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General Compliance Training

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1 General Compliance Training
Required General Compliance Training May 13, 2014 Presented by: Compliance Department

2 Overview BHN’s Mission, Vision and Values Culture Of Compliance
Ethics & Compliance Program Compliance Program Basics Compliance Questions Answered Compliance Attestations Laws and Regulations BHN Resources Additional Resources

3 BHN’s Mission, Vision And Values
We exist to make a difference in people’s lives through excellent patient care. We will be a national leader recognized for clinical excellence and innovation, preferred for a highly coordinated patient experience, and distinguished by the quality of our people. People Above All…by treating those we serve and each other with compassion, dignity, and respect; Excellence…by acting with integrity and striving for the highest quality care and service; Results…we show we value results by exceeding the expectations of the people we serve, as well as expectations we set for ourselves. Mission Vision Values

4 A Culture Of Compliance Within Banner Health Network
Do the right thing Prevents noncompliance Detects non compliance Corrects non compliance

5 Ethics – Do The Right Thing!
BHN is committed to possessing and demonstrating the reliability, honesty, trustworthiness and high degree of integrity expected of a leading healthcare organization and a participant in federally funded health-care programs. It is important that you conduct yourself in an ethical and legal manner. It’s about doing the right thing! Act fairly and honestly Comply with the letter and spirit of the law Adhere to high ethical standards in all that you do Report suspected violations

6 Ethics And Compliance Program
Banner Health Network’s (BHN) Compliance Program provides guidance employees and delegates/vendors to better understand and apply complex healthcare laws and regulations.  BHN's Compliance Program protects BHN, employees and delegates/vendors against risks that could result from a failure to comply with legal or ethical requirements

7 Ethics And Compliance Program (cont’d)
The Compliance Program also ensures BHN can seek reimbursement for services provided to Medicare and Medicaid participants. The Compliance Program helps ensure uniformity across BHN.  The Compliance Program and the policies and procedures that make up the Compliance Program apply equally to employees and delegates/vendors.

8 Compliance Program Basics
The Office of Inspector General (OIG) has outlined 7 components of an effective compliance program. Banner Health Network has incorporated these into our comprehensive compliance program. Written Policies, Procedures and Standards of Conduct; Compliance Leadership and Structure; Effective Training and Education; Effective Lines of Communication; Effective System for Routine Monitoring and Identification of Compliance Risks; and Enforcement of Compliance Standards; Procedures and System for Prompt Response to Compliance Issues

9 How Do I Know What Is Expected Of Me?
The BHN Code of Conduct and Compliance Handbook state compliance expectations and the principles and values by which the organization operates. Each Employee and delegate/vendor must report any issue or practice that they believe in good faith may constitute a violation of a law or BHN’s compliance policies. BHN strictly prohibits retaliation against any individual who in good faith reports a suspected violation or suspected illegal or unethical conduct. People who are found to have engaged in unlawful conduct or conduct in violation of BHN policies, or who have failed to detect, report and/or correct any offense, are subject to corrective action, up to and including termination.

10 Effective Line Of Communication
BHN has established lines of communication for compliance issues, including an open line of communication between the compliance department and all associates and delegates/vendors. The BHN ComplyLine ( ) or at are available to submit potential ethics issues or other compliance concerns. The Compliance Department is available to all associates and delegates/vendors to report compliance issues or to respond to compliance questions. BHN has a non-retaliation policy to protect anyone who makes a report in good faith about a potential compliance; fraud, waste and abuse; or ethics issue.

11 Who Is Responsible For Compliance?
Everyone is responsible for compliance. The Board of Directors and Executive Leaders have overall responsibility for the company’s Compliance Program, but each associate and delegate/vendor is responsible to know and comply with all laws related to his/her job and to report non-compliance to a supervisor, the ComplyLine, and/or the Compliance Department. Compliance

12 Why Is Compliance Important?
Compliance is “lights on.” BHN must be a compliant company to stay in business. Being a compliant company makes good business sense. The extent to which we are compliant affects our ability to grow our business, to maintain a positive reputation, and to become the innovative industry leader that we aspire to be. Our focus on compliance underscores our core values of honesty, integrity, transparency and accountability. Correcting compliance problems costs money and resources and reduces activities to grow and improve our company. If compliant programs are implemented and sustained, BHN can focus on its business opportunities.

13 What Does Non-Compliance Cost?
Non-compliance costs the company many ways in the short-term and long-term. In the short-term, it can lead to fines, lawsuits, increased regulatory scrutiny, bad publicity and even increased regulations. In the long-term, non-compliance can lead to loss of business, reputation, and revenue. Once the company is fined or sanctioned, the story is often repeated in related articles for many years continuing to damage the company’s reputation.

14 Compliance Attestation
Banner Health Network’s (BHN) triple aim goals are: improving the patient’s experience of care, improving the health of populations, and reducing the per capita cost of health care. To meet these goals and our commitment to compliance BHN must ensure that our delegates/vendors operate in compliance with the applicable law and regulatory guidance. To facilitate BHN’s responsibilities of ensuring delegates\vendors compliance with laws and regulatory guidance. Delegate/vendors must complete a Compliance Attestation upon contract execution and annually thereafter.

15 CMS Offshore Attestation
The CMS Offshore Attestation is an attestation that must be completed by delegate/vendor that intends to contract with an offshore subcontractor who has access to BHN’s Medicare members PHI/PII and/or fulfills their contract with BHN through offshore employees. Offshore is considered any country that is not one of the fifty United States or one of the United States Territories such as: American Samoa and Puerto Rico. Regardless of whether the subcontractor is American or foreign owned, if the services are performed by employees located in offshore countries, they are subject to complete a CMS Offshore Attestation.

16 Anti-Kickback Statutes
The anti-kickback statute is a federal law prohibiting persons from willfully offering, paying, seeking or receiving anything of value to bring about a referral for medical services or goods payable under Medicare or Medicaid. Failure to obey this law can result in fines, jail or exclusion from the Medicare and Medicaid programs. This law prohibits kickbacks and bribes. It also affects the way healthcare entities carry out a broad range of ordinary business deals.

17 Antitrust Laws Antitrust laws forbid companies from doing business in a way that gives them too much control in the marketplace. The purpose of these laws is to preserve competition. These laws may affect your dealing with patients, doctors, payers, suppliers and competitors. One application of antitrust laws is price fixing. Price fixing is an agreement between business competitors to provide the same service at the same price. In the U.S., price fixing can be prosecuted as a criminal felony offense under the Sherman Antitrust Act. Even exchanging prices may violate the antitrust laws.

18 Health Insurance Portability and Accountability Act (HIPAA)
HIPAA passed in 1996, is a law which governs the way health-related information is shared among healthcare providers. Basically, the only time you can look up person’s information if the person is your patient, or when the information is necessary to carry out your job. Even then, you cannot discuss that information with any one except the person without the person’s express permission. Information about a person’s medical condition is highly sensitive and its confidentiality must be maintained. No employee or delegate/vendor should ever release or discuss personal health information with others unless it is necessary to provide appropriate medical care, it is with the person’s written consent, or it is required by law.

19 Conflict Of Interest A conflict of interest arises whenever an employee’s interest or that of an employee’s immediate family conflicts or appears to conflict with the interest of BHN. Everyone has a duty to avoid conflicts of interest or the appearance of conflicts of interest. Conflicts of interest can occur when employees accept gifts, meals, sponsored training, or travel from outside entities.

20 False Claims Act The False Claims Act (FCA) became federal law in 1863 during the Civil War. Dollars and lives were being lost because unscrupulous contractors made “false claims” against the federal government. The Federal False Claims Act (FCA) imposes civil liability on any person or entity that knowingly submits, or causes to be submitted, a false or fraudulent claim for payment to the U.S. government. This would include fraud involving any federally funded contract or program such as Medicaid and Medicare. The FCA is violated when a person knowingly makes, uses, or causes to be made or used, a false record or statement to get a false or fraudulent claim paid or approved by the federal government.

21 False Claims Act (cont’d)
“Knowingly” may be defined as: A person has actual knowledge of the falsity of the information. A person acts in deliberate ignorance of the truth of falsity of the information. A person acts in reckless disregard of the truth or falsity of the information. A “claim” includes any requests or demand for money that is submitted to the U.S. government or is contractors.

22 False Claims Act (cont’d)
To provide consistent enforcement throughout the country, the Deficit Reduction Act of 2005 (DRA) encourages each state to have its own False Claims Act that is comparable to the federal False Claims Act. The Program Fraud Civil Remedies Act (PFCRA) provides administrative remedies against any person who makes, or causes to be made, a false claim or written statement to various federal agencies, including the Department of Health and Human Services.

23 Stark Law Civil law It owns penalties and connected to the False Claims Act Prohibits certain referrals Prohibits billing Medicare for items and services that are the result of certain services Strict Liability Law No billing Medicare or patient during disallowance period/non-compliance period

24 Intellectual Property
Intellectual property includes patents, trademarks, service marks, trade secrets, copyrights, proprietary information and inventions or techniques. Intellectual property is protected by federal and state laws. Violations of the intellectual property laws may result in personal civil damages or criminal charges. During the course of employment or contractual relationship you may have access to intellectual property owned by other businesses. This information is private and should not be disclosed to others.

25 BHN Resources Kathy Harris, CHC, CPC BHN Compliance Officer (602) BHN Code of Conduct BHN Compliance Handbook ComplyLine (888)

26 Additional Resources Social Security Act:
Title 18 Code of Federal Regulations*: 42 CFR Parts 422 (Part C) and 423 (Part D) and 425 (ACO) CMS Guidance: Manuals HPMS Memos CMS Contracts: Private entities apply and contracts are renewed/non-renewed each year Other Sources: OIG/DOJ (fraud, waste and abuse (FWA)) HHS (HIPAA privacy)

27 Additional Resources Title XVIII of the Social Security Act
Medicare Regulations governing Parts C and D (42 C.F.R. §§ 422, 423 and 425) Offshore Attestation Guidance 2008 CMS Call Letter issued 4/19/2007 HPMS Offshore Attestation memos dated 7/23/2007, 9/20/2007 and 8/26/2008 Civil False Claims Act (31 U.S.C. §§ ) Criminal False Claims Statute (18 U.S.C. §§ 287,1001) Anti-Kickback Statute (42 U.S.C. § 1320a-7b(b)) Antitrust Laws (15 U.S.C. §§ 1-7) (15 U.S.C. § 12-27) Stark Law Statute (Physician Self-Referral Law) (42 U.S.C. § 1395nn) Intellectual Property Law (U.S. Patent and Trademark Office) Exclusion entity instruction (42 U.S.C. § 1395a-7) The Health Insurance Portability and Accountability Act of 1996 (HIPAA) (Public Law ) (45 CFR Part 160 and Part 164, Subparts A and E) OIG Compliance Program Guidance for the Healthcare Industry:

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