1. 2010 Region II Conference Corporate Compliance Panel June 3, 2010
Tamy Skaist, Compliance Officer
Ezra Medical Center, Brooklyn, NY

2. My life before I became the Compliance Officer at Ezra Medical Center

3. My life after I became the Compliance Officer at Ezra Medical Center

4. Overview Background on Ezra Medical Center
Organization of Compliance Program
Compliance Officer
Compliance Committee of the Board
Board of Directors
Compliance Policy Overview
Compliance Training
Compliance Reporting System
Compliance Auditing
Other Relevant Policies and Procedures

5. Background on Ezra Medical Center
Located in Brooklyn, NY
State-of-the-art facility built in 2008

6. EZRA MEDICAL CENTER

7. Bird’s-Eye View of EMC Facility

8. Reception Area

9. Dental Exam Room

10. Background on Ezra Medical Center
Services offered:
Primary care, adults and pediatrics
Dentistry, adults and pediatrics, Mobile Dental Van
Optometry and vision therapy
Dermatology
Podiatry

11. Background on Ezra Medical Center
Ezra Medical Center opened its doors in With minimal resources, the health center created a vital community resource of medical, dental and social service visits for its target population.
During the past 5 years, we’ve seen a growth of over 1,000%.
Currently, we see over 3,000 visits per month.

12. Organization of Compliance Program
Compliance Officer
Manages Compliance Program
Tracks new developments
Ensures compliance reviews are performed
Conducts compliance training
Responds to reports, complaints and questions
Makes reports to Compliance Committee of the Board

13. Organization of Compliance Program
Compliance Committee of the Board
Oversees Compliance Program
Receives reports from Compliance Officer
Reviews compliance activities
Addresses specific compliance-related concerns
Makes recommendations for changes

14. Organization of Compliance Program
Employees
Given periodic compliance training
Front line in detecting potential compliance issues

15. Compliance Program Purpose Particular areas of focus include:
To ensure that Ezra Medical Center operates in full compliance with all relevant laws, regulations, and guidelines
Particular areas of focus include:
Accuracy of coding
Claims development and submission
Documentation of services rendered
Services are reasonable and necessary
False Claims Act issues
Fraud and abuse (kickbacks/self-referrals)

16. Compliance Policy Overview
Privacy and security:
Security Officer with responsibility for privacy and security issues
Regular HIPAA training for staff
Workstations are physically secure
Workstations in public areas are protected with privacy filters
Password protected screen savers when workstations unattended for 5 minutes or more
User accounts disabled immediately upon termination of user’s employment

17. Compliance Training Bi-annual compliance training for all staff
Review compliance program
Review of staff responsibilities
Discussion of reporting mechanisms
Coding and billing training:
Done upon hire, and two times a year

18. Compliance Reporting System
Staff are required to report any potential issues to their supervisor, another person in management, or the Compliance Officer
Compliance hotline has been established
Toll-free number
Available 24 hours per day, 7 days per week
Reports are anonymous
Reports go to Compliance Officer and/or the Executive Director

19. Compliance Auditing
Current and prospective employees are screened against applicable databases, including:
HHS OIG’s List of Excluded Individuals and Entities
GSA’s List of Parties Debarred from Federal Programs
New York State Medicaid Office of Inspector General List of Excluded Individuals and Entities
Regular self-audits
Done on a quarterly basis
Audit of sample charts to ensure that coding and billing accurate
Review by medical records personnel

20. Responding to Violations
Investigation by Compliance Officer
Ensure that investigation is initiated as soon as reasonably possible.
Identify and review relevant documentation
Identify and interview relevant staff members
Suspension of staff member from job function to protect integrity of investigation, if necessary
Involvement of legal counsel as required
Report to Compliance Committee of the Board
Corrective action
Up to and including termination of staff member(s) involved

21. Other Relevant Policies and Procedures
Whistleblower Protection Policy
Prohibits retaliation or discrimination against any person for making a complaint, assisting in an investigation, or reporting an incident of suspected illegal or unethical conduct
Subjects anyone engaging in retaliation to appropriate disciplinary action, which may include termination
Conflict of Interest Policy
Establishes policy for handling potential conflicts of interest
Among other things, requires approval of non-conflicted Board members for any transaction involving a conflicted party
Document Retention Policy
Implemented by Compliance Officer
Establishes minimum retention periods for records
Developed in consultation with legal counsel

22. Questions?