The document discusses the requirements for corporate compliance programs according to federal and state laws. It notes that health care entities that bill or pay out over $5 million annually in Medicaid must establish a compliance program. The focus of compliance programs is ethics, integrity, and compliance with fraud and abuse laws. Key components of compliance programs include a compliance officer, training, and anonymous reporting mechanisms. The document reviews several federal and state laws pertaining to fraud, kickbacks, and false claims. Employees' responsibilities to adhere to compliance policies and report any issues are emphasized.

1. Corporate
Compliance
Annual Update
2012

2. Corporate Compliance

The federal Deficit Reduction Act 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
Compliance Program. A program is recommended
for all health care entities.

3. Corporate Compliance

The focus of our program is on ethics and
integrity in the workplace and compliance with
federal and state laws related to fraud, false
claims, theft or embezzlement, kickbacks, or
other violations.

4. Corporate Compliance is…

A working environment that encourages -
 Ethical and Proper Ways to Do Business
 Commitment
 Encourages Problems to be Reported
 Provides a Process with Constant Monitoring
Processes which Prevent, Detect or Deter
Non-Compliant Behavior

5. What are the Benefits of a Corporate
Compliance Program?

 Increases awareness of compliance issues
among Board, staff, vendors, and providers;
 Prevents and detects violations;
 Reduces potential liability;
 Enhances positive reputation by exercising
due diligence.

6. The Guilford Center’s Corporate
Compliance Program Includes: 
 Corporate Compliance Officer;
 Corporate Compliance Committee;
 Policy and procedures;
 Corporate Compliance Plan (found by going to P:/ Drive, then the 2012
“Policies and Procedures” folder, and lastly the “Board and Director”
folder);
 Training for all employees, supervisors and providers;
 Code of Ethics;
 Screening procedures for all employees, independent contractors and
vendors to ensure they have not been sanctioned by a federal or state law
enforcement, regulatory or licensing agency;
 On-going risk assessment of business functions;
 Anonymous whistle blower hotline.

7. It is the policy of The Guilford Center…

 To review and investigate all allegations of
fraud and/or abuse, whether internal or
external;
 To take corrective actions for any supported
allegations after a thorough investigation; and
 To report confirmed misconduct to the
appropriate parties and/or Agencies.

8. The Guilford Center
Policies & Procedures

 Employment and/or Contracting with Excluded Parties
 Compliance Training
 Duty to Report
 County Compliance Hotline
 Non-Retaliation
 Responding to Reports of Non-Compliance
 Employee Consent to Search
 Voluntary Disclosure to Third Parties
 Responding to a Subpoena
 Responding to a Search Warrant
 Responding to Unannounced Visits by Government Officials/Auditors
B-6 Corporate Compliance Policy: Open Policy…

9. Laws and Regulations

Several federal and North Carolina statutes serve
as the basis for our requirements for compliance.
The following slides will outline statutes relating to
compliance issues.
As an employee of the Guilford Center it is your
responsibility to report any behaviors that
might constitute failure to comply.

10. North Carolina Laws

 Contracting for your own
benefit;
 Misuse of confidential
information;
 Gifts and favors;
 Secondary employment or private practice.

11. North Carolina General Statute

Contracting for your own benefit
North Carolina G.S. 14-234 This statute prohibits
making, or being in any manner concerned or
interested in making, a contract with the employer
(the Guilford Center) for one’s own benefit. The
penalty for violation of this general statute constitutes
a misdemeanor.

12. North Carolina General Statute

Misuse of confidential information
North Carolina G.S. 14-234.1 This general statute
applies to employees of the state of North Carolina
and any of the state’s political subdivisions, which
includes the Guilford Center.
This statute prohibits using confidential information obtained
by virtue of a public office (employment) for personal gain, or
aiding another to gain from using such information. Violation of
this general statute constitutes a misdemeanor.

13. North Carolina General Statute

Gifts and favors regulated
North Carolina G.S. 133-32 This statute states that employees who are
responsible for preparing plans, bid specifications or estimates for contracts, or
awarding or administering agency contracts cannot give or receive gifts or
favors from contractors, subcontractors or suppliers who have contracts with
local government agencies, or have performed under a contract within the past
year or anticipates bidding on one. Violation (by giver or receiver) constitutes a
misdemeanor.
Guilford Center employees are prohibited from accepting gifts from
consumers, providers or vendors, other than common courtesy items
such as coffee or snacks served during a training event.

14. Secondary Employment or
Private Practice

 Employees of the Guilford Center are prohibited from
secondary employment, including private practice, without
obtaining prior approval of their supervisor and management.
This approval includes completion of Form MHL 16.
 It is important that all such private practice endeavors be
distinct from Agency time and premises that have been paid
with public funds. Therefore, the Guilford Center prohibits any
employee from engaging in private practice on agency
property or during those hours that the employee is working
(or on duty) for the agency.

15. What Federal Laws Address
Fraud and Abuse?
 False Claims Act (FCA)
 Anti-Kickback Statute
 HIPAA
 Deficit Reduction Act
 Civil Monetary Penalties Act
 The False Claims Whistleblower Employee Protection Act

16. Civil and Administrative Statutes

The False Claims Act
(31 U.S.C. 3729-3733)
This is the law most often used to bring a case
against a health care provider for the submission
of false claims. The False Claims Act prohibits
knowingly presenting (or causing to be presented)
a false or fraudulent claim for payment or
approval.

17. The False Claims Act

A false claim is a claim for payment for
services or supplies that were not provided
specifically as presented or for which the
provider is otherwise not entitled to
payment.

18. False Claims Act Examples

A claim…
 indicating a higher level of service than was actually
provided
 for a service the provider knows is not reasonable and
necessary
 for clinical services provided by an individual who does not
meet the minimum education, experience or licensure
requirements to provide the service
 for a service or supply that was never provided
 indicating the service was provided for a diagnosis code
other than the true diagnosis code in order to obtain
reimbursement for the service (which would not have been
covered if the true diagnosis were submitted)

19. The False Claims Act Penalty for
Unlawful Conduct
The Penalty for violating the False Claims Act is a
minimum of $5,500 up to a maximum of $11,000 for
each false claim submitted. In addition, the
provider could be found liable for damages of up to
three times the amount unlawfully claimed.

20. Anti –Kickback
(U.S.C. 1320)

 Anti-Kickback
It is a crime to knowingly and willfully solicit,
receive, offer, or pay remuneration of any kind
(money, goods or services) for the referral of an
individual to another for the purpose of supplying
services that are covered by a Federal Health care
Program; or purchasing, leasing, ordering, or
arranging for any good, facility, service, or item
that is covered by a Federal health care program.

21. Anti-Kickback

Penalty for Unlawful Conduct
The penalty may include the imposition of a fine of up
to $25,000, imprisonment of up to 5 years, or both.
In addition, the provider can be excluded from
participation in Federal health care programs.

22. Anti-Kickback

Example
Provider pays a referral fee and records the
payment as salary or pays a higher than
normal pay rate to compensate for the
referrals.

23. Anti Kickback Statute

Examples of Kick-Backs:
 Money
 Waiver of co-pays
 Discounts
 Gifts
 Credits
 Commissions

24. The Deficit Reduction Act

Requires health care organizations who bill
(providers) or pay out (LMEs) more than $5
million annually in Medicaid to have an effective
corporate compliance program in place as of
January 1, 2007 as…
A Condition of Payment

25. Civil Monetary Penalties Law
(42 U.S.C. 1320)
 Not provided as indicated by the coding on the claim
 Not medically necessary
This is a comprehensive statute that covers an array of
fraudulent and abusive activities and is very similar to the False
Claims Act. This law prohibits a provider from presenting, or
causing to be presented, claims for services that the provider
“knows, or should have known” were…

26. Civil Monetary Penalties Law

 Furnished by a licensed physician who obtained his/her
license through misrepresentation of a material fact.
 Furnished by a physician who was not certified in the
medical specialty that he/she claimed to be certified in or
 Furnished by a practitioner who was excluded from
participation in the Federal Health Care Program to which
the claim was submitted

27. Obstruction of a Criminal Investigation of Health
Care Offenses
(18 U.S.C. 1518)

It is a crime to willfully prevent, obstruct, mislead,
or delay the communication of records relating to a
Federal health care offense to a criminal
investigator. This law also applies to most types of
health care plans.

28. Obstruction of a Criminal Investigation

Penalty for Unlawful Conduct
 The penalty may include the imposition of a fine,
imprisonment of up to 5 years, or both.
 Add exclusions and how you cannot do any role…

29. Your Responsibilities as Managers
with The Guilford Center

 Include staff adherence to rules,
regulations and overall compliance in
your evaluations;
 Maintain awareness in order to detect violations and
properly report them;
 Never retaliate against staff who report issues in good
faith.

30. Your Responsibility as Employees of
The Guilford Center 
 Be certain you have read the compliance plan, policies and
procedures related to your job and fully understand them.
 Ask questions about anything you are unsure of
 Perform your work with integrity
 If you learn of impropriety or suspect it, report it! Either by
informing management or through the hotline.
 Be cooperative with investigations

31. How Do I Report Suspected
Fraud and Abuse?
 Contact the Division of Medical Assistance by calling the
DHHS Customer Service Center at 1-800-662-7030
(English or Spanish) or;
 Call the Medicaid fraud, waste and program abuse tip-
line at 1-877-DMA-TIP1 (1-877-362-8471); or
 Call the Health Care Financing Administration Office of
Inspector General's Fraud Line at 1-800-HHS-TIPS; or
 Call the State Auditor's Waste Line: 1-800-730-TIPS; or
 Complete and submit a Medicaid fraud and abuse confidential on
.

32. Corporate Compliance Is In the
News… 
 The Affordable Care Act was enacted on March 23, 2010.
 CMS created the Center for Program Integrity on April 11, 2010.
 Governor Perdue signed Senate Bill 675, Prohibit Medicaid
Fraud/Anti-Kickback law (Session Law 2010-185).
 The results of Program Integrity’s efforts can be seen everyday at
the Office of Inspector General’s (OIG) website.
OIG’s Most Wanted List: http://oig.hhs.gov/fraud/fugitives/index.asp
In recent news, a Charlotte women was arrested for a $650,000
Medicaid fraud scheme. Click here to read the Press Release from
the Department of Justice.