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CORPORATE
COMPLIANCE
PROGRAM
HISTORY • Center for Medicare & Medicaid (CMS)
paid $20,000,000,000 in error !
• Improper payment due to:
CODING & BILLING ERRORS
FRAUD & ABUSE
• Enormous financial losses for government
PASSAGE OF HIPAA 1996
Government $$$$ for resources
to detect fraud & abuse
Criminal Offense
OIG strongly recommends
Corporate Compliance
HEALTHCARE FRAUD n.[<Lat. Fraus,
deceit.] 1. Any scheme to obtain money or
property of any healthcare benefit plan by
means of false or fraudulent pretenses,
representations or promises. 2. A deliberate
deception practiced so as to secure unlawful
gain.
.
HEALTHCARE FRAUD = A CRIMINAL OFFENSE
This applies to all claims under health benefit programs
Fines
Prison
Restitution
Sanctions
Corporate Probation
CORPORATE COMPLIANCE
PROGRAM • Designed to detect and prevent violations
of law by employees & physicians
• Offer a framework of ethical guidelines and expectations for the workplace – standards of conduct
• Goal is to ensure that the employees & physicians comply with applicable laws and regulations
• Essential to any organization committed to ethical conduct and sound business practices
GOALS
• Improve Quality of Care
• Improve Documentation
• Minimize Billing Mistakes
• Increase Awareness > Decrease Risk
• Reaffirm Commitment to Our Mission
BENEFITS • Established high ethical standards • Improved financial performance • Improved quality care • Improved documentation • Early detection of potential problems
7 BASIC ELEMENTS OF A
COMPLIANCE PROGRAM
1. Standards of conduct
2. Designated Compliance Officer
3. Effective education and training
4. Audits and other evaluation techniques
5. Internal reporting processes
6. Disciplinary mechanisms
7. Investigation and remediation
CORPORATE COMPLIANCE:
AN ONGOING PROCESS
1.Prevent
2. Detect/Correct 3. Defend/Mitigate
RISK
THE 3C DECISION
MAKING MODEL
Compliance: • Violation of a law, regulation or internal law or procedure
Conscience: • Violation of an ethical principle
Conduct: • Decide on appropriate course of action with which to resolve
the situation
Guides To Determine
Appropriate Behavior
• Integrity
• Common Sense
• Sound Judgment
Ask Yourself These
Questions…
• Are my actions legal?
• Is it fair and honest?
• Is this in the best interest of the
Center and the patients we serve?
• Will my actions stand the test of time?
• How will I feel about myself afterwards?
• Will I sleep soundly tonight?
• What would I tell my child to do?
• How would my words and actions look if
reported in the newspaper?
Examine Your Conscience - If You Think or Hear…
• “Shred that document.”
• “No one will get hurt.”
• “You never heard me say
that.”
• “It can’t hurt just this once…”
• “No one will ever find out…”
• “Everyone does it.”
REPORTING A VIOLATION
TSC Hotline 973 477-7217
Anyone can report a violation without fear of
ANY retaliation by:
Phone
Verbal
Written
CORPORATE COMPLIANCE PROGRAM
1. Written Policies and Procedures
2. Quality Care and Services
3. Reporting and Communication Policy
4. Compliance with Laws and Regulations
5. Medical Records
6. Personnel
7. Safe Work Environment
8. Conflicts of Interests
9. Coding, Billing and Documentation
10.Protecting Property
HINT HINT HINT HINT
• Corporate Compliance is NOT a
JCAHO requirement
• Corporate Compliance is NOT
just for healthcare industries
• ANYONE can report a violation
• Corporate Compliance Officer is
Meg Oser