Compliance Program Training May 7, 2014 Presented by: Compliance Department
Overview • Banner Health Network’s (BHN) Mission, Vision and Values • Culture of Compliance • Ethics – Do The Right Thing! • Compliance Program Basics • BHN Resources • Additional Resources
BHN’s Mission, Vision And Values Mission We exist to make a difference in people’s lives through excellent patient care. We will be a national leader recognized for clinical excellence and innovation, preferred for a highly coordinated patient experience, and distinguished by the quality of our people. People Above All…by treating those we serve and each other with compassion, dignity, and respect; Excellence…by acting with integrity and striving for the highest quality care and service; Results…we show we value results by exceeding the expectations of the people we serve, as well as expectations we set for ourselves. Vision Values
A Culture Of Compliance Within Banner Health Network • Do the right thing • Prevents noncompliance • Detects non compliance • Corrects non compliance
Ethics – Do The Right Thing! BHN is committed to possessing and demonstrating the reliability, honesty, trustworthiness and high degree of integrity expected of a leading healthcare organization and a participant in federally funded health-care programs. It is important that you conduct yourself in an ethical and legal manner. • It’s about doing the right thing! • Act fairly and honestly • Comply with the letter and spirit of the law • Adhere to high ethical standards in all that you do • Report suspected violations
How Do I Know What Is Expected Of Me? The BHN Code of Conduct state compliance expectations and the principles and values by which an organization operates. Each Employee and delegate/vendor must report any issue or practice that they believe in good faith may constitute a violation of a law or BHN’s compliance policies. BHN strictly prohibits retaliation against any individual who in good faith reports a suspected violation or suspected illegal or unethical conduct. People who are found to have engaged in unlawful conduct or conduct in violation of BHN policies, or who have failed to detect, report and/or correct any offense, are subject to corrective action, up to and including termination.
Compliance Program Basics The Office of Inspector General (OIG) has outlined 7 components of an effective compliance program. Banner Health Network has incorporated these into our comprehensive compliance program. • Written Policies, Procedures and Standards of Conduct; • Compliance Leadership and Structure; • Effective Training and Education; • Effective Lines of Communication; • Effective System for Routine Monitoring and Identification of Compliance Risks; and • Enforcement of Compliance Standards; • Procedures and System for Prompt Response to Compliance Issues
Written Policies And Procedures And Standards Of Conduct • Banner Health Network (BHN) has corporate policies and procedures (P&Ps) that address laws that affect all BHN associates, such as the Code of Conduct, reporting suspected non-compliance and HIPAA. • Business departments and delegates/vendors are required to develop and distribute P&Ps that address the laws specific to their business functions. • P&Ps should include the legal citations for the compliance requirements. • P&Ps should be reviewed and updated as needed, but no less than annually, to assess compliance with any current requirements. P&Ps should be reviewed when changes are made in business activities that may impact compliance or when new compliance requirements are identified.
Compliance Leadership And Structure • BHN has designated the leadership and defined a structure to oversee implementation and maintenance of the Compliance Program. • Appropriate compliance committees are charged with the responsibility and authority to direct and monitor components of the Compliance Program. • The Compliance Department reports monitoring results, regulator audits, and compliance issues and concerns to these committees.
Compliance Leadership And Structure (continued) • The purpose of the Compliance Department is to assist the company to be compliant with all laws and to monitor compliance to identify compliance issues. • Some of the key responsibilities of the Compliance Department are: • Interpret new laws and assist business departments to implement compliant processes • Complete a compliance risk assessment and conduct compliance oversight activities • Assist business departments to understand existing compliance requirements and develop and maintain compliant processes • Coordinate audits and responses and any subsequent CAPs • Monitor the Integrity Line and investigate and triage calls
Compliance Effective Training And Education BHN has regular compliance education and training programs for all associates. • Training programs • Formal training • Initial and annual compliance training programs required for all associates. • Specialized training in compliance requirements for specific business functions, such as claims payment, medical management and service center. • Focused training as needed • Informal and ongoing training • Emails • Newsletters • Posters
Effective Line Of Communication BHN has established lines of communication for compliance issues, including an open line of communication between the compliance department and all associates and delegates/vendors. • The BHN ComplyLine (888-747-7989) or at https://bannerhealthcomplyline.alertline.com are available to submit potential ethics issues or other compliance concerns. • The Compliance Department is available to all associates and delegates/vendors to report compliance issues or to respond to compliance questions. • BHN has a non-retaliation policy to protect anyone who makes a report in good faith about a potential compliance; fraud, waste and abuse; or ethics issue.
Auditing And Monitoring BHN monitors compliance to identify compliance deficiencies so that the deficiencies can be corrected. • The Compliance Department conducts a risk assessment, at least annually, to establish priorities for monitoring. • The Compliance Department uses a variety of methods to monitor compliance that include, but are not limited to: • Reviews critical documents used by business departments, including but not limited to policies, template letters, and provider & member communication to evaluate correct interpretation of compliance requirements.
Auditing And Monitoring (cont’d) • Collects results of compliance metrics. Metrics are most often used for reportable data, such as turnaround times and report rates. The Compliance Department monitors metrics submitted by the business departments. • Conducts compliance assessments on processes that are not easily measured by data and activities that are not audited by Internal Audit Department. • Priorities for assessments may be identified: • During the risk assessment. • During implementation or transition of implementation of new laws. • As part of Corrective Action Plans or monitoring requirements.
Auditing And Monitoring (cont’d) • Compliance monitoring is not just the responsibility of the Compliance Department. Business departments and delegates/vendors are expected to conduct ongoing compliance monitoring, too. • Appropriate compliance monitoring and reporting activities should be developed and implemented during implementation of any new or changed requirements. • The ability to produce evidence of compliance often requires some method of ongoing compliance monitoring to ensure that processes remain compliant and corrective actions are taken when deficiencies are identified. • The Compliance Department is available to discuss compliance monitoring activities upon request during implementation or at any time a department or delegate/vendor would like to initiate a new monitoring activity or review the effectiveness of an existing monitoring activity.
Auditing And Monitoring (cont’d) • Business departments and delegates/vendors should be able to provide evidence of compliance at all times. Evidence of compliance may be requested for many reasons, including regulatory audits, market conduct requests, legal requests, or concerns about compliance. • Evidence of compliance is documentation that can be produced on a periodic basis, or as requested, to demonstrate that a business department and delegate/vendor is maintaining sustained compliance with a regulatory requirement. • Evidence of compliance often requires evidence of compliant outcomes, such as claims payment, not just processes, such as P&Ps.
Enforcement Of Compliance Standards BHN has implemented disciplinary mechanisms to consistently enforce standards and address dealings with sanctioned and other specified individuals. • BHN’s P&Ps provide disciplinary guidance for associates who fail to comply with the Compliance Program or with compliance requirements. • BHN’s policy requires a reasonable and prudent background investigation to determine whether prospective associates, sub-contractors, agents or providers were ever criminally convicted, suspended, debarred or excluded from participation in a federal program.
Procedures And System For Prompt Response To Compliance Issues BHN has P&Ps about responding to detected compliance offenses, to initiate corrective action to prevent similar offenses, and to report to Government authorities when appropriate. • Compliance issues should be reported to the Compliance Department. Compliance issues may initially be reported by an associate to their supervisor and then escalated/reported to Compliance, as appropriate. • Business departments with an identified compliance issue are required to develop and implement a corrective action plan (CAP). The Compliance Department will review and monitor the CAP until the compliance issue is resolved. • The Compliance Department will determine when a compliance issue must be reported to a Government authority and will facilitate the report.
Who Is Responsible For Compliance? Everyone is responsible for compliance. The Board of Directors and Executive Leaders have overall responsibility for the company’s Compliance Program, but each associate and delegate/vendor is responsible to know and comply with all laws related to his/her job and to report non-compliance to a supervisor, the ComplyLine, and/or the Compliance Department. Compliance
Why Is Compliance Important? • Compliance is “lights on.” BHN must be a compliant company to stay in business. • Being a compliant company makes good business sense. The extent to which we are compliant affects our ability to grow our business, to maintain a positive reputation, and to become the innovative industry leader that we aspire to be. • Our focus on compliance underscores our core values of honesty, integrity, transparency and accountability. • Correcting compliance problems costs money and resources and reduces activities to grow and improve our company. If compliant programs are implemented and sustained, Banner Health Network can focus on its business opportunities.
What Does Non-Compliance Cost? • Non-compliance costs the company many ways in the short-term and long-term. • In the short-term, it can lead to fines, lawsuits, increased regulatory scrutiny, bad publicity and even increased regulations. • In the long-term, non-compliance can lead to loss of business, reputation, and revenue. Once the company is fined or sanctioned, the story is often repeated in related articles for many years continuing to damage the company’s reputation.
BHN Resources Kathy Harris, CHC, CPC BHN Compliance Officer (602)747-3460 Kathleen.Harris@bannerhealth.com BHN Code of Conduct BHN Compliance Handbook ComplyLine (888)747-7989 https://bannerhealthcomplyline.alertline.com
Additional Resources • Social Security Act: • Title 18 • Code of Federal Regulations*: • 42 CFR Parts 422 (Part C) and 423 (Part D) and 425 (ACO) • CMS Guidance: • Manuals • HPMS Memos • CMS Contracts: • Private entities apply and contracts are renewed/non-renewed each year • Other Sources: • OIG/DOJ (fraud, waste and abuse (FWA)) • HHS (HIPAA privacy)
Additional Resources • Title XVIII of the Social Security Act • Medicare Regulations governing Parts C and D (42 C.F.R. §§ 422, 423 and 425) • Offshore Attestation Guidance 2008 CMS Call Letter issued 4/19/2007 • HPMS Offshore Attestation memos dated 7/23/2007, 9/20/2007 and 8/26/2008 • Civil False Claims Act (31 U.S.C. §§ 3719-3733) • Criminal False Claims Statute (18 U.S.C. §§ 287,1001) • Anti-Kickback Statute (42 U.S.C. § 1320a-7b(b)) • Antitrust Laws (15 U.S.C. §§ 1-7) (15 U.S.C. § 12-27) • Stark Law Statute (Physician Self-Referral Law) (42 U.S.C. § 1395nn) • Intellectual Property Law (U.S. Patent and Trademark Office) • Exclusion entity instruction (42 U.S.C. § 1395a-7) • The Health Insurance Portability and Accountability Act of 1996 (HIPAA) (Public Law 104-191) (45 CFR Part 160 and Part 164, Subparts A and E) • OIG Compliance Program Guidance for the Healthcare Industry: http://oig.hhs.gov/compliance/compliance-guidance/index.asp