Transcript Statutory Background

CORPORATE COMPLIANCE
Tim Timmons
Vice President
Compliance and Regulatory Services
Health Future, LLC
PRESENTATION OUTLINE
WHAT IS A CORPORATE COMPLIANCE
PROGRAM
WHY DO WE NEED ONE
RECOMMENDED PROGRAM ELEMENTS
WHAT MAKES A PROGRAM EFFECTIVE
PLAN FOR ASSISTING AWPHD HOSPITALS
WHAT IS A CORPORATE
COMPLIANCE PROGRAM
WHAT IS A CORPORATE
COMPLIANCE PROGRAM

A program that articulates the hospitals’
commitment to the provision of health care
services in full compliance with all federal,
state and local laws and regulations, and that
sets forth a plan for proactively preventing,
detecting, and reporting violations of the laws
and regulations which govern the services that
they provide.
WHY DO WE NEED ONE?
REASONS TO DEVELOP A
CORPORATE COMPLIANCE
PROGRAM




Operationalizes the commitment to ethical and
lawful behavior
Reduces the liklihood of violations and
employee whistleblowing
Reduces exposure to civil and criminal liability
Enhances public credibility
REASONS TO DEVELOP A
CORPORATE COMPLIANCE
PROGRAM




Provides assurance of lawful behavior to Board
and senior management
Provides for mitigation of sentences if
convicted of criminal fraud
Protects Board members and officers Caremark decision
Improves the speed and quality of responses to
lawsuits or investigations
RECOMMENDED PROGRAM
ELEMENTS
OIG PROGRAM GUIDANCE

Compliance policies and procedures

Oversight by high-level personnel

Discretionary authority vested in reliable
individuals

Effective training and education

Auditing and monitoring

Consistent disciplinary mechanisms

Appropriate responses to detected violations
OIG PROGRAM GUIDANCE


The compliance program should include all
seven of the elements required by the U.S.
Sentencing Commission and OIG Guidelines
The recommendations of the OIG’s
Compliance Program Guidance for Hospitals
must be considered, depending upon their
applicability to each particular hospital. The
hospital should be prepared to justify noncompliance with any recommendations
WRITTEN POLICIES AND
PROCEDURES



The Hospital Code of Ethics is the foundation of
the compliance program
Each employee should sign an attestation that
he/she will abide by the Code and the
compliance program
Policies and procedures should be developed for
the hospital as a whole, and for the high risk
areas
OVERSIGHT BY HIGHLEVEL PERSONNEL





Designation of a corporate compliance officer
May be a part-time responsibility
Responsible for coordinating the planning,
implementation and monitoring of the program
Direct access to the CEO and the Board, regardless of
his/her direct reporting relationship
Establishment of a compliance committee
EFFECTIVE EDUCATION
AND TRAINING




Required of all hospital staff, employees,
physicians, independent contractors and other
significant agents
New employees must be educated early
Training in other languages for culturally diverse
staff should be used
Number of hours of training should be specified
• High-risk areas should receive more training
• Training must be documented
EFFECTIVE LINES OF
COMMUNICATION




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Access to the compliance officer necessary
Develop non-retaliation and confidentiality
policies
Advise employees that anonymity can’t be
guaranteed
Employees should report all suspected misconduct
Document employee questions and answers,
investigations and results
Use of hotlines is encouraged if needed
DISCIPLINARY
ENFORCEMENT


Discipline should be consistently enforced
Background investigations should be
conducted for new employees who have
discretionary authority to make decisions that
may involve compliance or who have
compliance oversight
AUDITING/MONITORING



All OIG Work Plan risk areas should be
reviewed over the course of the year
Additional high-risk areas should be reviewed
based on priority
The effectiveness of the compliance program
should be formally evaluated annually
AUDITING/MONITORING –
OIG PROGRAM GUIDANCE
Hospitals
Home Health
Long Term Care
Physician Offices
Medicare + Choice
Laboratories
Hospice
DME
Third Party Billing
Rx Manufacturers
RESPONSES TO DETECTED
VIOLATIONS



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Steps should be taken to immediately correct
problems detected
Report misconduct to the appropriate
governmental agency not more than 60 days
after discovering credible evidence of a
violation
Investigate suspected violations ASAP
Overpayments should be promptly refunded
WHAT MAKES A PROGRAM
EFFECTIVE?
WHAT MAKES A PROGRAM
EFFECTIVE?




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Support of board and executive staff
Ongoing education of staff, particularly in the highrisk areas
Monitoring and auditing (reviewing) high-risk areas
Consistency in enforcement
HCCA publishing effectiveness criteria
PLAN FOR ASSISTING
AWPHD HOSPITALS
PLAN FOR ASSISTING
MEMBER HOSPITALS

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
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Provide a model comprehensive compliance
program, addressing all high-risk areas
Provide compliance education to key hospital
personnel
Update AWPHD hospitals on significant new
compliance developments
Provide compliance tools for effective program
implementation
Provide compliance consultation
QUESTIONS?