Transcript Our Values and Ethics at Work Reference Guide

Compliance for Leaders
2008 Mandatory Corporate Responsibility Training
Saint Joseph Mount Sterling
About This Course
Welcome to the Corporate
Responsibility Program – Compliance
for Leaders Web-based course. As a
leader within CHI, you have a personal
and corporate responsibility to behave
ethically and appropriately in your
workplace. Employees are watching to
view how you handle situations and to
see if your actions support CHI’s
Standards of Conduct as defined in
Our Values and Ethics at Work
Reference Guide.
Course Objectives
After successfully completing the course, you will be able to:
• Understand how your behavior and actions as a leader impact the
culture of the organization.
• Confidently handle compliance situations that you commonly deal
with on a day-to-day basis.
• Describe the current regulatory environment
and how it affects your organization.
• Apply the Standards of Conduct
in your daily actions to reinforce
CHI’s mission, vision and core
values
Course Structure
This course is divided into the following Lessons:
• About this Course
• Never Enough Time—
Documentation
• CRP, CHI Polices, and Laws
• Looking Out for the Patient—
Coding and Ordering Tests
• Tone at the Top—Leadership
Behavior
• The Rent is a Steal—Leasing
Space to Physicians
• When to Say No—Gifts and
Gratuities
• Show Me the Money—Physician
Employment and
Recruitment
• Employees as Patients—HIPAA
• A Nose for Trouble—Claims
Processing
• Course Summary
• Final Test
Glossary Terms
You can view a list of glossary terms by accessing the
Glossary page located at the end of this course. Words that
show a blue and underlined are defined in the course glossary.
This is an example of a glossary term.
Getting Credit
This course will assist you in understanding the regulatory
environment of the health care industry and how your daily
actions reinforce our mission, vision and core values.
To test your understanding of this information and to receive
course credit, you are required to complete a 10 question final
test and receive a score of 80% or better. Please complete all
sections of the course before taking the final test.
After passing the final test,
you can complete the course
survey.
CRP, CHI Polices, and Laws
Introduction and Objectives
As a leader within CHI, you have a personal and corporate responsibility
to behave ethically and appropriately in your workplace. Employees are
watching to view how you handle situations and to see if your actions
support CHI’s Standards of Conduct as defined in Our Values and Ethics
at Work Reference Guide. The Corporate Responsibility Program (CRP)
provides you with the resources and tools to help you make ethical
decisions and to support the regulatory laws that govern our industry.
Compliance is a large part of the health care industry. As a leader, you
must be aware of applicable policies, laws, and regulations and know
what to do when faced with an issue. This lesson reviews some of the
organizational policies and health care statutes that will guide your
actions.
In this lesson you will review the following:
CHI and its Organizations'
Policies:
• Responsibility to Report
• Non-Retaliation Policy
• Conflicts of Interest
Health Care Statutes:
• False Claims Act (FCA)
• Stark Law
• Anti-kickback Statute
Responsibility to Report
All employees have a duty to act in a manner consistent with
our core values, policies and Standards of Conduct as defined
in Our Values and Ethics at Work Reference Guide. A part of
that duty is to promptly report potential violations of laws,
regulations, policies, procedures or Standards of Conduct.
As a leader, you have the added responsibility of:
• Making sure your employees have the proper training so they
understand the expectations for ethical business conduct.
• Creating an environment where employees feel comfortable reporting
concerns or asking questions.
• Addressing questions and concerns brought to your attention by
employees in a timely manner.
• Ensuring that employees know CHI’s reporting process to report an
issue or concern.
CHI’s Reporting Process
To support you in making the right decisions and getting
answers to your questions or concerns, CHI has developed
the following reporting process:
• Speak with your supervisor or another manager.
• If the supervisor/manager is not available, or you are not
comfortable speaking with him/her, or you believe the matter
has not been adequately resolved at this level, contact your
human resources representative or your local corporate
responsibility officer.
• If you want to report a concern anonymously, you have two
options:
1. Call the Ethics at Work Line phone number at 1-800/261-5607
2. File a report using the internet at www.ethicspoint.com
Non-Retaliation Policy
Since it is the duty of all employees to report possible policy
violations, as a leader you should promote an environment that
encourages employees to seek clarification of issues and report
questions and concerns without fear of retaliation. To do this,
you need to understand and implement CHI’s Non-Retaliation
Policy that states the following:
• No retaliatory action will be taken against an individual who
makes a report, complaint or inquiry in good faith.
In good faith means that the employee actually believes or
perceives the information reported to be true.
• Non-retaliation policies do not protect employees if their actions
violate the policies of CHI, its organizations and/or applicable
federal or state laws.
Conflicts of Interest
As an employee, and especially as a leader, you should avoid
situations where personal interests may influence your ability
to act in the best interest of CHI and its organizations. These
situations, or conflicts of interest, may involve obtaining a
direct or indirect personal gain or advantage or creating an
adverse or potentially adverse effect on the organization’s
interests. As a leader, you should report any potential conflicts
of interest situations in accordance with your organization’s
Conflicts of Interest policy. You should ensure that applicable
employees understand the Conflicts of Interest policy and
know how to report a potential situation.
Conflicts of Interest Examples
Relationships with
Vendors, Competitors or
Other Outside Interest
Holders
The personal interests of an employee may
conflict with the interests of CHI and its
organizations if the employee or an immediate
family member is a person who does business
with, seeks to do business with, or is in
competition with CHI or any of its organizations
It is a conflict of interest for an employee to
Confidential Information
Disclosure of Confidential disclose nonpublic, privileged or confidential
information relating to the business of CHI or
or Inside Information
any of its organizations or to use such
information for personal profit or advantage.
Conflicts of Interest Examples
Gifts Acceptance of Gifts, It may be a conflict of interest for an employee
to accept gifts (including cash or cash
Gratuities and
equivalents), excessive entertainment, or other
Entertainment
favors from any outside individual or entity that
does, or is seeking to do, business with, CHI or
any of its organizations if the action could be
inferred or intended to influence a business
decision. Generally, employees may accept noncash items of nominal value such as pens, tshirts, mugs, etc., if the gifts are in keeping with
CHI’s values.
False Claims Act
Many laws and regulations govern the health care industry. It
is your responsibility to be aware of this regulatory
environment and understand how it impacts your decisions
and the organization.
The first statute for review is the federal False Claims Act
(FCA). The federal FCA covers fraud and/or abuse related to
claims paid by any federal or state programs such as
Medicare and Medicaid. Under the federal FCA, it is a
violation to knowingly present or submit to the government a
false or fraudulent claim/bill in order to receive payment.
What is Knowingly?
The federal FCA defines knowingly as:
• Actual knowledge that the claim is false. For example, deliberately
documenting that a service was provided when it was not.
• Deliberate ignorance as to the truth or falsity of the claim. For example,
knowing a problem exists but not addressing it prior to the bill being
submitted.
• Reckless disregard for the truth or falsity of the claim. For example, having
inadequate controls in place to ensure claims are accurate (such as having
billing edit software installed however choosing not to use it).
What is a False/Fraudulent Claim?
A false or fraudulent claim is an inaccurate, deceptive or
misleading claim of entitlement to money or property. Examples
of fraudulent claims include:
• Assigning a higher code that is not reflective of the level or service
provided
• Unbundling of lab tests in an effort to receive higher reimbursement
• Billing for products and services that are not medically necessary
• Billing for products and services that are never provided
How Much Are Damages?
If you had 250 false claims at $50 per claim, the maximum
liability under the FCA could potentially be $2.8 million. Potential
damages and penalties for violating the FCA include: Three times
the amount of overpayment (treble damages) received from a
federally funded healthcare program. PLUS Civil penalties of not
less than $5,500 and not more than $11,000 per violation/claim
Stark Law
Another law that impacts the health care industry is the
federal Stark Law. This law, also known as the federal
physician self-referral statute, focuses on financial
relationships with physicians and their immediate family
members, and is intended to ensure that referrals of patients
and utilization of health care services are not improperly
influenced by financial considerations
Stark Law Specifics
Financial Penalties
The Stark Law is highly technical and can lead
to enormous financial penalties. Any financial
relationship between an organization and a
physician who refers Medicare patients (for
hospital and certain other services) must meet
a specific exception under the Stark Law, or
the referrals (and the organization’s ability to
bill Medicare for them) will be prohibited,
regardless of the parties’ intent.
Financial Penalties If an organization bills Medicare in violation
Example of Stark, then it may be required to refund all
Medicare reimbursement it has received, even
though the services were adequately provided
and were medically necessary.
Stark Law Specifics, Continuing
Written Agreement
All physician financial relationships must be
documented in a signed, written agreement. A
written agreement must be in effect at all
times during which there is any business
relationship between a physician and an
organization, whether it be a medical
directorship, a consulting agreement, a lease
for space or equipment, a purchased services
agreement, or other relationship.
Stark Law Specifics, Continuing
Fair Market Value
The financial terms of each arrangement with a
physician must be fair market value, without
taking into account referrals (or potential
referrals). Similarly, it is important to
document the fair market value of all
arrangements, to the extent possible, such as
requiring physicians to complete time logs
when the physicians are being paid for services
(i.e., medical director and consulting services).
Review for Relationships
Management MUST regularly review all financial
relationships between the organization and physicians and
family members of physicians, to ensure agreements comply
with all technical specifications of the Stark Law. Use of an
automated contracts management system would assist with
this process.
Saint Joseph Health System uses Meditract.
Christy Mattingly, Contract Services Coordinator, may be reached at
859.313.2012.
Anti-kickback Statute
Similar to the Stark Law, the federal Anti-kickback Statute
covers financial relationships with physicians, but also
includes relationships with suppliers, vendors and other
parties with whom a hospital does business. Like the Stark
Law, the Anti-kickback Statute is also intended to ensure that
referrals of patients and utilization of health care services are
not improperly influenced by financial considerations.
The Anti-kickback statute provides certain guidelines where
services that would normally be considered possible
violations may be acceptable. These are known as safe
harbors. Management should seek guidance from the CRO
and/or legal counsel as the rules pertaining to safe harbors are
complex.
Anti-kickback Details
Anti-kickback Details
Specifically, the Anti-kickback statute
prohibits offering or paying anything of value
(whether in cash, free goods or services, or
otherwise) in exchange for or to induce
referrals for health care services covered under
Medicare, Medicaid or any other federal health
care program. The Anti-kickback statute
provides certain guidelines where services that
would normally be considered possible
violations may be acceptable. These are known
as safe harbors. Management should seek
guidance from the CRO and/or legal counsel as
the rules pertaining to safe harbors are
complex.
Safe Harbor
Safe Harbor
A notable safe harbor to the Anti-kickback
statute protects some discount arrangements.
An example would be where a facility receives
a rebate check or credit towards future
purchases, premised on the facility’s having
purchased at least a specified volume of the
same (or similarly reimbursed) item during the
fiscal year. Discount arrangements must meet
several specific requirements, including,
among others, that they are appropriately
reflected on a facility’s cost report (if it files
cost reports). The Office of Inspector General
(OIG) reviews whether hospitals are properly
identifying purchase credits as a separate line
item in their cost reports.
Intent
Focuses on Intent
Unlike the Stark Law, this statute focuses on
the intent underlying the payment. The statute
may also be violated by so-called cross-referral
arrangements, in which two unrelated providers
agree that each will refer patients to the other.
Example: Improper An example of an improper cross-referral
Cross-Referral arrangement would be: If a CHI hospital was to
agree to refer patients to a non-CHI home
health agency, in exchange for the home health
agency’s agreeing that it would refer any
patients needing hospitalization to the CHI
hospital.
Identify and Take Action
Use your knowledge of these health care
statutes and CHI and Saint Joseph Health
System’s policies to help identify potential issues
and to take appropriate action, if necessary.
Summary
In this lesson, you learned that all employees have the
responsibility to behave ethically and appropriately in the
workplace. As a leader you have the added responsibilities of:
• Ensuring your employees understand health care statutes and CHI and
its organizations’ policies.
• Creating an environment where employees will report potential issues.
• Recognizing compliance issues and knowing the appropriate action to
take.
The rules and regulations related to the health care industry
can be complex. Therefore, use the resources and tools
provided by the CRP to help you and your employees make
ethical decisions.
Policies, Statutes Covered
The policies and statutes covered in this lesson are listed
below. Please read the terms in the Glossary section and
review their definitions.
CHI and SJHS’ Policies:
• Responsibility to Report
• Non-Retaliation Policy
• Conflicts of Interest
Health Care Statutes:
• False Claims Act
• Stark Law
• Anti-kickback Statute
Practice Quiz
1. The CRP provides guidelines, education, and tools to help CHI
employees and leaders make ethical decisions.
A. True
B. False
2. You discover an employee is knowingly billing for the same service
twice. This is a violation of which policy or statute?
A. Conflicts of Interest
B. False Claims Act
C. Stark Law
D. Anti-kickback Statute
Practice Quiz, Continuing…
3. Situations that result in obtaining a direct or indirect personal gain or
advantage are a violation of which policy of either CHI or its organizations?
A. Responsibility to Report
B. Non-Retaliation Policy
C. Three-step Reporting
D. Conflicts of Interest
4. Which of the following laws prohibit offering or paying anything of value
in exchange for or to induce referrals for health care services covered under
a federal health care program?
A. False Claims ActC. Anti-kickback Statute
B. Conflicts of Interest
D. Non-Retaliation
5. Which of the following is also known as the federal physician selfreferral statute?
A. False Claims Act
B. Anti-kickback Statute
C. Stark Law
D. Non-Retaliation
Practice Quiz Answers
1. The correct answer is: The CRP is a system-wide program
designed to provide guidelines, education and tools to help us make
ethical decisions. CRP provides tools such as "Our Values and Ethics at
Work Reference Guide" to help us in our day-to-day decisions. The
primary goals of the CRP are threefold: Prevent, Detect and Correct.
2. The correct answer is: It is a violation of the federal FCA to
submit fraudulent claims such as billing for a service twice. Damages and
penalties for violating the federal FCA can be substantial. As a leader, you
should immediately report potential violations to SJHS’ Corporate
Responsibility Officer (CRO).
Practice Quiz Answers, Continuing…
3. The correct answer is: As an employee, and especially as a leader,
you should avoid situations where personal interests may influence your
ability to act in the best interest of CHI and its organizations.
4. The correct answer is: The Anti-kickback Statute focuses on
financial relationships with physicians, suppliers, vendors and other parties
with whom a hospital does business and prohibits offering or paying anything
of value in exchange for referrals for health care services covered under a
federal health care program such as Medicare or Medicaid.
5. The correct answer is: The Stark Law, also known as the federal
physician self-referral statute, focuses on financial relationships with
physicians, and is intended to ensure that referrals of patients and utilization
of healthcare services are not improperly influenced by financial
considerations.
Tone at the Top - Leadership Behavior
Introduction
Imagine it is a hot summer day and you are
about to enjoy a 3-scoop chocolate ice cream
sundae. As the sundae sits on the table you
notice that the chocolate sauce is flowing into
the melting ice cream so that in the bottom of
the dish you have a swirl of ice cream and
chocolate. Imagine it is a hot summer day and
you are about to enjoy a 3-scoop chocolate ice
cream sundae. As the sundae sits on the table
you notice that the chocolate sauce is flowing
into the melting ice cream so that in the bottom
of the dish you have a swirl of ice cream and
chocolate
Tone at the Top - Leadership Behavior
So what does a chocolate sundae have to do with leadership at CHI and its
organizations? Your behaviors and how you support CHI’s Standards of
Conduct and core values are similar to the chocolate sauce in the sundae.
Your leadership sets the tone for the organization and flows through it much
like the chocolate sauce in the sundae. As a leader, you are called to create a
work place that fosters community, honors and cares for the dignity, safety
and well being of those with whom you serve. The way you support and
demonstrate CHI’s Standards of Conduct and core values will have a direct
impact on the culture of the organization.
This page outlines a scenario related specifically to support our values during
a tough situation. Read the scenario and take time to evaluate both the
scenario and related questions.
Scenario
You are the manager of the surgical center at your facility and have just
had a team meeting to review the CHI Standards of Conduct with your
staff. During the meeting you noticed some snickering and shuffling when
you talked about creating a work place that fosters respect for everyone.
The reaction during the team meeting is weighing on your mind the next
day but you are too busy with a hectic surgery schedule to take steps to
address it. However, following one surgery case, you hear the surgeon
yelling at the surgical staff. As the surgeon leaves the operating room, he
slams open the door, throws his gown and mask on the floor and stomps
down the hallway. As the remaining surgical staff leaves the room, you ask
them how things went and they all reply that the surgery went fine. Their
response was given without direct eye contact to you. As a leader, what
should you do in this situation?
Stop and Think
• Is the surgeon’s behavior a violation
of CHI's Standards of Conduct or its
organizations' guidelines or policies?
Is he breaking the law?
• How do you think the surgical staff
feels about their work place after a
successful surgery? Do they feel
differently about a successful surgical
outcome given the surgeon’s
condescending behavior?
• Once the surgeon’s behavior is not
creating an immediate legal risk, does
leadership need to take any action to
address this situation?
After you have considered how you
would react in this situation and the
effect of your actions, continue to
the next page.
As you think about your
possible actions, keep CHI's
mission, Standards of
Conduct, and core values in
mind. Here are some
questions and statements to
help you decide the correct
action to take.
Scenario Answer
You should NOT let this type of inappropriate behavior continue in
your unit since it does not support our Standards of Conduct and
core values. As a leader, you need to listen to your staff’s concerns.
Your staff was “telling you” through the snickers at the staff
meeting and lack of eye contact after the surgery incident that they
did not appreciate the surgeon’s behavior. It is up to you as the
leader to address this issue with the surgeon and take the steps
necessary to promote behavior consistent with the Standards of
Conduct and core values.
Additional Information
Below are some key skills and behaviors leaders must demonstrate to
support CHI's Standards of Conduct and core values:
• Model values through their individual behavior and attitude.
• Talk about values in common sense ways with their employees.
• Welcome employee concerns by using critical listening skills. Promote an
environment that encourages employees to seek clarification of issues and
report questions and concerns without fear of retaliation. If employees do
not feel like their leaders listen to them, they will not bring concerns
forward. Unaddressed concerns lead to continuance of behaviors and
practices not in line with core values and could lead to significant
compliance issues. Be respectful of employee conversations and concerns
by keeping information confidential as appropriate.
• Show respect by listening, participating, speaking kindly, and walking the
talk.
Additional Information, continued…
• Demonstrate community by saying hello, participating in team efforts,
working together to help those in need, prioritizing activities while
keeping the "big picture" in mind, keeping people informed.
• Demonstrate integrity by communicating honestly even when it is
hard to do so, being willing to stand alone in a difficult situation when
it is the right thing to do.
• Demonstrate and support excellence by being open to change, not
settling for the minimum necessary, always striving to do better.
• Lead innovation by thinking outside of the box, do research, share
best practices, take risks, allow failures to be opportunities, be
consistent, welcome concerns and ideas, provide timely response and
follow up.
• Be aware of tone of voice, body language and eye contact when
speaking with employees, visitors, patients, physicians.
All of your actions as a leader have an impact, either
positive or negative, on your work community.
Cause and Effect
As a CHI leader, your actions have a lasting effect on the CHI community. When you
understand the ramifications of your actions, you can make better decisions. Based on
this scenario, below are some of the potential positive, and not so positive, outcomes
of specific actions.
Positive
By taking action regarding the surgeon’s behavior, you are modeling the behavior
expected as outlined in CHI’s Standards of Conduct and core values. This sends a
clear message to the staff that you expect everyone to follow CHI’s values and that
you are ready to support those values. The way you, as a leader, react and behave will
have a direct impact on the way your unit reacts and behaves.
Consequence
If you do nothing and allow the surgeon to continue to behave inappropriately toward
staff, you are harming both the individual staff members and the entire unit. This
disruptive behavior can negatively impact employees and medical staff, patient safety,
and quality of care. Not surprisingly, staff may start to look for other employment
opportunities if they are not comfortable working in a culture that does not support the
organization’s values.
Summary
In summary, here are
some points to remember
based on this scenario:
• Leaders set the tone for their
organization. When leaders
demonstrate support of CHI’s
Standards of Conduct and core
values in their actions and
behaviors, then employees are
more likely to also support
them.
• Leaders must listen to concerns
from their staff and take action
when appropriate.
• Leaders must talk about the
organization’s values in
common sense ways with their
employees and model the
desired behaviors.
When to Say No - Gifts and Gratuities
Introduction
It is fun and exciting to receive an
unexpected gift. There are times when
patients and their family members want
to show appreciation for the excellent
care received by giving the staff a gift.
There are also situations when a vendor
or supplier offers a gift to say thank you
for your business or for gaining new
business. Based on the situation and the
gift, it may or may not, be acceptable to
keep the gift.
Scenario
You are a department manager at your facility. Two weeks
after attending a national health care conference, you receive a
$1,000 gift certificate from a business source you met during a
workshop. Attached to the gift certificate is a note from the
business source asking you to contact him at your convenience
to “discuss possible partnership opportunities.” What would
you do in this situation? Would you keep the gift certificate?
Stop and Think
• Is this a reasonable gift for you
to accept?
• Based on Our Values and Ethics
at Work Reference Guide, would
this gift be considered nominal in
value?
• What types of gifts can I accept
from a business source?
• Are there any specific laws or
regulations that I need to think
about in this situation?
After you have considered how
you would react in this situation
and the effect of your actions,
continue to the next page.
As you think about your
possible actions, keep CHI's
mission, Standards of
Conduct, and core values in
mind. Below are some
questions to help you decide
the correct action to take.
Scenario Answer
You should NOT accept the $1,000 gift certificate from the business
source. A gift certificate is a cash equivalent and should NEVER be
accepted. Gifts that are excessive and over nominal value, as described
in organizational policy, could be perceived as an inducement to
influence future business decisions and should not be accepted.
Gifts accepted from or given to anyone with whom an organization
does business should only be promotional in nature and nominal
in value (such as T-shirts,
promotional pens or office
supplies, or flowers, fruit,
candy or other small,
perishable gifts).
Additional Information
Business courtesies, such as reasonably priced meals, can be accepted if the
reason for them is appropriate and legitimate and not extravagant or frequently
provided. For example, a reasonably priced meal provided by a business
source in conjunction with a business discussion wherein both representatives
of the CHI entity and the business source are present, is generally acceptable.
A business courtesy should not be accepted if the business source has the
expectation of something in return, may be attempting to gain an unfair
advantage or influence the employee’s judgment, or if acceptance creates the
appearance of any impropriety. Consult your local Gifts Policy if you have any
questions about the appropriateness of receiving or accepting gifts from
business sources.
All of your actions as a leader have an impact, either positive or negative, on
your work community.
Cause and Effect
As a CHI leader, your actions have a lasting effect on the CHI community.
When you understand the ramifications of your actions, you can make better
decisions. Based on this scenario, below are some of the potential positive,
and not so positive, outcomes of specific actions.
Positive
As an employee and especially as a leader, you do not want to accept a gift
that may be perceived as influencing future business decisions or favoring a
specific business source. By not accepting the $1,000 gift certificate, you are
observing the Anti-kickback Statute and applying CHI’s core value of
Integrity and the Standards of Conduct.
Consequence
If you accept the gift certificate, or any excessive business courtesy, it may be
a violation of the Anti-kickback Statute. This law applies civil and criminal
penalties to individuals and entities that knowingly offer, pay, solicit or
receive bribes or kickbacks or other remuneration in order to induce business
reimbursable by Medicare, Medicaid, or other governmental healthcare
programs.
Summary
In summary, following are some points to remember based
on this scenario:
• Avoid any conduct that violates, or appears to violate, federal or
state anti-kickback laws.
• Gifts that are promotional in nature and nominal in value as
described by organizational policy may be acceptable.
• Cash or cash equivalents should never be accepted or offered to
business sources.
Reference
Anti-kickback Statute, 42 U.S.C.§ 1320a-7b (2000)
Employees as Patients – HIPAA
Introduction
Many of us enjoy reading a good mystery
and playing the role of detective to figure
out a problem or to solve a mystery. As a
leader, you are asked to help solve many
problems and to give your opinion
regarding different situations. To solve
some of these issues, you may need to
access confidential information that only
you, as the leader, have access to. During
these situations, you need to keep in mind
the HIPAA Privacy regulations and be
careful about protecting individuals’
protected health information (PHI).
Scenario
You are an employee of a large physician medical practice. You receive a
phone call from a local pharmacy. The pharmacist expresses concern
regarding the number of prescriptions written for Jane Doe, a patient from the
medical practice. You bring this situation to the office manager’s attention. In
order to research this matter, the manager obtains copies of the prescriptions
from the pharmacy. The office manager reviews Jane Doe’s medical record
from the medical practice to compare the pharmacy prescriptions to the
documented prescriptions in Jane Doe’s medical records. Discrepancies are
found in the records. It is also discovered that Jane Doe is an employee of the
medical practice. The office manager and you suspect that Jane Doe is
abusing drugs and is using her status as an employee to obtain prescriptions.
Based on the information from the pharmacy and the review of the
employee’s medical records from the medical practice, Jane Doe is
terminated from employment with the medical practice for abuse of position
and policy.
Was this situation handled properly?
Stop and Think
Some other questions to
consider are the following:
• Can the employee’s PHI from
the medical practice be used by
management in order to perform
employment related activities?
• What steps can be taken to
resolve this issue without
violating HIPAA or other
confidentiality laws?
As you think about how you would
handle this situation, keep in mind that
the primary purpose of the HIPAA
privacy regulations is to protect the
privacy and confidentiality of
individuals’ PHI. CHI employees
should always be mindful of the
confidential nature of PHI and that
efforts should be made to limit use,
disclosure of, and requests for PHI to
the minimum necessary to accomplish
the intended purpose.
Scenario Answer
The medical practice must remain cognizant of its dual role as
both a health care provider and an employer and only use
employees’ PHI for treatment, payment or health care
operations. In this scenario, using the employee’s medical
records for an employment related activity would be
considered an impermissible use and disclosure of PHI. The
employee’s PHI is not part of the employment record.
Additional Information
If PHI is central to a specific investigation, such as in this scenario, several
questions should be considered when determining what actions to take:
• Is this a patient issue or an employee issue?
• Is there an “immediate danger” to the health and safety of patients and/or other
individuals if you do not look at the PHI?
• Is there an exception in the Privacy Rule that may apply?
•
•
Mandatory reporting requirement to a state oversight agency
Required by law
• Is there an alternative to using the PHI, such as Human Resource policies?
•
•
•
Fitness for Duty, Drug and Alcohol testing
Return to work, clearance from a medical doctor
Responsibility to self-report medical condition that may impact patient care
• Should the employee be approached to obtain an authorization to use his/her PHI
in the investigation?
At CHI, a patients’ PHI (regardless of their status as an employee) is protected
as required by HIPAA and applicable state privacy and confidentiality laws. In
addition, CHI’s Our Values and Ethics at Work Reference Guide states, “We
keep employee information confidential, following human resources policies."
Additional Information, continued…
At CHI, a patients’ PHI (regardless of their status as an
employee) is protected as required by HIPAA and
applicable state privacy and confidentiality laws. In
addition, CHI’s Our Values and Ethics at Work Reference
Guide states, “We keep employee information confidential,
following human resources policies." PHI is maintained
in the same confidential manner.
This includes wage and salary information,
employment agreements, Social Security
numbers, financial and banking information.
Acceptable Disclosures
The HIPAA privacy regulations permit the disclosure of PHI between
health care providers, including physicians, laboratories, and nurses if
the communication is related to the patient’s treatment and reasonable
safeguards are observed.
Disclosures are also permitted without the patient's authorization if
there are extenuating circumstances in which disclosing information
for the public good outweighs an individual’s privacy interests, such as
law enforcement purposes, judicial proceedings, government authority,
and public health activities.
All of your actions as a leader have
an impact, either positive or negative,
on your work community.
Cause and Effect
As a CHI leader, your actions have a lasting effect on the CHI community.
When you understand the ramifications of your actions, you can make
better decisions. Based on this scenario, below are some of the potential
positive, and not so positive, outcomes of specific actions.
Positive
By not using the employee’s PHI for employment related actions, you are
supporting the HIPAA regulation and the CHI confidentiality guidelines.
By maintaining confidentiality, you will also build trust with your
employees and business partners.
Consequence
Breaking HIPAA or state privacy and confidentiality laws may result in
civil or criminal penalties for CHI and/or the responsible individuals. We
do not use, disclose or discuss patient specific information with others
unless it is necessary to provide care or is required by law or written
authorization.
Summary
In summary, following are some
points to remember based on this
scenario:
Reference
Health Insurance Portability and
Accountability Act of 1996 (HIPAA),
Public Law 104-191, and 45 C.F.R.
pts. 160, 162, 164 (2006)
• CHI strives to maintain
confidentiality of health information
based on HIPAA and state privacy and
confidentiality laws.
• At CHI, we keep employee
information confidential following our
human resources policies.
• Consult your local CRO and/or
HIPAA Privacy Officer if you have
questions or to discuss options
available to ensure patient safety is not
compromised.
A Nose for Trouble – Claims Processing
Introduction
A good storyteller weaves together
typical events into an entertaining and
interesting story that keeps your
attention. Sometimes storytellers
stretch the truth or adjust some of the
details to make the story just a bit
more exciting or outrageous. Since
storytelling is generally for
entertainment, these embellishments
do not hurt anyone.
The next scenario outlines a situation
where some of the supporting
documentation for a typical procedure
is adjusted to make a better story.
Scenario
As you think about what actions are appropriate for this
situation, consider the following questions:
• Is it right for the nurse to share his observations with you?
• Should the nurse remain quiet about this situation since it is a
physician’s responsibility to diagnose problems and treatment?
• Now that you know this information, what should you do about it?
• Is the surgeon’s behavior a violation of CHI’s Standards of
Conduct or its organizations’ guidelines or policies?
Scenario, Continuing…
A prestigious plastic surgeon recently began practicing at your
facility. An operating room nurse tells you that he has found the
new doctor to be a dedicated, competent physician. He also
said that he noticed a large number of procedures being
performed for a deviated septum, yet he believes most patients
are really having cosmetic surgery. Today, after the procedure,
he raised the issue with the physician. The physician said a
deviated septum diagnosis is the only way that the insurance
companies will pay for the surgery. The physician told the nurse
that it is not his problem, because it is the physician’s
responsibility to diagnose problems and provide appropriate
treatment. “Besides," he said, “Why should only rich people be
able to have such deformities corrected?” Since you are the
nurse’s supervisor, should you take any action?
Stop and Think
As you think about what actions are
appropriate for this situation, consider
the following questions:
• Is it right for the nurse to share his
observations with you?
• Should the nurse remain quiet about this
situation since it is a physician’s
responsibility to diagnose problems and
treatment?
• Now that you know this information,
what should you do about it?
• Is the surgeon’s behavior a violation of
CHI’s Standards of Conduct or its
organizations’ guidelines or policies?
Scenario Answer
By listing the wrong diagnosis and treatment codes, rather than the
appropriate codes, the physician is submitting a false and fraudulent claim
and is violating the federal False Claims Act (FCA) and CHI's Standards of
Conduct. It is right for the nurse to contact his supervisor immediately
because all employees have a responsibility to report any suspected
misconduct in a timely manner.
According to CHI's guidelines for conducting internal investigations, as a
leader, once you are informed of possible misconduct (including violations of
laws and regulations, potential criminal acts, and CHI and its organizations'
policies/procedures), you should (1) act upon the issue immediately and (2)
contact the local Corporate Responsibility Officer (CRO) who will be
responsible for directing internal investigations. If the allegation is criminal
in nature, the CRO will consult with CHI Legal Counsel to determine
whether to refer the matter to a law enforcement agency.
Additional Information
As a leader, you need to ensure that your employees know and
understand the Non-Retaliation Policy and CHI's Reporting
Process so that they feel comfortable reporting issues or
Cause and Effect
As a CHI leader, your actions have a lasting effect on the CHI community.
When you understand the ramifications of your actions, you can make
better decisions. Based on this scenario, below are some of the potential
positive, and not so positive, outcomes of specific actions.
Positive
By immediately contacting the CRO to report potential false and
fraudulent claims, you are acting in the best interest of the organization
and CHI in support of the core values, policies and Our Values and Ethics
at Work. Damages and penalties for violating the federal FCA can be
substantial so immediate attention to this situation is crucial.
Consequence
Damages and penalties for violating the federal FCA can be substantial so
by not reporting a potential violation you are putting the organization and
CHI at risk. By submitting inaccurate claims, the organization and its
leaders and CHI could also be prosecuted and/or required to refund
payments for filing inaccurate or fraudulent claims.
Summary
In summary, following are some points to remember based on this scenario:
• Assigning incorrect diagnosis and treatment codes, rather than the appropriate
codes, may be considered a false and fraudulent claim.
• All employees have a professional and ethical responsibility to report any suspected
violation of CHI's Standards of Conduct and its organizations’ guidelines or
policies in a timely manner.
• When informed of a suspected policy violation, leaders should contact the CRO.
Reference
Office of Inspector General (OIG) Compliance Program Guidance for Hospitals,
published in the OIG Federal Register on March 3, 1997 (62 FR 9435)
OIG Compliance Program Guidance for Hospitals, 63 Fed. Reg. 8987 (Feb. 23, 1998)
OIG Supplemental Compliance Program Guidance for Hospitals, 70 Fed. Reg. 4858
(01.31.2005)
Never Enough Time – Documentation
Introduction
As work demands increase, time
management becomes a key ingredient
to success. In a time pressed
environment, each person will establish
a routine that he or she believes works
best for the situation. In some cases, an
individual’s time management style is
appropriate; however, when it comes to
documentation, organizational policies
and procedures, and health care laws
must be followed.
Scenario
You are supervising a surgical resident who has just been
assigned to the Emergency Department (ED) at your hospital.
After a few days on the job, you check-in with her to see how
things are going. She tells you that the pace is much more
hectic than she anticipated and that she often finds herself
scrambling to document tests and procedures in the patients’
charts. She decided it would be more efficient to wait until
the end of the day when she has more time to enter patient
notes into the charts. Is this a good strategy to wait until the
end of the day to complete the documentation?
Stop and Think
• Since we want our care
providers to think independently, is it reasonable for the
surgical resident to design a
documentation plan that fits the
situation?
• How would a delay in the
documentation jeopardize
patient care?
• Are there CHI or organizational
guidelines, policies or
applicable federal and state
laws and regulations regarding
documentation?
At CHI, all care providers are
responsible for the accuracy, timeliness
and completeness of organizational
documents and records. Complete
documentation is an important means of
complying with regulatory and legal
requirements and supports sound
business practices.
As you think about what actions are
appropriate for this situation, consider
these questions:
Scenario Answer
Documentation in patient medical records should always be
accurate and completed in a timely manner so waiting until
the end of the day is NOT acceptable. A delay in
documentation, however small it may seem, increases the
possibility of recording information incorrectly, which can
have a negative effect on an organization’s ability to provide
quality patient care and appropriately collect payment for
services. Anyone authorized to document in the medical
record has an obligation to follow organizational policies and
procedures, bylaws and all applicable federal and state laws
regarding documentation. Contact the Corporate
Responsibility Officer (CRO) if you have questions about
documentation.
Additional Information
As a leader, you should ensure that documentation
requirements, enforcement measures and consequences for
inaccurate and/or incomplete records are outlined in:
•
•
•
•
Organizational policy and procedures.
Medical staff bylaws.
Orientation and annual training materials.
All of your actions as a leader have an impact, either positive or
negative, on your work community.
Cause and Effect
As a leader, your actions have a lasting effect on the CHI community.
When you understand the ramifications of your actions, you can make
better decisions. Based on this scenario, below are some of the potential
positive, and not so positive, outcomes of specific actions.
Positive
By educating the surgical resident on organizational documentation
policies and procedures, you are helping her to understand the importance
of accurate and timely documentation of services and how this supports
our Standards of Conduct, mission and core values.
Consequence
All care providers are responsible for accurate and timely documentation
of the services provided to patients in our care. If our documentation is not
accurate and timely, we may jeopardize patient care and be in violation of
the applicable federal or state laws and regulations. In addition, financial
and accounting records, including cost reports, research reports, time
sheets, mileage reimbursement, expense reports and other non-patient care
documents, must also be maintained accurately.
Summary
In summary, following are some
points to remember based on this
scenario:
Reference
-Medicare Conditions of Participation
-The Joint Commission Standards
-Medical Staff Bylaws, Rules and Regulations
-Organizational Policies
• Those individuals who provide
services to patients/residents in our care
are responsible for accurate and timely
documentation of the services rendered.
• Leaders must ensure individuals who
provide patient care are trained on
documentation requirements.
• A delay in documentation may
jeopardize patient care and could impact
the organization’s ability to receive
payment from federal or state health
care programs.
Coding and Ordering Tests
Introduction
The health care profession
revolves around helping others.
Many people join this profession
to experience the satisfaction of
improving the health, and
ultimately the lives, of other
people. A career in health care can
be very rewarding and satisfying.
A dilemma occurs when a specific
treatment or test is preferred but
the patient’s insurance plan does
not cover it.
Scenario
You are an attending physician at a CHI hospital. A patient is
complaining of, among other symptoms, chest pain, shortness
of breath, and pain radiating down the left arm. Based on the
patient’s history, symptoms, and a physical exam, you suspect
he may be having a mild heart attack. You would like to
perform a Coronary Computed Tomography Angiogram
(CTA) but this test is not covered for reimbursement by
Medicare, the payor. Instead, you decide to order a Chest
Computed Tomography scan (CT) (which you know is
covered) but perform the Coronary CTA instead. You figure
no one will ever find out and it is actually a more appropriate
test for diagnosing the patient’s condition. Is this the correct
decision?
Stop and Think
As you think about what actions
are appropriate for this situation,
consider the following questions:
• Giving the best treatment available is
the most important thing to consider so
isn’t the physician’s decision correct?
• Is documenting a procedure code
different than the actual procedure
completed a violation of CHI or its
organizations' policies or federal or
state laws?
Scenario Answer
Documenting procedures not performed may be considered
fraud. When informed of a suspected violation, leaders should
contact the Corporate Responsibility Officer (CRO) and CHI
Legal Counsel.
It is important that procedure codes accurately reflect the
procedure performed to avoid any potential charges of fraud or
abuse to the organization. If a false claim is submitted to
Medicare or Medicaid for reimbursement and the discrepancy is
later discovered, the organization could be held liable for civil
penalties or excluded from participation in federal health care
programs. Similarly, when dealing with private payors,
inaccurate coding may result in breach of the payor contract and
result in cancellation of the contract or imposition of damages
or other penalties.
Consider…
If an employee has questions about a procedure or service that is not
covered, the employee may contact the local Medicare contractor or
carrier, who often has local discretion to determine if a procedure is
reasonable and necessary and can also initiate a local coverage process. If
the procedure is still not covered, a local coverage determination may be
requested. The Centers for Medicare and Medicaid Services (CMS)
periodically will issue a National Coverage Determination (NCD) in cases
involving a variation of local policies, although 90% of coverage is
handled on the local level.
Procedural codes are updated at least annually so a good chance exists that
a procedure may become covered once its effectiveness is better known
and documented. For example, on January 27, 2005, CMS announced its
final decision to expand Implantable Cardioverter Defibrillator (ICD)
coverage to thousands of patients at an elevated risk for sudden cardiac
death (Change Request (CR) 3604). Based on overwhelming clinical
evidence, CMS determined that lifesaving ICD therapy is reasonable and
necessary for many more Medicare patients.
Cause and Effect
As a leader, your actions have a lasting effect on the CHI community.
When you understand the ramifications of your actions, you can make
better decisions. Based on this scenario, below are some of the potential
positive, and not so positive, outcomes of specific actions.
Positive
It is imperative that all hospital employees and medical staff members
practicing at CHI accurately document services provided, using the proper
codes. As a leader, you will build trust with employees and medical staff
when they observe that you follow the rules regarding proper
documentation and that you support the CHI Standards of Conduct.
Consequence
Fraudulent coding is a violation of the CHI Standards of Conduct and is
not tolerated in any circumstances. If you are aware of false coding and
choose to ignore it, you are putting the organization at risk for potential
exclusion from participation in federal health care programs. You are also
destroying the trust you have established with employees and they may not
respect your future decisions.
Summary
In summary, following are some points to remember based on this scenario:
• Fraudulent coding is a direct violation of the CHI Standards of Conduct and is not
tolerated in any circumstance.
• The organization could be held liable for civil penalties or terminated from
participation in the Medicare or Medicaid program for submitting false claims.
• Contact the local Medicare contractor or carrier with questions regarding covered
procedures.
• When informed of a suspected fraud violation, leaders should contact the CRO.
Reference
-Diagnosis-Related Group classification and weighting factors, 42 CFR § 412.60
(2005)
-For a free online ICD-9-CM Manual, go to http://icd9cm.chrisendres.com/.
Leasing Space to Physicians
Introduction
Quid pro quo is a Latin phrase that
means “something for something.”
This term generally indicates a
more-or-less equal exchange of
goods or services. For example, I’ll
make dinner, if you will wash the
dishes. Quid pro quo agreements are
sometimes viewed negatively when
one party receives more benefits
than the other.
Scenario
You are a facility administrator and it has come to your
attention that the hospital appears to be giving favored status
to a physician who recently began to admit patients to the
hospital. He rents space at the adjacent medical office
building owned by the hospital at half the rate charged to
other physicians who rent space in the building. You inquire
about this issue with a colleague whom you trust in
Administration. He explains that this physician refers more
patients to the hospital than anyone else and that necessitates
his spending more time at the hospital. As such, the hospital
has made appropriate accommodations for him recognizing
that fact. Should you be satisfied with this answer?
Stop and Think
Consider the following questions:
• Is this conduct supportive of CHI's
mission and core values?
• What are the federal and state laws or
regulations pertaining to payment for
referrals?
• How would this look if it was
discussed in an article in the
newspaper?
• Does it seem appropriate to offer a
discounted lease arrangement to only
one doctor? Why or why not?
Scenario Answer
In this case, the physician is a referral source who is getting a below fair
market lease rate. The discounted rate could be viewed as a potential
inducement to the physician, taking into account the volume or value of
the physician’s referrals to the hospital. You should report this
arrangement to the local CRO or CHI Legal Counsel so that the financial
relationship may be investigated. According to the Anti-kickback Statute
and Stark Law, providing office space at less than fair market value to
physicians may be considered inappropriate. Public policy disfavors any
inducements that may be designed to influence medical decisions about
what is best for a patient. In addition, Federal land many state laws
prohibit inducements to referral sources (most often physicians) in order
to get business. Fair market value is a key concept to ensuring compliance
with these laws.
Additional Information: Stark Law
The Stark Law applies only to
physicians who refer Medicare and
Medicaid patients for designated
health services to entities with
which they, or an immediate family
member, have a financial
relationship. In order to enter into a
financial relationship with a
physician (or immediate family
member) safely, the Stark Law
requires that the parties satisfy some
very specific requirements. When
an office or equipment lease is
involved, the following specific
criteria must be satisfied:
•
•
•
•
•
The lease must be in writing, signed by
the parties, and specify the space or
equipment covered.
The space or equipment leased must not
exceed what is reasonable and necessary
for the legitimate business purposes of the
lease and must be used exclusively by the
lessee.
The lease term must be at least one year.
The rental charges over the lease term
must be set in advance, consistent with
fair market value and not determined in a
manner that takes into account the volume
or value of any referrals or other business
between the parties.
The lease must meet any other
requirements set by the Secretary of the
federal Department of Health and Human
Services to protect against program or
patient abuse.
Additional Information:
Stark Law Exceptions
The Stark Law has almost 20
exceptions, which must be strictly
adhered to in order to ensure
compliance. When determining
whether the Stark Law applies to a
particular arrangement, it is usually
necessary to establish:
• If a financial relationship exists
between the physician (or a family
member of the physician) and the
entity involved;
• If a designated health service is
involved; and/or
• The circumstances of the
arrangement, including the potential
for referral.
A financial relationship between a
physician (or immediate family
member) and a hospital also would
violate the Stark Law if the principle
of fair market value (comparable
pricing for similar services within a
community) was not observed
properly. The elements are simple:
• Flow of benefit to a source of referrals
for the company’s services.
• The source refers business
All business or financial arrangements with referral sources must be
“arms length,” based on fair market
value, and commercially
reasonable.
Additional Information:
Anti-kickback Statute
The Anti-kickback Statute contains similar requirements as in
the Stark Law and provides that any inducements that might
lead to the following are illegal:
•
•
•
•
Increased or over-utilization
Increased costs to government health care programs
Restriction on competition
Limiting patient choice.
Cause and Effect
As a leader, your actions have a lasting effect on the CHI community. When you
understand the ramifications of your actions, you can make better decisions. Based on
this scenario, below are some of the potential positive, and not so positive, outcomes of
specific actions.
Positive
By contacting the local CRO or CHI Legal Counsel about this questionable financial
practice, you can help ensure that the hospital conducts its operations in compliance
with all federal and state laws and regulations applicable to physician transactions,
including space or office leases. The laws are very complex and have exceptions so it is
best to have an expert review a proposed financial arrangement with a physician (or
immediate family member) before entering into it. Once the arrangement has been given
appropriate legal/compliance review, it should be presented to the hospital’s Physician
Transaction Review Committee (PTRC), consistent with the organization’s PTRC
policy.
Consequence
If you do nothing and allow the arrangement to continue, the organization could incur
sanctions for failing to comply with the Stark Law. Sanctions may include refunding
payments received in connection with each illegal claims submission, substantial civil
monetary penalties for each known violation and for failing to report the violations,
exclusion from Medicare/Medicaid, and denial of payment for services. Intent is not a
factor.
Summary
In summary, following are some points to
remember based on this scenario:
• Consult your local CRO or CHI Legal Counsel if
you observe a questionable financial practice
relating to physician referrals or financial
relationships.
• Providing office space at less than fair market
value to physicians poses a significant risk to the
organization and may result in a Stark violation
including substantial civil penalties.
Reference
-Stark Law (Physician Self-Referral Act, Section
1877 of the Social Security Act)
-Stark Law, 42 U.S.C. § 1395nn (2000)
Physician Employment & Recruitment
Introduction
Many businesses use famous people
or athletes to advertise their products
and services because consumers
tend to purchase more products that
are endorsed by a famous person
than products that are not.
Sometimes, athletes are paid
thousands of dollars to wear a
specific shirt or logo. Famous people
use their fame to help generate sales.
A well-known physician can also
draw more patients to a hospital and,
as a result, generate more revenue
for the hospital.
Scenario
A CHI hospital plans to recruit a renowned neurosurgeon to the area. The
surgeon is nearing retirement and would like to work a less aggressive
surgical schedule. Based on his prestigious reputation, the surgeon has
suggested that, if he is able to bring in a specified number of referrals, he
should receive a bonus. The hospital is considering one of two possible
arrangements with the surgeon. In the first arrangement, the hospital
would employ the surgeon. In the second arrangement, the surgeon would
establish an independent practice in the community and receive
recruitment assistance (i.e., an income guarantee) from the hospital. The
surgeon’s proposed bonus would be in addition to a contracted, full-time
salary if the hospital is to employ the surgeon or in addition to the income
guarantee if the hospital is to provide recruitment assistance. Is the
suggested bonus an acceptable request?
Stop and Think
As you think about what actions are
appropriate for this situation,
consider the following questions:
• Are there any federal or state laws or
regulations to consider
with physician employment or
recruitment arrangements?
• Is it reasonable for the surgeon to
receive both a salary or income
guarantee and a referral-based bonus?
Scenario Answer
This is NOT an acceptable request from the surgeon and
violates the Stark Law. While a contracted salary or income
guarantee is acceptable, the neurosurgeon’s proposed referralbased bonus is not. Specific criteria must be satisfied before
certain financial arrangements with physicians (or immediate
family members) may be entered into. The Stark Law
expressly prohibits tying compensation to referrals.
As with most questions regarding a financial practice relating
to physician referrals or financial relationships, you should
consult with the local Corporate Responsibility Officer
(CRO) or CHI Legal Counsel.
Cause and Effect
As a leader, your actions have a lasting effect on the CHI community. When you understand the
ramifications of your actions, you can make better decisions. Based on this scenario, below are
some of the potential positive, and not so positive, outcomes of specific actions.
Positive
By contacting the CRO or CHI Legal Counsel about this questionable financial practice, you can
help ensure that the hospital conducts its operations in compliance with all federal and state laws
and regulations applicable to physician transactions, including physician employment or
recruitment agreements. Being able to distinguish between the types of bonuses that may be
allowed (e.g. productivity-based or sign-on) from those that are prohibited (e.g. referral-based)
before any promises are made, will avoid Stark Law violations and promote positive physician
relations. Documentation supporting the fair market value of any physician-related financial
relationship should be maintained in the contract file as a record of the commercial
reasonableness of the transaction as of the time it was entered into. Also, the hospital’s Physician
Transaction Review Committee (PTRC) should be asked to review and approve the arrangement,
consistent with the organization’s PTRC policy.
Consequence
If you agree to a referral-based bonus, the organization could incur sanctions for failing to comply
with the Stark Law, including civil monetary penalties and exclusion from the Medicare and
Medicaid program. Strong physician relationships are essential to the hospital. Making promises
that you or the hospital may not be able to keep can damage these relationships.
Summary
In summary, following are some points to remember based on
this scenario:
• Do not pay or offer to pay patients, physicians or other health care
providers for patient referrals.
• Physician compensation must be based on fair market value.
• Contact your local CRO or CHI Legal Counsel with questions related
to financial relationships with physicians.
Reference
-Stark Law (Physician Self-Referral Act,
Section 1877 of the Social Security Act)
-Stark Law, 42 U.S.C. § 1395nn (2000)
Course Summary
Congratulations! You have
reached the summary for the Corporate
Responsibility Program - Compliance
for Leaders course.
In this final lesson you will:
• Review the health care statutes and CHI
polices covered in this course.
• Complete a final test to receive credit for
the course.
• After passing the final test, you may
access the course survey and print a course
certificate.
Through the previous scenarios, you
saw that the decisions you make as a
leader impact both the immediate work
community and the CHI community.
By becoming more familiar with the
tools provided by the CRP, the CHI
policies, and health care laws, you can
be more confident in handling
compliance and confidential situations.
With this added knowledge, you can
also apply the Standards of Conduct in
your daily work to reinforce our
mission, vision and core values
CRP, CHI Policies and Laws
As demonstrated in this course, compliance is a large part of
the health care industry. CHI created the CRP to provide you
with resources to help you make ethical decisions in a variety
of situations. To make ethical decisions you must also have a
firm understanding of CHI and its organizations, as well as the
polices, guidelines and federal and state law that govern the
health care industry.
“Catholic Health Initiatives is poised to lead boldly into a world that
is filled with risks, but with the risks come great rewards for the
people and communities we serve.”
Kevin Lofton, President and Chief Executive Officer of Catholic Health Initiatives
CHI and its Organizations' Policies
Responsibility to Report
• All employees have a duty to act in a manner consistent
with our core values, policies, and Our Values and Ethics
at Work. A part of that duty is to promptly report potential
violations of law, regulations, policies, procedures or Our
Values and Ethics at Work.
• As a leader, you have the added responsibility of:
• Making sure employees have the proper training so they
understand the expectations for ethical business conduct;
• Creating an environment where employees feel
comfortable reporting a concern or asking a question; and
• Ensuring employees know CHI’s reporting process so they
know how to report an issue or concern.
CHI and its Organizations' Policies
Non-Retaliation Policy
• No retaliatory action will be taken against an individual for
making a report, complaint or inquiry in good faith.
However, non-retaliation policies do not protect employees
if their actions violate the policies of CHI or its
organizations, and/or applicable federal or state laws.
CHI and its Organizations' Policies
Conflicts of Interest
• Conflicts of interest occur when personal interests or
activities influence, or appear to influence, our ability to
act in the best interest of CHI.
• These situations may involve the following:
• Obtaining a direct or indirect personal gain or advantage
• Creating an adverse or potentially adverse effect on the
organization’s interests
Health Care Statutes
False Claims Act
• The federal False Claims Act (FCA) prohibits fraud and/or
abuse related to claims submitted to be paid by any federal
or state healthcare programs, such as Medicare and
Medicaid. The FCA prohibits a person from knowingly
presenting or submitting claims or making a false record or
statement in order to secure payment of a false or
fraudulent claim/bill by the federal government.
Health Care Statutes
Stark Law
• The Stark Law, also known as the federal physician self-referral statute,
focuses on financial relationships with physicians and family members
of physicians, and is intended to ensure that referrals of patients and
utilization of health care services are not improperly influenced by
financial considerations.
Anti-kickback Statute
• The federal Anti-kickback Statute covers financial relationships with
physicians, but also includes relationships with suppliers, vendors, and
other parties with whom a hospital does business. Like the Stark Law,
the Anti-kickback Statute is also intended to ensure that referrals of
patients and utilization of health care services are not improperly
influenced by financial considerations.
Reference Material
• Many resources are available to assist leaders in doing the
right thing. Some of those resources include but are not
limited to the items below.
• CHI Resources
• Our Values and Ethics at Work Reference Guide
• CHI national and local policies, procedures
and guidance documents
• National and local Corporate
Responsibility Officers
• CHI Legal Counsel
• Local and CHI National
Leadership and Management staff .
Reference Material
Government Agencies
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Centers for Medicare and Medicaid Services (CMS)
Department of Health and Human Services (HHS)
Office of Inspector General (OIG)
Office of Civil Rights (OCR)
Professional Organizations
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Health Care Compliance Association (HCCA)
American Hospital Association (AHA)
Healthcare Financial Management Association (HFMA)
American Health Information Management Association (AHIMA)
Getting Credit
• To receive course credit on your transcript you must
complete a 10 question final test and pass with a score of
80% or better. You man retake the final test up to five
times.
• Click here to begin test