Physician Compliance Education Compliance promotes prevention, detection and correction of errors, waste, abuse, and fraud

Catholic Health Values Reverence We honor the value of each individual we encounter at Catholic Health Compassion We commit to walking with others through both joy and suffering Justice We dedicate ourselves to treat all people with respect, dignity and fairness Excellence We commit to exceed the expectations of our patients, residents, their families, and all the people we meet at Catholic Health

Catholic Health Code of Conduct Uphold Legal and Regulatory Compliance Promote Ethical Business Conduct Disclose Potential Conflicts of Interest Appropriately Use Resources Preserve Confidentiality Exhibit Catholic Health Behavioral Conduct Act Responsibly & Be Accountable The entire Catholic Health Code of Conduct is available on the CH website

Medical Record Documentation Documentation must be complete and accurate Impacts Patient Care Supports Coded Data Reviewed for Medical Necessity (Inpatient Admission) Utilized in Quality and Core measures reporting Evaluated in Medicolegal Reported in Statistics Best evidence in response to audits

If it’s not documented, it’s not done It is fraudulent to either document services that were not performed or to submit claims for services without appropriately documenting those services. Missing clinical notes or test results, (dates, signatures, orders, care or service rendered), incomplete or illegible documents, or improper billing and coding can be interpreted as fraud or abuse and lead to a false claim with the government resulting in penalties.

Fraud and Abuse Laws False Claims Act STARK & Anti-Kickback Statute Exclusion Statute Conflicts of Interest Sunshine Act Civil Monetary Penalties Law

Types of Improper Payments Mistake Inefficiencies Bending Intentional the Rules Deception Error Waste Abuse Fraud Incorrect coding Medically unnecessary service Improper Billing practices (such as, upcoding) Billing for services or supplies that were not provided

A false claim can include billing for service that: False Claims Act Governs Fraud, Waste & Abuse 31 U.S.C. Section 3729-3733 NYS SFL Sections 187-197 It is a crime to knowingly make a false record, file, or submit a false claim with the government for payment A false claim can include billing for service that: was not provided or documented not ordered by a physician was of substandard quality It is also unlawful to improperly retain overpayments- FERA 2009 Mandatory return of overpayments within 60 days- PPACA 2010 Allows for Qui Tam Relator -Whistleblower provision

Physician Self-Referral Law (STARK) The Physician Self-Referral Law, often called the Stark Law, prohibits a physician from making a referral for certain designated health services to an entity in which the physician (or member of his or her immediate family) has an ownership/investment interest or with which he or she has a compensation arrangement, unless an exception applies. Example: A provider refers a beneficiary for a designated health service to a business in which the provider has an investment interest. Penalties: Penalties for physicians who violate the Stark Law include fines, repayment of claims, and potential exclusion from participation in all Federal health care programs

Anti Kick-back Statute 42 U.S.C Section 1320a-7b, 1972 Prohibits the knowing or willful offer, payment, solicitation, or receipt of any form of remuneration (payment) in order to induce business (referral) for which payment may be under a federal health care program. (Bribes) Includes: inducement of referrals purchasing leasing ordering arranging for goods or services - some Safe Harbors do exist

Stark Law & the Anti-Kickback Statute Enforcement of the Stark Law & the Anti-Kickback Statute is intended to ensure that physicians' medical judgment is not compromised by improper financial incentives. The Stark Law forbids a clinic or hospital from billing Medicare for certain services referred by physicians who have a financial relationship with the entity. The Anti-Kickback Statute prohibits offering, paying, soliciting or receiving remuneration to induce referrals of services or items covered by federal health care programs, including Medicare.

Exclusion Statute (Sanction) An exclusion is an administrative action that is mandatory against an individual or entity who has either: a) been convicted of, b) pleaded guilty to, or c) had their license revoked for:  Felony Fraud as it relates to federal healthcare programs Felony Substance Abuse Felony Patient Abuse or Neglect All felony fraud cases result in an automatic exclusion by the OIG If an individual or entity has been convicted or pleaded guilty to a misdemeanour for any of the fraud exclusions lists above and/or is in default of their student loan, they could be excluded by the OIG or have their license revoked as a result as well. 

Medicare Conditions of Participation (CoP) Sanction Check Exclusion Statute 42USC§1320a-7 Prohibits payment for items or services furnished at the medical direction or on the prescription of an excluded person when the person furnishing the items or services knew or should have known of the exclusion. Individuals or entities can be excluded from participation in Medicare & Medicaid programs. If sanctioned, the person/entity must provide notification immediately to Compliance

Sunshine Act- Open Payments The Sunshine Act, a provision of the Affordable Care Act (aka Obamacare), requires companies that make drugs, medical devices, and biological medicines to report payments and items of value given to physicians and teaching hospitals. (specifics outlined by NEJM and AMA). August 1st, 2013 is the deadline to start reporting information. Additionally manufacturers and group purchasing organizations must report certain ownership interests held by physicians and their immediate family members. The Sunshine Act will expose or stop many physicians from making additional money through relationships with manufacturers that represent a conflict of interest. Refer to Catholic Health Conflict of Interest and Non-monetary Compensation policies for additional information.

Conflicts of Interest Do not accept gifts, entertainment, meals, or other incentives given for the purpose of: Influencing a purchasing or contracting decision Encouraging or rewarding patient referrals That could be perceived as a bribe, payoff, deal, or any other attempt to gain a competitive advantage. Do not accept cash or items redeemable for cash, such as checks or gift cards.

Conflict of Interest Potential Conflicts of Interest Relationships Secondary Employment/Agreements Consultant Speakers’ bureau Advisory Panel Administrative positions with Pharm or DME Third party payor Other entities doing business with CH

Civil Monetary Penalties HHS-OIG is authorized to impose civil penalties for violations of the Anti-Kickback Statute as well as a range of other violations. Penalties range from approximately $10,000 to $20,000 per claim. These violations include, but are not limited to, the following: Submitting false claims; Violating Medicare assignment provisions or the physician agreement; Providing false or misleading information expected to influence a decision to discharge a patient; Failing to provide an adequate medical screening examination for patients who present to a hospital emergency department with an emergency condition or in labor; and Making false statements on applications or contracts to participate in a Federal health care program.

Individual Accountability for Corporate Wrongdoing Deputy U.S. Attorney General Sally Yates recently vowed … Federal prosecutors would no longer enter into settlement agreements with companies whose internal investigations do not disclose the “culpable individuals.” DOJ Memo (Sept. 9, 2015) Criminal and civil corporate investigations should focus on individuals from the inception of the investigation

CMS Conditions of Participation Federal and state health care programs, such as Medicare and Medicaid, as well as commercial insurance and other third parties, pay for a majority of the health care services Catholic Health provides to our patients, residents, and communities. These payers have established requirements that must be followed to receive payment for services.

Medicare and Medicaid (CMS) Enrollment Physicians and non-physician practitioners who are enrolled in the Medicare program, but have not submitted the CMS 855I since 2003, are required to submit a Medicare enrollment application (i.e., Internet-based PECOS or the CMS 855I) as an initial application when reporting a change for the first time.” Licensed Medical Residents need to enroll in NYS Medicaid OPRA (Ordering, Prescribing, Referring, Attending) Affordable Care Act and subsequent federal regulations (42CFR 455.410)

Other Healthcare Regulations Department of Health and Human Services Patient Rights HIPAA (Confidentiality/Privacy) Patient Communication (Language Assistance)

. Review the Physician HIPAA Education information available on the Catholic Health website

Patient Communication Language Assistance Program Ensures that limited English proficiency, or hard of hearing persons utilizing CH services are able to understand and communicate with CH associates and physicians Provided FREE of charge to the patient Each time medical information is communicated to a Limited English Proficient or hard of hearing/deaf person, language assistance services must be offered. DOCUMENTATION IS REQUIRED

Recommended Compliance Educational Materials Office of Inspector General (OIG) https://oig.hhs.gov/compliance/101/cme.asp (CME Credits available) https://oig.hhs.gov/compliance/physician-education/index.asp CMS-Centers for Medicare and Medicaid Services https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/CMS1254524.html Open Payments https://openpaymentsdata.cms.gov/ NY Office of Medicaid Inspector General (OMIG) https://www.omig.ny.gov/compliance/compliance-library Medicare University- Computer Based Courses* http://www.medicareuniversity.com/ngs/home.html National Government Services (NGS)* https://ngsmedicare.com Education-Webinars, Teleconferences & Events * Need to have or create a user ID and password

Catholic Health Compliance Know and follow Federal, State and Local laws, rules & regulations Uphold CHS Code of Conduct, Medical Staff By-laws Report suspected or actual Compliance/HIPAA concerns to: your Medical Director the Compliance Officer, or the 24/7 Compliance Hotline (1-888-200-3380) Reporters of concerns are protected by the CHS non-retaliation policy All calls are confidential Leonardo Sette-Camara, Esq. Deputy Counsel, Compliance & Privacy Officer 716.821.4469 lcamara@chsbuffalo.org