1. An Introduction to Compliance Program at Tri-City Health Center Presented by Linh Phan

2. “ Any health care entity which does not have a compliance program is ‘ institutionally nuts’ ” Karen Morrisette Deputy Chief of Criminal Division U.S. Department of Justice

23. “ A compliance program is never finished; it should always be a work in progress.” “No Compliance officer can master all applicable rules, regulations, codes, etc

37. Tentative Timeline for Development of the Compliance Plan CO Training & Launching the Program CO Reporting & Investigating, disciplinary & remediation mechanisms July 2009 August 2009 Sep-Oct 2009 CO Risk Assessment CO & Department leads Auditing & Monitoring Vendor Compliance Education & Training Designees 1 st quarter 2010 Nov- Dec 2009 Action Plan CO Establishment of the Code of Conduct, Policies & Procedures, Hotline CO, Committee & Board Program evaluation Committee & Board Review & Approval

38. Compliance Strategies Improved Compliance Processes Compliance Laws Rules Regulations Quality Excellent Brilliant Superior

59. Important Laws & Regulations AKS & Stark: What to know AKS Intent based Criminal/Civil Any Federal Healthcare Program Requires Proof of Improper Intent Applies to Any Referral Source Safe Harbors OIG Advisory Opinions STARK Fact based Civil only Medicare only Strict liability Must be a Physician & an Entity in the mix Exceptions CMS Advisory Opinions * Both AKS & STARK are difficult to defend * The absence of one does not preclude the other

63. Measuring Effectiveness Awareness External Review Outcomes Repayments

65. Program Evaluation Structure The capacity to promote compliance with applicable regulatory requirement Process How the compliance program operates in practice to address identified risk areas Outcome Actual performance of the organization on identified compliance standards Effectiveness