Transcript CORPORATE COMPLIANCE QUARTERLY UPDATE

HAYS MEDICAL CENTER
CORPORATE COMPLIANCE
CODE OF CONDUCT TRAINING FOR
ASSOCIATES
Joannah Applequist, J.D.
In-House Counsel &
Corporate Compliance Officer
2010
LESSON ONE
INTRODUCTION
Introduction
Welcome to the introductory lesson on
HMC’s Compliance Program and Code of
Conduct
“Associates”
You will notice the term “Associates” is used throughout this
training. “Associates” is a broad term that represents all the
following individuals who are associated with HMC:









Employees
Volunteers
Students
Other trainees
Members of the Board of Directors
Locum Tenens
Contract Staff
Independent Contractors
Other persons whose conduct is under the direct control of
HMC (whether or not they are compensated by HMC for such
services)
Course Rationale
In this course, you will learn about:

The purpose and structure of HMC’s
Compliance Program

Your role in HMC’s Compliance Program

HMC’s Code of Conduct
Course Goals
After completing this course, you should:



Appreciate the importance of the
Compliance Program within the
organization
Know your compliance responsibilities
Understand the principles and standards
outlined in HMC’s Code of Conduct
Course Outline




This introductory lesson gives you the course
rationale, goals, and outline
Lesson 2 talks about the goals and structure of
HMC’s Compliance Program
Lesson 3 explains your compliance
responsibilities
Lesson 4 explains each of the principles and
standards outlined in HMC’s Code of Conduct
LESSON TWO
GOALS AND STRUCTURE OF OUR
COMPLIANCE PROGRAM
Introduction & Objectives
Welcome to Lesson 2 on the goals and
structure of HMC’s Compliance Program
After completing this lesson, you should
be able to:


Identify the goals of HMC’s Compliance
Program
Understand how HMC’s Compliance Program
operates
Complex Legal Requirements




Healthcare providers face complex legal
requirements
Ignorance of these requirements is not a
valid defense
No one person can ensure HMC’s compliance
with these requirements
All Associates must pay careful attention to
detect and prevent violations of the law
Government Enforcement Activity



The state and federal government spend billions
of dollars on healthcare programs each year
As spending has grown, investigations and
prosecutions of healthcare providers also have
increased
These investigations can result in administrative
penalties, civil and criminal liability (including jail
time), and damage to HMC’s reputation
Compliance Program Goals
HMC’s Compliance Program has two goals:


Prevent and detect misconduct
Promote an organizational culture that
encourages ethical conduct and a
commitment to compliance with the law
The Compliance Program Meets
These Goals By:

Educating you on how to do your job in an ethical
and legal way

Answering your questions about legal requirements

Providing a confidential process for reporting
concerns

Conducting investigations

Responding to problems
HMC’s Compliance Officer
HMC’s Compliance Officer
is Joannah Applequist. She
is responsible for the dayto-day operation of HMC’s
Compliance Program.
HMC’s Board Of Directors
HMC’s Board of Directors oversees the
Compliance Program. The Compliance Officer
makes regular reports to the Board concerning
compliance-related matters.
HMC’s Department Directors


Each department Director or Manager is
responsible for compliance-related activities
within his or her department
The Compliance Officer serves as a resource for
department managers
Summary
You have completed Lesson 2 on
the goals and structure of our Compliance Program
Remember:




The government is looking closely at healthcare
The penalties for misconduct can be significant
The goals of HMC’s compliance program are to prevent
and detect misconduct and promote a culture of
compliance
HMC’s Compliance Officer is Joannah Applequist. She
manages the Compliance Program and serves as a
resource person for department managers.
Introduction & Objectives
Welcome to Lesson 3 on
your compliance responsibilities
After completing this lesson, you should be able to:


Understand your duty to comply with all applicable
legal and ethical obligations
Appreciate your role in detecting and correcting
violations of the law
Your Duty



You have a duty to comply with all applicable
legal and ethical obligations in the performance
of your job duties
You will be evaluated for your understanding of
and compliance with those obligations
You will be disciplined for non-compliance
Your Role In The Compliance
Program




Learn
Ask
Report
Cooperate
Remember this acronym: LARC
Learn
Your duty to learn includes:


Understanding the laws that impact your job
Participating in educational programs concerning
compliance-related issues
Ask
Your duty to ask includes:

If you have a question concerning a compliance-related
issue, ask for guidance from the Compliance Officer

Remember, there are no stupid questions!

Keep asking until you receive an answer

Never accept “we’ve always done it that way” as an
answer

If you are asked a question you do not know the answer
to, find the answer and report back to the person who
asked the question
Report



All Associates shall report any known or
suspected incident of non-compliance on the
part of any HMC Associate, Physician, Vendor,
Volunteer, Student, Trainee, or Agent, and may
be disciplined for failing to do so
An Associate is obligated to report these matters
to the Compliance Officer, even if his or her
supervisor has directed the Associate to do
otherwise
If something just does not feel right, report it
Cooperate
Your duty to cooperate includes:



Cooperate fully with any internal investigation
concerning possible violations of the law
Provide complete and accurate answers and locate and
provide relevant documents
Cooperate fully with any action taken to remedy noncompliance
Reporting Mechanisms
Contact one of the following to ask a question about legal
requirements or report any suspicion of inappropriate conduct:

The Compliance Officer – Joannah Applequist
in person, by telephone at (785) 650-2759,or
by mail at Compliance Officer, P.O. Box 8100, Hays, KS 67601

Compliance Hotline – (785) 623-6311

Compliance Voice Mail Box – (785) 623-6310


Compliance Department Internal E-mail address – HMC Compliance
Report Line
Compliance Department Internet Address – [email protected]
Confidentiality And Retaliation


All questions and reports will be kept
confidential to the fullest extent possible
HMC will not tolerate retaliation of any type
against a person who, in good faith, raises
questions concerning legal compliance and/or
reports any suspicion of inappropriate conduct,
either internally or to any government entity
Anonymous Reporting




Individuals are not required to give their name when
reporting an issue or concern
HMC will take all efforts to protect the anonymity of the
reporting individual
Dial a “9” to access an outside line if calling from an
internal telephone when an anonymous telephone call is
desired
Do not send messages via Internet e-mail if anonymous
reporting is desired
Summary
You have completed Lesson 3 on your compliance
responsibilities
Remember:





Perform your job in compliance with all applicable legal
and ethical obligations
Learn, Ask, Report, Cooperate
There are several ways in which to ask questions or
report concerns
No type of retaliation against a person who asks a
question or reports a concern will be tolerated
You may report concerns anonymously
Introduction & Objectives
Welcome to Lesson 4 on
HMC’s Code of Conduct
After completing this lesson, you should be able to:


Know the role the Code of Conduct plays in the
organization
Understand the principles and standards outlined in
HMC’s Code of Conduct
HMC’s Code Of Conduct


As part of HMC’s Compliance Program, the
Board of Directors has adopted a Code of
Conduct
The Code of Conduct provides standards by
which Associates shall conduct themselves
Code Of Conduct Violations

All Associates have been furnished with a copy of the Code,
and it is available on the HMC website at www.haysmed.com

You are expected to understand the Code and follow it at all
times

If you have any question concerning any provision in the
Code, contact the Compliance Officer

Employees who violate the Code may be disciplined, and
students who violate the Code may be excluded from
participation in educational opportunities at HMC
Organization Of The
Code Of Conduct

The Code identifies 7 principles:
1.
2.
3.
4.
5.
6.
7.

Patient Care And Treatment
Compliance With Health Care Laws
Compliance With Other Laws
Confidentiality
Business Ethics
Protection Of Assets
Conflicts Of Interest
Under each of these principles, there are standards governing our
conduct
Principle 1
Patient Care And Treatment



The first principle in the Code of Conduct
addresses patient care and treatment
HMC is committed to providing the highest
quality patient care and protecting patient safety
All Associates shall treat patients in a manner
that preserves their dignity, autonomy, selfesteem, civil rights, and involvement in their
own care
Principle 1
Patient Care And Treatment



Associates cannot solicit or encourage any type of gift
from a patient or family member
Associates may accept a personal gift of nominal value
(less than $50) from a patient or family member, but
should share the gift with co-workers to fullest extent
possible
Hays Medical Center shall provide care and treatment to
patients without regard to the race, color, religion,
creed, sex, national origin, age, or disability of such
person, or any other classification prohibited by law
Principle 2
Compliance With Health Care Laws



The second principle in the Code of Conduct is
compliance with healthcare laws
HMC shall conduct its operations in compliance
with all state and federal laws specific to
healthcare providers
HMC shall cooperate with any government
inquiry concerning our operations
Healthcare Laws
Important laws and regulations for healthcare include:











False Claims Act
Medicare and Medicaid regulations
Anti-kickback statute
Stark law
Patient inducements
HIPAA Privacy and Security Rules
Licensing requirements
Controlled substances
Safe Medical Devices Act
EMTALA
Mandatory reporting obligations
On the following slides, let’s take a closer look at some
of these laws and regulations
False Claims Act
Under the False Claims Act, it is illegal to:



submit a falsified bill to a government agency
submit a false record in order to obtain payment
from the government
make false statements to retain money
wrongfully received from the government
A Healthcare Provider Violates The
False Claims Act If It Knowingly:

submits a claim to a federal healthcare program (such as
Medicare, Medicaid, etc.) for services not provided to the patient

submits a claim to a federal healthcare program for services not
provided in compliance with applicable law

submits a claim to a federal health care program for services
different than those actually provided to the patient

retains an overpayment made by a federal healthcare program
Liability Under
The False Claims Act
A healthcare provider that submits a false claim
must pay the government:

three times the amount of the claim, and

a penalty of $5,500 to $11,000 per claim
Whistleblower Provisions Of The
False Claims Act



The False Claims Act allows private individuals to bring a
claim on behalf of the government
These “whistleblowers” or “qui tam relators” may receive
a percentage of the money recovered by the government
An employer cannot retaliate in any way against a
whistleblower
Medicare And Medicaid
Regulations
Medicare and Medicaid regulations require that any
service billed to a federal healthcare program must
be:




properly documented
medically necessary
performed in accordance with all applicable rules
accurately coded
Medicare And Medicaid
Regulations



If you have a question concerning the application of
Medicare and Medicaid regulations in particular
circumstances, seek assistance from an appropriate
person
If you suspect these rules have been violated in a
particular situation, report your concerns to the
Compliance Officer
HMC shall promptly refund any payment it receives
from Medicare or Medicaid to which it is not entitled
Anti-kickback Statute


The Anti-kickback Statute makes it illegal to ask
for, receive, or offer anything of value in
exchange for patient referrals
Arrangements that are common in other
business sectors, such as offering gifts as
rewards for past or potential future referrals, are
prohibited in the health care industry
Anti-kickback Statute



Violation of the anti-kickback statute may result in
criminal penalties, civil money penalties, and exclusion
from federal healthcare programs (Medicare, Medicaid,
etc.)
Any business arrangement involving another healthcare
provider – whether formal or informal - must be
scrutinized for compliance with the anti-kickback statute
An Associate who is concerned about HMC’s relationship
with another healthcare provider should report those
concerns to the Compliance Officer
The Stark Law



The Stark Law prohibits HMC from submitting claims to
Medicare for services referred by a physician who has a
financial relationship with HMC unless certain regulatory
requirements are satisfied
Any financial relationship with a physician or a
physician’s immediate family member must be
scrutinized for compliance with the Stark Law
An Associate who is concerned about HMC’s relationship
with a Medical Staff member should report those
concerns to the Compliance Officer
Patient Inducements



HMC cannot offer anything of value to Medicare or
Medicaid beneficiaries to attract their business
There are certain limited exceptions to this broad
prohibition
Any Associate who has concerns about patient
inducements should report those concerns to the
Compliance Officer
HIPAA Privacy & Security Rules


Associates must comply with all HMC
policies addressing HIPAA Privacy and
Security Rules’ requirements
Those policies are the subject of a
separate course you will be required to
complete
Consequences Of
Violating Healthcare Laws



A violation of healthcare laws can result in significant
penalties for HMC, even if the violation was unintentional
Certain violations may expose individuals to criminal
liability
Every Associate must play a role in detecting and
preventing such violations
Learning what the law requires
Asking what the law requires in specific
circumstances
Reporting any suspected violations of the law
Cooperating with investigations or corrective action
Principle 3
Compliance With Other Laws
In addition to the laws specific to healthcare providers,
HMC will conduct its operations in compliance with other
federal and state laws, including the following:









Tax Laws
Health and Safety Laws
Environmental Compliance
Weapons, Illegal Drugs, and Alcohol
Equal Employment Opportunity
Antitrust
Copyright
Accuracy and Retention of Records
Identity Theft
Accuracy And Retention Of
Records



Each Associate is responsible for the accuracy and
integrity of all records (both paper and electronic)
prepared by the Associate while performing his/her job
duties or training
All records shall be maintained in compliance with record
retention policies
No record shall be destroyed in an effort to avoid
criminal or civil liability
Identity Theft


Misuse or diversion of patients’ confidential
financial information – called “identity theft” can cause devastating financial loss
Associates must follow appropriate procedures
to detect, prevent, and mitigate any identity
theft
Principle 4
Confidentiality
All Associates are required to read, sign, and
follow HMC’s Confidentiality Agreement
Principle 5
Business Ethics


Associates shall accurately and honestly represent HMC
and shall not engage in any activity or scheme intended
to defraud anyone of money, property, or honest
services
The standards of conduct addressed under Principle 5
include:






Honest Communication
Advertising and Marketing
Patient Billings
Business Transactions
Conflict Resolution
Relationships Among Associates
Honest Communication
No Associate shall make a false or misleading
statement to anyone – including other
Associates - concerning any aspect of HMC’s
operations
Business Transactions


Business dealings with vendors and
contractors must be free from offers or
solicitations of gifts, favors, or other
improper inducements
All Associates must adhere to HMC’s policy
on interactions with vendor
representatives
Patient Billings



The importance of submitting proper claims to Medicare
and Medicaid has been discussed previously
The same standards of conduct apply to claims for
services provided to patients with private insurance and
self-pay patients
If you have any concerns regarding a bill submitted to a
patient or private insurance company, report your
concerns to the Compliance Officer
HMC’s policy on Interactions With
Vendor Representatives
This Policy addresses the following:







Prohibition on kickbacks
Educational programs
Charitable contributions
Educational and promotional materials
Gifts and entertainment
Food and beverages
Consulting services
Prohibition on Kickbacks


Associates cannot solicit or accept (directly or
indirectly) cash, cash equivalents, goods, or
services from a vendor representative in
exchange for assisting the vendor representative
in his/her dealings with HMC
Do not accept anything of value from a vendor
representative if doing so may leave the
impression the representative is somehow
buying influence
Educational Programs

Associates may attend a vendor-sponsored
educational program for which there is no
registration fee or the vendor waives such fee


Associates cannot solicit or accept payment of any
expense associated with attendance at such program
(e.g., travel, lodging) without express written
permission of the Compliance Officer
Associates cannot otherwise solicit or accept
payment of any expense associated with an
educational program or professional meeting
from a vendor representative
Gifts and Entertainment



Associates cannot accept cash or cash
equivalents (e.g., gift certificates) under any
circumstances
May accept non-monetary gifts only if they are
of nominal value or the gift is primarily of an
advertising or promotional nature
Cannot encourage or solicit a vendor
representative to furnish tickets to sporting or
entertainment event or other recreational
opportunities

May accept such an opportunity only if it is
reasonable, occurs infrequently, and does not involve
lavish expenditures
Food and Beverages


Cannot require a vendor representative to provide food
or beverages as a condition of meeting with any
Associate
A vendor may provide food or beverages in connection
with a presentation or discussion at HMC’s facilities
concerning vendor’s products or services if:



Presentation/discussion has legitimate educational value for
attendees
Food or beverage is modest by local standards
Food or beverage is served in manner conducive to
communications
Cannot provide food or beverage to be consumed
outside HMC’s facilities or while vendor representative is
not present
Food and Beverages

An Associate may accept a meal furnished by a vendor
outside HMC’s facilities only if:





Associate must be a decision-maker with respect to the use or
purchase of product or service
Vendor representative cannot furnish meal for spouse,
significant other, family members
Meal must be furnished during a meeting whose sole purpose is
discussion of vendor’s product or service
Vendor representative must be present for the entire meal
Value of food and beverage furnished to Associate over the
course of a day cannot exceed $125.00
Consulting Services

An Associate must obtain prior approval
from the Compliance Officer to provide the
following services for a vendor:



Product evaluation (including surveys and
questionnaires)
Research
Training and teaching
Conflict Resolution


Associates may have disagreements among
themselves regarding job responsibilities,
accountabilities, policies, procedures, and
practices
Associates must work to resolve these
differences using established procedures and
mechanisms, because such conflict could
threaten patient safety and undermine quality of
care
Relationships Among Associates


No Associate should feel required or compelled
to give a gift to a co-worker
Any gift-giving among Associates should be
appropriate in the circumstances


For example, an Associate should not give a lavish
gift to his/her supervisor
No Associate should feel required to participate
in any fundraising activity or contribute to a
charitable organization
Principle 6
Protection Of Assets
All Associates shall strive to preserve and
protect HMC’s assets by making prudent
and effective use of HMC’s resources and
accurately reporting its financial condition
Principle 6 Standards
The standards of conduct addressed under
Principle 6 include:
-
-
Internal Controls and Financial Reporting
Contracts
Business Expenses
Personal Use of Corporate Assets
Intellectual Property Rights and Obligations
Use Of Computers, Communication Systems,
and Related Equipment
Political Activity
Contracts


All proposed contracts must go through
the established review and approval
process
No Associate shall purport to enter into
any agreement on behalf of HMC or
modify an existing agreement unless
specifically authorized to do so
Contracts
The only Associates who are authorized to
sign contracts are:
Dr. Jeter
Some of the Vice-Presidents
No other Associate may sign a contract on
behalf of HMC.
Personal Use Of
Corporate Assets


Any use of items or information belonging to
HMC for personal, financial gain is prohibited
Any use of items or information belonging to
HMC for community or charitable purposes must
be approved in advance
Intellectual Property
Rights and Obligations
Any work of authorship or invention
created by an Associate as part of his/her
work for HMC belongs to HMC
Business Use Of Computers And
Communications Systems


All work-related electronic messages should be
composed in a professional manner similar to messages
sent on HMC letterhead
Computers, communications systems, and related
equipment and the information they contain are HMC
property and shall be primarily used for business
purposes
Personal Use Of Computers And
Communications Systems



Highly limited reasonable personal use of such
equipment is permitted
However, HMC has the right to access an Associate’s
computer files and drives and e-mail and voice mail
messages
Your communications are not private or confidential
Political Activity


Associates cannot use any corporate resource
(including e-mail) for personal political
activity
While you may participate in the political
process on your own time and your own
expense, you cannot give the impression that
you are acting on behalf of or representing
HMC
Principle 7
Conflicts Of Interest
Associates owe a duty of undivided and
unqualified loyalty to HMC. Associates
shall not use their positions to profit
personally or to assist others in profiting in
any way at HMC’s expense
Principle 7 Standards
The following standards of conduct are
addressed under Principle 7:
-
Outside financial interests
Services for competitors/vendors
Outside Financial Interests
An Associate must remain free of any conflict of
interest
A conflict of interest may occur if:


an Associate’s outside financial interests appear to
influence his/her ability to make objective decisions
in performing his/her job duties
the demands of outside activities hinder or district
an Associate from performing his/her job duties
Services From
Competitors And Vendors


No Associate shall work for or have a business
connection with another healthcare provider without
his/her supervisor’s approval
No Associate shall work for or have a business
connection with any person or company that does
business or seeks to do business with HMC without
his/her supervisor’s approval
Summary
You have completed Lesson 4 on the Code of Conduct
Remember:
The Code of Conduct identifies 7 principles:
Patient care and treatment
 Compliance with health care laws
 Compliance with other laws
 Confidentiality
 Business ethics
 Protection of assets
 Conflicts of interest

Summary


Under each principle, there are standards by
which Associates shall conduct themselves
If you have any question concerning any
provision in the Code, contact the Compliance
Officer