GBMC Ethics and Compliance
Program
To every patient, every time, we will provide the care that we
would want for our own loved ones.
Health, healing and hope.
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 .
•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.
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.
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).
Consequences:
•Millions of 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.
•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.
•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.
•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.
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.
Elements of Ethics & Compliance Program
“Tone at the Top”
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
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.
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 completion 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.
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:
○“We Strive to Provide Outstanding Service to Our Patients”
○“We Strive to Abide by the Law and Maintain High Ethical
Standards in Our Business Decision Making”
○“We Strive to Maintain a High Standard of Accuracy and
Completeness in Our Records”
○“We Strive to Maintain a Professional and Safe Work
Environment”
○“We Take Personal Responsibility for Protecting the
Organization’s Resources and Achieving Our Ethical
Goals”
○“We Report Our Compliance Concerns by Using the
Appropriate Chain of Command”
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 Programs.
•Stacey McGreevy, 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.
Audit and Compliance Committee of
the Board of Directors
Dr. John Chessare
President & Chief
Executive Officer
Eric Melchior
Executive Vice President & Chief
Financial Officer
Administrative Reporting Relationship
Stacey McGreevy, CPA
Chief Audit Executive,
Compliance & Privacy Officer
Element #3 Trustworthy Individuals
•The Organization must have used due care not to delegate
substantial discretionary authority to individuals who the
organization knew, or should have known through the exercise of
due diligence, had a propensity to engage in illegal activities.
○GBMC conducts pre-employment screening, including background checks, on employees.
○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.
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.
○GBMC has incorporated Ethics and Compliance Program
training into the mandatory annual competency plan
(That’s why you’re here!!).
○The New Employee Orientation Program contains
training on the Ethics and Compliance Program.
○Specialized training is provided on specific compliance
areas on an as-needed basis throughout the year by the
Compliance Department.
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.
○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.
○Departments throughout GBMC perform various auditing and
monitoring activities to ensure compliance, e.g., the Coding
Department, Medical Records, etc.
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, Stacey McGreevy: 443-849-4325
○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.
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.
○GBMC has a progressive disciplinary policy in place to deal
with individuals who do not comply with internal policies,
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 non-compliance
in good faith. Individuals who report in good faith will be
protected from retaliation.
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.
○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 re-occurrence. Corrective action plans
are followed up on by the Compliance Department.
Areas Where Compliance Risk May Exist
•Confidential Patient Information: 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.
•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. 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.
•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.
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.
•Receiving Gifts and Business Courtesies: GBMC has straightforward, clear cut guidelines outlined in a 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.
For Employee who work in the Medical Center
What I Need to Know About the FCA and GBMC
What is the Deficit Reduction Action
•One issue addressed under the Deficit Reduction Act of 2005 (DRA) is the
increasing problem of fraud and abuse against the Medicaid and Medicare
programs funded by the federal and state governments.
•Under the DRA, any employee who receives move than $5 million per year
in Medicaid payments is required to provide certain education to its
employees. Because GBMC meets the monetary threshold in payments
received from Medicaid, we must provide information and education
regarding:
○The Federal and Maryland False Claims Acts,
○Penalties for violating the False Claims Acts.
○Whistleblower protections
○GBMC’s policies and procedures for detecting and preventing fraud, waste,
and abuse,
○Reporting Concerns and
○GBMC Responsibility
Penalties For Violating The False Claims Act
•Healthcare providers who violate the False Claims Act can be subject to civil
and monetary penalties ranging from $5,500 to $11,000 for each false claim
submitted.
•Healthcare providers can also be required to pay three times the amount of
damages sustained by the U.S. government.
•If the provider is convicted of a False Claims Act violation, the Office of
Inspector General (OIG) may exclude the provider from participation in
federal health care programs.
•GBMC may not employ anyone who has been excluded by the OIG,
therefore at the time of hire and on an ongoing monthly basis all employees
and physicians are checked against the exclusion database to ensure that we
are in compliance.
False Claims Act
•There is a federal False Claims Act (FCA) and a Maryland state version
of the FCA covers fraud involving any federally funded contract or
program in which a person knowingly presents a false or fraudulent claim
to the U.S. government for payment. Similarly the Maryland FCA
applies to anyone who submits false or fraudulent claims to the Medicaid
Program.
•Health care providers can be prosecuted for a wide variety of conduct
that leads to the submission of fraudulent claims to the government, such
as:
○Knowingly making false statements,
○Falsifying records,
○Double-billing for items or services, or
○Submitting bills for services never performed or items never furnished.
Whistleblower Protections
•GBMC offers protection to anyone who suspects and reports a
compliance problem.
•You may report all of your compliance concerns using any one of the
options listed below:
○Contact the Compliance Hotline at 1-800-299-7991 (allows for
anonymous reporting)
○Contact GBMC’s Compliance Officers at (443)849-4325
○Email the GBMC Compliance Department at compliance@gbmc.org
•You may also file a lawsuit on behalf of the U.S. government should
you have actual knowledge of allegedly false claims to the government,
however specific steps must be followed should a person file a lawsuit.
Detains regarding the process may be obtained from the GBMC
Compliance Department
GBMC’s Administrative Policies and Procedures For Detecting And Preventing Fraud, Waste & Abuse
•#009 False Claims Act and Whistleblower Protections Policy
•#003 Compliance Program Policy
•#010 Medicare – Medical Necessity for Ancillary Services
•#005 Conflicts of Interest Policy for Board Members and Officers
•#011 Advanced Beneficiary Notices
•#006 Conflicts of Interest Policy for Management
•#012 Extending Business Services to Division
•#007 Receiving Business Courtesies
Heads/Chiefs/Chairmen
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 Officer, or use the GBMC Business Ethics
Line. 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.