Training

1
Training

• Corporate Compliance Update
• 2008

2
Objectives

• Review the basics of compliance
• Identify common issues and concerns
• Identify additional resources

3
Agenda

• UMCs Corporate Compliance Program
• Brief overview of laws and regulations
• Contact information

4
UMC Corporate Compliance Program

• UMC developed a Corporate Compliance Program in
  1998 in response to federal laws and regulations,
  such as the Stark Physician Self Referral, and
  OIG guidance suggesting the development of such
  programs.
• As a result of an Office of the Inspector General
  (OIG) inquiry UMC was required to satisfy
  specific Integrity Provisions from 2002 2005.
• UMC was required to improve the Compliance
  program, implement training programs, and make
  regular reports on compliance activities to the
  OIG.

5
UMC Corporate Compliance Program

• UMCs Corporate Compliance Program consists of
  the following
• A Compliance Manual and Handbook
• A Compliance Committee to oversee the Compliance
  Program
• Compliance training for all employees
• A Compliance Officer that reports directly to the
  Board of Hospital Trustees
• An anonymous Compliance Hotline [phone]) to
  handle complaints
• A Compliance Department that investigates
  complaints and disseminates information on
  Corporate Compliance

6
Compliance Program Mission

• To ensure that all UMC healthcare services are
  provided in compliance with federal and state
  laws and guidelines.

7
Federal Laws and Regulations

• False Claims Act
• Stark Physician Self Referral
• Anti Kickback Statute

8
False Claims Act

• Applies to claims submitted by healthcare
  providers to a federally funded healthcare
  program, such as Medicare.
• Makes it a crime to knowingly make a false record
  or file a false claim with the government for
  payment or approval.
• Penalties range from 5,500 to 11,000 in fines
  for each claim plus three times the value of the
  claim.

9
False Claims Act

• Whistleblower protections
• Any person with knowledge of a false claim may
  file a lawsuit on behalf of the government.
• The government chooses whether to pursue the
  lawsuit. If they choose not to pursue the
  action, the person may continue on their own.
• The whistleblower may be eligible to receive a
  portion of the settlement.
• UMC will not retaliate, in any form, against any
  person making a report, complaint, inquiry, or
  participating in an investigation in good faith.

10
Cardiologist pays 1.8 million for Medicare
scheme

• (Healthcare Auditing Weekly Oct. 31, 2007)
• An Ohio cardiologist, Mohammed Aiti, pleaded
  guilty to ordering cardiology tests that weren't
  medically necessary in a scheme to defraud
  Medicare. He performed unnecessary stress tests,
  and only ordered tests based on whether or not
  insurance would cover them, not based on the
  medical needs of patients. He received at least
  1.8 million in reimbursement from Medicare
  through his scheme.
• Aiti agreed to give up more than 1.8 million,
  lost his medical license, and can no longer
  participate in any federal healthcare programs.
  He faces up to five years in prison and a fine of
  250,000.

11
Stark Physician Self Referral

• Prohibits a physician from making a referral for
  a Medicare beneficiary for any of 10 designated
  health services to an entity with which the
  physician or a member of the physicians family
  has a financial relationship.
• General exceptions allow certain referrals.
• A relationship must fit in one of the exceptions
  to be allowed.
• Does not matter if you intended to violate, even
  innocent mistakes may result in penalty.

12
Stark Physician Self Referral

• 10 Designated Health Services
• Clinical laboratory services
• Physical therapy, occupational therapy, and
  speech-language pathology services
• Radiology and certain other imagine services
• Durable medical equipment and supplies
• Parenteral and enteral nutrients, equipment, and
  supplies
• Prosthetics, orthotics, and prosthetic devices
  and supplies
• Home health services
• Outpatient prescription drugs
• Inpatient and outpatient hospital services

13
Stark Sanctions

• Denial of payment for services in violation of
  Stark.
• Refund of amounts received for services in
  violation of Stark within 60 days.
• Civil monetary penalty of up to 15,000 for each
  service (each billed item) and up to three times
  the amount of the service.
• Possible exclusion from Medicare

14
Anti-Kickback Statute

• Illegal to make or receive kickbacks for items or
  services covered by a federally funded healthcare
  program, such as Medicare or Medicaid.
• Some types of illegal behaviors
• Cash for patients
• Cash to patients
• Contests and giveaways
• Discriminatorily discounted services

15
Safe Harbors

• The Anti-Kickback Statute includes several Safe
  Harbors. A safe harbor is a specific set of
  circumstances that allow an exception to the
  rule.
• Arrangements that fall under a safe harbor are
  acceptable, but those that do not may also be
  acceptable depending on circumstances.
• The government must prove you intended to violate
  the law.
• An arrangement may be acceptable under an
  Anti-kickback safe harbor, but may still be
  unacceptable under Stark.

16
Safe Harbors

• There are currently 24 safe harbors. Some types
  of safe harbors include
• Investments
• Space rental
• Equipment rental
• Personal services and management contracts
• Employees
• Price reductions offered to health plans
• Discounts
• Referral agreements for specialty services
• Price reductions offered to eligible managed care
  organizations

17
Anti-Kickback Sanctions

• Civil monetary penalties of up to 50,000 per
  violation, plus three times the amount illegally
  received.
• Criminal penalties of up to 25,000 fine and 5
  years in prison plus possible exclusion from
  federally funded health care programs.

18
Physician Orders

• A physician ordered a Chem 7, can the nurse
  complete the order for a Basic Metabolic Panel?

19
NO

• The Basic Metabolic Panel includes 8 tests. All
  tests must be medically necessary as evidenced by
  a physician order or UMC could be in violation of
  the False Claims Act. In this case, the nurse
  should ask the physician to correct the order.

20
New Requirements

• There have been several new compliance related
  requirements during the past year, and more are
  proposed or effective next year. Many of these
  changes have the ability to have significant
  impact on UMC.
• Some current or recent changes you may be
  involved with include
• Physician Quality Reporting Initiative
• Present on Admission
• Severity Adjusted DRG
• Important Message from Medicare
• Tamper Resistant Prescription Pads
• National Drug Code Reporting for Medicaid

21
Responsibility for Corporate Compliance

• Ensuring Corporate Compliance is every employees
  responsibility.
• Failure to comply with the regulations and UMCs
  policies may result in disciplinary action per
  UMC policies and procedures and UMCs Collective
  Bargaining Agreement
• What can you do to ensure Corporate Compliance?
• Read the Compliance Manual and Handbook and make
  sure you understand their contents.
• Be aware of policies and practices that may be
  questionable, even if they have existed for a
  long period of time.
• Report any suspicious or questionable practices
  to your supervisor, Administrator, or the
  Compliance Officer.

22
Compliance Hotline

• The Compliance Department maintains a
  confidential hotline for Compliance and HIPAA
  related complaints. If you wish to make a
  confidential complaint, please call 383-2208.
• Alternatively, if you wish to speak directly
  with the Compliance Officer or Privacy Officer,
  you can call
• Angela Darragh, Compliance Officer 383-6211
• Hope Hammond, Privacy Officer 383-3854

23
Corporate Compliance Office

• Angela Darragh, MBA, CPA, CISA, CFE, CHC
• Compliance Officer
• 1800 W Charleston Blvd.
• Trauma Center 4th Floor
• Las Vegas, NV 89102
• Phone [phone]
• Hotline [phone]
• Fax [phone]
• Email angela.darragh_at_umcsn.com

24
Summary

• We have now covered the following
• UMCs Corporate Compliance Program
• An overview of select Federal Laws and
  Regulations affecting Compliance
• Who to contact for more information or to make a
  complaint