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What Every Employee Should Know About Compliance

What Every Employee Should Know About Compliance. What is compliance? An evolving program Now mandatory to participate in Medicare / Medicaid programs; mandated by the Patient Protection / Affordable Care Act (PPACA), 2010

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What Every Employee Should Know About Compliance

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  1. What Every Employee Should Know About Compliance

  2. What is compliance? • An evolving program • Now mandatory to participate in Medicare / Medicaid programs; mandated by the Patient Protection / Affordable Care Act (PPACA), 2010 • Enforced by the federal Department of Health and Human Services’ Office of Inspector General • Healthcare fraud is a federal crime! • Conservative estimates that over $100 Billion is lost to healthcare fraud each year ($273 M / day!) SSH Compliance Program

  3. What is the purpose of the SSH Compliance Program? • To promote honest, ethical behavior in every day operations • To identify, correct and prevent illegal conduct • Compliance applies to EVERY “workforce member” (employees, contractors, vendors, everyone!) SSH Compliance Program

  4. Eight Essential Requirements: • Code of Ethical Conduct / Standards of Conduct • Compliance program policies and procedures • Designating a compliance officer • Internal monitoring and auditing • Training and education of staff • Open lines of communication, including allowing for anonymous reporting • Responding to detected offenses and developing corrective action • Enforcing disciplinary standards SSH Compliance Program

  5. Billing for Services not rendered • Providing medically unnecessary services • Upcoding / “DRG creep” • Duplicate Billing • Stark physician self-referral law • HIPAA violations • Improper payments (“Kickbacks”) • Fraud, abuse, waste Several Risk Areas of OIG Concern:

  6. You are our first line of defense in detecting and preventing violations • Know the rules. Complying with them at all times • Reporting any violations or suspicious activity • Comply with all policies and standards of the hospital • Accept accountability for your role in compliance What is Your Role and Responsibility?

  7. Always obey the law • Carefully bid, negotiate, and perform contracts • Generate accurate billing and claims • Maintain the integrity of physicians, agents, consultants and representatives • Promote a positive work environment • Protect confidentiality • Refuse bribes, kickbacks, and inappropriate referrals What Do We Mean By Standards of Conduct ?

  8. (1) As a general rule, you should use the chain of command whenever possible (2) Speak to your immediate supervisor/manager first, when possible, if you have a question or concern (3) If circumstances exist that prevent you from doing so (such as your concern is with your immediate supervisor, or your immediate supervisor is unavailable) then contact the next level of management (4) Contact the SSH Compliance Officer Compliance Action Rules

  9. For SSH penalties on False Claims may include: • Treble damages of amount sustained by government • Fines of between $5,500 - $11,000 per false claim • Exclusion from Federal health care programs (Medicare, Medicaid) • For “Workforce Members”: • Any workforce member who violates compliance standards is subject to disciplinary action up to and including termination of employment or contract and referral for criminal prosecution • Healthcare fraud is a FEDERAL crime! Consequences:

  10. Honesty • Integrity • Respect • Trust • Responsibility • Citizenship Principles of Compliance (aka: Everything I ever learned I learned in kindergarten!)

  11. Stanislaus Surgical Hospital is fully committed to obeying all laws. • Stanislaus Surgical Hospitalhas zero tolerance for fraud and abuse. • Compliance is not optional, but the way we will operate as an organization. What Will We Do?

  12. Thank You!

  13. Which government agency oversees / enforces the federal compliance program? • The Department of Health and Human Services’ Office of Inspector General • What is the estimated annual dollar amount lost due to healthcare fraud in the United States? • $100 Billion / year • If you suspect fraudulent activity, what actions should you take? • Report it! • Follow your chain of command • If necessary, report incident to higher level or Compliance Officer Compliance Program Questions:

  14. Name 3 of the 8 key risk areas identified by the OIG mentioned in the presentation: • Billing for services not rendered • Providing medically unnecessary services • Duplicate billing • HIPAA violations • Stark physician self-referring • Upcoding / DRG “creep” • Fraud, abuse, waste • Improper payments (“Kick backs”) Compliance Program Questions:

  15. Who is included in the term “SSH workforce”? • All SSH part time, full time, PRN employees • All SSH contracted labor and consultants • All SSH vendors • What is the overriding purpose for the SSH Compliance Program? • To promote honest, ethical behavior in every day operations • To identify, correct and prevent illegal conduct Compliance Program Questions:

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