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                        GBMC Ethics and
                       Compliance Program

                                                    Health. Healing. Hope.
The Mission of GBMC HealthCare is to provide medical care and service of the highest quality to each patient leading to health, healing
                                                           and hope.

                                            Medical sophistication with personalized service.
 The Vision of GBMC is to be the preferred medical center in Maryland for the best physicians, nurses and staff by providing medical
sophistication with personalized service, enhanced by clinical education and research with the guiding principle that “the patient always
                                                              comes first.”

    The Values of GBMC are GREATER Values of Respect, Excellence, Accountability, Teamwork, Ethical Behavior and Results.
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• Compliance
 – Conformity; acting according to certain accepted standards

• Ethics
 – The study of: moral values and rules; right and wrong
 – Contemporary Ethics focuses on Choices

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          Compliance & Ethics

• 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.

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          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.

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• 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)

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          Fraud and Abuse

• Consequences
 – 40-60 million 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.

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         Government’s Response
– 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.

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         Government’s Response
– 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.

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        Government’s Response
– 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

– 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.

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          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

– The purpose of our Ethics and Compliance Program is to:
   o Prevent violations of the law,
   o Detect violations of the law,
   o Document our efforts in the event violations exist that are not

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      Elements of Ethics & Compliance Program

                                 OIG                                                                                              CMS

DOJ                                                                   “Tone at the Top”
                                    Ethical Corporate Culture
                                Elements of a Compliance Program (OIG)

                                                                                                                        Enforcement & Discipline
       Standards & Procedures

                                                            Trustworthy Individuals

                                                                                                                                                   Response & Prevention
                                     High Level Oversight

                                                                                                  Monitoring & Audits

                                     GBMC Board of Directors
                                Reinforcement of GBMC’s Commitment to Compliance                                                                                                  11
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            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.
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           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
  competition 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.
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            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:

      o “We Strive to Provide Outstanding Service to Our Patients”
      o “We Strive to Abide by the Law and Maintain High Ethical Standards
        in Our Business Decision Making”
      o “We Strive to Maintain a High Standard of Accuracy and
        Completeness in Our Records”
      o “We Strive to Maintain a Professional and Safe Work Environment”
      o “We Take Personal Responsibility for Protecting the Organization’s
        Resources and Achieving Our Ethical Goals”
      o “We Report Our Compliance Concerns by Using the Appropriate
        Chain of Command”
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            Element #1 Standards & Procedures

• These Guiding Principles are defined more thoroughly in the
  Code, along with examples of compliance-related practices that
  we are required to follow in furtherance of those principles.
  Please take the time to review the Code prior to taking the
  online test at the end of this section. The Code of Business
  Ethics may be obtained electronically via the Compliance Web
  Page on the InfoWeb.

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                 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 Program.

   • 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.                      16
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            Element #3 Trustworthy Individuals

• The organization must have used due care not to delegate
  substantial discretionary authority to individuals whom the
  organization knew, or should have known through the
  exercise of due diligence, had a propensity to engage in
  illegal activities.

      o GBMC conducts pre-employment screening, including background
        checks, on employees.

      o 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.

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            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.
      o GBMC has incorporated Ethics and Compliance Program training into
        the mandatory annual competency plan (THAT’S WHY YOU’RE
        HERE !!).
      o The New Employee Orientation Program contains 30 minutes of
        training on the Ethics and Compliance Program.
      o The New Physician Orientation Program contains 30 minutes of
        training on the Ethics and Compliance Program.
      o Specialized training is provided on specific compliance areas on an
        as-needed basis throughout the year by the Compliance Department.
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            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

      o 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.
      o Departments throughout GBMC perform various auditing and
        monitoring activities to ensure compliance, e.g., the Coding
        department, Medical Records, etc.
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               Element #5 Monitoring & Auditing

• Employees are educated about the resources
  available to them to report compliance concerns
   – Supervisor or Chain of Command
   – Compliance Officer, Stacey McGreevy: 443-849-4325

   – Compliance Office email:

   – 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.
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            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.

      o GBMC has a progressive disciplinary policy in place to deal with
        individuals who do not comply with internal polices, 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.                                      21
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        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.

      o 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.

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            Areas Where Compliance Risk May Exist

•   Patient Information – We collect information about the patient’s
    medical condition, history, medication, and family illnesses to provide
    quality care. 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. This also
    applies to situations where our fellow employees become patients.

•   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. Due to the
    complexity of these relationships, it may be appropriate to seek
    guidance from internal resources such as the Compliance or Legal
    Department. 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.

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               Areas Where Compliance Risk May Exist
•   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.
    Billing must comply with the requirements of state and federal payers and
    conform to all payer contracts and agreements. There are federal and state
    laws that make it illegal to receive payment for false claims. Hospitals that
    engage in practices that violate the False Claims Act could face fines and
    penalties. GBMC has processes in place that support the detection and
    prevention of fraud and abuse including, external and internal billing and
    coding audits, billing compliance committees, monthly monitoring and
    employee education.
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            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.
    A good rule of thumb that a potential conflict of interest may exist is any
    time an objective observer might wonder if your actions are motivated
    solely by your responsibilities to GBMC or because you stand to reap
    some personal benefit from the situation.
•   Receiving Gifts and Business Courtesies – GBMC has
    straightforward, clear cut guidelines outlined in 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. No member of GBMC may ever accept cash or a cash
    equivalent (e.g., gift certificates) from anyone in a position to do
    business with GBMC, regardless of amount or whether it is directed at
    an individual or department. There are ways that vendors can extend
    business courtesies to our employees that are appropriate and in
    accordance with policy. If you are unsure as to the appropriateness of
    a gift or courtesy, ask.
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              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 Office, or use the GBMC
         Business EthicsLine. 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.
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        GBMC Ethics & Compliance Program

• Final Thoughts
  – Compliance impacts all functional areas of the hospital. It is not
    just a Billing or Finance problem. We all have a responsibility to
    carry out our activities in a manner that is ethical, legal and in
    support of the behaviors outlined in the Code of Business Ethics.
    Some of us have jobs that are subject to greater levels of
    compliance scrutiny and we should be familiar with those
  – The GBMC Ethics and Compliance Program does not need to be
    perfect as long as it demonstrates due diligence. That is why it
    is an active, evolving process and not simply a static document.
    We can never say that we have finished complying. The very
    nature of the healthcare environment eliminates any possibility of
    a final compliance product. Laws and rules change constantly
    and GBMC has positioned itself to be able to respond and react
    to the rapidly changing regulatory environment.

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      GBMC Ethics & Compliance Program

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