Corporate Compliance (Physicians)

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  • The focus on compliance was fueled by the financial audit of the Department of Health and Human Services’ audit of the Healthcare Financing Administration (HCFA) now known as CMS
  • Legislation passed afterwards made it easier for the government to prove violations of reimbursement. Resources were increased devoted to enforcing healthcare laws and regulations (hiring lawyers, FBI involvement, etc.) Healthcare fraud under HIPPA became a criminal offense. This applies to all claims under health benefit programs, regardless if government funded or not.
  • Corporate Compliance (Physicians)

    1. 1. CORPORATE COMPLIANCE PROGRAM
    2. 2. HISTORY <ul><li>Center for Medicare & Medicaid (CMS) paid $20,000,000,000 in error ! </li></ul><ul><li>Improper payment due to: </li></ul><ul><ul><li>CODING & BILLING ERRORS </li></ul></ul><ul><ul><li>FRAUD & ABUSE </li></ul></ul><ul><li>Enormous financial losses for government </li></ul>
    3. 3. <ul><li>PASSAGE OF HIPAA 1996 </li></ul><ul><li>Government $$$$ for resources to detect fraud & abuse </li></ul><ul><li>Criminal Offense </li></ul><ul><ul><ul><li>Fines, Prison, Restitution, Sanctions, Corporate Probation </li></ul></ul></ul><ul><li>OIG strongly recommends Corporate Compliance </li></ul>
    4. 4. Purpose of the Corporate Compliance Program <ul><li>to maintain the highest level of professionalism and ethical standards in the conduct of its business </li></ul><ul><li>to maintain the importance of our reputation for honesty, integrity and high ethical standards </li></ul>
    5. 5. Physicians and all TSC Employees <ul><li>are obligated to conduct themselves in a manner to ensure the maintenance of these standards </li></ul><ul><li>are expected to adhere to ethical conduct and exhibit personal and professional integrity at all times </li></ul><ul><li>to show respect for the rights and feelings of patients, co-workers and others </li></ul><ul><li>refrain from any behavior that may be harmful or that may be viewed unfavorably by patients, co-workers and others </li></ul>
    6. 6. CORPORATE COMPLIANCE PROGRAM <ul><li>Written Policies and Procedures </li></ul><ul><li>Quality Care and Services </li></ul><ul><li>Reporting and Communication Policy </li></ul><ul><li>Compliance with Laws and Regulations </li></ul><ul><li>Medical Records </li></ul><ul><li>Personnel </li></ul><ul><li>Safe Work Environment </li></ul><ul><li>Conflicts of Interests </li></ul><ul><li>Coding, Billing and Documentation </li></ul><ul><li>Protecting Property </li></ul>
    7. 7. CORPORATE COMPLIANCE: AN ONGOING PROCESS 1.Prevent 2. Detect/Correct 3. Defend/Mitigate RISK
    8. 8. REPORTING A VIOLATION TSC Hotline 973-477-7217 email megoser@thestonecenter.org <ul><li>Anyone can report a violation without fear of ANY retaliation by: </li></ul><ul><ul><ul><ul><ul><li>Phone </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Verbal </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>E-mail </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Written </li></ul></ul></ul></ul></ul>

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