Community Health Systems Compliance Program

1. Community Health Systems Compliance Program Deaconess Medical Center February 2010 Terri McDaniel, Privacy Officer Compliance - It's everyone's responsibility

2. What are we about in Compliance? …a responsibility not only to provide high quality healthcare, but also to personally conduct yourself in such a way that is consistent with the organization’s commitment to operate with the highest standards of integrity and behavior. Wayne T. Smith, CEO Compliance - It's everyone's responsibility

3. Simply stated… Our Compliance program exists to facilitate both ethical and legal conduct. Compliance - It's everyone's responsibility

4. Healthcare, as an Industry, is Becoming Progressively more Regulated… • False Claims Act • Anti-Kickback Statute • STARK • EMTALA • Health Insurance Portability and Accountability Act (HIPAA) • Deficit Reduction Act (DRA) • Sarbanes-Oxley Compliance - It's everyone's responsibility

5. Special Areas of OIG Concern • Billing for items or services not actually rendered • Providing medically unnecessary services • Upcoding • DRG creep • Outpatient services rendered in connection with inpatient stays Compliance - It's everyone's responsibility

6. Special Areas of OIG Concern • Duplicate billing • Unbundling • False cost reports • Billing for discharge in lieu of transfer • Failure to refund credit balances • Patients’ freedom of choice (on discharge - home health, DME, long-term care or rehab) Compliance - It's everyone's responsibility

7. Special Areas of OIG Concern • Financial arrangements between hospitals and physicians (excessive medical director payments, below market fees for space/equipment rental, failure to collect rent, excessive payments to physicians when buying practices) • Patient dumping (EMTALA) Compliance - It's everyone's responsibility

8. Risks Associated with Non-compliance are Significant • Civil Monetary Penalties including potential for Treble Damages • Criminal liability • Administrative exclusion • Local community’s loss of confidence Compliance - It's everyone's responsibility

9. It’s Important to Understand that Every Member of Management has a Lead Role in Compliance • Though all CHS colleagues are required to follow the Code of Conduct, all managers, directors, supervisors, board members, and corporate staff are expected to set the example by conducting their business affairs consistent with the highest ethical and legal standards. [CHS Code of Conduct, pg. 4] • So, how do we do that? I’m glad you asked! Compliance - It's everyone's responsibility

10. Role of Each Individual in Compliance • Perform daily activities with the highest standards of ethics and compliance • Be familiar with and comply with the Code of Conduct • Notify the Facility Ethics & Compliance Officer (ECO), Corporate Compliance department or the Confidential Disclosure line of any actual or suspected violations of any law, the Code of Conduct or Compliance Policy Compliance - It's everyone's responsibility

11. Role of Each Individual in Compliance • Get involved • Management examines existing policies, procedures, practices and records to determine if problems exist • Staff to abide by policies, procedures and practices. • Don’t ignore problems • Ask questions and bring issues to the attention of the appropriate committee or person for action • Staff to bring issues or concerns to their supervisor, member of management or Confidential Disclosure Program. Compliance - It's everyone's responsibility

12. CHS Compliance Program Elements • Corporate Compliance Officer • Corporate Compliance Workgroup • Corporate Compliance Directors • Code of Conduct • Facility Ethics and Compliance Officer (ECO) • Facility Compliance Committee (FCC) • Written Policies and Procedures • Training and Education • Auditing and Monitoring • Eligibility Screening Process • Confidential Disclosure Program Compliance - It's everyone's responsibility

13. CHS Corporate Compliance Officer • Corporate Compliance Officer has oversight and responsibility for the CHS Compliance Program • The Corporate Compliance Officer is also the CHS Privacy Officer • Facility Privacy Officer is sometimes the Facility Compliance Officer or HIM Director. Compliance - It's everyone's responsibility

14. Corporate Compliance Workgroup (CWG) • Members of the CWG function as subject matter resources. • The Workgroup develops and creates both Policies and Tools. • The CWG reviews auditing and monitoring activities. • The CWG also evaluates the Compliance Program with a view to future development and improvement. Compliance - It's everyone's responsibility

15. Our Code of Conduct • The Code of Conduct is the foundation of our Compliance Program. • The Code of Conduct is distributed at time of hire and annually to all employees. Compliance - It's everyone's responsibility

16. Facility Ethics and Compliance Officer (ECO) • Monitor and support the implementation of the CHS Compliance Program for the facility. • Coordinate Compliance Training programs • Coordinate and perform reviews of facility operations to audit and monitor compliance with established laws, regulations, company policies, and managerial guidelines. • Assist in the development and implementation of corrective action plans when areas of non-compliance are identified. • Work with CCO and CHS Compliance Director in investigating reports of alleged non-compliance. Compliance - It's everyone's responsibility

17. The Facility Compliance Committee (FCC) • Conducts training and education programs; • Communicates “downstream” and “upstream”; • Auditing and monitoring, reporting and certifying results; • Developing and implementing action plans for issues identified during auditing and monitoring activities; • Conducting additional activities as specifically designated by the Corporate Compliance and Privacy Officer, such as investigations; Compliance - It's everyone's responsibility

18. The FCC • Provide details when reporting audit findings • Action Plans • What will be accomplished • Who is responsible • Timelines for significant actions, and • Confirmation items/issues identified were completed Compliance - It's everyone's responsibility

19. Facility Compliance Committee Compliance - It's everyone's responsibility

20. Facility Compliance Committee Compliance - It's everyone's responsibility

21. Ad-Hoc Committee Members Compliance - It's everyone's responsibility

22. Compliance Reporting Compliance Reporting CHS Holdings Corporation (Board of Directors) • Quarterly meeting reports by CCO CHS Corporate Management Compliance Committee • Quarterly reports by CCO • Monthly • Compliance Program activities • Risk Assessment reporting • Action plans/education programs Corporate Compliance Workgroup • Monthly • Compliance Program activities • Status Reports • Facility Self Risk Assessments • Action plan development Facility Compliance Committee Compliance - It's everyone's responsibility

23. Auditing and Monitoring • The Compliance Department, as needed, may direct focused audits. • Facility Self Risk Assessments (FSRA) • Validation Audits Compliance - It's everyone's responsibility

24. Compliance Facility Self Risk Assessments (FSRAs) • Used to identify high risk areas • Not punitive • Communication with ECO • Collaboration between facility departments • completion of assessments • identification, completion & follow-up on action plans • Corporate Subject Matter Resource • Reminder Emails from Corporate • Not Started • Incomplete • Questions under Review • Action • System Follow-up • FCC Reporting Follow-up Compliance - It's everyone's responsibility

25. Confidential Disclosure Program • 24/7 Toll free 800-495-9510 • Reporting of known or suspected violations of law, statute, regulations, CHS Code of Conduct, and/or CHS Policy. • A policy and practice of non-retaliation/non-retribution is strictly enforced. • Whistleblower protections are provided under such as areas as FCA, DRA, and Sarbanes-Oxley. Compliance - It's everyone's responsibility

26. The Life of Compliance Line Call 3. Call information is transmitted via interface into Compliance Task Management System (CTMS) 2. Trained operators take caller information 24/7 1. Call contact via 1-800 number 7. A verbal response is made to the caller when the caller completes his/her follow up 6. An appropriate response is drafted for the caller. 4. Call is Triage to determine Compliance vs. Human Resources 5. Locally, an appropriate investigation occurs Compliance - It's everyone's responsibility

27. HIM COMPLIANCE • Pre-Bill Audit – Choose focused DRG’S • Discharge Disposition Review- 100% • OPPS AUDIT – quarterly • Coding • Charge review • PHIPP – Patient Health Information Improvement Project/Teaming for Documentation (TDI) • Coding Compliance Manual • Advance Learning Center • Revenue Cycle Team Member Compliance - It's everyone's responsibility

28. Summary/Questions