Valuing IntegrityValuing IntegrityCorporate ComplianceCorporate Compliance

October 2006October 2006

Anne AdamsAnne AdamsChief Compliance Officer Chief Compliance Officer

Emory Healthcare and Emory Medical Care Emory Healthcare and Emory Medical Care FoundationFoundation

Sue DaleSue Dale Administrator, Gynecology and ObstetricsAdministrator, Gynecology and ObstetricsEmory University School of Medicine and Emory University School of Medicine and

The Emory ClinicThe Emory Clinic

What is Compliance ?What is Compliance ?

Complying with applicable Federal and State Complying with applicable Federal and State laws and regulations.laws and regulations.

Following all Emory and departmental policies Following all Emory and departmental policies and procedures.and procedures.

Doing the right thing!Doing the right thing!

Compliance ProgramCompliance 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.

Elements of a Compliance Elements of a Compliance ProgramProgram

Compliance Standards & ProceduresCompliance Standards & Procedures Chief Compliance OfficerChief Compliance Officer Employee TrainingEmployee Training Monitoring & AuditingMonitoring & Auditing Reporting ProcessReporting Process Response & PreventionResponse & Prevention Enforcement & DisciplineEnforcement & Discipline

Role of the Compliance OfficeRole of the Compliance Office

Establish, oversee implementation, and revise the Establish, oversee implementation, and revise the Compliance ProgramCompliance Program

Provide oversight for organization’s compliance activitiesProvide oversight for organization’s compliance activities Provide educationProvide education Provide advice and guidanceProvide advice and guidance Develop compliance policiesDevelop compliance policies Investigate reports of non-complianceInvestigate reports of non-compliance Monitor compliance with rules & regulationsMonitor compliance with rules & regulations Coordinate response to external investigationsCoordinate response to external investigations Oversee corrective actionsOversee corrective actions

WhyWhy Do Organizations Need a Do Organizations Need a Compliance Program?Compliance Program?

Government focus/enforcementGovernment focus/enforcement Risk of prosecution/penaltiesRisk of prosecution/penalties Protect system resources/reputationProtect system resources/reputation Health Insurance Portability and Accountability Act (HIPAA)Health Insurance Portability and Accountability Act (HIPAA) Grants and ContractsGrants and Contracts Research/IRB/FDA/OHRPResearch/IRB/FDA/OHRP Sarbanes/OxleySarbanes/Oxley Healthcare Industry Fraud and AbuseHealthcare Industry Fraud and Abuse

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?

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

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

Non-Retaliation PolicyNon-Retaliation Policy

It is the policy of EIt is the policy of EMORYMORY that individuals making that individuals making good-faith reports of compliance concerns will good-faith reports of compliance concerns will not experience any form of retaliation.not experience any form of retaliation.

If you experience or witness retaliation, report it If you experience or witness retaliation, report it to the Compliance Office immediately.to the Compliance Office immediately.

Incidents of retaliation will have serious Incidents of retaliation will have serious consequencesconsequences..

Are We Getting Our Voluntary Compliance Program Right?

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.

Strengths

Leadership

Physicians committed to patient care

Encourage open communication/questions with managers

Employee commitment

Excellent internal consultants

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 – do’s and don'ts; general deterrence of bad conduct though emphasis on punishment and avoidance.

Must continue to have leadership support – words and resources.

The Role of ManagementThe Role of Management Management serves as the primary example Management serves as the primary example

and the primary source of information for our and the primary source of information for our employees.employees.

Management fosters open communication Management fosters open communication regarding compliance and answers questions regarding compliance and answers questions raised by employees.raised by employees.

Management is accountable for their own actions Management is accountable for their own actions as well as the actions of those they supervise.as well as the actions of those they supervise.

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.

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.

Don’t 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.

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.

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

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

Administrator’s Administrator’s PerspectivePerspective

Most difficult challenge is the task of influencing Most difficult challenge is the task of influencing physicians to adopt compliance as an integral physicians to adopt compliance as an integral part of our standard operating procedures.part of our standard operating procedures.

This is not Monopoly – there is not a get out of jail This is not Monopoly – there is not a get out of jail free cardfree card

““Teaching physicians suffer from mural dyslexia”Teaching physicians suffer from mural dyslexia” ((Fast Tracking Compliance Training in Academic Practices article MGMA)Fast Tracking Compliance Training in Academic Practices article MGMA)

Cannot see the handwriting on the wallCannot see the handwriting on the wall Why are we spending money on compliance?Why are we spending money on compliance? Compliance is a control programCompliance is a control program

Expecting Reactions To Expecting Reactions To ComplianceCompliance

Typical Reactions to ComplianceTypical Reactions to Compliance:: Great men can’t be ruledGreat men can’t be ruled What rules? When did this start?What rules? When did this start? Glassed over eyes – asleepGlassed over eyes – asleep Must not be talking to meMust not be talking to me

Administrator’s ReactionAdministrator’s Reaction:: Never react back or will be seen as the evil oneNever react back or will be seen as the evil one Use positive argumentsUse positive arguments Use a physician championUse a physician champion

What are the Physicians’ What are the Physicians’ ExpectationsExpectations

Communication:Communication: Communicate both good and bad news; communicate Communicate both good and bad news; communicate

regularlyregularly Honor confidentialityHonor confidentiality Share dataShare data Allow venting of frustrations Allow venting of frustrations Stay on their side – avoid defensivenessStay on their side – avoid defensiveness Use examplesUse examples ConsistencyConsistency And…..be cheerful, confident, and optimisticAnd…..be cheerful, confident, and optimistic

Best Practice – Consistent Best Practice – Consistent ThemesThemes

Physician-to-physician communication that Physician-to-physician communication that compliance is not optional – based on compliance is not optional – based on integrityintegrity

Staff need to hear and see that leadership Staff need to hear and see that leadership has taken a stance in favor of ethnical has taken a stance in favor of ethnical business practices.business practices.

Train physicians and staff in small Train physicians and staff in small specialty specific groups – more relevant specialty specific groups – more relevant and makes it practical application easier.and makes it practical application easier.

Best Practice – Consistent Best Practice – Consistent ThemesThemes

Use numerous examples from their own Use numerous examples from their own notes and specialty to demonstrate the notes and specialty to demonstrate the point and use as examples.point and use as examples.

Make the education and training Make the education and training interactive.interactive.

Have a sense of humor.Have a sense of humor. Recent documentation -Recent documentation - The lab test indicated abnormal The lab test indicated abnormal

lover function; The patient is still under our car for physical therapy; The lover function; The patient is still under our car for physical therapy; The patient is numb from her toes down; Patient was alert and unresponsive; patient is numb from her toes down; Patient was alert and unresponsive; When she fainted her eyes rolled around the room; Patient seen in the ED, When she fainted her eyes rolled around the room; Patient seen in the ED, examined, x-rated and sent home.examined, x-rated and sent home.

Questions?

Emory Healthcare Compliance Program404-778-2757 or Extension 8-2757

Anne Adams, MS, JDChief Compliance OfficerEmory HealthcareEmory Medical Care Foundation

Emory Trust Line 1-888-550-8850

Compliance Programs

Questions regarding Research Compliance

Kristin H. West, J.D.Assoc. V.P. & DirectorEmory UniversityOffice of Research Compliance1784 N. Decatur Road, Suite 510Atlanta, GA 30322Phone: (404) 727-2398; FAX: (404) 727-2328

Emory Trust Line 1-888-550-8850

http://www.cms.hhs.govCenters for Medicare and Medicaid Services (CMS)

http://www.georgiamedicare.com/Georgia Medicare Part A

http://www.gamedicare.com/Georgia Medicare Part B

http://www.cms.hhs.gov/hipaa/CMS - HIPAA Main Page

Teaching Big Shots to Behave and other Human Resource ChallengesBy Stephen M Paskoff, Esq.

Helpful Resources

(Visit the OCP web-site to see more resources)

Compliance Office Motto