Gwinnett Health System’s Annual Education 2014
Corporate Compliance:
Our Commitment to Excellence
Prepared by:
The Office of Corporate Compliance & HIPAA Administration
Objectives
After completing this Computer-Based Learning (CBL)
module, you should be able to:
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Define compliance.
Describe the GHS Code of
Conduct and Associate
Handbook, including:
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The topics they cover, and
Where to obtain a copy of
each.
Define the role of the Office of
Corporate Compliance &
HIPAA Administration.
List examples of ethical
behavior.
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Describe how the Fraud,
Waste, and Abuse Laws
apply at GHS.
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List associate responsibilities
for compliance.
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List the ways to report any
concern.
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Describe the GHS nonretaliation policy and your
rights and protection.
Compliance Education
Compliance education is required for:
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All newly hired associates during general
orientation,
All associates annually, and
Associates in some areas that require additional
education depending on their role at GHS.
What is Compliance?
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Compliance in the workplace means following the rules,
regulations, and laws set forth by the government and GHS
policies and procedures.
Compliance is being ethical and honest in everything you do.
Examples include:
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Obeying the law.
Following GHS policies and procedures.
Responding appropriately when you discover errors.
Timely reporting when you have concerns.
Understanding the constant changes in healthcare:
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Rules and regulations.
Coding and billing.
Payments or reimbursement.
Medicare and Medicaid Coverage rules.
Corporate Compliance Program
The Corporate Compliance Program is how we
promote and monitor compliance at GHS.
 The program includes the seven elements of an
effective compliance program defined by the
U.S. Federal Sentencing Guidelines.
 The seven elements were developed to assist
organizations in creating a “Compliant
Environment.”
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The Seven Elements
1.
Designation of a Chief Compliance Officer/Compliance
Committee/Compliance Program.
2.
Develop written standards of conduct and policies and procedures.
3.
Provide regular compliance training and education for all associates.
4.
Have effective and open lines of communication to receive
anonymous complaints and to allow complaints from associates
without fear of retaliation, such as a hotline.
5.
Auditing and monitoring to identify potential problem areas.
6.
Prevention and process improvement to remedy any opportunities
found within the system that have the potential to lead to a violation.
7.
Enforcement and disciplinary actions to respond to allegations of
wrongdoing and to enforce disciplinary action against those who have
violated the Code of Conduct and GHS polices and procedures.
Compliance Resources
Compliance resources:
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GHS Code of Conduct
GHS Associate Handbook
GHS policies and procedures
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The GHS Corporate Compliance Program, Policy
#9510-01-01
Annual compliance education
Corporate Compliance intranet web site
Compliance Hotline: 1-888-696-9881
Directly contact the Compliance Office
GHS Code of Conduct
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Our Code of Conduct is GHS’s written commitment
to compliance.
It covers a variety of topics, including:
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Referral relationships.
Vendor relationships.
Conflicts of interest.
Billing and coding.
Reporting compliance concerns.
Workplace conduct.
Patient quality of care.
Patient and associate safety.
Confidentiality.
GHS Associate Handbook
Our Associate Handbook:
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Is a companion resource to the
Code of Conduct.
Explains how GHS complies
with employment-related laws
and regulations.
Provides guidance about GHS:
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Human Resources policies
and procedures.
Employment, benefits, and
pay practices.
Expectations for proper
workplace conduct.
ASSOCIATE HANDBOOK
Revision Date: June 2007
February 2008
GMCConnect Resources
The GHS Code of Conduct and the Associate
Handbook are available on GMCConnect under
Resources/Associate/Organizational Expectations.
GHS Policies and Procedures
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Know and understand the policies and procedures in
your area.
Ask when you aren’t sure of the correct way to do
something, or if something doesn’t seem right.
GHS policies and procedures are available on
GMCConnect under Quick Links/View Important
Documents.
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Intranet Compliance Web Site
Compliance resources and Compliance team
member contacts are also available on the
Corporate Compliance intranet web site.
 The Corporate Compliance intranet web site is
available on GMCConnect. To access it, click on
Departments/Corporate Compliance.
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The Value of Participation
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You are the key to a successful compliance program.
Help make GHS stronger by:
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Participating in:
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Policy development.
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Department meetings.
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Town hall meetings.
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Other opportunities to learn about our healthcare system.
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Your professional association.
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Communicating effectively and professionally with
management, physicians, and co-workers.
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Asking questions!
Remember: You are the key to our success!
Have a Concern?
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Any associate can report a concern.
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Managers typically offer the best and quickest
response to situations.
If you are not comfortable talking to your manager, or
feel a concern is not being addressed, contact:
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The Office of Corporate Compliance & HIPAA
Administration, or
The associate relations director in Human Resources.
You can report any concern at any time to the
Compliance Hotline at 1-888-696-9881.
The Compliance Hotline
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The Compliance Hotline is a toll-free number
operated by an outside vendor, not by GHS
associates.
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You can call any time, from anywhere.
You do not have to say who you are.
The call is not recorded.
The hotline provides you with a report number and a PIN
number.
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You can use these numbers to follow up and get additional
information.
The Office of Corporate Compliance & HIPAA
Administration investigates all issues and responds
to the caller via the outside vendor.
GHS Non-Retaliation Policy
GHS has a strict non-retaliation policy for any associate
who reports a problem.
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You will not be fired or sanctioned in any way for reporting a
concern in good faith, even if it turns out there isn’t a problem.
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However, you cannot avoid discipline by reporting an incident in
which you are involved.
You will not be fired or sanctioned for reporting an unresolved
quality of care concern to:
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The Joint Commission (JC),
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Centers for Medicare and Medicaid Services (CMS), or
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A state agency.
Retaliation is not tolerated and subject to discipline up to and
including termination.
Additional Reporting Options
If a concern has not been resolved internally –
through internal reporting options, the Compliance
Hotline, and/or the chief compliance officer – you
can also report a concern to:
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The Joint Commission (JC),
Centers for Medicare and Medicaid Services (CMS),
and
Government enforcement entities:
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The Office of Inspector General (OIG) of the
Department of Health and Human Services,
Department of Justice (DOJ).
Reporting Quality Concerns
You may report internal quality or safety concerns to
your manager, and to other departments, by using any
of the following tools as appropriate:
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Patient/Visitor Variance Report, Form # 1836 – report of
unusual or unexpected patient or visitor event or patient
care concerns.
Medication Error Information Form # 14070 – report of
actual or potential medication variance.
Fall Variance Report, Form # 19587 – report of actual or
potential patient fall.
OHNO! – report of associate illness or injury.
Hazard Tracker Report Form # 18515 – report
environmental safety concerns.
Fraud, Waste, and Abuse Laws
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Fraud, Waste, and Abuse (FWA) Laws include
the:
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False Claims Act,
Anti-Kickback Statute,
Physician Self Referral Statute,
Exclusion Statute, and
Civil Monetary Penalties Law.
The government requires FWA training for all
new associates and FWA training for all
associates on an annual basis.
Fraud, Waste, Abuse, cont’d
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Fraud
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Waste
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Healthcare fraud refers to receiving or obtaining
a benefit by an intentional misrepresentation or
concealment of material facts.
Waste includes incurring unnecessary costs as a result
of deficient management, practices, or internal controls.
Abuse
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Abuse is similar to fraud but there is no evidence that
the act was intentional.
Abuse includes excessive or improper use of
government resources.
Examples of Fraud
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Billing for services or supplies not furnished.
Duplicate billing: Billing for services already covered by
another claim.
Unbundling: Billing separately for services that should be
a single service.
Billing for services not supported by documentation in the
medical record.
Falsely reporting diagnoses or procedures to maximize or
increase payment.
Falsifying information on records.
Offering or accepting bribes, payment or incentives in
exchange for healthcare referrals.
Examples of Abuse
Providing services that are not medically
necessary.
 Providing services that do not meet
professionally recognized standards.
 Providing services that are not fairly priced.
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False Claims Act
Prohibits the submission of false or fraudulent
claims for payment to Medicare and Medicaid.
 Fines for False Claims Act violations can be up
to three times the program’s loss, plus $11,000
per claim.
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 You can be punished if you act with
deliberate ignorance or reckless
disregard of the truth.
 This means you cannot hide your
head in the sand and avoid liability.
Anti-Kickback Statute
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Prohibits asking for, offering, or receiving anything of
value in exchange for referrals of federal healthcare
program business.
The Anti-Kickback Statute applies to both payers
and recipients of kickbacks.
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Just asking for or offering a kickback
could violate the law.
A kickback can be anything of value,
not just cash!
As a GHS associate, you may not ask for,
offer or take anything of value in exchange for
patient referrals.
Anti-Kickback Statute, cont’d
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GHS does not pay or offer to pay anyone for
patient referrals. This includes:
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Colleagues,
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Colleagues include GHS officers, associates, medical
and affiliated staff, volunteers, vendors, agents, and
anyone else affiliated with GHS or those with whom
you have professional contact.
Physicians, and
Other persons or entities.
Physician Self-Referral Statute
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The Physician Self-Referral Statute is
sometimes called the Stark Law.
Stark prohibits physicians from referring
Medicare or Medicaid patients to entities
for designated health services where they
have a financial relationship, unless an
exception applies.
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Financial relationships covered by this law
include ownership/investment interests, as well
as compensation relationships.
This law applies to physician financial
relationships and those of their immediate
family members.
Exclusion Statute
Under the Exclusion Authorities, individuals and
entities can be excluded from participation in the
federal healthcare programs.
 Some refer to exclusions as a “financial death
sentence” because excluded persons and
entities may not receive payment for treating any
Medicare and Medicaid beneficiaries.
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GHS conducts routine exclusion checks.
GHS does not employ, grant or renew privileges to, or
contract with, any individual or entity who is under
sanction or excluded from participation in federal
healthcare programs.
Civil Monetary Penalties Law
Penalties range from $10,000 to
$50,000 per violation.
 The government may seek civil
monetary penalties for a wide variety
of fraudulent and abusive conduct in
addition to:
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Exclusion from the Medicare and
Medicaid program,
Criminal conviction, and
Jail time.
‘Whistleblower’ Provisions
State and federal governments permit private
citizens to file lawsuits on behalf of the government
when fraud is suspected.
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This is the qui tam or “whistleblower” provision.
GHS does not retaliate against any associate who
files a qui tam action or other lawful acts such as
assisting in a False Claims Act investigation.
GHS encourages associates to report suspected
fraud internally so that we can investigate and
immediately correct any problems.
Laws and Regulations
GHS has policies and procedures in place to
promote compliance with all applicable federal,
state, and local laws and regulations set forth by the:
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Department of Health and Human Services Office of
Inspector General (OIG).
Federal Drug Administration (FDA).
Environmental Protection Agency (EPA).
Centers for Medicare and Medicaid Services (CMS).
Drug Enforcement Agency (DEA).
Department of Community Health (Georgia Medicaid).
Office for Civil Rights (OCR).
Charging, Billing, Coding
GHS is committed to honesty, accuracy and
integrity in all its charging, billing, coding and
documentation activities.
 GHS associates must assure that documentation
in the medical record supports the services billed
to any payor.
 GHS can bill only for services ordered, provided
and documented.
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Charging, Billing, Coding, cont’d
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Charging for a service that is not ordered,
provided or documented in the record is
inappropriate.
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It is not acceptable to “fix” the record to make it match
the bill.
Falsifying medical records is grounds for disciplinary
action up to and including termination.
See GHS Discipline Policy (HR 300-504).
See GHS Charging, Coding and Billing Compliance
Policy #9510-04-10.
Protection of Property
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All goods and items purchased by GHS are the
property of GHS.
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Any item taken from GHS, without appropriate
authorization to sell, donate or for personal use, no
matter the cost or value of the item, is considered
theft.
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Theft is prohibited by:
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GHS Code of Conduct.
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Georgia state law.
GHS does not tolerate theft of any kind and involves
the police when necessary to resolve property theft.
Environmental Laws
GHS maintains, administers and disposes of
hazardous drugs in a manner which protects
associates and patients.
 GHS is compliant with EPA requirements.
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It is a violation of Safety Policy 900.03.08 to dispose
of hazardous drugs in a manner not identified in the
policy.
If an associate witnesses the improper administration
or disposal of hazardous drugs, the associate
has an obligation to report the incident to
a supervisor immediately.
Harassment and Retaliation
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Harassment is prohibited by:
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HR policy 300-103.
The Associate Handbook.
The Code of Conduct.
Retaliation for reporting a concern or
violation of a policy is prohibited by:
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The Complaints and Grievances Policy,
HR policy 300-503.
The Code of Conduct.
To Report any Concern
Use one of the following options to report:
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Speak to your manager immediately.
Call:
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Chief Compliance and Privacy Officer
 678-312-4388
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Compliance Manager
 678-312-3321
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Compliance Analyst
 678-312-2485
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Compliance Hotline
 1-888-696-9881
Congratulations!
Compliance is our ongoing commitment to “do
the right thing” for our patients and GHS.
 You have completed this CBL module.
 Click on Take Test to continue.
