Back
Menu
Next
GBMC Ethics and
Compliance Program
MISSION
Health. Healing. Hope.
The Mission of GBMC HealthCare is to provide medical care and service of the highest quality to each patient leading to health, healing
and hope.
VISION
Medical sophistication with personalized service.
The Vision of GBMC is to be the preferred medical center in Maryland for the best physicians, nurses and staff by providing medical
sophistication with personalized service, enhanced by clinical education and research with the guiding principle that “the patient always
comes first.”
VALUES
The Values of GBMC are GREATER Values of Respect, Excellence, Accountability, Teamwork, Ethical Behavior and Results.
Back
Menu
Next
Definitions
• Compliance
– Conformity; acting according to certain accepted standards
• Ethics
– The study of: moral values and rules; right and wrong
conduct
– Contemporary Ethics focuses on Choices
2
Back
Menu
Next
Compliance & Ethics
• Taken together, they define the
essence of the GBMC Ethics and
Compliance Program:
– A values-based culture that guides our actions in the
workplace so that our daily activities are performed with
honesty, integrity, and in support of the organization’s
Mission, Vision and Values.
3
Back
Menu
Next
Ethical Corporate Culture
• Benefits
– Ethics plays an important role in deterring fraud and abuse
in organizations. The overall goal of an effective compliance
program is to create an ethical corporate culture.
– An ethical corporate culture reduces the chance that fraud
and abuse will occur; or, if it does occur, it reduces the
chance that it will go undetected.
4
Back
Menu
Next
Definitions
• Fraud
– Intentional deception, misrepresentation or perversion of
truth in order to damage another or to obtain personal gain
• Abuse (in healthcare compliance terms)
– “Honest” mistakes or errors that organizations should have
known were mistakes or errors; Culpable Ignorance – a lack
of knowledge for which one can be blamed and held
accountable (not an excuse for non-compliance)
5
Back
Menu
Next
Fraud and Abuse
• Consequences
– 40-60 million Americans cannot afford or are not offered
access to health insurance. The main barrier to coverage is
cost and the biggest single contributor to unnecessary
spending is fraud and abuse.
– The price tag for fraud and abuse is estimated at $100 billion
each year. The losses caused by fraud and abuse are
passed on to individuals through increased insurance
premiums, reduced wages, and increased taxation to fund
government programs.
6
Back
Menu
Next
Government’s Response
– Virtually every week, a story appears in the news concerning
the government's investigation of a health care provider or
organization. Behind violent crime and terrorism, health care
fraud has been targeted as the number one white-collar
priority of federal prosecutors.
– Since 1996, Congress has significantly increased the
funding for health care fraud and abuse enforcement efforts.
Additionally, Congress has created powerful new criminal
and civil enforcement tools that have enabled the
government to expand and intensify the fight against health
care fraud and abuse.
7
Back
Menu
Next
Government’s Response
– Along with these increased investigations, comes the ability
of the government to impose significant fines and penalties
on healthcare organizations and individuals, including
disqualification from health care programs and even prison.
8
Back
Menu
Next
Government’s Response
– The Office of the Inspector General (OIG) believes that
significant reductions in fraud and abuse liability can be
accomplished through the use of compliance programs. An
effective compliance program can minimize the
consequences resulting 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 model
compliance program guidance. There are specific elements
that the OIG requires organizations adopt to be considered
as having an effective compliance program.
9
Back
Menu
Next
GBMC’s Response
– Voluntary development of an Ethics and Compliance
Program based on the OIG’s requirements that ensures that
corporate policies, practices, and culture foster the
understanding of, and compliance with, applicable legal
requirements.
– The purpose of our Ethics and Compliance Program is to:
o Prevent violations of the law,
o Detect violations of the law,
o Document our efforts in the event violations exist that are not
detected.
10
Back
Menu
Next
Elements of Ethics & Compliance Program
CMS
OIG
“Tone at the Top”
DOJ
FBI
Ethical Corporate Culture
Response & Prevention
Enforcement & Discipline
Monitoring & Audits
Education
Trustworthy Individuals
High Level Oversight
Standards & Procedures
Elements of a Compliance Program (OIG)
GBMC Board of Directors
Reinforcement of GBMC’s Commitment to Compliance
11
Back
Menu
Next
Element #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 and
procedures to address many legal and regulatory requirements.
However, it is impractical to develop policies and procedures that
encompass the full body of applicable law and regulation that
affects our industry. Obviously, those laws and regulations not
covered in organization policies and procedures must be followed.
GBMC has a range of expertise within the organization, including
legal counsel and numerous functional experts who should be
consulted for advice concerning human resources, legal, billing,
tax, and other regulatory requirements.
12
Back
Menu
Next
Element #1 Standards & Procedures
• One of the most critical components
that 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
competition 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.
13
Back
Menu
Next
Element #1 Standards & Procedures
• The Code is divided into 6 Guiding Principles which are closely
aligned with GBMC’s objectives, goals and service excellence
behaviors. They are:
o “We Strive to Provide Outstanding Service to Our Patients”
o “We Strive to Abide by the Law and Maintain High Ethical Standards
in Our Business Decision Making”
o “We Strive to Maintain a High Standard of Accuracy and
Completeness in Our Records”
o “We Strive to Maintain a Professional and Safe Work Environment”
o “We Take Personal Responsibility for Protecting the Organization’s
Resources and Achieving Our Ethical Goals”
o “We Report Our Compliance Concerns by Using the Appropriate
Chain of Command”
14
Back
Menu
Next
Element #1 Standards & Procedures
• These Guiding Principles are defined more thoroughly in the
Code, along with examples of compliance-related practices that
we are required to follow in furtherance of those principles.
Please take the time to review the Code prior to taking the
online test at the end of this section. The Code of Business
Ethics may be obtained electronically via the Compliance Web
Page on the InfoWeb.
15
Back
Menu
Next
Element #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 Program.
Audit and Compliance
Committee of the Board
of Directors
Dr. John Chessare
President & Chief
Executive Officer
Robert W. Thornton, CPA
Executive Vice President &
Chief Financial Officer
• Heather Hill, 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.
Heather Hill, CPC CCS
Chief Compliance
Officer & Director
Revenue Integrity
Heather Breidigam, RN
Clinical Documentation
Specialist
Michelle Abrams, RN
Clinical Documentation
Specialist
Terri Schorr, CPC, CHC
Compliance Manager &
HIPAA Privacy Officer
Barbara Olsen, CPC
Vacant
Medical Auditor
16
Back
Menu
Next
Element #3 Trustworthy Individuals
• The organization must have used due care not to delegate
substantial discretionary authority to individuals whom the
organization knew, or should have known through the
exercise of due diligence, had a propensity to engage in
illegal activities.
o GBMC conducts pre-employment screening, including background
checks, on employees.
o The GBMC Compliance Department performs monthly checks
against a Federal Government database to ensure no sanctions have
been imposed against GBMC employees and physicians that would
expose GBMC to any financial risk.
17
Back
Menu
Next
Element #4 Education
• The organization must have taken steps to communicate
effectively its standards and procedures to all employees
by requiring participation in training programs or by
disseminating publications that explain in a practical
manner what is required.
o GBMC has incorporated Ethics and Compliance Program training into
the mandatory annual competency plan (THAT’S WHY YOU’RE
HERE !!).
o The New Employee Orientation Program contains 30 minutes of
training on the Ethics and Compliance Program.
o Specialized training is provided on specific compliance areas on an
as-needed basis throughout the year by the Compliance Department.
18
Back
Menu
Next
Element #5 Monitoring & Auditing
• The organization must take reasonable steps to achieve
compliance with its standards, e.g., by utilizing monitoring
and auditing systems reasonably designed to detect
inappropriate conduct by its employees and by having in
place and publicizing a reporting system whereby
employees can report compliance concerns without fear of
retribution.
o Every year, the Compliance Department develops an annual
compliance audit plan which outlines the areas that will be audited to
ensure compliance with internal policies, laws, regulations, and
contracts. Audit areas are determined based on a risk assessment
process that considers the likelihood and impact of noncompliance.
o Departments throughout GBMC perform various auditing and
monitoring activities to ensure compliance, e.g., the Coding
department, Medical Records, etc.
19
Back
Menu
Next
Element #5 Monitoring & Auditing
• Employees are educated about the resources
available to them to report compliance concerns
including:
– Supervisor or Chain of Command
– Compliance Officer, Teresa Schorr: 443-849-2358
– Compliance Office email: compliance@gbmc.org
– Compliance Page on the InfoWeb
– Compliance Hotline, a confidential reporting service
operated 24 hours a day, 7 days a week at 1-800-299-7991;
anonymity of the person placing the report is protected to the
extent possible as dictated by federal and state law.
20
Back
Menu
Next
Element #6 Enforcement & Discipline
• The standards must have been consistently enforced
through appropriate disciplinary mechanisms, including,
as appropriate, discipline of individuals responsible for the
failure to detect an offense. Adequate discipline of
individuals responsible for an offense is a necessary
component of enforcement; however, the discipline that
will be appropriate will be case-specific.
o GBMC has a progressive disciplinary policy in place to deal with
individuals who do not comply with internal polices, laws, and
regulations. The Compliance Department’s responsibility is to
present the facts of the case and provide supporting documentation
and details as necessary. The Human Resources Department is
ultimately responsible for disciplinary procedures as they deem
appropriate. All employees have a duty to report instances of noncompliance in good faith. Individuals who report in good faith will be
protected from retaliation.
21
Back
Menu
Next
Element #7 Response & Prevention
• After an offense has been detected, the organization
must have taken all reasonable steps to respond
appropriately to the offense and to prevent further
similar offenses.
o GBMC requires that issues of noncompliance be responded
to in writing by the appropriate management. This response
must outline the corrective action to be taken, by whom, and
in what timeframe to deter against the possibility of reoccurrence. Corrective action plans are followed up on by
the Compliance Department.
22
Back
Menu
Next
Areas Where Compliance Risk May Exist
•
Patient Information – We collect information about the patient’s
medical condition, history, medication, and family illnesses to provide
quality care. We realize the sensitive nature of the information and are
committed to maintaining its confidentiality. Consistent with HIPAA, we
do not use, disclose or discuss patient-specific information with others
unless it is necessary to serve the patient or required by law. This also
applies to situations where our fellow employees become patients.
•
Relationships with Physicians – Federal and state laws and
regulations govern the relationship between hospitals and physicians
who may refer patients to our facilities. It is important that all
arrangements with physicians be properly structured to comply with
laws such as Stark, Anti-Kickback and IRS regulations. Due to the
complexity of these relationships, it may be appropriate to seek
guidance from internal resources such as the Compliance or Legal
Department. The two fundamental principles we should all keep in
mind are that we do not pay for patient referrals, nor do we accept
payments for referrals we make.
23
Back
Menu
Next
Areas Where Compliance Risk May Exist
•
Licensure and Certification Renewals – GBMC staff who hold positions
which require professional licenses, certifications, or other 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 actually rendered.
Services rendered must be accurately and completely documented and
coded to ensure both proper billing and the integrity of the medical record.
Billing must comply with the requirements of state and federal payers and
conform to all payer contracts and agreements. There are federal and state
laws that make it illegal to receive payment for false claims. Hospitals that
engage in practices that violate the False Claims Act could face fines and
penalties. GBMC has processes in place that support the detection and
prevention of fraud and abuse including, external and internal billing and
coding audits, billing compliance committees, monthly monitoring and
employee education.
24
Back
Menu
Next
Areas Where Compliance Risk May Exist
•
Conflicts of Interest – A conflict of interest may occur if your activities
or personal interests appear to or may influence your ability to make
objective decisions required of your job at GBMC. We try to minimize
these situations, but if they do occur, we disclose them to management.
A good rule of thumb that a potential conflict of interest may exist is any
time an objective observer might wonder if your actions are motivated
solely by your responsibilities to GBMC or because you stand to reap
some personal benefit from the situation.
•
Receiving Gifts and Business Courtesies – GBMC has
straightforward, clear cut guidelines outlined in policy regarding what
types of courtesies are appropriate for GBMC staff to accept from a
person or organization that does business or may want to do business
with GBMC. No member of GBMC may ever accept cash or a cash
equivalent (e.g., gift certificates) from anyone in a position to do
business with GBMC, regardless of amount or whether it is directed at
an individual or department. There are ways that vendors can extend
business courtesies to our employees that are appropriate and in
accordance with policy. If you are unsure as to the appropriateness of
a gift or courtesy, ask.
25
Back
Menu
Next
Reporting Concerns
• Resources for Guidance
– To obtain guidance on a compliance issue or to report a
concern, individuals may choose from several options:
• We encourage human resources-related issues to be handled by the
Human Resources Department experts.
• As an expected good practice, when you are comfortable in doing so
and think it appropriate under the circumstances, raise concerns first
with your supervisor.
• If you are uncomfortable in going to your supervisor or it is
inappropriate considering the situation, you may contact another
member of management, the Compliance Office, or use the GBMC
Business EthicsLine. All of these resources are clearly defined in the
Code 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.
26
Back
Menu
Next
GBMC Ethics & Compliance Program
• Final Thoughts
– Compliance impacts all functional areas of the hospital. It is not
just a Billing or Finance problem. We all have a responsibility to
carry out our activities in a manner that is ethical, legal and in
support of the behaviors outlined in the Code of Business Ethics.
Some of us have jobs that are subject to greater levels of
compliance scrutiny and we should be familiar with those
requirements.
– The GBMC Ethics and Compliance Program does not need to be
perfect as long as it demonstrates due diligence. That is why it
is an active, evolving process and not simply a static document.
We can never say that we have finished complying. The very
nature of the healthcare environment eliminates any possibility of
a final compliance product. Laws and rules change constantly
and GBMC has positioned itself to be able to respond and react
to the rapidly changing regulatory environment.
27
Back
Menu
Next
GBMC Ethics & Compliance Program
We hope this Computer-Based Learning course has
been both informative and helpful.
Feel free to review this course until you are confident
about your knowledge of the material presented.
Click the Take Test button on the left side when you are
ready to complete the requirements for this course.
Click on the My Records button to return to your CBL
Courses to Complete list.
Click the Exit button on the left to close the Student
Interface.
28