• The federal Deficit Reduction Act (DRA)
and subsequent Medicaid Integrity
Program requires that all health care entities
that annually bill or pay out $5 million or more
in Medicaid establish a Corporate
• A program is recommended for all health
Purpose of P&S Corporate
To have an effective compliance and ethics program:
– To exercise due diligence to prevent and detect wrong-doing
– To promote an organizational culture that encourages ethical
conduct and a commitment to compliance with the law.
– To raise awareness
– To positively impact corporate reputation/culture
– To provide a “safe” mechanism(s) for reporting and seeking help
Objectives of P&S Corporate
To meet the objectives of the 7 elements of a corporate compliance program
as outlined by the (FSG) Federal Sentencing Guidelines:
1. Review Written Policies & Procedures
2. Select Compliance Officer & Committee
3. Training & Education
4. Effective Lines of Communication
5. Discipline & Background Checks
6. Auditing and Monitoring
7. Responding & Corrective Action
Written Policies & Procedures
• The focus of our program is on ethics and integrity in the workplace and
compliance with federal and state laws related to:
Theft or embezzlement
• The Compliance Program develop and implement policies, procedures, and
best-practices designed to ensure compliance with state & federal
regulations and programs.
– Accreditation Agency (DNV)
– Medicare/Medicaid requirements (CMS)
– HIPAA/HITECH requirements (OIG/OCR)
A working environment that
• Ethical and proper ways to do business
• Encourages problems to be reported
• Provides a process with constant monitoring
– Prevent Non-Compliant Behavior
P&S Code of Conduct
• P&S Surgical Hospital strives to provide the highest quality
procedural care in a patient-focused environment. P&S
Surgical Hospital is committed to our core values of:
The Code of Conduct provides standards by which all members of the organization
will conduct themselves.
Individual’s conduct must be in a manner that protects and promotes
organizational-wide integrity and enhances P&S Surgical Hospital’s ability to achieve
its objectives and mission.
This applies to all employees, officers, administrators, board members, medical
staff, vendors, contracted employees, consultants, students, and volunteers.
P&S’s Corporate Compliance
Corporate Compliance Officer
– Report on a regular basis to the CEO, compliance committee, and when necessary to the
– Continue to design, implement, oversee, and monitor the compliance program.
Corporate Compliance Committee
Policy and procedures
Corporate Compliance Plan
Develop, coordinate, and participate in a multifaceted educational & training.
Ensure that independent contractors and agents are aware of the organization’s compliance
Assist with internal compliance review and monitoring activities.
Training & Education
• Communication process to report any compliance issues or concerns
• New Hire Orientation
• Code of Conduct Training – Annually
• 7 Elements of an Effective Compliance Program – Annually
• Conflict of Interest Statements – Annually
• Safe guarding PHI/ePHI
It is every employee’s responsibility to report suspected
violations of the laws, regulations and policies, or other
Effective Lines of
Reporting Compliance Issues or Concerns:
1. Your manager
2. Executive Team Member
3. Director of Human Resources
Chenire Craig- 998-7307
4. Compliance Officer
Dirk Rhodes – 998-6135
5. Compliance “Anonymous” Hotline - 1-866-570-2523
Effective Lines of
• Dirk Rhodes, Corporate Compliance Officer
– Phone: (318) - 998-6135
– Contact via E-mail: DirkRhodes@pssurgery.com
• P&S Corporate “Hotline” ComplianceLine:
– 100% anonymous; Available 24 hours a day/ 7 days a
– There will be no retaliation for reporting concerns in
good faith, but appropriate disciplinary action will be
taken against those who commit misconduct.
• All reported allegations will have to be verified before any
actions are taken.
Discipline / Background
• Upon hire all employees undergo a background check/
• Monthly SanctionCheck is performed on all
employees, medical staff, vendors, & contracts/business
associates to show that P&S is compliant with
CMS, federal & state regulations and various programs
that we participate in.
• Annually employee(s) should receive a copy of the
Sanction Policy that supports the Code of Conduct and
outlines the disciplinary actions taken in the event of
Auditing & Monitoring
• Unethical or inappropriate
care of patients
• Lack of correct and
sufficient documentation in
admitting / discharging
• Medical Necessity
• Billing for services or
supplies that were not
• Altering claims for higher
• 2 Annual (External)
• MCR inpatient one
• Conflict of Interest
• Inappropriate access
and/or release of
• Bribes or kickbacks
• Business Associate
• Physician Ownership
The Compliance Department reviews all allegations in a serious manner and takes
the necessary steps to deter, detect, correct, & prevent any wrong-doing or
– All reported allegations will have to be verified before any actions are taken.
All allegations, audits (internal & external), and monitoring is reported directly to the
CEO/ Compliance Committee/Board as necessary.
All allegations, audits (internal & external), and monitoring tools are responded back
to in the allotted time frame per the institution guidelines.
In regards to the P&S “Hotline” ComplianceLine
– ≤ 72 hours to respond to any issue or concern (Severity I to III)
– May take longer considering certain factors and seeking P&S Legal Counsel for
We want to provide a safe patient centered environment for
Patients & Employees!!
• All employees are held responsible and accountable for
compliance and can be charged with fraud
• The corporate compliance committee investigates every
complaint of noncompliance
• There will be no retaliation for reporting concerns in good
faith, but appropriate disciplinary action will be taken
against those who commit misconduct
• Law prohibits asking for or receiving anything of value
to induce or reward referrals of Federal health care
• Never read another employee’s confidential records without permission
• Never use another person’s password to access confidential information
• Only discuss a patient’s condition with those involved in the patient’s care
• Never treat or act differently to someone because they identified a
compliance or ethical issue
• Accepting gifts from vendors, providers, or third parties are prohibited as
outlined in the conflict of interest policy at P&S. All gifts (>$25.00 per person
per transaction) need prior administration approval before accepting.
• Only bill for visits, procedures and/or tests performed
• Always provide complete documentation for ALL services performed
DO THE RIGHT THING:
• When you become aware of or observe something
you believe to be improper, report it.
• Keep yourself trained and informed.
• No retaliation for reporting in good faith!
No Pointing Fingers!!