CORPORATE

COMPLIANCE

PROGRAM

HISTORY • Center for Medicare & Medicaid (CMS)

paid $20,000,000,000 in error !

• Improper payment due to:

CODING & BILLING ERRORS

FRAUD & ABUSE

• Enormous financial losses for government

PASSAGE OF HIPAA 1996

Government $$$$ for resources

to detect fraud & abuse

Criminal Offense

OIG strongly recommends

Corporate Compliance

HEALTHCARE FRAUD n.[<Lat. Fraus,

deceit.] 1. Any scheme to obtain money or

property of any healthcare benefit plan by

means of false or fraudulent pretenses,

representations or promises. 2. A deliberate

deception practiced so as to secure unlawful

gain.

.

HEALTHCARE FRAUD = A CRIMINAL OFFENSE

This applies to all claims under health benefit programs

Fines

Prison

Restitution

Sanctions

Corporate Probation

CORPORATE COMPLIANCE

PROGRAM • Designed to detect and prevent violations

of law by employees & physicians

• Offer a framework of ethical guidelines and expectations for the workplace – standards of conduct

• Goal is to ensure that the employees & physicians comply with applicable laws and regulations

• Essential to any organization committed to ethical conduct and sound business practices

GOALS

• Improve Quality of Care

• Improve Documentation

• Minimize Billing Mistakes

• Increase Awareness > Decrease Risk

• Reaffirm Commitment to Our Mission

BENEFITS • Established high ethical standards • Improved financial performance • Improved quality care • Improved documentation • Early detection of potential problems

7 BASIC ELEMENTS OF A

COMPLIANCE PROGRAM

1. Standards of conduct

2. Designated Compliance Officer

3. Effective education and training

4. Audits and other evaluation techniques

5. Internal reporting processes

6. Disciplinary mechanisms

7. Investigation and remediation

CORPORATE COMPLIANCE:

AN ONGOING PROCESS

1.Prevent

2. Detect/Correct 3. Defend/Mitigate

RISK

THE 3C DECISION

MAKING MODEL

Compliance: • Violation of a law, regulation or internal law or procedure

Conscience: • Violation of an ethical principle

Conduct: • Decide on appropriate course of action with which to resolve

the situation

Guides To Determine

Appropriate Behavior

• Integrity

• Common Sense

• Sound Judgment

Ask Yourself These

Questions…

• Are my actions legal?

• Is it fair and honest?

• Is this in the best interest of the

Center and the patients we serve?

• Will my actions stand the test of time?

• How will I feel about myself afterwards?

• Will I sleep soundly tonight?

• What would I tell my child to do?

• How would my words and actions look if

reported in the newspaper?

Examine Your Conscience - If You Think or Hear…

• “Shred that document.”

• “No one will get hurt.”

• “You never heard me say

that.”

• “It can’t hurt just this once…”

• “No one will ever find out…”

• “Everyone does it.”

REPORTING A VIOLATION

TSC Hotline 973 477-7217

Anyone can report a violation without fear of

ANY retaliation by:

Phone

Verbal

E-mail

Written

CORPORATE COMPLIANCE PROGRAM

1. Written Policies and Procedures

2. Quality Care and Services

3. Reporting and Communication Policy

4. Compliance with Laws and Regulations

5. Medical Records

6. Personnel

7. Safe Work Environment

8. Conflicts of Interests

9. Coding, Billing and Documentation

10.Protecting Property

HINT HINT HINT HINT

• Corporate Compliance is NOT a

JCAHO requirement

• Corporate Compliance is NOT

just for healthcare industries

• ANYONE can report a violation

• Corporate Compliance Officer is

Meg Oser