1 CORPORATE COMPLIANCE 2016 competency

2 Corporate Compliance Purpose of the Corporate Compliance Plan is: To promote legal and ethical behavior To provide a guide for conduct for employees, contractors, agents & physicians To prevent and detect violations of law See the Corporate Compliance Plan, located on spineNet.Corporate Compliance Plan

3 Corporate Compliance In addition to other local and state regulatory bodies, our hospital is governed by the federal agency Centers for Medicare & Medicaid Services (CMS). CMS is responsible for developing health and safety standards for providers of health care services authorized by Medicare and Medicaid legislation. This program helps to ensure that Medicare and Medicaid beneficiaries receive quality health care services at a reasonable cost.

4 Is everyone required to know about Corporate Compliance? Yes! Everyone is responsible for Corporate Compliance. Federal Sentencing Guidelines mandate training on ethics and legal compliance for all public and privately held companies. These guidelines were amended in November of 2004 to include training for all employees, after Enron and other corporations were found to be grossly negligent in their training and application of ethics and compliance.

5 Corporate Compliance Every employed or contracted person is responsible at all times: To act honestly, ethically and professionally To comply with all KSSH policies, and applicable laws and regulations pertaining to his/her position To maintain the confidentiality of patient information and records To report suspected wrongful conduct in good faith and immediately

6 Corporate Compliance MISSION STATEMENT A dream, to have a state-of-the-art facility to deliver care par excellence and compassion, come true. Our solemn pledge to live the dream for our patients and their families. For this blessing, we thank God. CORE VALUES

7 Corporate Compliance Be aware of issues surrounding fraud abuse and conflict of interest. If you question if a practice is being carried out ethically or correctly, it is your duty to use the proper channels to inquire about it, or report it.

8 Definitions… Fraud: An intentional deception or misrepresentation made by an individual knowing it to be false with the intent it could result in an unauthorized benefit. Abuse: Incidents or practices to providers, physicians, or suppliers of services and equipment inconsistent with accepted sound medical, business or fiscal practices. These practices may directly or indirectly result in unnecessary costs, improper payment, or payment for services that fail to meet recognized standards of care, or that are deemed medically unnecessary.

9 Definitions… Conflict of Interest: A conflict of interest may exist when an employee is involved in an activity or has a personal interest that may interfere with their ability to objectively perform their responsibilities at Kansas Spine & Specialty Hospital.

10 Types of situations which constitute “wrongful conduct” Allegations of items or services not received, but that were billed. Allegations services received were inconsistent with the services billed. Allegations a supplier billed both the beneficiary and Medicare for the same item or service. Allegations regarding waiver of coinsurance or deductibles that do not follow established policy.

11 Allegations a supplier misrepresented itself as having an affiliation with an agency or department of state, local, or federal government, whether expressed or implied. Beneficiary inquiries concerning payment for an item or service, which is believed to far exceed a reasonable payment for the service received, (i.e., the supplier or physician has “up coded” to receive a higher payment). Types of situations which constitute “wrongful conduct” (Continued)

12 Measures we take to prevent wrongful conduct Commitment to legal and ethical behavior through the promotion of our Mission Statement and Core Values. Due diligence through completing criminal background checks on all employees. Policies and procedures are in place and are enforced to prohibit and detect wrongful conduct. Annual training on Corporate Compliance and Harassment is required for all employees to ensure awareness of these policies and procedures. Internal and external audits ensure consistent and accurate practice. Methods of reporting are in place to ensure employees are able to report concerns without fear of retaliation.

13 Corporate Compliance How do I report suspected wrongful conduct? First, report your concern to your direct supervisor. If this is not an option, report your concern up the chain of command (to your supervisor’s boss, etc.) If this is not an option, report your concern to Human Resources. If this is not an option, report your concern to the Compliance Officer, or call the Hotline ( ).

14 What if wrongful conduct is reported? If wrongful conduct is found or reported, KSSH will investigate and will comply with any and all outside governing bodies which are impacted and appropriate. KSSH will not retaliate or discriminate against any person who makes a good faith report of a suspected violation by reason of that report being made. Confidentiality of identity will be maintained as much as possible; however, it may become necessary for such employee’s identity to become known or revealed during the investigation process.

15 Corporate Compliance Employees violating applicable federal or state laws or regulations, or who deviate from appropriate standard of conduct as outlined in the Corporate Compliance Plan will be subject to disciplinary action. This may include an oral or written warning, disciplinary probation, suspension, reduction in salary, demotion, or termination of employment or contractual relationship. Reports which are made and are knowingly false will be addressed with disciplinary action up to and including termination.

16 Harassment KSSH prohibits any form of harassment relating to race, color, religion, sex, national origin, disability, age, and all other protected categories. Harassment is verbal or physical conduct that denigrates or shows hostility or aversion toward an individual because of race, color, religion, sex (including sexual orientation), national origin, disability or age and: Creates an intimidating, hostile, or offensive environment Unreasonably interferes with the individual’s work performance Adversely affects the individual’s employment opportunities Source: KSSH Manual: Human Resources – Harassment Harassment

17 Sexual Harassment Sexual harassment, specifically, refers to unwelcome behavior that is personally offensive and undermines or interferes with the ability of the employee to work effectively. Unwanted sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature constitute sexual harassment when any of the following conditions exist: Submission to conduct is a term or condition of employment Submission or rejection of such conduct is basis for employment decisions that affect the individual. The harassment unreasonably interferes with the employee’s work or creates an intimidating, hostile, or offensive environment.

18 Types of Sexual Harassment Hostile environment Quid Pro Quo

19 Quid Pro Quo (Translation: “This for That”) Unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature constitutes sexual harassment when: Submission to such conduct is made a term or condition of employment Submission to or rejection of such conduct is used as basis for employment decisions

20 Hostile Work Environment Unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature that have the purpose or effect of unreasonably interfering with an individual’s work performance or those actions that creating an intimidating, hostile, or offensive working environment.

21 What Constitutes a Hostile Work Environment? Was conduct verbal or physical or both? Was conduct one time or repeated? Was conduct hostile and patently offensive? Was alleged harasser a co-worker or supervisor? Did others participate in the harassment? Was the harassment directed at more than one individual?

22 Sexual Harassment Is Not: A relationship between consenting adults A comforting hug between friends or co-workers Mutual attraction, flirtation or expression of affection between friends Complimenting a person on their colorful clothing, new hair style, cool tie, or the like

23 What to do if you believe you are being harassed: 1. Tell the other person that the conduct is unwelcome and must stop. (If taking this step feels threatening to you, proceed to step 2.) 2. If the conduct does not stop immediately, or if it does stop, but you still want to report the situation, contact your supervisor, Human Resources, the Corporate Compliance Officer, or the Compliance Hotline. 3. A thorough investigation will be performed. This may include interviews with other employees and the accused. Interviews are expected to be confidential, breaches of confidentiality will result in discipline up to, and including, termination of employment.

24 What to do if you are harassed (continued): 4. You, or other employees associated with the investigation, may be placed on investigative leave for a variety of reasons. 5. The reporting employee will be notified after the investigation of the findings and the general action taken. 6. If the harassment still does not stop, or if you experience retaliation of any kind, contact Human Resources, the Compliance Officer, or the Compliance Hotline immediately.

25 Retaliation against employees who: Oppose harassment Make a harassment charge Participate in a harassment investigation …is PROHIBITED!

26 Zero Tolerance! Harassment is against the law Harassment will not be tolerated All complaints of harassment will be taken seriously and immediately investigated Once investigated, action will be taken appropriate to the situation Action includes discipline up to, and including, termination of employment

27 KSSH CORPORATE COMPLIANCE OFFICER Claudia Ellerman, MBA,LPN, RHIA Health Information Manager Housed in Administration

28 Corporate Compliance Hotline We maintain a contract with ComplianceLine, Inc. for the external reporting of violations. They may be reached 24/7. CORPORATE COMPLIANCE HOTLINE:

29 Corporate Compliance 2016 Annual Competency 1.One purpose of the Corporate Compliance Plan is to promote legal and ethical behavior. True or False 2.Only Management is responsible for corporate compliance. True or False 3.Everyone who is employed or contracted with KSSH is responsible at all times to act honestly, to comply with all KSSH policies, to maintain patient confidentiality and to report suspected wrongful conduct immediately. True or False 4.Who is the Corporate Compliance Officer for KSSH? ________________________. 5.If you question if a practice is being carried out ethically, it is your duty to use the proper channels to inquire about it or report it. True or False

30 Corporate Compliance 2016 Annual Competency 6. Abuse is an intentional deception or misrepresentation made by an individual knowing it to be false with the intent it could result in an unauthorized benefit. True or False 7. In addition to other local and state regulatory bodies, KSSH is governed by the federal agency Centers for Medicare & Medicaid Services. True or False 8. Normally, wrongful conduct should first be reported to your direct supervisor. True or False 9. KSSH prohibits any form of harassment relating to race, color, national origin, disability, age, and all other protected categories. True or False 10. The Corporate Compliance hotline number is: _____________________.