CORPORATECOMPLIANCE

PROGRAM

The Center for Hospice & Palliative Care

Purpose of Corporate Compliance

The Center for Hospice & Palliative Care has established a Compliance Plan to ensure that its employees comply with Federal and State fraud and abuse laws, including:

• the Anti-Kickback Law, • the False Claims Act• the Stark Self-Referral Act, and

• NYS False Claims Act.

Corporate Compliance Programs…

Definition:

“A comprehensive and formal program designed to prevent, detect and respond to violations of the law by an organization’s employees.”

Program Intentions

Compliance programs are a remedy for controlling health care fraud.

Help employees better understand the ethical, professional and legal obligations we have as health care providers.

Program Intentions

Keep all employees familiar with the ethical standards that should guide our actions.

Program Intentions

Educate all employees regarding our standards and expectations

Program Intentions

Provide tools for making responsible decisions and a process for reporting concerns

Program Intentions

Prevent, find and correcting violations of CHPC standards and governmental laws and rules.

Program Intentions

Provide for disciplinary action up to and including termination to be taken for violations of compliance regulations

Fraud:

Material false statements or representations made to obtain some benefit to which one is not entitled

What Constitutes Fraud and Abuse?

Fraud

Violations of regulations or laws that occur when committed for self or on behalf of another party

Acts in violation of laws or regulations that are performed knowingly and intentionally

Fraud Examples

Documenting that a visit was made, but there is no clinical documentation to show that the clinician was actually there.

Documenting anticipated information on an assessment prior to actually seeing the patient.

Abuse:

Practices resulting, directly or indirectly, in unnecessarily increased costs

Overuse of medical services, products or both

Abuse Examples:

Medically unnecessary services

Failure to conform to professionally recognized code

Abuse Examples:

Unfair or unreasonable pricing

Restrictions of patient choice for his/her healthcare

Federal Laws

Anti-Kickback Law

The Federal Anti-Kickback Law prohibits the knowing and willful offer or receipt of money or anything else of value (including any kickback, bribe, or rebate), directly or indirectly, in return for, or to induce the referral or recommendation of, Medicare or Medicaid business.

The Stark Act

With certain exceptions, the Stark Law prohibits a physician who has a “financial relationship” with an entity from referring patients to that entity for certain “designated health services”.

The False Claims Act

Individuals or entities that knowingly file fraudulent or false claims that are payable by the Medicare program are subject to both criminal and civil liability.

HIPAA

The federal Health Insurance Portability and Accountability of 1996 (HIPAA).

This law is covered in its own Mandatory Education Program

State Law

Deficit Reduction Act

Signed into law in February 2006.

Goal is to reduce federal deficit due to Medicaid fraud and abuse cases

Rewards states that find fraud and abuse cases.

Protects whistle blowers. Claims must be substantiated

NYS False Claims Act (Passed April, 2007)

Establishes liability for certain acts related to any person who:

1. knowingly presents, or causes to be presented, a false or fraudulent claim for payment or approval;

2. knowingly makes, a false record or statement to get a false or fraudulent claim paid or approved;

3. conspires to defraud the state or a local government by getting a false or fraudulent claim allowed or paid;

Standards of Conduct Statement

In keeping with the mission and goals of The Center for Hospice & Palliative Care, and in keeping with compliance of Federal and State laws, all staff, volunteers, and other agents are expected to comply with the following guidelines.

Standards of Conduct

1. Maintain a high level of business ethics

2. All communications must be honest and contain no false or misleading statements.

Standards of Conduct

3. Staff and contractors are prohibited from soliciting tips, personal gratuities, or gifts from patients. They may accept unsolicited non-monetary gratuities and gifts of nominal value from patients.  For purposes of this standard, “nominal value” is defined as $50 or less.

Standards of Conduct

4. Staff and contracted individuals must refrain from conduct that violates applicable fraud and abuse laws or regulations

5. Care must be exercised in acceptance of Honoraria and offers for attendance at vendor sponsored workshops. Staff should check with their supervisor if there is any uncertainty

Standards of Conduct

6. Staff cannot use business inducements, through the improper use of payments, to gain any advantage

7. CHPC staff and Board Members must disclose any relationship or conflict of interest that might impede the exercise of their duties

Standards of Conduct

8. Staff must avoid the inappropriate release of confidential, sensitive or proprietary information, whether patient or personnel data, and comply with all HIPAA requirements.

Cannot share patient information with friends or family

Standards of Conduct

9. CHPC funds, time or equipment must not be used by staff for lobbying or political purposes.

10. It is the policy of CHPC to provide equal opportunity to staff and patients in compliance with all applicable local, State and Federal laws

Standards of Conduct

11. CHPC must comply and respect environmental laws and regulations as well as conserve natural resources.

12. Improper or fraudulent accounting or documentation of financial reporting is contrary to CHPC policy and may be in violation of applicable laws.

Standards of Conduct

13. It is CHPC’s policy that representatives shall not suffer a financial loss or financial gain as a result of business travel or entertainment.

14. Staff are not permitted to use CHPC equipment, facilities, supplies and services for personal benefits.

Standards of Conduct

15. Violations of the Standards of Conduct will be addressed at all levels fairly and without prejudice. In the event of a violation, personnel will be subject to corrective action in accordance with applicable policies including, but not limited to, probation, suspension or termination.

Standards of Conduct

16. The discovery of any event or behavior which is of questionable, fraudulent or illegal in nature or which appears to be in violation of the Standards of Conduct or is in violation of CHPC policies and procedures is to be reported immediately to appropriate supervisory or management personnel of CHPC or to the Corporate Compliance Officer.

Specific Risk Standards

AdmissionsBilling/FiscalReferrals/Marketing/ Patient

Solicitation IDG OversightHome Health CareNursing Homes

Admissions/Eligibility

Uninformed Consent to elect Medicare Hospice benefits.

Patients admitted who are not terminally ill.

Admissions/Eligibility

Untimely/forged MD certifications on plans of care.

Pressure on patients to revoke benefit when still eligible and desire care.

Billing/Fiscal

Billing for higher level of care than necessary.

Knowing misuse in provider certification numbers which results in improper billing.

Billing/Fiscal

Failure to return overpayments made by Federal health care programs.

Billing/Fiscal

Arrangement with another health care provider who a Hospice knows is submitting claims for services already covered by the Medicare Hospice benefit.

Referrals/Marketing/Patient Solicitation

High pressure marketing of Hospice care to ineligible beneficiaries.

Improper patient solicitation activities, such reviewing medical records in order to recruit based on diagnosis.

Referrals/Marketing/Patient Solicitation

Sales commission based on length of stay in Hospice

Non-response to late Hospice referrals by physicians.

Referrals/Marketing/Patient Solicitation

Hospice incentive to actual or potential referral sources (MD’s, NH’s, hospital patients, etc.) that may violate the anti-kickback statute or other Federal/State statutes or regulations.

Interdisciplinary Group (IDG) Oversight

1. Inadequate or incomplete services rendered by the IDG

Services provided in timely manner

2. Hospice must ensure appropriate oversight of Medicare criteria for continued patient participation.

Interdisciplinary Group (IDG) Oversight

Under-utilization – Cannot reduce services for purpose of reducing costs

Deficient coordination of volunteers

Interdisciplinary Group (IDG) Oversight

Failure to adhere to Hospice licensing requirements and Medicare Conditions of Participation.

Falsified medical records or plans of care.

Interdisciplinary Group (IDG) Oversight

Untimely and or forged physicians’ certifications on plans of care.

False dating amendments to medical records.

Nursing Homes

Hospice incentives to referral sources that may violate the anti-kickback statute or others laws.

Overlap in services

Nursing Homes

Improper relinquishment of core services and professional management responsibilities.

Providing Hospice services before finalized written agreement.

Compliance Education

All Board members, CHPC staff and contracted professionals associated with this organization.

Employee education Attendance at scheduled training/education sessions is mandatory and will be considered

with each employee annual evaluation

Reporting Concerns: Recommended Three Step Process..

Immediate Supervisor Higher Level Manager Corporate Compliance Officer

NOTE: If concerns regarding questionable behaviors involve an employee’s immediate supervisor the Corporate Compliance Officer may be contacted

directly.

Methods of Reporting..

Suspected instances of fraud and abuse can be reported via the following options: :

1. Telephone hotline. 1-800-822-3384. This is a toll-free number which will have a voicemail capability for receiving and recording reports. The Corporate Compliance Officer will have access to this line.

2. HOSPICE WEBsite access. Employees and contractors will have the option

of reporting using the HOSPICE WEBsite: www.palliativecare.org An online form will available to file a report. This Form will automatically forward an email to the Corporate Compliance Officer without identification of the sender.

3. Use of the Compliance Violation Reporting Form (Attachment D). This

form can be forwarded to the Corporate Compliance Officer or any member of the Compliance Committee. Copies will be available in accessible locations throughout the HOSPICE buildings.

What Types of Situations Should be Reported to the Hotline?

Typical calls could pertain to billing fraud, suspected embezzlement; time or expense abuses, conflicts of interest, kickbacks, discrimination, harassment or other violations of federal or state laws.

Misconduct not dissatisfaction

Not employee disputes or routine workplace issues.

Additional Questions

Corporate Compliance Officer:

1-800-822-3384

Thank you for participating in this session.

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