WMO Atlanta Law WMO Atlanta Law Model Hospital Compliance Program - Form
Office of Inspector General's Compliance Program Guidance for Hospitals Is Finally Released
_________________
COMPLIANCE PROGRAM
("Compliance Program")
I. STATEMENT OF POLICY OF ETHICAL PRACTICES ("Policy")
_________________ (the "Hospital") has a policy of maintaining the highest level of professional and ethical standards in the conduct of its business. The Hospital places the highest importance upon its reputation for honesty, integrity and high ethical standards. This Policy Statement is a reaffirmation of the importance of the highest level of ethical conduct and standards.
These standards can only be achieved and sustained through the actions and conduct of all personnel of the Hospital. Each and every employee, including management employees, of the Hospital is obligated to conduct himself/herself in a manner to ensure the maintenance of these standards. Such actions and conduct will be important factors in evaluating an employee's judgement and competence, and an important element in the evaluation of an employee for raises and for promotion. Employees who ignore or disregard the principles of this Policy will be subject to appropriate disciplinary actions.
Employees must be cognizant of all applicable federal and state laws and regulations that apply to and impact upon the Hospital's documentation, coding, billing and competitive practices, as well as the day to day activities of the Hospital and its employees and agents. Each employee who is materially involved in any of the Hospital's documentation, coding, billing or competitive practices has an obligation to familiarize himself or herself with all such applicable laws and regulations, and to adhere at all times to the requirements thereof. Where any question or uncertainty regarding these requirements exists, it is incumbent upon, and the obligation of, each employee to seek guidance from a knowledgeable officer of, or attorney for, the Hospital.
In particular, and without limitation, this Policy prohibits the Hospital and each of its employees from directly or indirectly engaging or participating in any of the following:
1.Improper Claims.
Presenting or causing to be presented to the United States government or any other health care payer a claim:
a.Item or Service Not Provided As Claimed.
For a medical or other item or service that such person knows or should know(1) was not provided as claimed, including a pattern or practice of presenting or causing to be presented a claim for an item or service that is based on a code that such person knows or should know will result in a greater payment to the claimant than the code such person knows or should know is applicable to the item or service actually provided;
b.False Claim.
For a medical or other item or service and such person knows or should know the claim is false or fraudulent;
c.Service by Unlicensed Physician.
For a physician's service (or an item or service incident to a physician's service) when such person knows or should know the individual who furnished (or supervised the furnishing of) the service -
i. was not a licensed physician;
ii. was licensed as a physician, but such license had been obtained through a misrepresentation of material fact (including cheating on an examination required for licensing); or
iii. represented to the patient at the time the service was furnished that the physician was certified in a medical specialty by a medical specialty board when the individual was not so certified;
d.Excluded Provider.
For a medical or other item or service furnished during a period in which such person knows or should know the claimant was excluded from the program under which the claim was made;
e.Not Medically Necessary.
For a pattern of medical or other items or services that such person knows or should know are not medically necessary;
2.False Statement in Determining Rights to Benefits.
Making, using or causing to be made or used any false record, statement or representation of a material fact for use in determining rights to any benefit or payment under any health care program;
3.Conspiracy to Defraud.
Conspiring to defraud the United States government or any other health care payer by getting a false claim allowed or paid;
4.Patient Dumping.
Refusing to treat, transferring or discharging any individual who comes to the emergency department, and on whose behalf a request is made for treatment or examination, without first providing for an appropriate medical screening examination to determine whether or not such individual has an emergency medical condition, and, if such individual has such a condition, stabilizing that condition or appropriately transferring such individual to another hospital in compliance with the requirements of 42 U.S.C. § 1395dd.
5.Provision of care to contract HMO patients.
Knowingly failing to provide covered services or necessary care to members of a health maintenance organization with which the Hospital has a contract.
6.Health Care Fraud/False Statements Relating to Health Care Matters.
Executing or attempting to execute a scheme or artifice to defraud any health care benefit program, or to obtain, by means of false, fictitious 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;
7.Anti-Referral.
Presenting or causing to be presented a claim for reimbursement to any individual, third party payor, or other entity for designated health services(2) which were furnished pursuant to a referral by a physician who has a financial relationship with the Hospital, as such is defined in 42 U.S.C. § 1395nn;
8.Anti-Kickback.
Except as otherwise provided in 42 U.S.C. § 1320a-7b(b), knowingly and willfully:
a. soliciting or receiving any remuneration (including any kickback, bribe, or rebate) directly or indirectly, overtly or covertly, in cash or in kind either:
i. in return for referring an individual to a person for the furnishing or arranging for the furnishing of any item or service for which payment may be made in whole or in part under a Federal health care program; or
ii. in return for purchasing, leasing, ordering, or arranging for or recommending purchasing, leasing, or ordering any good, facility, service, or item for which payment may be made in whole or in part under a Federal health care program; or
b. offering or paying any remuneration (including any kickback, bribe, or rebate) directly or indirectly, overtly or covertly, in cash or in kind to any person to induce such person either:
i. to refer an individual to a person for the furnishing or arranging for the furnishing of any item or service for which payment may be made in whole or in part under a Federal health care program; or
ii. to purchase, lease, order, or arrange for or recommend purchasing, leasing, or ordering any good, facility, service, or item for which payment may be made in whole or in part under a Federal health care program;
9.Antitrust.
Engaging in any activity, including without limitation being a member of a multiprovider network or other joint venture or affiliation, which is in restraint of trade or which monopolizes, or attempts to monopolize, any part of interstate trade or commerce; or
10.Failure to Report Violations to Compliance Coordinator.
Failing to promptly report to the Compliance Coordinator (as defined below) any instance described in subparagraphs 1 - 9 above with respect to the Hospital or any of its employees which is known to such person.
II. APPOINTMENT OF COMPLIANCE COORDINATOR
A. The Compliance Coordinator
In an effort to ensure compliance with this Policy, the Board of Directors is adopting a formal Compliance Program. To oversee and implement this program, the Hospital has appointed _________________ as its Compliance Coordinator. The Hospital has chosen its Compliance Coordinator based on his/her outstanding record of commitment to honesty, integrity and high ethical standards, and on his/her knowledge and understanding of the applicable laws and regulations. The Compliance Coordinator will provide for education and training programs for employees, respond to inquiries from any employee regarding appropriate billing, documentation, coding and business practices and investigate any allegations of possible impropriety.
B. Duties and Responsibilities of the Compliance Coordinator
The duties and responsibilities of the Compliance Coordinator shall include, but not be limited to, the following:
(i) Working with the Board of Directors, chief executive officer, chief financial officer, chief operating officer and general counsel in the preparation and development of, and overseeing the implementation of, written guidelines on specific federal and state legal and regulatory issues and matters involving ethical and legal business practices, including, without limitation, documentation, coding and billing practices with respect to requests for payments and/or reimbursements from Medicare or any other federally funded health care program, the giving and receiving of remuneration to induce referrals and engagement in certain business affiliations or pricing arrangements that may affect competition;
(ii) Developing and implementing an educational training program for Hospital personnel to ensure understanding of federal and state laws and regulations involving ethical and legal business practices including, without limitation, documentation, coding and billing practices with respect to requests for payments and/or reimbursements from Medicare or any other federally funded health care program, the giving and receiving of remuneration to induce referrals and engagement in certain business affiliations or pricing arrangements that may affect competition;
(iii) Handling inquiries by employees regarding any aspect of compliance;
(iv) Investigating any information or allegation concerning possible unethical or improper business practices and recommending corrective action when necessary;
(v) Providing guidance and interpretation to the Board of Directors, the chief executive officer and Hospital personnel, in conjunction with the Hospital's legal counsel, on matters related to the Compliance Program;
(vi) Planning and overseeing regular, periodic audits of the Hospital's operations in order to identify and rectify any possible barriers to the efficacy of the Compliance Program;
(vii) Preparing at least annually a report to the Board of Directors and the chief executive officer concerning the compliance activities and actions undertaken during the preceding year, the proposed compliance program for the next year, and any recommendations for changes in the Compliance Program;
(viii) Coordinating personnel issues with the Hospital's human resources office (or its equivalent) to ensure that the National Practitioner Data Bank and Cumulative Sanction Report have been checked with respect to all employees, medical staff and independent contractors;
(ix) Ensuring that independent contractors and agents who furnish medical services to the Hospital are aware of the Hospital's Compliance Program including, without limitation, its policies with respect to the specific areas of documentation, coding, billing and competitive practices; and
(x) Performing such other duties and responsibilities as the Board of Directors may request.
C. Compliance Committees
The Compliance Coordinator may create one or more committees to advise the Compliance Coordinator and assist in the implementation of the compliance program. Each committee may have one or more members, who may be hospital employees, independent contractors or other interested parties, and such members shall serve at the pleasure of the Compliance Coordinator. The purpose of providing for such committees is to allow the Hospital and the Compliance Coordinator to benefit from the combined perspectives of individuals with varying responsibilities in the Hospital such as, by way of example only and not obligation, operations, finance, audit, human resources, utilization review, social work, discharge planning, medicine, coding and legal, as well as employees and managers of key operating units.
D. Reporting by Compliance Coordinator
In general, recommendations from the Compliance Coordinator regarding compliance matters will be directed to the appropriate officer or manager of the Hospital. If the Compliance Coordinator is not satisfied with the action taken in response to its recommendations, he will report such concern to the Board of Directors and the chief executive officer. In no case will the Hospital endeavor to conceal Hospital or individual wrongdoing.
E. Establishment of a Hotline
The Compliance Coordinator shall have an "open door" policy with respect to receiving reports of violations, or suspected violations, of the law or of the Policy and with respect to answering employee questions concerning adherence to the law and to the Policy. In addition, the Hospital shall establish a Hotline to the Compliance Coordinator for such reporting or questions. The telephone number for the Hotline is _________________. Telephone calls to the Hotline may come from Hospital employees, patients of the Hospital or others, whether or not affiliated with the Hospital. All information reported to the Hotline by any employee in accordance with the Compliance Policy shall be kept confidential by the Hospital to the extent that confidentiality is possible throughout any resulting investigation; however, there may be a point where an employee's identity may become known or may have to be revealed in certain instances when governmental authorities become involved. Under no circumstances shall the reporting of any such information or possible impropriety serve as a basis for any retaliatory actions to be taken against any employee, patient or other person making the report to the Hotline.
The telephone number for the Hotline, along with a copy of the Compliance Policy, shall be posted in conspicuous locations throughout the Hospital.
III. EDUCATIONAL PROGRAM
A. Purpose of Educational Program
The Compliance Program promotes the Hospital's policy of adherence to the highest level of professional and ethical standards, as well as all applicable laws and regulations. The Hospital will make available appropriate educational and training programs and resources to ensure that all employees are throughly familiar with those areas of law that apply to and impact upon the conduct of their respective duties, including, without limitation, the specific areas of documentation, coding, billing and competitive practices of the Hospital.
B. Responsibility for Educational Program
The Compliance Coordinator, in conjunction with the Hospital's legal counsel, is responsible for implementation of the educational program. The program is intended to provide each employee of the Hospital with an appropriate level of information and instruction regarding ethical and legal standards, including, without limitation, standards for documentation, coding, billing and competitive practices, and with the appropriate procedures to carry out the Policy. Education and training of all employees shall be conducted at least annually. The determination of the level of education needed by particular employees or classes of employees will be made by the Compliance Coordinator. Each educational program presented by the Hospital shall allow for a question and answer period at the end of such program.
C. Subject Matter of Educational Program
The educational program shall explain the applicability of pertinent laws, including, without limitation, applicable provisions of the False Claims Act (31 U.S.C. § 3729), the civil and criminal provisions of the Social Security Act (42 U.S.C. § 1320a-7a and § 1320a-7b, respectively), the patient anti-dumping statute (42 U.S.C. § 1395dd), laws pertaining to the provision of medically necessary items and services that are required to be provided to members of an HMO with whom the Hospital contracts (42 U.S.C. § 1320a-7(b)(6)(D)), criminal offenses concerning false statements relating to health care matters (18 U.S.C. § 1035), the criminal offense of health care fraud (18 U.S.C. § 1347), the Federal Anti-Referral Laws (42 U.S.C. § 1395nn), the Anti-Kickback Laws (42 U.S.C. § 1320a-7b(b)) and the Sherman Antitrust Act (15 U.S.C. §§ 1, 2 and 18). As additional legal issues and matters are identified by the Compliance Coordinator, those areas will be included in the educational program. Each education and/or training program conducted hereunder shall reinforce the fact that strict compliance with the law and with the Hospital's Policy is a condition of employment with the Hospital.
D. Training Methods
Different methods may be utilized to communicate information about applicable laws and regulations to Hospital employees, as determined by the Compliance Coordinator. The Hospital may conduct training sessions regarding compliance which may be mandatory for selected employees. The seminars will be conducted by the Compliance Coordinator, legal counsel for the Hospital or, where appropriate, by Hospital managers or consultants. The Compliance Coordinator may require that certain employees or representatives of the Hospital attend, at the Hospital's expense, publicly available seminars covering particular areas of law. The Hospital's orientation for new employees will include discussions of the Compliance Program and an employee's obligation to maintain the highest level of ethical and legal conduct and standards.
While the Hospital will make every effort to provide appropriate compliance information to all employees, and to respond to all inquiries, no educational and training program, however comprehensive, can anticipate every situation that may present compliance issues. Responsibility for compliance with this Compliance Program, INCLUDING THE DUTY TO SEEK GUIDANCE WHEN IN DOUBT, rests with each employee of the Hospital.
IV. EMPLOYEE OBLIGATIONS
The Compliance Policy imposes several obligations on Hospital employees, all of which will be enforced by the standard disciplinary measures available to the Hospital as an employer. Adherence to the Compliance Program will be considered in personnel evaluations.
A. Employee Obligations
(i) Reporting Obligation. Employees must immediately report to the Compliance Coordinator any suspected or actual violations (whether or not based on personal knowledge) of applicable law or regulations by the Hospital or any of its employees. Any employee making a report may do so anonymously if he/she so chooses. Once an employee has made a report, the employee has a continuing obligation to update the report as new information comes into his/her possession. All information reported to the Compliance Coordinator by any employee in accordance with the Compliance Policy shall be kept confidential by the Hospital to the extent that confidentiality is possible throughout any resulting investigation; however, there may be a point where an employee's identity may become known or may have to be revealed in certain instances when governmental authorities become involved. Under no circumstances shall the reporting of any such information or possible impropriety serve as a basis for any retaliatory actions to be taken against any employee making the report.
(ii) Acknowledgment Statement. Each employee must complete and sign from time to time an Acknowledgment Statement to the effect that the employee fully understands the Compliance Program, and acknowledges his/her commitment to comply with the Program as an employee of the Hospital. Each acknowledgment statement shall form a part of the personnel file of each employee. It shall be the responsibility of each manager to ensure that all employees under his/her supervision who are materially involved in any of the Hospital's documentation, coding, billing and competitive practices have executed such an acknowledgment.
B. Hospital Assessment of Employee Performance Under Compliance Program
(i) Violation of Applicable Law or Regulation. If an employee violates any law or regulation in the course of his/her employment, the employee will be subject to sanctions by the Hospital.
(ii) Other Violation of the Compliance Program. In addition to direct participation in an illegal act, employees will be subject to disciplinary actions by the Hospital for failure to adhere to the principles and policies set forth in this Compliance Program. Examples of actions or omissions that will subject an employee to discipline on this basis include, but are not limited to the following:
(a) a breach of the Hospital's Policy;
(b) failure to report a suspected or actual violation of law or a breach of the Policy;
(c) failure to make, or falsification of, any certification required under the Compliance Program;
(d) lack of attention or diligence on the part of supervisory personnel that directly or indirectly leads to a violation of law; and/or
(e) direct or indirect retaliation against an employee who reports a violation of the Compliance Policy or a breach of the Policy.
(iii)Possible Sanctions. The possible sanctions include, but are not limited to, termination, suspension, demotion, reduction in pay, reprimand, and/or re-training. Employees who engage in intentional or reckless violation of law, regulation or this Compliance Program will be subject to more severe sanctions than accidental transgressors.
C. Employee Evaluation
Employee participation in, and adherence to, the Compliance Program and related activities will be an element of each employee's annual personnel evaluations including, without limitation, annual personnel evaluations of Hospital supervisors and managers. As such, it will affect decisions concerning compensation, promotion and retention.
D. Non-Employment or Retention of Sanctioned Individuals
The Hospital shall not knowingly employ any individual, or contract with any person or entity, who has been convicted of a criminal offense related to health care or who is listed by a Federal agency as debarred, excluded or otherwise ineligible for participation in federally funded health care programs. In addition, until resolution of such criminal charges or proposed debarment or exclusion, any individual who is charged with criminal offenses related to health care or proposed for exclusion or debarment shall be removed from direct responsibility for, or involvement in, documentation, coding, billing or competitive practices. If resolution results in conviction, debarment or exclusion of the individual, the Hospital shall terminate its employment of such individual.
V. RESPONSE TO REPORTS OF VIOLATIONS
The Hospital, along with its legal counsel where necessary, shall promptly respond to and investigate all allegations of wrongdoing of Hospital employees, whether such allegations are received through the Hotline or in any other manner.
A. Investigation
Upon the discovery that a material violation of the law or of the Policy has occurred, the Hospital shall take immediate action to rectify the violation, if possible, and to report the violation to the appropriate regulatory body, if necessary, and to appropriately sanction the culpable employee(s) of the Hospital. Promptly after any discovered material violation is addressed, the Hospital shall, with the assistance of the Compliance Coordinator, amend this Policy in any manner that the Hospital or the Compliance Coordinator feels will prevent any similar violation(s) in the future.
If an investigation of an alleged violation is undertaken and the Compliance Coordinator believes the integrity of the investigation may be at stake because of the presence of employees under investigation, the employee(s) allegedly involved in the misconduct shall, at the discretion of the Compliance Coordinator, be removed from his/her/their current work activity until the investigation is completed. In addition, the Hospital and the Compliance Coordinator shall take any steps necessary to prevent the destruction of documents or other evidence relevant to the investigation. Once an investigation is completed, if disciplinary action is warranted, it shall be immediate and imposed in accordance with the Hospital's written standards of disciplinary action.
VI. AUDITING AND MONITORING
A. Importance of Auditing and Monitoring
It is critical to the Hospital's compliance with the Policy for the Hospital to conduct regular auditing and monitoring of the activities of the Hospital and its employees in order to identify and to promptly rectify any potential barriers to such compliance.
B. Regular Audits
Regular, periodic audits, as periodically as the Compliance Coordinator shall prescribe, shall be conducted with the assistance of the Hospital's legal counsel at the Compliance Coordinator's direction. Such audits shall evaluate the Hospital's compliance with its Compliance Policy and determine what, if any, compliance issues exist. Such audits shall be designed and implemented to ensure compliance with the Hospital's Compliance Policy and all applicable federal and state laws.
Compliance audits shall be conducted in accordance with the comprehensive audit procedures established by the Compliance Coordinator and shall include, at a minimum:
(i)interviews conducted by the Hospital's legal counsel with personnel involved in management, operations and other related activities;
(ii)reviews, at least annually, of whether the Compliance Program's elements have been satisfied (e.g. whether there has been appropriate dissemination of the Compliance Program's standards, training, disciplinary actions, etc.);
(iii)random reviews of Hospital records with special attention given to procedures relating to documentation, coding, billing, the giving and receiving of remuneration to induce referrals and engagement in certain business affiliations or pricing arrangements that may affect competition; and
(iv)reviews of written materials and documentation used by the Hospital.
All compliance audit procedures shall be conducted with the assistance of the Hospital's legal counsel and all investigations, and the results thereof, are confidential.
C. Formal Audit Reports
Formal audit reports shall be prepared with the assistance of the Hospital's legal counsel and submitted to the Compliance Coordinator and the Board of Directors to ensure that management is aware of the results and can take whatever steps necessary to correct past problems and deter them from recurring. The audit or other analytical reports shall specifically identify areas where corrective actions are needed and should identify in which cases, if any, subsequent audits or studies would be advisable to ensure that the recommended corrective actions have been implemented and are successful.
D. Compliance with Applicable Fraud Alerts
The Compliance Coordinator shall regularly and periodically monitor the issuance of fraud alerts by Office of the Inspector General of the Department of Health and Human Services. Any and all fraud alerts so issued shall be carefully considered by the Compliance Coordinator and by the Hospital's legal counsel. The Hospital shall revise and amend this Compliance Policy, as necessary, in accordance with such fraud alerts. In addition, the Hospital shall immediately cease and correct any conduct applicable to the Hospital and criticized in any such a fraud alert.
E. Retention of Records and Reports
The Hospital shall document its efforts to comply with applicable statutes, regulations and federal health care program requirements. All records and reports created in conjunction with the Hospital's adherence to the Compliance Policy are confidential and shall be maintained by the Hospital, through the Compliance Coordinator, in a secure location until such time as the Compliance Coordinator, through consultation with the Hospital's legal counsel, determines that the destruction of such documentation is appropriate.
This Compliance Program has been adopted by the Board of Directors as of the ____ day of __________________, 1998.
NOTES:
1. For purposes of this Policy, the term "should know" means that a person, with respect to information (i) acts in deliberate disregard of the truth or falsity of the information, or (ii) acts in reckless disregard of the truth or falsity of the information.
2. The term "designated health services"
means any of the following items or services: clinical laboratory services; physical
therapy services; occupational therapy services; radiology services, including magnetic
resonance imaging, computerized axial tomography scans, and ultrasound services; radiation
therapy services and supplies; durable medical equipment and supplies; parenteral and
enteral nutrients, equipment, and supplies; prosthetics, orthotics, and prosthetic devices
and supplies; home health services; outpatient prescription drugs; or inpatient and
outpatient hospital services.
ACKNOWLEDGMENT
I hereby acknowledge that I have received and reviewed _________________ (the "Hospital")'s Corporate Compliance Program, including its Policy Statement on Ethical Practices ("Policy"). I fully understand that, as an employee, I have an obligation to fully adhere to these policies and principles.
In particular, I hereby acknowledge and affirm that:
1. I fully understand the Hospital Policy and the Compliance Program, and I acknowledge my commitment to comply with the Hospital Policy and Compliance Program as an employee of the Hospital.
2. When I have a concern about a possible violation of Hospital Policy, I will promptly report the concern to the Compliance Coordinator in accordance with the Compliance Program.
__________________
Date
_________________________________
Employee's signature
_________________________________
Printed name of employee
This page and all pages on the WMO website are © 1995, 1996, 1997 and/or 1998 Scott
C. Withrow and/or Withrow, McQuade & Olsen, LLP. All rights reserved.
NOTE: This site does not, and does not intend to, give legal advice. This form is made available for example purposes only. It is not guaranteed to be complete or up-to-date. This web site is not intended to create an attorney-client relationship between you and Withrow, McQuade & Olsen, LLP and you should not act or rely on any information on this site without seeking the advice of a competent attorney.
This form, and all compliance policies, must be tailored to the particular circumstances of each health care provider. Training is an integral part of an effective compliance program under the guidelines promulgated by the Inspector General of the Department of Health and Human Services. The omission of any element of the written compliance program or the training may cause the design of the program to be challenged by federal authorities. Consultation with competent counsel is strongly recommended. Parties using this form do so at their own risk.
Please send any comments about this web site to wmo@atl.mindspring.com, or contact Scott Withrow at 404-814-0200, fax 404-814-0009.
Return to "Health Care Billing Compliance Programs Strongly Recommended by HHS OIG"
Take a quiz to see if your organization has an effective compliance program
Office of Inspector General's Compliance Program Guidance for Hospitals Is Finally Released
Return to WMO Atlanta Law Home Page
Last updated by Scott Withrow on February 26, 1998