Compliance for Me
2012
Objectives
After reviewing this training and successful passing
of the quiz, you will be able to:
• Understand your responsibilities in maintaining a
culture of compliance in the workplace
• Learn where compliance policies and
documents are located for easy reference
• Fulfill training requirements established
by Federal and State laws
Exploring Questions & Answers
• What is Compliance?
• What are my
responsibilities as an
employee?
• Where do I find
assistance when needed?
• Where are resources
located? Your Text Here
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COMPLIANCE
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What is Compliance?
Optima Health demonstrates compliance when our
business is conducted legally and ethically, using
the highest clinical and business ethics for our
members and employees while complying with all
the laws that govern our day-to-day operations.
Integrity
1st attribute
Integrity
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COMPLIANCE
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Integrity
Code of Compliance
Use the Code of Compliance as a guide to help
you in your daily work.
• The Code provides general compliance guidelines that
are explained in the company’s policies and
procedures.
• Located on Wavenet/Optima Health/Related Links.
• Training is provided at time of hire and yearly
– Your annual signature is an agreement to comply with
the Code of Compliance and to report any suspected
or possible violations to the appropriate
resource(s).
Integrity
Conflict of Interest
A conflict of interest exists when there is a
conflict between a person’s private or personal
interests and his/her responsibility as an employee.
You must avoid entering into relationships or activities
that could interfere or appear to interfere with your
judgment in making sound business decisions for Optima
Health.
Examples of conflict of interest:
• Investments, employment or other business
relationship with a competitor or customer of Optima.
• Gifts (money, favors, discounts, meals or travel) from
vendors or competitors to you and your family
in excess of $25.
Integrity
Gifts
Our success in the marketplace results from providing superior
services at competitive prices. Our company does not seek
to gain improper advantage by offering business courtesies,
such as entertainment, meals, transportation, or lodging to
our customers.
• Gifts (money, favors, discounts, meals or travel) from
vendors or competitors to you and your family in
excess of $25.
• Gifts to Physicians may not exceed the federal
limit for the year. All gifts must be approved by a Senior
Leader and logged on the shared drive.
• Gifts to Government employees must be
less than $20.
• Gifts to non-government employees must
be less than $25.
Integrity
Member’s Gifts & Prizes
• The Legal and/or Compliance Department must
approve all activities that includes selling, offering
or promising of any gift, raffle, prize, giveaway or
other incentives to members.
• Gifts and incentives to Medicaid members may not
exceed $15. Gifts to Federal Employee members
gifts may not exceed $5. Amounts for gifts to
Commercial members must be approved prior to
offering.
• This includes gifts, rewards, or incentives for
Wellness Programs, HRAs, Disease Management,
etc.
Behavior
2nd attribute
Integrity
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COMPLIANCE
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Behavior
Behavior
Use of Resources
Use of company equipment such as stamp
machines, long distance service, copier, video
equipment, etc. is not permitted for personal use,
except in emergencies or when extenuating
circumstances warrant it.
Any improper financial gain to an employee
through misconduct involving Optima Health property,
including theft of property, embezzlement of money or
the use of money belonging to Optima Health for
anything other than an authorized purpose is a serious
violation and may lead to prosecution.
Behavior
Social Media
• Employees are expected to portray a positive image of Optima,
refrain from spreading rumors and gossip, and not share
confidential or proprietary information on the internet.
• Optima employees will be held accountable for any internet
postings, personal or business-related as outlined in the
Statement of Employee Responsibility & Confidentiality, and
HIPAA regulations.
• Prohibited Personal Internet Activities:
– Cannot use Optima logo.
– No photos or videos from Optima posted.
– No negative postings about Optima employees, Physicians,
members, vendors, partners or competitors.
– No member information posted.
Attitude
3rd attribute
Integrity
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COMPLIANCE
Attitude
Behavior
Attitude
Confidentiality
Employees have a responsibility to not talk
about internal company information, our
members, employees and/or business
associates to anyone outside the company.
This responsibility includes any nonpublic
business plans, financial, personnel or
technological information.
This confidentiality restriction applies even
after employment ends.
Attitude
Team Spirit
Team spirit is defined as the spirit of a group
that makes the members want the group to
succeed.
You are part of the team and you can make a
valuable contribution every day.
Let’s keep the spirit going!
Leadership
Integrity
4th attribute
Leadership
COMPLIANCE
Attitude
Behavior
Leadership
Policies & Procedures
Policies reflect the rules governing the implementation of
the company’s procedures and processes.
Optima has a “Policy Template” for all Departments to use
for all policies and procedures.
The purpose of a standard template is to provide a
consistent, logical framework, making it easy for
regulators to identify which process is associated with a
regulation and assist employees to do their jobs.
The policy and procedure format should be used during
policy reviews and at the time new policies are
developed. The template can be found on SAL,
under the badge in the Compliance folder.
Leadership
Compliance Advice
When seeking advice from the Compliance Department on regulations,
issues, problems, etc:
1.
Your question:
Be very specific when describing the situation,
and provide details, which may affect the answer.
2. Compliance Response:
The Compliance Department gives conservative
interpretations of regulations, not legal advice.
Confidentiality is maintained as much as possible.
3. Your Responsibility:
The Business Owner and Senior Leadership must decide
how to use the information to make the best business
decisions. Decisions should be documented
for future reference.
Leadership
Reporting
Reporting concerns so they are properly addressed is
everyone’s responsibility.
If a concern is identified but not reported, there is
the potential for that concern to remain
“undetected” and this can place employees,
members and the organization at risk in any
number of ways.
Compliance will carefully assess all facts without bias and
evaluate the process or system to determine the necessary
response, this ensures that the regulations and standards
are handled consistently and fairly. This process assists in
creating a safe reporting environment and a just and
ethical culture.
Leadership
Reporting Violations
If you feel there is a situation or problem that needs
to be reported - ask yourself the following
questions:
• Is this behavior in compliance with the Code of
Compliance, Optima Health policies, Federal &
State laws and/or regulations?
• Is this situation uncomfortable?
• What would the general public think?
Report your concerns to your supervisor, your
supervisor’s supervisor, HR, the Compliance
Officer, a Compliance Committee Member, the
two different Hotlines or the
FWA email.
Leadership
Hotline Reporting
If you choose to utilize the Hotline for reporting your
concern or problem, the Hotline:
• Allows you to receive clarification on ethical issues and
any areas of the Code of Compliance;
• Is available for reporting concerns or potential violations;
and
• Guarantees that all calls are confidential and may be
made anonymously.
Call: Sentara Integrity Hotline 1-800-981-6667
Optima FWA Hotline 1-86-826-5277 or
Email: www.compliancealert@sentara.com
Leadership
Record/Documentation Management
• All employees must take great care to guarantee that all
Optima Health records and transactions are complete,
accurate, timely and in compliance with policies and
procedures.
• Marketing documents for commercial products must be
approved and filed through the Compliance Department
according to the regulations of the Bureau of Insurance.
• All Commercial, Medicare and Medicaid documentation,
records and transactions must be kept on file and
retrievable for a period of ten (10) years.
• If you have any questions about document
destruction, please contact Compliance.
Leadership
Contracts
Contract Management for your Department/Unit is the
responsibility of the Manager/Director/VP (Business
Owner).
• Guidelines for drafting, approving, executing, tracking,
and storing of contracts or letters of agreement are
posted on the shared drive/everyone.
• All contract documentation including attachments
and addendums (Business Associate Agreement,
etc.) must be submitted for review and approval
by the Legal Department.
• The Business Owner is responsible for maintenance
and storage of all contracts.
Leadership
Responsibility
• We are all expected to do the jobs we were
hired to do and that means we need to
stay informed about appropriate
standards to properly carry out our
duties.
• Being a leader, maintaining your integrity,
demonstrating good behavior and having a
positive attitude helps contribute to creating a
just and ethical culture within Optima.
Compliance is Everyone’s
Responsibility
Integrity
Leadership
COMPLIANCE
Attitude
Behavior
This is the end of the 2nd Module of the
2012 Optima Health Compliance Course.
Please begin Quiz #2
Integrity
Leadership
COMPLIANCE
Attitude
Behavior