Valuing Integrity

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• Valuing Integrity
• Corporate Compliance
• October 2006
• Anne Adams
• Chief Compliance Officer
• Emory Healthcare and Emory Medical Care
  Foundation
• Sue Dale
• Administrator, Gynecology and Obstetrics
• Emory University School of Medicine and
• The Emory Clinic

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What is Compliance ?

• Complying with applicable Federal and State laws
  and regulations.
• Following all Emory and departmental policies and
  procedures.
• Doing the right thing!

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Compliance Program

• Committed to conducting business in
  compliance with all federal, state, and local
  laws.
• Committed to preventing and detecting
  non- compliance .
• Standards of Conduct and other policies to
  guide our activities.

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Elements of a Compliance Program

• Compliance Standards Procedures
• Chief Compliance Officer
• Employee Training
• Monitoring Auditing
• Reporting Process
• Response Prevention
• Enforcement Discipline

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Role of the Compliance Office

• Establish, oversee implementation, and revise the
  Compliance Program
• Provide oversight for organizations compliance
  activities
• Provide education
• Provide advice and guidance
• Develop compliance policies
• Investigate reports of non-compliance
• Monitor compliance with rules regulations
• Coordinate response to external investigations
• Oversee corrective actions

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Why Do Organizations Need a Compliance Program?

• Government focus/enforcement
• Risk of prosecution/penalties
• Protect system resources/reputation
• Health Insurance Portability and Accountability
  Act (HIPAA)
• Grants and Contracts
• Research/IRB/FDA/OHRP
• Sarbanes/Oxley
• Healthcare Industry Fraud and Abuse

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Who Are the Players?

• Centers for Medicare Medicaid Services
  (CMS)
• Office of Inspector General (OIG)
• Department of Justice (DOJ)
• Federal Bureau of Investigation (FBI)
  Financial Crimes Section
• Georgia Bureau of Investigation (GBI)
• Medicare/Medicaid Fraud Unit
• Office of Civil Rights (OCR)

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Your Responsibility

• To know the rules that apply to your
  section/department.
• Follow the rules, help find and report
  potential violation and problems.
• Actively participate in and promote compliance.

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• Main Areas of Risk
• Teaching physician presence.
• Billing for items or services not rendered (or
  documented).
• Providing medically unnecessary services.
• Upcoding/ Unbundling.
• Failure to properly use modifiers (25, 26, 59,
  etc.).
• Consultations/New vs. established.
• Misrepresenting diagnosis to justify service.
• Billing for a non-covered service as covered.
• Research misconduct
• Research Effort Reporting

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Non-Retaliation Policy

• It is the policy of EMORY that individuals making
  good-faith reports of compliance concerns will
  not experience any form of retaliation.
• If you experience or witness retaliation, report
  it to the Compliance Office immediately.
• Incidents of retaliation will have serious
  consequences.

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Are We Getting Our Voluntary Compliance Program
Right?
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• Are compliance efforts impacting employee and
  organizational activity?
• Enhance to improve quality/to make greater.
• Culture social behavior patterns typical of a
  population or community at a given
  time.
• Education.
• Resources.
• Awareness/Open communication.
• Influence positive behavior.
• Meet requirements of the Federal Sentencing
  Guidelines.
• We have a solid foundation and we want to build
  on that foundation and reaffirm our commitment.

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• Strengths
• Leadership
• Physicians committed to patient care
• Encourage open communication/questions with
  managers
• Employee commitment
• Excellent internal consultants

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A blended program value based awareness of
key organizational principles
prevention core principals are offered
employees are individually accountable to
values encourage employees to question
decisions before taking action. rules
based dos and don'ts general deterrence of
bad conduct though emphasis on punishment and
avoidance. Must continue to have leadership
support words and resources.
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The Role of Management

• Management serves as the primary example and the
  primary source of information for our employees.
• Management fosters open communication regarding
  compliance and answers questions raised by
  employees.
• Management is accountable for their own actions
  as well as the actions of those they supervise.

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• Compliance is a team effort Everyone is
  responsible for making a winning team.
• No room for behavior not geared to
  professionalism, integrity, compliance and
  excellence.
• Off Messages that are inconsistent with a
  culture of compliance risks our reputation of
  excellence.
• Lead by example - we have set clear expectations
  for documentation and coding compliance.
• Emory goes beyond compliance.

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• We must maintain a culture of
  professionalism, integrity and compliance at
  Emory.
• Current culture is healthy, but want to
  continue to maintain/improve health and wellness
  continue to ask questions and raise compliance
  concerns.
• Dont want to leave organization, employees
  and physicians vulnerable to not meeting
  regulations/ government inquiry.
• Accurate documentation, coding and billing
  are critically important functions.
• Non-compliance by a few puts Emory at risk.

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• Integrity and Ethics physicians,
  administrators, staff, board members are all
  involved and it reaches across all functions.
• Ultimately enhancing our culture of compliance
  goes to integrity strategy compliance plays a
  role/faciliate, but managers at all
  levels and across functions are involved in
  the process.
• Physician/Management Driven.
• Must have a willingness to seek solutions
  within framework of values.
• Values are integrated into the normal channels
  of managements.
• Support and reinforce organizational values.

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Commitment to Compliance

• Follow applicable rules and regulations.
• Ask questions if the rules are unclear.
• Act when your instincts tell you something is
  wrong.
• You must report potential violations.
• Be a part of the solution if a problem is found.

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Reporting Potential Problems

• Who do I go to?
• Supervisor or Manager
• Compliance Department 404-778-2757
• Emory Healthcare Trust Line
• 1-888-550-8850 (Anonymous Reporting 24/7)

• What will happen?
• Determination who will handle issue
• Investigation
• Action

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Administrators Perspective

• Most difficult challenge is the task of
  influencing physicians to adopt compliance as an
  integral part of our standard operating
  procedures.
• This is not Monopoly there is not a get out of
  jail free card
• Teaching physicians suffer from mural dyslexia
  (Fast Tracking Compliance Training in Academic
  Practices article MGMA)
• Cannot see the handwriting on the wall
• Why are we spending money on compliance?
• Compliance is a control program

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Expecting Reactions To Compliance

• Typical Reactions to Compliance
• Great men cant be ruled
• What rules? When did this start?
• Glassed over eyes asleep
• Must not be talking to me
• Administrators Reaction
• Never react back or will be seen as the evil one
• Use positive arguments
• Use a physician champion

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What are the Physicians Expectations

• Communication
• Communicate both good and bad news communicate
  regularly
• Honor confidentiality
• Share data
• Allow venting of frustrations
• Stay on their side avoid defensiveness
• Use examples
• Consistency
• And..be cheerful, confident, and optimistic

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Best Practice Consistent Themes

• Physician-to-physician communication that
  compliance is not optional based on integrity
• Staff need to hear and see that leadership has
  taken a stance in favor of ethnical business
  practices.
• Train physicians and staff in small specialty
  specific groups more relevant and makes it
  practical application easier.

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Best Practice Consistent Themes

• Use numerous examples from their own notes and
  specialty to demonstrate the point and use as
  examples.
• Make the education and training interactive.
• Have a sense of humor.
• Recent documentation - The lab test indicated
  abnormal lover function The patient is still
  under our car for physical therapy The patient
  is numb from her toes down Patient was alert and
  unresponsive When she fainted her eyes rolled
  around the room Patient seen in the ED,
  examined, x-rated and sent home.

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Compliance Programs
Questions? Emory Healthcare Compliance
Program 404-778-2757 or Extension 8-2757 Anne
Adams, MS, JD Chief Compliance Officer Emory
Healthcare Emory Medical Care Foundation Emory
Trust Line 1-888-550-8850
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Questions regarding Research Compliance Kristin
H. West, J.D. Assoc. V.P. Director Emory
University Office of Research Compliance 1784 N.
Decatur Road, Suite 510 Atlanta, GA 30322 Phone
[phone] FAX [phone] Emory
Trust Line 1-888-550-8850
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Helpful Resources
http//www.cms.hhs.gov Centers for Medicare and
Medicaid Services (CMS) http//www.georgiamedicar
e.com/ Georgia Medicare Part A http//www.gamedic
are.com/ Georgia Medicare Part B http//www.cms.h
hs.gov/hipaa/ CMS - HIPAA Main Page Teaching Big
Shots to Behave and other Human Resource
Challenges By Stephen M Paskoff, Esq.
(Visit the OCP web-site to see more resources)
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Compliance Office Motto