Corporate Compliance and HIPAA 2011

1. Corporate Compliance and HIPAA 2011 Description Annual compliance update training, mandatory for all Aurora caregivers. Includes reminders, information regarding compliance references and resources, and training in areas of special importance. It’s estimated it will take 45 minutes to complete this course. Instructions for Printing to Paper Content Contact: • From the PowerPoint toolbar, select File, Print • Under “Print What”, select Handouts • Under “Color/Grayscale”, select Grayscale • Under “Handouts/Slides Per Page”, select 2 • Select OK. Nancy Vogt Director, Corporate Compliance Created: May 2005 Updated: January 2011

2. Learning Objectives After completion of this course, you will be able to: • Describe your role and responsibilities in helping ensure that Aurora fulfills its legal and ethical obligations, including actions to take in the event of a compliance concern or question. • Explain the healthcare laws that relate to the work that you do. • Describe compliance resources that are available to you. • Describe how to protect patient privacy in accordance with the HIPAA Privacy and Security Rules, and how to appropriately use and protect Aurora’s electronic systems.

3. Would you know what to do? Would you know what to do if you were approached by an FBI agent at home or at work who started asking questions about your department or practice?

4. Would you know what to do? Do you know why you cannot just ignore a situation at work that seems illegal or unethical? Do you know how patients and the government may find out if you would view health information when it was not necessary to perform your job?

5. Stay Tuned to Learn the Answers Stay tuned to learn the answers to these and other questions you may have, because it’s time for your favorite program…

6. The Aurora Health Care Compliance Program Carrie Killoran, Chief Compliance and Integrity Officer

7. Nick Turkal, M.D. President and Chief Executive Officer Message from Nick Turkal, MD Our 2011 season premiere includes a special message from our President and CEO, Nick Turkal, M.D. Nick will lead us off by explaining why ethical and legal conduct is so important at Aurora Health Care.

8. High Integrity Caregivers “We know that when caregivers are engaged at work, it makes a positive difference for our patients.  Ethical and legal conduct is a component of this engagement – it helps make Aurora an organization of high integrity caregivers who are proud of our work. An ethical work environment helps to ensure that we can deliver an excellent patient experience, which is by far our paramount goal.” Nick Turkal, MD President & CEO

9. Code of Ethical Conduct Our Code of Ethical Conduct places the PATIENT FIRST, ALWAYS. You’ll note the title includes, “Providing patient-centered care with integrity.” • The Code provides guidance to all caregivers, physicians, contractors, and those who do business with us. • The Code’s guidance relates to our conduct as caregivers, and our conduct as an organization. Some of the areas it speaks to are: - High quality and safe patient care - Accurate documentation and billing practices - Appropriate relationships with physicians, vendors, and government representatives

10. ACTION Code of Ethical Conduct Read the Code of Ethical Conduct. You can find it on: • Read the Code of Ethical Conduct • You can find on: • -The Compliance and Ethics website. • -The Employee Connection iConnect (under “Tell Me About… • Aurora Policies and Procedures”)

11. 2011 Schedule of Topics • Gifts and the Caregier • Documentation and Biling • Physician Financial Relationships • Privacy Security of Health Information • Other Compliance and Legal Requirements • Reporting Compliance and Ethical Concerns • Government Investigations • How Compliance Fits In

12. Gifts and the Caregiver Gifts and the Caregiver Let’s tune in…

13. Gifts and the Caregiver In general, we think of gifts as being something good — and they are! We like to receive gifts, and we feel good when we give gifts. In health care, however, a gift might be a problem and giving or receiving it might violate Aurora’s Gifts and Business Courtesies Policy. What do the items below have in common?

14. Gifts and the Caregiver They’re all considered to be gifts. Keep in mind that a “gift” in terms of our policy means anything of value.

15. Why is this not allowed? The following are examples of how gifts can be used inappropriately (and in some cases, illegally) in health care. • A vendor offers to pay for the registration and travel for four Aurora caregivers to attend a professional association conference. Why is this not allowed? The vendor is using a gift to potentially influence our continued business. We need to choose products based upon what is best for our patients in terms of quality, effectiveness and cost. • A clinic offers $25 restaurant certificates to all patients who make an appointment with a new physician. Why is this not allowed? The clinic is trying to influence patients to choose a physician because of a gift, not because that physician is the best choice for the patient. • A patient offers a $100 gift card to a caregiver for exceptional service. Why is this not allowed? All caregivers are expected to offer exceptional service to patients. This caregiver may come to expect rewards from patients just for doing her job, and patients may come to believe they must offer gifts in order to get the best service.

16. Influence of Gifts Gifts such as the examples just provided create ethical issues. • We need to select our vendors based upon what is best for our patients… • Patients need to select Aurora as their health care provider because we offer the best quality, service and cost… • We need to do our jobs with the highest quality and service possible… …because our PATIENTS ARE FIRST, ALWAYS, not because we are influenced by or influence others with gifts.

17. Illegal It is also important for you to know that in some cases, gifts are illegal under federal law. The Anti-Kickback Statute prohibits offering or receiving anything of value when the intent is to influence decisions related to items or services that will be billed to a federal health care program. Violating this law is a felony. Penalties can include a fine and/or a prison sentence. The government takes kick-backs seriously. The construction project manager at MetroHealth, an Ohio health system, faces up to 11 years in prison for accepting gifts from a construction company with whom MetroHealth did business.

18. Under Federal Law Individuals and Organizations Fined Under federal law, an organization (like Aurora) can be fined, or an individual working for Aurora can be fined and/or sentenced to prison. Federal law (Civil Monetary Penalties) prohibits offering gifts to patients in order to influence them to seek services. Penalties can include a $10,000 fine per item offered. The government takes patient inducements seriously. One example occurred in Texas. A home health agency received a significant fine for offering free nursing services to patients.

19. A Word About Vendors You may be wondering, who is a vendor? A vendor is anyone who does business with Aurora. This includes many types of businesses, including: • Any company or business that provides us products or services (whether or not the products or services are directly related to patient care) • Any other health care provider with whom we contract or with whom we share patients (for example, a nursing home, a medical director, etc.)

20. First Response Dover Vendor Gift Examples Examples of gifts that might be offered by a vendor include (but are not limited to): • - Promotional items such as pens and coffee mugs • - Gift cards • - Restaurant certificates • -Trips/travel or registration fees for professional association conferences • -Tickets to sporting events • -Work areas should be free of items with outside vendor logos.-Meals (at work or outside of work)

21. Patients First, Always Patients First, Always Gifts Must Benefit Patients The Gifts and Business Courtesies Policy allows us to accept some gifts, depending upon the purpose and circumstances and only if the gift will benefit our patients. Promotional Items: Caregivers may not have promotional items provided by vendors (such as pens, notepads, coffee mugs, etc.) on the premises of any Aurora facility. Food and Meals: Vendors are not allowed to bring in food or meals to an Aurora facility. Vendors may provide financial support for meals at educational events through grants managed by the Aurora Grant Development office. Vendors may pay for meals that are provided at an off-site business meeting held during meal times, as long as the value of the meal is $25 or less for breakfast or lunch, and $50 or less for dinner. Patient Educational Materials: Journal reprints and patient educational materials may be accepted from vendors, even if they are branded with the vendor’s name and logo. The Gifts and Business Courtesies Policy addresses these and additional types of gifts.

22. Gifts to Patients Gifts (anything of value) may be offered to patients only if: • The gift is not in the form of cash or a gift card (unless the gift card has been approved by Compliance) • The gift is valued at $10 or less; and the total for all gifts given during the year is $50 or less; or • The gift is a free service that meets one of the exceptions in the law. If you have not received specific training on these exceptions, contact a compliance officer before offering the free service; or • The service is discounted through the Helping Hands financial assistance program.

23. Gifts from Patients A caregiver may accept a gift from a grateful patient only if: • The gift is a modest token of appreciation (approximate value of $50 or less); • The gift is not cash or a cash equivalent (such as a gift card); and • The circumstances are such that the refusal of the gift could hurt the patient’s feelings or otherwise be counterproductive to a patient relationship. If possible, patients who wish to give a gift should be directed to the Aurora Foundation. When a gift does not meet the guidelines above and cannot be graciously refused, the gift may be accepted and must be delivered to the Aurora Foundation. Perishable gifts like food and flowers should be shared with the caregiver’s co-workers.

24. Gifts and Business Courtesies Policy The Gifts and Business Courtesies Policy addresses various types of gifts, including some of those already discussed: • Gifts from vendors • Gifts from patients • Gifts to patients • Gifts among caregivers • Gifts to government officials • Vendor-sponsored events • Food and meals • Charitable contributions The policy also includes enforcement of the policy, both for caregivers and vendors. The policy, however, does not include all types of relationships with vendors (for example, training provided by vendors on their products, consulting relationships with vendors, accepting samples and demo items, etc.) These other vendor relationships will be addressed in a separate policy.

25. Conflict of Interests Policy We are also committed to managing any conflicts of interests that caregivers, physicians, or board members may have. A conflict of interest can occur when there is a personal interest in an entity with which Aurora does business. It may be difficult for a person in this situation to act in Aurora’s best interest. That is why our leaders, physicians, and board members are required to disclose their potential conflicts. A few examples of potential conflicts are: • An administrator is selecting a new cleaning service for her clinic. One of the two services under consideration is owned by her brother-in-law. • A physician’s son is a sales representative for a medical device company. The physician is in a position to select the company that will supply medical devices for his patients. • A caregiver is participating in confidential negotiations between Aurora and two medical device companies that offer similar products. The caregiver accepted a gift from one of the companies in exchange for information regarding the other company’s proposed pricing. [Note: while most conflicts can be managed, this type of conflict is strictly prohibited.]

26. Take Action! ACTION! Before accepting or offering a gift of any kind, review the Gifts and Business Courtesies Policy (AHC System Policy #130). If you potentially have a conflict of interest that needs to be disclosed, review the Conflicts of Interest Policy (AHC System Policy #80.) **Add Aurora Administrative Manuals to your quick links in iConnect. Click on Aurora System Manual, click on Table of Contents on the right hand side and scroll to the above policies.

27. A Word From Our Sponsor – Gifts QUIZ QUESTION: If a vendor who does business with Aurora Health Care made the following offers to you, which one could you accept? a. A ticket to the Packers vs. Bears Game b. A free lunch at work while you listen to the vendor representative explain his products c. An educational booklet for patients about managing their diabetes d. None of the above

28. A Word From Our Sponsor – Gifts QUIZ ANSWER c. You may accept an educational booklet for patients about managing their diabetes. This put the patient first, always!

29. Documentation and Billing Up next…

30. Code of Ethical Conduct Summary Our Code of Ethical Conduct summarizes our obligations related to documentation and billing. The first two are: First, we will document diagnosis and treatment accurately and in a timely manner. Second, we will bill only for services that are actually provided and appropriately documented.

31. Patients First, Always Patients First, Always Code of Ethical Conduct Summary - continued While accurate and timely documentation is important for billing, it is even more important for providing the best care possible for our patients. It is also important to recognize that the government is doing more auditing and monitoring than ever before. The auditors will deny payment if documentation does not support our charges. That means we will have provided the best care possible to patients, but will not receive the payment because we failed to document the care. In the recent Recovery Audit Contractor (“RAC”) 3-year pilot program conducted by Medicare, the auditors took back nearly $1 billion dollars in just three states (and that was just the pilot program!)

32. Code of Ethical Conduct Summary - continued This means every dollar lost due to inadequate documentation is a dollar we cannot spend on our patients and on our caregivers.

33. Inadequate Documentation and Billing Errors QUIZ QUESTION 1:: According to our Code of Ethical Conduct we will document diagnosis and treatment accurately and in a timely manner. Which one answer below would be considered accurate and timely documentation. a. Documentation was entered into the patient’s record immediately after care was provided b. A dictated report was not signed in a timely manner c. An order for a service was not signed and dated by the physician d. A report was not dictated in a timely manner] e. A description of the exam or treatment was brief and did not include all the services that were actually provided.

34. Inadequate Documentation and Billing Errors QUIZ ANSWER 1: a. Documentation was entered into the patient’s record immediately after care was provided. Documenting and signing immediately after services are provided is best practice.

35. Inadequate Documentation and Billing Errors QUIZ QUESTION 2: According to our Code of Ethical Conduct we will bill only for services that are actually provided and appropriately documented. In the list below, which indicate that billing errors have been made. (Choose all that apply.) a. A charge was submitted for a service that was cancelled b. A caregiver accidentally enters a wrong charge code for a service c. Too many charges (units) for a service were submitted d. A charge was submitted for a service that was only partially provided

36. Inadequate Documentation and Billing Errors QUIZ ANSWER 2: All of the above billing errors were made

37. Avoid Fraud In addition to unintentional or accidental billing and documentation errors, we need to be on the lookout for fraud. Committing fraud means the person knows they are submitting a false claim. Fraud is unethical and illegal. Federal law (The False Claims Act) and Wisconsin state laws prohibit submitting fraudulent claims. Penalties can include paying back up to three times the amount of the charges submitted, plus up to $15,000 per claim.The government takes fraud seriously, and even has deployed special audit and SWAT teams dedicated to finding fraud in health care.

38. Examples of Fraud QUIZ QUESTION: Committing fraud means the person knows they are submitting a false claim or creating false documentation. Which below indicates fraud has occurred (list all that apply.) a. A caregiver submits charges for a service that the caregiver knows was never provided b. A physician changes a patient’s diagnosis in order to get a claim covered by an insurance company c. A nurses uses a physician’s ID and password to document in the patient’s electronic health record.

39. Examples of Fraud QUIZ ANSWER: All of the examples listed are examples of fraud!

40. Government is Fighting Fraud Some recent actions by government agencies are examples of how the government is fighting fraud, waste, and abuse in health care, and demonstrate how serious the consequences of fraud can be. • In March, 2010, a Detroit-area physical therapist was sentenced to 62 months in prison for submitting claims to Medicare and falsifying medical records for services that were not actually provided to Medicare beneficiaries. The therapist will also need to repay $2.9 million in restitution. • In January, 2009, nine podiatrists in Manhattan were sentenced to prison terms ranging from 6 months to 63 months for committing Medicare fraud. Four of their billing and administrative staff were previously convicted of charges. These podiatrists handed out flyers advertising “free treatment,” and falsified their patients’ conditions in their medical records in order to get claims paid for services that otherwise would not have been covered by Medicare.

41. How to Handle Billing Errors Our Code of Ethical Conduct describes how we handle our billing errors: First, we will correct any billing errors and refund money received in error in a timely manner. Second, we will refund over-payments in a timely manner.

42. Report Possible Issues Paying back money to our patients, Medicare and other payers that we should not have received is the right thing to do, and our patients would expect us to do so. Failure to repay in a timely manner can also mean significant financial penalties under the False Claims Act. One of the ways we detect billing errors is by performing audits. We also find billing errors because caregivers report possible issues to our compliance officers.

43. Take Action! ACTION! Our Detecting, Preventing and Responding to Fraud, Waste, and Abuse Policy (AHC System Policy #174) provides more details. Add Aurora Administrative Manuals to your quick links in iConnect. Click on Aurora System Manual, click on Table of Contents on the right hand side and scroll to down to the policy. If you believe you might know of a possible billing error or a practice that might create billing errors, or if you suspect someone in your area is committing fraud, report your concern to a compliance officer or to the anonymous Compliance Hotline at 888-847-6331. Hotline. The phone numbers of compliance officers and the Hotline are listed on the Compliance & Ethics website.

44. A Word From Our Sponsor – Accidental Billing QUIZ QUESTION: If Aurora Health Care learned we accidentally billed Medicare for a service that was not provided, which of the following is true? a. We must pay the money back to Medicare. b. We can keep the money because it was an accidental mistake. c. It is up to us to determine whether or not we pay the money back to Medicare.

45. A Word From Our Sponsor – Accidental Billing QUIZ ANSWER: a. We must pay the money back to Medicare! Paying back money to our patients, Medicare and other payers that we should not have received is the right thing to do, and our patients would expect us to do so.

46. Physician Financial Relationships Stay tuned…

47. Code of Ethical Conduct with Physicians Our Code of Ethical Conduct requires ethical relationships with our physicians. It is important to our patients that physicians choose to practice at Aurora facilities because we offer the best patient experience available anywhere, not because we create inappropriate financial relationships with our physicians.

48. Physician Compensation and Services Federal law, including “Stark” and the Anti-Kickback Statute, must also be considered whenever money exchanges hands between Aurora and a physician. These laws are complex, and you should contact a compliance officer for assistance. Two important guiding principles in these laws are: • Physician compensation arrangements require a written agreement to be signed by both parties, in advance of any services being provided. There are specific requirements for these agreements. • Compensation must be set at Fair Market Value (“FMV”). In addition, any items or services provided to physicians (like office space leases, advertising services, etc.) must be charged at FMV. Finally, FMV may not necessarily be Aurora’s costs for those services, but rather must reflect what those services would cost the physician if he purchased them in the local market. Due to the complexity, do not attempt to create your own agreements. When you need an agreement to be drafted, contact the Contract Coordinator in the Legal Services Department.

49. Physician Gifts and Courtesies All gifts, entertainment, and business courtesies (with limited exceptions) offered to physicians must be entered into the Physician Gifts and Courtesy tracking system on iConnect. It is important to enter the benefit before offering it, to ensure the maximum annual limit is not exceeded.

50. Physician Gifts and Courtesies Physician Gifts and Courtesies These same laws limit non-monetary gifts, entertainment, and business courtesies that we can offer to physicians who refer or may refer patients to Aurora entities. This also applies to our own employed physicians in some situations. No gift, regardless of the value, can be given if the intent is to solicit referrals from the physician. Gifts for appropriate purposes are limited to a maximum of $355 per physician per year, and can never be cash or a cash equivalent.