Presentation on theme: "GBMC Ethics and Compliance Program"— Presentation transcript:
1GBMC Ethics and Compliance Program To every patient, every time, we will provide the care that wewould want for our own loved ones.
2Definitions Compliance: Ethics: Conformity; acting according to certain accepted standards.Ethics:The study of: moral values and rules; right and wrong conduct.Contemporary Ethics focuses on Choices .Taken together, they define the essence of the GBMC Ethics and Compliance Program:○A values-based culture that guides our actions in theworkplace so that our daily activities are performed withhonesty, integrity, and in support of the organization’sMission, Vision and Values.
3Ethical Corporate Culture Benefits:Ethics plays an important role in deterring fraud and abuse inorganizations. The overall goal of an effective complianceprogram is to create an ethical corporate culture.An ethical corporate culture reduces the chance that fraud andabuse will occur; or if it does occur, it reduces the chance thatit will go undetected.Fraud:Intentional deception, misrepresentation or perversion of truthin order to damage another or to obtain personal gain.Abuse (in healthcare compliance terms):“Honest” mistakes or errors that organizations should haveknown were mistakes or errors; Culpable Ignorance – a lack ofknowledge for which one can be blamed and held accountable(not an excuse for non-compliance).Ethical Corporate Culture
4Consequences:Millions of Americans cannot afford or are not offered access tohealth insurance. The main barrier to coverage is cost and thebiggest single contributor to unnecessary spending is fraud andabuse.The price tag for fraud and abuse is estimated at $100 billioneach year. The losses caused by fraud and abuse are passed onto individuals through increased insurance premiums, reducedwages, and increased taxation to fund government programs.Virtually every week, a story appears in the news concerningthe government’s investigation of a health care provider ororganization. Behind violent crime and terrorism, health carefraud has been targeted as the number one white-collar priorityof federal prosecutors.Since 1996, Congress has significantly increased the funding forhealth care fraud and abuse enforcement efforts. Additionally,Congress has created powerful new criminal and civilenforcement tools that have enabled the government to expandand intensify the fight against health care fraud and abuse.
5Along with these increased investigations, comes the ability of the government to impose significant fines and penalties onhealthcare organizations and individuals, includingdisqualification from health care programs and even prison.The Office of the Inspector General (OIG) believes thatsignificant reductions in fraud and abuse liability can beaccomplished through the use of compliance programs. Aneffective compliance program can minimize the consequencesresulting from a violation of the law and may, in some cases,convince a prosecutor not to pursue criminal action.The OIG has provided the healthcare industry with modelcompliance program guidance. There are specific elementsthat the OIG requires organizations adopt to be consideredas having an effective compliance program.
6GBMC’s Response Voluntary development of an Ethics and Compliance Program based on the OIG’s requirements that ensuresthat corporate policies, practices, and culture foster theunderstanding of, and compliance with, applicable legalrequirements.
7GBMC Board of Directors Elements of Ethics & Compliance ProgramExternal ForcesExternalForces“Tone at the Top”Ethical Corporate CultureElements of a Compliance Program (OIG)Standards & ProceduresHigh Level OversightTrustworthy IndividualsEducationMonitoring & AuditsEnforcement & DisciplineResponse & PreventionGBMC Board of DirectorsReinforcement of GBMC’s Commitment to Compliance
8Element #1 Standards & Procedures The organization must have established compliance standards and procedures to be followed by its employees that are reasonably capable of reducing the prospect of unlawful activity.○We have developed and continue to develop policies andprocedures to address many legal and regulatoryrequirements. However, it is impractical to develop policiesand procedures that encompass the full body of applicablelaw and regulation that affects our industry. Obviously,those laws and regulations not covered in organizationpolicies and procedures must be followed. GBMC has arange of expertise within the organization, including legalcounsel and numerous functional experts who should beconsulted for advice concerning human resources, legal,billing, tax, and other regulatory requirements.
9Element #1 Standards & Procedures One of the most critical componentsthat supports the OIG requirement for standards and procedures is the GBMC Code of Business Ethics (the “Code”). The purpose of the Code is to articulate GBMC’s message of fair completion and ethical business practices. It addresses some of the complex legal and business ethical issues we face every day and provides guidance for handling some specific compliance scenarios. The Code should be used in conjunction with GBMC policies to provide guidance on regulatory matters.
10Element #1 Standards & Procedures The Code is divided into 6 Guiding Principles which areclosely aligned with GBMC’s objectives, goals and serviceexcellence behaviors. They are:○“We Strive to Provide Outstanding Service to Our Patients”○“We Strive to Abide by the Law and Maintain High EthicalStandards in Our Business Decision Making”○“We Strive to Maintain a High Standard of Accuracy andCompleteness in Our Records”○“We Strive to Maintain a Professional and Safe WorkEnvironment”○“We Take Personal Responsibility for Protecting theOrganization’s Resources and Achieving Our EthicalGoals”○“We Report Our Compliance Concerns by Using theAppropriate Chain of Command”
11Element #2 High Level Oversight Specific individual(s) within high-level personnel of the organization must be assigned overall responsibility to oversee compliance with such standards and procedures.The Audit and Compliance Committee of the Board of Directors is responsible for the oversight of the Ethics and Compliance Programs.Stacey McGreevy, Compliance Officer, is responsible for day-to-day Ethics and Compliance Program activities; as Compliance Officer, she reports to the President & CEO, with an administrative reporting relationship to the EVP & CFO; the Compliance Officer has direct access and provides periodic reports to the Audit Committee.Audit and Compliance Committee of the Board of DirectorsDr. John ChessarePresident & Chief Executive OfficerEric MelchiorExecutive Vice President & Chief Financial OfficerAdministrative Reporting RelationshipStacey McGreevy, CPAChief Audit Executive,Compliance & Privacy Officer
12Element #3 Trustworthy Individuals The Organization must have used due care not to delegatesubstantial discretionary authority to individuals who theorganization knew, or should have known through the exercise ofdue diligence, had a propensity to engage in illegal activities.○GBMC conducts pre-employment screening, including back-ground checks, on employees.○The GBMC Compliance Department performs monthlychecks against a Federal Government database to ensure nosanctions have been imposed against GBMC employees andphysicians that would expose GBMC to any financial risk.
13Element #4 EducationThe organization must have taken steps to communicateeffectively its standards and procedures to all employees byrequiring participation in training programs or bydisseminating publications that explain in a practical mannerwhat is required.○GBMC has incorporated Ethics and Compliance Programtraining into the mandatory annual competency plan(That’s why you’re here!!).○The New Employee Orientation Program containstraining on the Ethics and Compliance Program.○Specialized training is provided on specific complianceareas on an as-needed basis throughout the year by theCompliance Department.
14Element #5 Monitoring & Auditing The organization must take reasonable steps to achieve compliancewith its standards, e.g., by utilizing monitoring and auditingsystems reasonably designed to detect inappropriate conduct by itsemployees and by having in place and publicizing a reportingsystem whereby employees can report compliance concerns with-out fear of retribution.○Every year, the Compliance Department develops an annualcompliance audit plan which outlines the areas that will beaudited to ensure compliance with internal policies, laws,regulations, and contracts. Audit areas are determined basedon a risk assessment process that considers the likelihood andimpact of noncompliance.○Departments throughout GBMC perform various auditing andmonitoring activities to ensure compliance, e.g., the CodingDepartment, Medical Records, etc.
15Element #5 Monitoring & Auditing Employees are educated about the resources available to them toreport compliance concerns including:○Supervisor or Chain of Command○Compliance Officer, Stacey McGreevy:○Compliance Office○Compliance Page on the InfoWeb○Compliance Hotline, a confidential reporting service operated24 hours a day, 7 days a week at ; anonymityof the person placing the report is protected to the extentpossible as dictated by federal and state law.
16Element #6 Enforcement & Discipline The standards must have been consistently enforced throughappropriate disciplinary mechanisms, including, as appropriate,discipline of individuals responsible for the failure to detect anoffense. Adequate discipline of individuals responsible for anoffense is a necessary component of enforcement; however, thediscipline that will be appropriate will be case-specific.○GBMC has a progressive disciplinary policy in place to dealwith individuals who do not comply with internal policies,laws, and regulations. The Compliance Department’sresponsibility is to present the facts of the case and providesupporting documentation and details as necessary. TheHuman Resources Department is ultimately responsible fordisciplinary procedures as they deem appropriate. Allemployees have a duty to report instances of non-compliancein good faith. Individuals who report in good faith will beprotected from retaliation.
17Element #7 Response & Prevention After an offense has been detected, the organization musthave taken all reasonable steps to respond appropriately to theoffense and to prevent further similar offenses.○GBMC requires that issues of noncompliance beresponded to in writing by the appropriate management.This response must outline the corrective action to betaken, by whom, and in what timeframe to deter againstthe possibility of re-occurrence. Corrective action plansare followed up on by the Compliance Department.
18Areas Where Compliance Risk May Exist Confidential Patient Information: We realize the sensitive nature of the information and are committed to maintaining itsconfidentiality. Consistent with HIPAA, we do not use, discloseor discuss patient-specific information with others unless it isnecessary to serve the patient or required by law.Relationships with Physicians: Federal and state laws andregulations govern the relationship between hospitals andphysicians who may refer patients to our facilities. It is importantthat all arrangements with physicians be properly structured tocomply with laws such as Stark, Anti-Kickback and IRSregulations. The two fundamental principles we should all keepin mind are that we do not pay for patient referrals, nor do weaccept payments for referrals we make.
19Licensure and Certification Renewals: GBMC staff who hold positions which require professional licenses, certifications, orother credentials are responsible for maintaining the current status of their credentials and for complying with any federal or state requirements applicable to their roles. GBMC does not allow any colleague, independent contractor, or practitioner to work without valid licenses or credentials.Billing Practices: GBMC will bill only for services actuallyrendered. Services rendered must be accurately and completelydocumented and coded to ensure both proper billing and theintegrity of the medical record.
20Areas Where Compliance Risk May Exist Conflicts of Interest: A conflict of interest may occur if youractivities or personal interests appear to or may influence yourability to make objective decisions required of your job at GBMCWe try to minimize these situations, but if they do occur, wedisclose them to management.Receiving Gifts and Business Courtesies: GBMC has straight-forward, clear cut guidelines outlined in a policy regarding whattypes of courtesies are appropriate for GBMC staff to accept froma person or organization that does business or may want to dobusiness with GBMC.
21What I Need to Know About the FCA and GBMC For Employee who work in the Medical CenterWhat I Need to Know About the FCA and GBMCWhat is the Deficit Reduction ActionOne issue addressed under the Deficit Reduction Act of 2005 (DRA) is the increasing problem of fraud and abuse against the Medicaid and Medicare programs funded by the federal and state governments.Under the DRA, any employee who receives move than $5 million per year in Medicaid payments is required to provide certain education to its employees. Because GBMC meets the monetary threshold in payments received from Medicaid, we must provide information and education regarding:○The Federal and Maryland False Claims Acts,○Penalties for violating the False Claims Acts.○Whistleblower protections○GBMC’s policies and procedures for detecting and preventing fraud, waste, and abuse,○Reporting Concerns and○GBMC ResponsibilityPenalties For Violating The False Claims ActHealthcare providers who violate the False Claims Act can be subject to civil and monetary penalties ranging from $5,500 to $11,000 for each false claim submitted.Healthcare providers can also be required to pay three times the amount of damages sustained by the U.S. government.If the provider is convicted of a False Claims Act violation, the Office of Inspector General (OIG) may exclude the provider from participation in federal health care programs.GBMC may not employ anyone who has been excluded by the OIG, therefore at the time of hire and on an ongoing monthly basis all employees and physicians are checked against the exclusion database to ensure that we are in compliance.False Claims ActThere is a federal False Claims Act (FCA) and a Maryland state version of the FCA covers fraud involving any federally funded contract or program in which a person knowingly presents a false or fraudulent claim to the U.S. government for payment. Similarly the Maryland FCA applies to anyone who submits false or fraudulent claims to the Medicaid Program.Health care providers can be prosecuted for a wide variety of conduct that leads to the submission of fraudulent claims to the government, such as:○Knowingly making false statements,○Falsifying records,○Double-billing for items or services, or○Submitting bills for services never performed or items never furnished.Whistleblower ProtectionsGBMC offers protection to anyone who suspects and reports a compliance problem.You may report all of your compliance concerns using any one of the options listed below:○Contact the Compliance Hotline at (allows for anonymous reporting)○Contact GBMC’s Compliance Officers at (443)○ the GBMC Compliance Department atYou may also file a lawsuit on behalf of the U.S. government should you have actual knowledge of allegedly false claims to the government, however specific steps must be followed should a person file a lawsuit. Detains regarding the process may be obtained from the GBMC Compliance DepartmentGBMC’s Administrative Policies and Procedures For Detecting And Preventing Fraud, Waste & Abuse#009 False Claims Act and Whistleblower Protections Policy#010 Medicare – Medical Necessity for Ancillary Services#011 Advanced Beneficiary Notices#012 Extending Business Services to Division Heads/Chiefs/Chairmen#003 Compliance Program Policy#005 Conflicts of Interest Policy for Board Members and Officers#006 Conflicts of Interest Policy for Management#007 Receiving Business Courtesies
22Reporting Concerns Resources for Guidance ○To obtain guidance on a compliance issue or to report aconcern, individuals may choose from several options:▪We encourage human resources-related issues to behandled by the Human Resources Department experts.▪As an expected good practice, when you arecomfortable in doing so and think it appropriate underthe circumstances, raise concerns first with yoursupervisor.▪If you are uncomfortable in going to your supervisoror it is inappropriate considering the situation, youmay contact another member of management, theCompliance Officer, or use the GBMC Business EthicsLine. All of these resources are clearly defined in theCode along with corresponding contact information.Employees should never feel that they have no where to go when they want to discuss a compliance-related concern.