1. CORPORATECORPORATE
COMPLIANCECOMPLIANCE
PROGRAMPROGRAM

2. HISTORY
• Center for Medicare & Medicaid (CMS)
paid $20,000,000,000 in error !
• Improper payment due to:
CODING & BILLING ERRORS
FRAUD & ABUSE
• Enormous financial losses for
government

3. PASSAGE OF HIPAA 1996
Government $$$$ for resources
to detect fraud &
abuse
Criminal Offense
OIG strongly recommends

4. HEALTHCARE FRAUD n.[<Lat. Fraus,
deceit.] 1. Any scheme to obtain money or
property of any healthcare benefit plan by
means of false or fraudulent pretenses,
representations or promises. 2. A deliberate
deception practiced so as to secure unlawful
gain.
.

5. HEALTHCARE FRAUD = A CRIMINAL OFFENSE
This applies to all claims under health benefit programs
Fines
Prison
Restitution
Sanctions
Corporate Probation

6. CORPORATE COMPLIANCE
PROGRAM
• Designed to detect and prevent violations
of law by employees & physicians
• Offer a framework of ethical guidelines
and expectations for the workplace –
standards of conduct
• Goal is to ensure that the employees &
physicians comply with applicable laws
and regulations
• Essential to any organization committed to
ethical conduct and sound business
practices

7. GOALS
• Improve Quality of Care
• Improve Documentation
• Minimize Billing Mistakes
• Increase Awareness > Decrease Risk
• Reaffirm Commitment to Our Mission

8. BENEFITS
• Established high ethical
standards
• Improved financial performance
• Improved quality care
• Improved documentation
• Early detection of potential
problems

9. 7 BASIC ELEMENTS OF A
COMPLIANCE PROGRAM
1. Standards of conduct
2. Designated Compliance Officer
3. Effective education and training
4. Audits and other evaluation techniques
5. Internal reporting processes
6. Disciplinary mechanisms
7. Investigation and remediation

10. CORPORATE COMPLIANCE:
AN ONGOING PROCESS
1.Prevent
2. Detect/Correct
3. Defend/Mitigate
RISK

11. THE 3C DECISION
MAKING MODEL
Compliance:
• Violation of a law, regulation or internal law or procedure
Conscience:
• Violation of an ethical principle
Conduct:
• Decide on appropriate course of action with which to resolve
the situation

12. Guides To Determine
Appropriate Behavior
• Integrity
• Common Sense
• Sound Judgment

13. Ask Yourself These
Questions…
• Are my actions legal?
• Is it fair and honest?
• Is this in the best interest of the
Center and the patients we serve?
• Will my actions stand the test of time?

14. • How will I feel about myself afterwards?
• Will I sleep soundly tonight?
• What would I tell my child to do?
• How would my words and actions lookif
reported in the newspaper?

15. Examine Your Conscience - If
You Think or Hear…
• “Shred that document.”
• “No one will get hurt.”
• “You never heard me say
that.”
• “It can’t hurt just this once…”
• “No one will ever find out…”
• “Everyone does it.”

16. REPO RTING AVIO LATIO N
TSC Hotline 973 477-7217
Anyone can report a violation without fear of
ANY retaliation by:
Phone
Verbal
E-mail
Written

17. CORPORATE COMPLIANCE PROGRAMCORPORATE COMPLIANCE PROGRAM
1. Written Policies and Procedures
2. Quality Care and Services
3. Reporting and Communication Policy
4. Compliance with Laws and Regulations
5. Medical Records
6. Personnel
7. Safe Work Environment
8. Conflicts of Interests
9. Coding, Billing and Documentation
10.Protecting Property

18. HINT HINT HINT HINT
• Corporate Compliance is NOT a
JCAHO requirement
• Corporate Compliance is NOT
just for healthcare industries
• ANYONE can report a violation
• Corporate Compliance Officer is
Meg Oser