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					        Valuing Integrity
      Corporate Compliance

             October 2006

             Anne Adams
       Chief Compliance Officer
Emory Healthcare and Emory Medical Care

                Sue Dale
Administrator, Gynecology and Obstetrics
Emory University School of Medicine and
            The Emory Clinic
       What is Compliance ?

   Complying with applicable Federal and State
    laws and regulations.

   Following all Emory and departmental policies
    and procedures.

   Doing the right thing!
       Compliance Program

Committed to conducting business in
compliance with all federal, state, and local
Committed to preventing and detecting non-
compliance .
“Standards of Conduct” and other policies to
guide our activities.
    Elements of a Compliance
   Compliance Standards & Procedures
   Chief Compliance Officer
   Employee Training
   Monitoring & Auditing
   Reporting Process
   Response & Prevention
   Enforcement & Discipline
    Role of the Compliance Office
   Establish, oversee implementation, and revise the
    Compliance Program
   Provide oversight for organization’s compliance activities
   Provide education
   Provide advice and guidance
   Develop compliance policies
   Investigate reports of non-compliance
   Monitor compliance with rules & regulations
   Coordinate response to external investigations
   Oversee corrective actions
    Why Do Organizations Need a
      Compliance Program?
   Government focus/enforcement
   Risk of prosecution/penalties
   Protect system resources/reputation
   Health Insurance Portability and Accountability Act
   Grants and Contracts
   Research/IRB/FDA/OHRP
   Sarbanes/Oxley
   Healthcare Industry Fraud and Abuse
     Who Are the Players?
Centers for Medicare & Medicaid Services (CMS)
Office of Inspector General (OIG)
Department of Justice (DOJ)
Federal Bureau of Investigation (FBI) Financial
Crimes Section
Georgia Bureau of Investigation (GBI)
Medicare/Medicaid Fraud Unit
Office of Civil Rights (OCR)
         Your Responsibility

To know the rules that apply to your

Follow the rules, help find and report potential
violation and problems.

Actively participate in and promote compliance.
                Main Areas of Risk

Teaching physician presence.
Billing for items or services not rendered (or documented).
Providing medically unnecessary services.
Upcoding/ Unbundling.
Failure to properly use modifiers (25, 26, 59, etc.).
Consultations/New vs. established.
Misrepresenting diagnosis to justify service.
Billing for a non-covered service as covered.
Research misconduct
Research Effort Reporting
          Non-Retaliation Policy
   It is the policy of EMORY that individuals making
    good-faith reports of compliance concerns will
    not experience any form of retaliation.

   If you experience or witness retaliation, report it
    to the Compliance Office immediately.

   Incidents of retaliation will have serious
Are We Getting Our Voluntary
Compliance Program Right?
Are compliance efforts impacting
employee and organizational activity?
  Enhance – to improve quality/to make greater.
  Culture – social behavior patterns typical of a
  population or community at a given time.
  Awareness/Open communication.
  Influence positive behavior.
  Meet requirements of the Federal Sentencing
  We have a solid foundation and we want to build on
  that foundation and reaffirm our commitment.


Physicians committed to patient care

Encourage open communication/questions with

Employee commitment

Excellent internal consultants
A blended program

     value based – awareness of key organizational
     principles; prevention; core principals are offered;
     employees are individually accountable to values;
     encourage employees to question decisions before
     taking action.

     rules based – do’s and don'ts; general deterrence
      of bad conduct though emphasis on punishment
      and avoidance.

Must continue to have leadership support – words and
        The Role of Management
   Management serves as the primary example
    and the primary source of information for our

   Management fosters open communication
    regarding compliance and answers questions
    raised by employees.

   Management is accountable for their own
    actions as well as the actions of those they
Compliance is a team effort – Everyone is responsible for
making a winning team.

No room for behavior not geared to professionalism,
integrity, compliance and excellence.

“Off Messages” that are inconsistent with a culture of
compliance risks our reputation of excellence.

Lead by example - we have set clear expectations for
documentation and coding compliance.

Emory goes beyond compliance.
We must maintain a culture of professionalism,
integrity and compliance at Emory.

Current culture is healthy, but want to continue to
maintain/improve health and wellness – continue to ask
questions and raise compliance concerns.

Don’t want to leave organization, employees and
physicians vulnerable to not meeting regulations/
government inquiry.

Accurate documentation, coding and billing are critically
important functions.

Non-compliance by a few puts Emory at risk.
Integrity and Ethics – physicians, administrators, staff,
board members are all involved and it reaches across all

Ultimately enhancing our culture of compliance goes to
integrity strategy – compliance plays a role/faciliate, but
managers at all levels and across functions are involved in
the process.

Physician/Management Driven.

Must have a willingness to seek solutions within framework
of values.

Values are integrated into the normal channels of

Support and reinforce organizational values.
   Commitment to Compliance
Follow applicable rules and regulations.

Ask questions if the rules are unclear.

Act when your instincts tell you something is

You must report potential violations.

Be a part of the solution if a problem is found.
   Reporting Potential Problems
Who do I go to?
    Supervisor or Manager
    Compliance Department 404-778-2757
    Emory Healthcare Trust Line
    1-888-550-8850 (Anonymous Reporting 24/7)

What will happen?
    Determination who will handle issue
         Administrator’s Perspective
   Most difficult challenge is the task of influencing
    physicians to adopt compliance as an integral
    part of our standard operating procedures.
             This is not Monopoly – there is not a get out of jail
              free card
   “Teaching physicians suffer from mural dyslexia”
    (Fast Tracking Compliance Training in Academic Practices article MGMA)

           Cannot see the handwriting on the wall
           Why are we spending money on compliance?

           Compliance is a control program
    Expecting Reactions To Compliance

   Typical Reactions to Compliance:
       Great men can’t be ruled
       What rules? When did this start?
       Glassed over eyes – asleep
       Must not be talking to me
   Administrator’s Reaction:
       Never react back or will be seen as the evil one
       Use positive arguments
       Use a physician champion
            What are the Physicians’
   Communication:
       Communicate both good and bad news; communicate
       Honor confidentiality
       Share data
       Allow venting of frustrations
       Stay on their side – avoid defensiveness
       Use examples
       Consistency
       And… cheerful, confident, and optimistic
    Best Practice – Consistent Themes
   Physician-to-physician communication that
    compliance is not optional – based on
   Staff need to hear and see that leadership
    has taken a stance in favor of ethnical
    business practices.
   Train physicians and staff in small
    specialty specific groups – more relevant
    and makes it practical application easier.
    Best Practice – Consistent Themes
   Use numerous examples from their own
    notes and specialty to demonstrate the
    point and use as examples.
   Make the education and training
   Have a sense of humor.
   Recent documentation - The lab test indicated abnormal
    lover function; The patient is still under our car for physical therapy; The
    patient is numb from her toes down; Patient was alert and unresponsive;
    When she fainted her eyes rolled around the room; Patient seen in the ED,
    examined, x-rated and sent home.
          Compliance Programs


     Emory Healthcare Compliance Program
               404-778-2757 or
              Extension 8-2757

Anne Adams, MS, JD
Chief Compliance Officer
Emory Healthcare
Emory Medical Care Foundation

Emory Trust Line 1-888-550-8850
Questions regarding Research Compliance

Kristin H. West, J.D.
Assoc. V.P. & Director
Emory University
Office of Research Compliance
1784 N. Decatur Road, Suite 510
Atlanta, GA 30322
Phone: (404) 727-2398; FAX: (404) 727-2328

Emory Trust Line 1-888-550-8850
               Helpful Resources
Centers for Medicare and Medicaid Services (CMS)
Georgia Medicare Part A
Georgia Medicare Part B
CMS - HIPAA Main Page

Teaching Big Shots to Behave and other Human Resource Challenges
By Stephen M Paskoff, Esq.
                                        (Visit the OCP web-site to
                                         see more resources)
Compliance Office Motto

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