements of EPIC s standards and rules of ethical business conduct. We need a Compliance Program for the following reasons: To provide a formal statement of EPIC s standards and rules of ethical conduct to all EPIC employees and business partners. To inform employees about existing and future laws and EPIC policies. To investigate reports of unethical or unlawful behavior and stop such behavior after it is discovered. To protect EPIC from legal action should a breach of ethical conduct occur. The Code of Conduct is a key part of EPIC s Compliance Program. There are nine areas of conduct covered in the code: 1. Ethical Responsibilities 2. Compliance with Laws and Regulations 3. Fraud and Abuse 4. Patient s Rights 5. Anti-Trust 6. Safety, Health and Environment 7. Confidentiality and Business Information 8. Employee s Rights and Obligations 9. Financial Accounting and Records 65

66 About the Code of Conduct The Compliance Program applies to everyone. No person s job or position at EPIC is more important than preserving EPIC s reputation for integrity. Acting with integrity begins with understanding and abiding by the laws, regulations, Company policies and contractual obligations that apply to our roles and activities. The Code of Conduct cannot anticipate every circumstance an employee may encounter. If you have questions or need advice about a specific situation, talk to your supervisor or your administrator, or call the Compliance HotLine at Reporting potential Code or policy violations helps us address issues quickly and thoroughly. You also help us identify opportunities to provide guidance on how the Code and policies apply in specific situations. In all, you help us to help you live the organization s values and fulfill its mission. 66

67 Ethical Responsibilities ETHICAL PERFOMANCE As an employee of EPIC, you have an obligation to be honest in all your dealing with clients, patients, vendors, and third parties. You must know and comply with applicable laws and all policies and procedures. Claims of ignorance, good intentions, or using poor judgment will not be accepted as an excuse for noncompliance. Maintaining ethical standards is everyone s responsibility. If you know of a problem, you cannot remain silent. You must step forward to solve it! ETHICAL LEADERSHIP Leadership requires setting a personal example of high ethical standards in the performance of your job. It is up to you as management, to set the tone for EPIC. You must take responsibility for the actions of your employees. You will be accountable for making sure that your employees understand and apply the ethical standards set forth in the Code of Conduct. This is accomplished through adequate training, supervision and vigilance. You must also listen to your employee s questions and diligently act on their concerns. 67

68 Compliance with Laws and Regulations We will comply with all laws and regulations that apply to EPIC s operations, business and dealings. We must comply with both the spirit and letter of all laws that apply to EPIC operations, business and dealings. We must cooperate with the government officials who are responsible for administering and enforcing those laws and for monitoring and regulating EPIC s activities. We are expected to have a practical working knowledge of the laws and regulations that affect our job responsibilities. If a representative of any government agency contacts you, you should immediately consult with your supervisor for guidance to insure that the government agency receives full cooperation. 68

69 Fraud and Abuse We will maintain honest and accurate records concerning the provision of health care services, and never offer, pay or receive any money, gifts or services in return for the referral of patients or to induce the purchase of items or services. Employees must not make false statements or misrepresentations at any time. We will not engage in any of the following activities, all of which are prohibited by law: Billing for supplies or services not delivered; Misrepresenting or duplicate billing of services actually rendered; Falsely certifying that services were medically necessary; Seeking to collect amounts exceeding the co-payment and deductible from a Medicare or Medi- Cal beneficiary who has assigned benefits; or Soliciting, offering or receiving a kickback, bribe or rebate in exchange for patient referrals. We bill only for services actually rendered. Services rendered must be accurately and completely coded to ensure both proper billing and integrity of the medical data base. Billing must comply with the requirements of state and federal payors and conform to all payor contracts and agreements. We will collect any co-payments and/or deductible amounts per payor agreements. Decision to waive any co-payment or deductible must be disclosed and implemented in accordance with EPIC s discount policy. We prohibit any payment that may be viewed as a bribe, kickback or inducement. Prohibited inducements include gifts of more than small value, excessive entertainment or other considerations given to government employees, physicians or any other party in a position to influence patient referrals. 69

70 Patients Rights Patients must receive quality care delivered in a considerate, respectful and costeffective manner. Patients have the right to make their own health care decisions after disclosure of all relevant information. We must at all times treat patients with dignity and respect. We shall continue to seek new approaches to increase the quality of care delivered to our patients while ensuring that care is delivered in a cost-effective manner. Treatment of patients shall be consistent with appropriate informed consent as determined by California law. Questions concerning a patient s competence or the right of another person to act on a patient s behalf should be handled in accordance with EPIC s policy. We must protect a patient s personal privacy and preserve the confidentiality of a patient s medical treatment program, including the patient s medical records. We must observe the highest standards of ethical and legal conduct with respect to such information. HIPAA regulations mandate how and when we may disclose protected health information. These regulations also describe how a patient may request to limit the amount and the method that protected health information is disclosed. 70

71 Anti-Trust We will avoid activities that reduce or eliminate competition, control prices, allocate markets or exclude competitors. The purpose of antitrust and trade regulation laws is to protect EPIC and other companies from unfair trade practices, promote competition, and preserve the free enterprise system. The antitrust and trade regulation laws are based on the belief that businesses and individuals should act independently in order to serve the economic good of all. We will negotiate and enter into contracts with competitors, potential competitors, contractors or suppliers on a competitive basis based upon factors like price, quality and service. If you have responsibilities such as purchasing, planning or marketing this is especially important. We will not share with competitors any pricing information not normally available to the public. This could be perceived as an effort to fix fees or limit competition. When attending trade shows, professional meetings and other gatherings, we will avoid subjects that affect competition including prices, pricing policy, profit margins, or credit and billing practices. 71

72 Safety, Health, and Environment We will maintain a safe and healthy working environment. We have a responsibility to follow safe operating procedures, to safeguard our health as well as that of our co-workers and patients, and to maintain a safe and healthful workplace. The United States has federal, state and local agencies to ensure that everyone complies with laws and regulations affecting safety, health and environmental protection. It is our policy to comply with the standards and regulations of these agencies. If you do not know the correct procedure for handling or disposing of any material, promptly ask your supervisor or another EPIC resource such as your safety officer for assistance. 72

73 Confidentiality and Business Information We will protect confidential and proprietary information including patient information. Never disclose confidential patient information to any unauthorized person. Common curiosity makes us wonder about people we know who become patients. It is never ethical or proper to look in a patient s confidential record unless it is required as part of your job. We must safeguard EPIC s confidential information and trade secrets. Confidential and trade secret information includes any information that is not generally disclosed to the public. This information generally describes proposed EPIC actions that would be useful or helpful to EPIC s competitors. Examples of confidential and trade secret information include: Financial data Planned new projects or information about areas where EPIC intends to expand Employee information, wage and salary data Capital investment plans and projected earnings Changes in management or policies of EPIC Discuss restricted, or exclusive, information with others only on a need-to-know basis. Be cautious about accidently discussing confidential information or trade secrets in social conversations or in normal business relations. 73

74 Employee s Rights and Obligations We will maintain a working environment free from harassment, abuse of any kind and unlawful discrimination. We expect supervisors, co-workers, vendors and medical staff to treat one another with dignity, respect and courtesy. EPIC is an equal opportunity employer. We prohibit discrimination in any workrelated decision on the basis of race, creed, gender, age, disability status, national origin, medical condition, or any other illegal basis. We strictly prohibit harassment, including sexual harassment. Sexual harassment includes sexual advances, requests for sexual favors, or any sexually offensive verbal, visual or physical conduct, or when such conduct creates an intimidating, hostile or offensive work environment. Any form of harassment will not be tolerated. We are committed to providing an efficient and productive working environment. We must perform our job duties safely, competently and efficiently in a manner that protects EPIC s interests and those of their co-workers. Any involvement with illegal and/or mood altering drugs or consumption of alcohol in the work place by employees is prohibited and may result in corrective action, up to and including dismissal. 74

75 Financial Accounting and Records We will maintain honest and accurate financial records. EPIC relies on its business records for making business decisions; for billing the government, third-party payors, customers and patients; for paying its vendors and for making representations to the government and others. We must record all entries in EPIC s books and records accurately, honestly and fairly so that these entries reflect the true nature and purpose of the transactions that are being recorded. No compromise of the integrity of financial records or financial statements and no off the books transactions will be permitted. Financial reports must fairly and consistently reflect performance and accurately disclose the results of operations. They must also comply with Generally Accepted Accounting Principles, regulations of the Centers for Medicare and Medicaid (CMS) and other applicable rules. Accuracy of EPIC s books and records begins with each employee. Whether the record are time cards, expense reports, general accounting records, purchasing records, or billing/coding entries, you have a personal responsibility to ensure that every document and entry is complete and accurate. 75

76 Conclusion This Code sets forth EPIC guidelines and expectations about proper job-related conduct. However, this Code cannot anticipate every situation that you as an employee may encounter. You should consult with your supervisor for guidance if this Code does not provide adequate direction or if you are being pressured to compromise your behavior, whether by another employee, a physician, a supplier, a competitor or a patient. If you are unable to resolve your concerns with your supervisor, you should contact the Compliance Officer. Any questions about interpretations of the law or the legality of a particular course of conduct should be discussed with the Compliance Officer who may in turn consult with legal counsel. No employee s concern is too small or unimportant if he or she thinks it implicates policies concerning proper conduct. An employee will find that by seeking guidance a resolution can be found which will both meet the employee s concerns and be consistent with this Code. 76

77 Conclusion (continued) Reporting Misconduct If you encounter what you believe to be a potential Code or policy violation, speak up. Speaking up is not only the right thing to do, it s required by Company policy. EPIC, CMS, and your health plans provide many ways to report concerns. You always have the option of reporting anonymously, and, regardless of how you report, you are protected from retaliation whenever you speak up in good faith. All reports will be reviewed and, if necessary, investigated. 77

78 Additional Sources for EPIC Employees Employee Handbook Fraud and Abuse: Administrative Policy & Procedure Manual Management Information Systems Physician Section & Patient Financial Services Discount and Co-payment Guidelines Patients Rights: Patient s Bill of Rights Notice of Privacy Practices Administrative Policy & Procedure Manual Quality Management Physician s Section Medical Records Compliance & Privacy Non-Disclosure Acknowledgement Anti-Trust: Administrative Policy & Procedure Manual Legal Guidelines and Responsibilities Safety, Health and Environment: Administrative Policy & Procedure Manual Emergency/Safety/OSHA Infection Control Radiology Laboratory Organized Plans of Operation Manual Confidentiality and Business Information: Administrative Policy & Procedure Manual Medical Records Non-Disclosure Acknowledgement Employee s Rights and Obligations: Equal Employment Opportunity Commission Administrative Policy & Procedure Manual Human Resources Non-Disclosure Acknowledgement Financial Accounting and Records: Administrative Policy & Procedure Manual Human Resources 78

79 Connecting with your patients Developed By: Industry Collaboration Effort (ICE) Cultural and Linguistic Services Main Team Cultural Competency Training Workgroup Approved on January 18, 2013 by ICE Leadership 79

80 Training Goals Define culture and cultural competence Explain the three benefits of clear communication Explore and understand LGBT (lesbian, gay, bisexual, and transgender) communities Address health care for refugees and immigrants Reflect on strategies when working with seniors and people with disabilities 80

81 Defining culture and cultural Culture refers to integrated patterns of human behavior that include the language, thoughts, actions, customs, beliefs, values, and institutions that unite a group of people. competence Cultural competence is the capability of effectively dealing with people from different cultures. Adapted from 81

82 How does culture impact the care that is given to my patients? Culture informs: o concepts of health, healing o how illness, disease, and their causes are perceived o the behaviors of patients who are seeking health care o attitudes toward health care providers 82

83 Culture impacts every health care encounter Culture defines health care expectations: o who provides treatment o what is considered a health problem o what type of treatment o where care is sought o how symptoms are expressed o how rights and protections are understood Because health care is a cultural construct based in beliefs about the nature of disease and the human body, cultural issues are actually central in the delivery of health services. 83

84 Clear Communication: The Foundation of Culturally Competent Care Did you know? 20% of people living in the U.S. speak a language other than English at home The Hispanic population has grown by 43% in the U.S. between 2000 and % of the foreign born population in the U.S. are classified as newly arrived (arriving in 2005 or later) 1 out of 2 adult patients has a hard time understanding basic health information Average physician interrupts a patient within the first 20 seconds 84

85 Clear Communication Benefits Reduce Malpractice Risk Improve Safety & Adherence Improve Office Process Saves Time & Money Physician & Patient Satisfaction 85

86 Cultural Influences Acculturation Privacy Cultural Influences Botanical Treatments & Healers Language Skills & Preferences Decision Making 86

87 Clear Communication I tell you I forgot my glasses because I am ashamed to admit I don t read very well I don t know what to ask and am hesitant to ask you When I leave your office I often don t know what I should do next Here s What We Wish Our Health Care Team Knew Use a variety of instruction methods Encourage Questions & use Ask Me 3 Use Teach Back Here s What Your Team Can Do 87

88 Clear Communication I put medication into my ear instead of my mouth to treat an ear infection. Use specific, plain language on prescriptions I am confused about risk and information given in numbers like % or ratios how do I decide what I should do. Use qualitative plain language to describe risks and benefits, avoid using just numbers. Here s What We Wish Our Health Care Team Knew Here s What Your Team Can Do 88

89 Clear Communication My English is pretty good but at times I need an interpreter When I don t seem to understand, talking louder in English intimidates me If I look surprised, confused or upset I may have misinterpreted your nonverbal cues Here s What We Wish Our Health Care Team Knew Office staff should confirm interpreter needs during scheduling Match the volume and speed of the patient s speech Mirror body language, position, eye contact Ask the patient if you are unsure Here s What Your Team Can Do 89

90 Clear Communication I am not able to make important decisions by myself I am more comfortable with a female doctor Its important for me to have a relationship with my doctor I use botanicals and home remedies but don t think to tell you Here s What We Wish Our Health Care Team Knew Confirm decision making preferences Office staff should confirm preferences during scheduling Spend a few minutes building rapport Ask about the use of home remedies & healers Here s What Your Team Can Do 90

91 Interpreter Tips Inform the interpreter of specific patient needs Hold a brief introductory discussion o Your name, organization and nature of the call/visit o Reassure the patient about confidentiality Allow enough time for the interpreted sessions Avoid interrupting during interpretation 91

92 Interpreter Tips Speak in the first person Speak in a normal voice, try not to speak fast or too loudly Speak in short sentences Avoid acronyms, medical jargon and technical terms Face and talk to the patient directly Be aware of body language in the cultural context 92

93 Cultural Competence & the LGBT* Communities Some LGBT Terminology Orientation Sexual Orientation: A person s emotional, sexual, and/or relational attraction to others. Usually classified as heterosexual, bisexual, and homosexual (i.e. lesbian and gay). o Describes how people locate themselves on the spectrum of attraction and identity o It is distinct from gender identity or gender expression o Transgender people exhibit the full range of sexual orientations, from homosexual to bisexual and heterosexual *(lesbian, gay, bisexual, and transgender) 93

94 Cultural Competence & the LGBT* Communities Some LGBT Terminology Orientation (cont d) Bisexual: One whose sexual or romantic attractions and behaviors are directed at both sexes to a significant degree. Bisexuality is a distinct sexual orientation. MSM: Men who have sex with men. Usually identify as gay. WSW: Women who have sex with women. Usually identify as lesbian. *(lesbian, gay, bisexual, and transgender) 94

95 Cultural Competence & the LGBT* Communities Some LGBT Terminology (cont d) Gender Identity Transgender: Describes people whose gender identity and/or expression is different from that typically associated with their assigned sex at birth. Genderqueer: Describes people who see themselves as outside the usual binary man/woman definitions. o Having elements of many genders, being androgynous or having no gender. o Also Gender Non-Conforming (GNC) Bigender: Describes people whose gender identity encompasses both male and female genders. Some may feel that one identity is stronger, but both are present. *(lesbian, gay, bisexual, and transgender) 95

96 Cultural Competence & the LGBT* Communities Some LGBT Terminology (cont d) Gender Identity (cont d) MtF: Male-to-female; a person who was assigned the male sex at birth but identifies and lives as a female. Also trans woman. o MtF persons will still need to have prostate exams according to standard guidelines. FtM: Female-to-male; a person who was assigned the female sex at birth but identifies and lives as a male. Also trans man or trans male. o FtM persons will need to have breast exams and Pap tests according to standard guidelines Transsexual: Medical term for people who have used surgery or hormones to modify their bodies. Some trans people find this term offensive. *(lesbian, gay, bisexual, and transgender) 96

97 Health Disparities of LGBT Populations 60% Heterosexual Lesbian, gay, or bisexual Transgender 50% 48% (FtM) 50% 44% 40% 30% 29% 33% 25% 27% 20% 17% 19% 18% 16% 15% 10% 0% 5% Delaying Care Violent injury 2% 5% Suicidal Ideation Alcohol Abuse Smoke Cigarettes 97

98 Cultural Competence & LGBT We come to you with an extra layer of anxiety o Verbally or physically abused o Rejected by families due to our sexual and gender identity o Discriminated against within the health care setting We ve experienced harshness such as with rough blood draws, rude orders, or ridicule Here s What We Wish Our Health Care Team Knew Communities A little warmth can make all the difference! o Signage or intake form verbiage that is safe, judgment-free, and non-discriminatory o Policies indicating nondiscrimination for sexual and gender identity displayed in common areas Listen to how patients refer to themselves and loved ones (pronouns, names) o Use the same language they use o If you re unsure, ask questions Here s What Your Team Can Do 98

99 Cultural Competence & LGBT That heteronormative assumptions and attitudes dissuade our future care-seeking Discrimination in healthcare may delay or defer treatment Communities Anticipate that all patients are not heterosexual o Use partner instead of spouse or boy/girlfriend o Replace marital status with relationship status on forms Here s What We Wish Our Health Care Team Knew Here s What Your Team Can Do 99

100 Cultural Competence & LGBT We feel our HIPAA rights to privacy are not honored o Amazingly, some personnel Here s What We Wish Our Health Care Team Knew Communities Openly discuss our sexual orientation or gender identity with coworkers Don t realize or care that we can see or hear them making fun of us with coworkers Protect the patient s rights o Sharing personal health information, including sexual orientation or gender identity, is a violation of HIPAA o Confirm that the patient s rights are protected under the HIPAA Privacy Rule Here s What Your Team Can Do 100

101 Cultural Competence & LGBT Check your surprise, embarrassment, or confusion o Many do not disclose our sexual orientation or gender identity because we don t feel comfortable or we fear receiving substandard care o Your gaydar might be off when determining whether we might be LGBT most of us don t fit the stereotypes Recognize that coming out to you does not mean we are coming on to you Here s What We Wish Our Health Care Team Knew Communities Identify your own LGBT perceptions and biases as a first step in providing the best quality care Practice some helpful phrases: o Do you have sex with men, women, or both? o What pronoun do you prefer I use when referring to you? o I m glad you shared that with me. I know that might have been difficult to tell me. Is there anything else in connection with your health care that I should know about? Here s What Your Team Can Do 101