Compliance for Our Medical Center The University of Illinois Medical Center at Chicago is dedicated to providing the highest level of education, research and patient care. The University expects all of its staff to act ethically and legally. We have established a Code of Ethics meant to ensure that these expectations are understood and met.

Compliance Plan – University of Illinois Med Center Rephrasing Portions of Our Code of Ethics (GO 1.02) Be Honest and Ethical. Every member of the staff is expected to have high ethical standards when he or she acts on behalf of the Medical Center. Obey the Law. There a many laws and regulations that govern our activities, and it can be very confusing. If you are not certain what to do, ask for help.

Compliance Plan – University of Illinois Med Center Be Truthful. Care should be taken to make sure that all communications inside and outside the Medical Center are truthful, accurate, and complete. Honor Confidences. Our patients expect – rightly so – that their medical information is handled appropriately. In addition, confidential information related to University activities should also be protected. Report Conduct That Concerns You. If you believe that you have information about an activity that may be illegal or unethical, you should report it to appropriate individuals. Such reports can be made anonymously. Rephrasing Portions of Our Code of Ethics (GO 1.02)

Compliance Plan – University of Illinois Med Center Why is the Medical Center Concerned? The Medical Center supports and promotes DOING THE RIGHT THING! We have an obligation to our patients, our employees, and our University to act in a correct and forthright manner.

Compliance Plan – University of Illinois Med Center After the War on Terrorism, what is the second highest priority for the Federal Government? And another thing: It is the detection and elimination of Health Care Fraud.

Compliance Plan – University of Illinois Med Center So there is another reason to be concerned. There have been an increasing number of high-visibility reports of illegal, unethical, and inappropriate actions by a number of medical centers across the country. In many incidents, there have been large fines levied against the institutions.

Compliance Plan – University of Illinois Med Center What is Health Care Fraud? It is the submission of incorrect bills to the Federal Government – whether intentional or unintentional – for hospital and outpatient services, supplies, or equipment provided to Medicare and Medicaid patients.

Compliance Plan – University of Illinois Med Center How does this all affect me?  Excessive dollars are taken out of the Medicare Trust Fund ($13.3 Billion in 2002) - will anything be left for you?  It jeopardizes a major source of our Medical Center’s operating budget – Medicare and Medicaid Incorrect billing has two major impacts.

Compliance Plan – University of Illinois Med Center Who in the Federal Government is watching? OIGOffice of the Inspector General (staffed by former FBI agents) CMSCenters for Medicare & Medicaid Service (formally HCFA) CERTComprehensive Error Rate Testing Program HPMPHospital Payment Monitoring Program There is an alphabet-soup of groups and programs.

Compliance Plan – University of Illinois Med Center But anybody can make a mistake. What is the attitude of the OIG? The Office of the Inspector General used to have an attitude of acceptance and forgiveness for providers who hadn’t been aware that wrongdoing was occurring but had corrected the problem. Now it levies penalties against providers “who know or should have known” that fraud was being committed. With the Medicare program in financial trouble, no leeway is given for those who misunderstand. There are no pardons for those who are confused, no allowances for errors.

Compliance Plan – University of Illinois Med Center Nobody really pays fines or gets into trouble, do they? In 2000, a total of 467 defendants were convicted of health care fraud-related crimes. In 2000, 3,350 individuals and ‘entities’ were excluded from taking part in Medicare and Medicaid programs. In 2000, in addition to the return of incorrect payments, the Federal government won more than $1.2 billion in judgments and penalties. That’s not true -

Compliance Plan – University of Illinois Med Center This is scary. What’s the Medical Center doing about this? The Medical Center is fine-tuning a Compliance Program, important parts of which are spelled out in the remainder of this unit. The Compliance Program is a formal way an organization such as ours makes sure we all comply with applicable laws and regulations, ethical standards, and our own policies and procedures.

Compliance Plan – University of Illinois Med Center Why is a Compliance Program Needed? It’s needed to – Reinforce high standards of ethics, quality, proper behavior and performance Help fulfill legal responsibilities to the government and private payers Show a strong commitment to honesty and responsibility Identify and encourage prompt correction of errors or misconduct Help protect us against government actions and avoid large fines

Compliance Plan – University of Illinois Med Center Do Compliance Plans really work? Not just wasted motion? Since the Federal Government strongly suggested in 1998 that providers create Compliance Programs, improper payments have significantly decreased. In 1996, it is estimated that these improper payments were $23.2 billion. In 2002, improper payments were estimated at $13.3 billion – a marked drop. Much of this decrease is attributed to compliance programs, but some may have been due to the aggressiveness of the OIG. About 95 % of health care providers (hospitals, physician office practices, outpatient clinics, nursing homes, etc.) already have Compliance Plans.

Compliance Plan – University of Illinois Med Center What are the OIG’s and auditors “trouble-spots” ? Medical Necessity Issues: Documenting that the test, procedure, device, or study was really necessary for the care of the patient’s problem. (For example, most so-called “screening” tests are not billable to Medicare.) Billing and Coding Issues: Inaccurate billing codes, ‘upcoding’ and ‘unbundling’ – inappropriate practices that charge the payers more that they should be charged.

Compliance Plan – University of Illinois Med Center What are the OIG’s and auditors “trouble-spots” ? Business Arrangement Issues: Kick-backs to physicians and vendors of supplies to the provider, conflicts of interest, etc. Transfers and “Dumping”: Moving patients with limited or no insurance to other institutions, often endangering their care.

Compliance Plan – University of Illinois Med Center What makes up the Compliance Program? The OIG has given guidance for the development of such a program. There are a minimum of seven elements of the plan.

Compliance Plan – University of Illinois Med Center 1. Standards and Procedures 2. Compliance Oversight 3. Education and Training 4. Effective Communication 5. Auditing and Monitoring 6. Disciplinary Procedures 7. Corrective Action and Prevention The Seven Elements of the Compliance Program

Compliance Plan – University of Illinois Med Center 1.Standards and Procedures The organization must have established compliance standards and procedures to be followed by its employees and other agents and staff that are reasonably capable of reducing the prospect of criminal conduct. This means that health care facilities must spell out in writing the specific rules and regulations, policies and procedures that they need to follow to comply with all government regulations.

Compliance Plan – University of Illinois Med Center 2.Compliance Oversight Specific high-level personnel of the organization must be assigned overall responsibility to oversee compliance with such standards and procedures. The government wants hospitals to appoint a ‘corporate compliance officer’ (CCO). This individual should be responsible for implementing and overseeing the Compliance Program. The CCO’s duties include – Receiving reports of problems or violations and correcting them Overseeing a periodic compliance audit, and monitoring compliance performance Training physicians, employees, and staff in compliance matters

Compliance Plan – University of Illinois Med Center Who is the Corporate Compliance Officer? The CCO in our institution is William Chamberlin, MD, Medical Director of the Medical Center

Compliance Plan – University of Illinois Med Center 3.Education and Training The organization must take steps to share its standards effectively with all physicians and employees by having them take part in annual training programs and by making available publications that explain - in a practical way - what is required. All staff must be educated on the organization’s standards and procedures as well as the Compliance Program itself. This NetLearning unit is an overview targeting all staff and physicians. Other specific programs tailored to your job will be developed and be available.

Compliance Plan – University of Illinois Med Center 4.Effective Communication The organization must have a system by which staff can report suspicious activity by others within the organization without any threat to their job. The OIG recommends that the Medical Center establish hotlines, addresses, and other forms of messaging for suspected compliance violations. This must be done in a confidential way and no retaliatory steps may be taken against the person honestly making his or her suspicions known. The compliance Hotline Number for our Medical Center is (866)

Compliance Plan – University of Illinois Med Center 5.Auditing and Monitoring The organization must take steps to achieve compliance with its standards by using monitoring and auditing systems designed to detect criminal misconduct by its employees and other staff. Monitoring and Auditing are different. Monitoring is another word for “tracking.” We take a look at what is going on right now – to get a baseline of where we are. Auditing is like a “probe” – an investigation when someone finds a problem. It’s done ‘on demand.’

Compliance Plan – University of Illinois Med Center 6.Disciplinary Procedures The standards must be enforced through the right disciplinary mechanisms. This includes action, where needed, for the failure to detect an offense by others. The goal is to make sure that every physician and staff member understands what will happen if violations of the compliance program take place. Although the Medical Center already has disciplinary procedures in place, additional ones – specifically related to compliance violations - may be needed.

Compliance Plan – University of Illinois Med Center 7.Corrective Action and Prevention After an offense is detected, the organization must take all reasonable steps to respond to the offense and take steps to prevent it happening again. The Chief Compliance Officer will promptly investigate any reports of noncompliance, and decide whether there is evidence supporting the charge. If a violation has occurred, he will take steps that may include - Changing the compliance program Disciplining an individual Contacting outside agencies.

Compliance Plan – University of Illinois Med Center Where does HIPAA fit into all of this? The main goal of HIPAA (Health Insurance Portability and Accountability Act) is the protection of privacy of the individual patient. The main goal of the Compliance Program is the protection of the payer against fraudulent activities. It was needed because of a history of abuses in the billing and other financial operations of hospitals. In most academic medical centers such as ours, HIPAA is part of the overall Compliance Program.

Compliance Plan – University of Illinois Med Center Summary The Compliance Program of our Medical Center has been created to help us make certain we are good corporate citizens. That is, that our Medical Center– Lives up to our Code of Ethics Acts honestly, ethically, and truthfully Bills all parties appropriately Makes financial decisions strictly on the merits of the situation (without kickbacks!) Follows all applicable Federal and State regulations and laws This overview unit only summarizes these issues and more detailed information will be available.