DIVISION OF HEALTH SCIENCES
OFFICE OF
INSTITUTIONAL INTEGRITY
Protecting Yourself and Your Practice
WHAT IS HEALTHCARE COMPLIANCE?
Wide range of activities to help
prevent, detect, and avoid fraud and abuse.
 Follow institutional policy, state and federal laws & regulations
 Monitor practice ethics and patient rights legislation
 Effective training, communication, monitoring, enforcement and response
WHO IMPLEMENTS THE
COMPLIANCE PROGRAM?
Office of Institutional Integrity
• Chief Institutional Integrity Officer- Kenneth DeVille, PhD, JD
• Executive Assistant- Lauren Perry
• Healthcare Regulatory Specialist- Michelle C. Evans, MPA
• Billing Compliance Manager- Brandy Styron, RHIA, CCS-P
• Billing Compliance Reviewers- Michele Lang, Kenya Dudley,
Ashley Ross
• Administrative Support Associate- Pam Martin
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Compliance Committees (BSOM, CAHS, SoDM, CoN)
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Most important resource: Individual Employees!
TOP COMPLIANCE RISK AREAS
 Documentation and Billing Integrity
 Fraud and Abuse Laws
 HIPAA Privacy
DOCUMENTATION AND BILLING
 Accurate Coding and Billing are Critical
Fraudulent Billings Result in Stiff Penalties
Billing and Reimbursement Reviews
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Billing for services not performed (or underperformed)
Ordering/billing for medically unnecessary
services
Double billing, Upcoding/Downcoding
If it’s not documented, it will not be
reimbursed
DOCUMENTATION AND BILLING
 Teaching Physician Documentation Rules
Generally need evidence of physician presence during key portion
of medical management with resident.
 Electronic Medical Record Issues
 Sharing of passwords prohibited
 Cutting and pasting is not recommended
 Easy for internal reviewers and external auditors to track.
 Assuming notes (History and Physical, progress notes, office visit,
consults) instead of adding an addendum. (i.e. when adding a
teaching statement, do not click “make me the author”)
NAVIGATING FRAUD AND ABUSE LAWS
FUNDAMENTAL POINTS
 Laws are very broad
 Laws are complex and not intuitive
 Laws apply to a wide variety of common financial relationships
that are not obvious kickbacks or fraud
 Penalties are serious
 Enforcement is rising because of financial benefit to government.
 Mistakes are not fraud, BUT lack of system to control mistakes or
insufficient response to mistakes MAY BE
 Defense is very expensive, even if successful.
FEDERAL FALSE CLAIMS ACT
31 U.S.C. §§ 3729-33
 False Claims Act (FCA) prohibits anyone from “knowingly”
submitting a false or fraudulent claim for payment to the
government.
 “Knowingly” means (i) actual knowledge; (ii) acts in deliberate
ignorance of the truth or falsity of the information; or (iii) acts in
reckless disregard of the truth or falsity of the information.
 No proof of specific intent to defraud is required.
FEDERAL FALSE CLAIMS ACT
False Claims “can” result from actions such as:
 Billing for services not rendered
 “Upcoding”
 “Double-billing”
 Lack of medical necessity
 Pattern of insufficient documentation
 Violation of billing rules
 False certification
FEDERAL FALSE CLAIMS ACT
QUI TAM ACTIONS
 The FCA allows a private person (a “qui tam relator”)
to bring a civil action in the name of the United States.
 Qui tam relators share in any money recovered
(including settlements).
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If government joins in action, relator is entitled to 15% to
25% of proceeds depending on relator’s contribution to case.
If government does not join in action, court may award
relator not less than 25% and not more than 30% of
proceeds.
FEDERAL FALSE CLAIMS ACT
 Civil Penalties:
 Triple damages and penalties of $5,500 to $11,000 per false
claim for submission or causing submission of false claim.
 Criminal Penalties:
 Felony conviction: 5-20 years in jail
 Misdemeanor conviction: 1 year in jail
FEDERAL ANTI-KICKBACK STATUTE
(42 USC § 1320A-7B(B))
Prohibits offering, paying,
soliciting or receiving
anything of value to induce
or reward referrals or
generate Federal health
care program business
FEDERAL ANTI-KICKBACK STATUTE
Statute makes it a crime (felony) to:
 Knowingly and willfully
 Solicit, offer, receive, or pay
 Any remuneration (cash or in kind)
 With intent to induce
 Referrals of an individual for
 The furnishing of a service or item or procedure
 For which a federal healthcare program will pay.
FEDERAL ANTI-KICKBACK STATUTE
 Examples of Kick-backs:
Money, discounts, gifts, and credits
 Criminal and civil liability for failure to comply

Criminal fines up to $25,000 and up to 5 yrs prison term per
violation
 Civil money penalties of $50,000 per violation
 Up to 3 times the amount of kickback
 Exclusion from federal health care programs
 *Possible violation of the False Claims Act
FEDERAL PROHIBITION ON PHYSICIAN
SELF-REFERRAL
STARK LAW (42 USC § 1395NN)
 Prohibits a physician from referring
Medicare patients for designated health
services to an entity with which the
physician (or immediate family
member) has a financial relationship,
unless an exception applies
 Prohibits the designated health services
entity from submitting claims to
Medicare for those services resulting
from a prohibited referral
http://blog.tcs-inc.us/the-medsafe-compliance-corner/bid/54023/The-Stark-Law
PHYSICIAN SELF-REFERRAL
STARK LAW
 Only certain “designated health services” subject to Stark Law
 Stark Safe Harbor/Exceptions
Civil liability for failure to comply
 Overpayment/refund obligation
 False Claims Act liability
 Civil monetary penalties and program exclusion for knowing
violations
 Potential $15,000 CMP for each service
 Civil assessment of up to three times the amount claimed
HIPAA PRIVACY RULE
45 CFR PART 160
SUBPARTS A & E OF PARTS 164
 Use and Disclosure of Protected Health Information (PHI)
 Patient Rights regarding PHI
 University Privacy Officer responsible for implementation
and day-to-day administration
 All privacy complaints should be directed to the
University Privacy Officer
OFFICE OF INSTITUTIONAL INTEGRITY
CODE OF CONDUCT
 Standards for conduct at BSOM
 Must read and sign attestation for Code of Conduct
 Individual commitment to understanding and
following the rules and ethical standards
 Condition of employment
REPORTING INCIDENTS OF POTENTIAL
NON-COMPLIANCE TO THE
OFFICE OF INSTITUTIONAL INTEGRITY
Encouraged to use supervisors, administrators as the first line of
reporting of any known incidents of noncompliance
Compliance Hotline
 Available 24 hours a day, 7 days a week
 Can be anonymous
 Toll free 1-866-515-4587
 E-mail bsomcompliance@ecu.edu
No retaliation for good faith reporting of incidents of noncompliance
All good faith reports will be fully investigated
Confidentiality maintained to the fullest extent possible
Physicians and staff have a professional duty to report potential
problems.
DIVISION OF HEALTH SCIENCES
OFFICE OF
INSTITUTIONAL INTEGRITY
bsomcompliance@ecu.edu
744-5200