Valuing Integrity Corporate Compliance October 2006 Anne Adams Chief Compliance Officer Emory...

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Transcript of Valuing Integrity Corporate Compliance October 2006 Anne Adams Chief Compliance Officer Emory...

  • Slide 1
  • Valuing Integrity Corporate Compliance October 2006 Anne Adams Chief Compliance Officer Emory Healthcare and Emory Medical Care Foundation Sue Dale Administrator, Gynecology and Obstetrics Emory University School of Medicine and The Emory Clinic
  • Slide 2
  • What is Compliance ? Complying with applicable Federal and State laws and regulations. Complying with applicable Federal and State laws and regulations. Following all Emory and departmental policies and procedures. Following all Emory and departmental policies and procedures. Doing the right thing! Doing the right thing!
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  • Compliance Program Committed to conducting business in compliance with all federal, state, and local laws. Committed to preventing and detecting non- compliance. Standards of Conduct and other policies to guide our activities.
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  • Elements of a Compliance Program Compliance Standards & Procedures Compliance Standards & Procedures Chief Compliance Officer Chief Compliance Officer Employee Training Employee Training Monitoring & Auditing Monitoring & Auditing Reporting Process Reporting Process Response & Prevention Response & Prevention Enforcement & Discipline Enforcement & Discipline
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  • Role of the Compliance Office Establish, oversee implementation, and revise the Compliance Program Establish, oversee implementation, and revise the Compliance Program Provide oversight for organizations compliance activities Provide oversight for organizations compliance activities Provide education Provide education Provide advice and guidance Provide advice and guidance Develop compliance policies Develop compliance policies Investigate reports of non-compliance Investigate reports of non-compliance Monitor compliance with rules & regulations Monitor compliance with rules & regulations Coordinate response to external investigations Coordinate response to external investigations Oversee corrective actions Oversee corrective actions
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  • Why Do Organizations Need a Compliance Program? Government focus/enforcement Government focus/enforcement Risk of prosecution/penalties Risk of prosecution/penalties Protect system resources/reputation Protect system resources/reputation Health Insurance Portability and Accountability Act (HIPAA) Health Insurance Portability and Accountability Act (HIPAA) Grants and Contracts Grants and Contracts Research/IRB/FDA/OHRP Research/IRB/FDA/OHRP Sarbanes/Oxley Sarbanes/Oxley Healthcare Industry Fraud and Abuse Healthcare Industry Fraud and Abuse
  • Slide 7
  • Centers for Medicare & Medicaid Services (CMS) Office of Inspector General (OIG) Department of Justice (DOJ) Federal Bureau of Investigation (FBI) Financial Crimes Section Georgia Bureau of Investigation (GBI) Medicare/Medicaid Fraud Unit Office of Civil Rights (OCR) Who Are the Players?
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  • To know the rules that apply to your section/department. Follow the rules, help find and report potential violation and problems. Actively participate in and promote compliance. Your Responsibility
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  • Main Areas of Risk Teaching physician presence. Billing for items or services not rendered (or documented). Providing medically unnecessary services. Upcoding/ Unbundling. Failure to properly use modifiers (25, 26, 59, etc.). Consultations/New vs. established. Misrepresenting diagnosis to justify service. Billing for a non-covered service as covered. Research misconduct Research Effort Reporting
  • Slide 10
  • Non-Retaliation Policy It is the policy of E MORY that individuals making good-faith reports of compliance concerns will not experience any form of retaliation. It is the policy of E MORY that individuals making good-faith reports of compliance concerns will not experience any form of retaliation. If you experience or witness retaliation, report it to the Compliance Office immediately. If you experience or witness retaliation, report it to the Compliance Office immediately. Incidents of retaliation will have serious consequences. Incidents of retaliation will have serious consequences.
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  • Are We Getting Our Voluntary Compliance Program Right?
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  • Are compliance efforts impacting employee and organizational activity? Enhance to improve quality/to make greater. Culture social behavior patterns typical of a population or community at a given time. Education. Resources. Awareness/Open communication. Influence positive behavior. Meet requirements of the Federal Sentencing Guidelines. We have a solid foundation and we want to build on that foundation and reaffirm our commitment.
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  • Strengths Leadership Physicians committed to patient care Encourage open communication/questions with managers Employee commitment Excellent internal consultants
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  • A blended program value based awareness of key organizational principles; prevention; core principals are offered; employees are individually accountable to values; encourage employees to question decisions before taking action. rules based dos and don'ts; general deterrence of bad conduct though emphasis on punishment and avoidance. Must continue to have leadership support words and resources.
  • Slide 15
  • The Role of Management Management serves as the primary example and the primary source of information for our employees. Management serves as the primary example and the primary source of information for our employees. Management fosters open communication regarding compliance and answers questions raised by employees. Management fosters open communication regarding compliance and answers questions raised by employees. Management is accountable for their own actions as well as the actions of those they supervise. Management is accountable for their own actions as well as the actions of those they supervise.
  • Slide 16
  • Compliance is a team effort Everyone is responsible for making a winning team. No room for behavior not geared to professionalism, integrity, compliance and excellence. Off Messages that are inconsistent with a culture of compliance risks our reputation of excellence. Lead by example - we have set clear expectations for documentation and coding compliance. Emory goes beyond compliance.
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  • We must maintain a culture of professionalism, integrity and compliance at Emory. Current culture is healthy, but want to continue to maintain/improve health and wellness continue to ask questions and raise compliance concerns. Dont want to leave organization, employees and physicians vulnerable to not meeting regulations/ government inquiry. Accurate documentation, coding and billing are critically important functions. Non-compliance by a few puts Emory at risk.
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  • Integrity and Ethics physicians, administrators, staff, board members are all involved and it reaches across all functions. Ultimately enhancing our culture of compliance goes to integrity strategy compliance plays a role/faciliate, but managers at all levels and across functions are involved in the process. Physician/Management Driven. Must have a willingness to seek solutions within framework of values. Values are integrated into the normal channels of managements. Support and reinforce organizational values.
  • Slide 19
  • Follow applicable rules and regulations. Ask questions if the rules are unclear. Act when your instincts tell you something is wrong. You must report potential violations. Be a part of the solution if a problem is found. Commitment to Compliance
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  • Who do I go to? Supervisor or Manager Compliance Department 404-778-2757 Emory Healthcare Trust Line 1-888-550-8850 ( Anonymous Reporting 24/7) What will happen? Determination who will handle issue Investigation Action Reporting Potential Problems
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  • Administrators Perspective Most difficult challenge is the task of influencing physicians to adopt compliance as an integral part of our standard operating procedures. Most difficult challenge is the task of influencing physicians to adopt compliance as an integral part of our standard operating procedures. This is not Monopoly there is not a get out of jail free card This is not Monopoly there is not a get out of jail free card Teaching physicians suffer from mural dyslexia (Fast Tracking Compliance Training in Academic Practices article MGMA) Teaching physicians suffer from mural dyslexia (Fast Tracking Compliance Training in Academic Practices article MGMA) Cannot see the handwriting on the wall Cannot see the handwriting on the wall Why are we spending money on compliance? Why are we spending money on compliance? Compliance is a control program Compliance is a control program
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  • Expecting Reactions To Compliance Typical Reactions to Compliance : Typical Reactions to Compliance : Great men cant be ruled Great men cant be ruled What rules? When did this start? What rules? When did this start? Glassed over eyes asleep Glassed over eyes asleep Must not be talking to me Must not be talking to me Administrators Reaction : Administrators Reaction : Never react back or will be seen as the evil one Never react back or will be seen as the evil one Use positive arguments Use positive arguments Use a physician champion Use a physician champion
  • Slide 23
  • What are the Physicians Exp