1. What Every Employee
Should Know
About Compliance

2. SSH Compliance Program
What is compliance?
An evolving program
Now mandatory to participate in Medicare / Medicaid programs; mandated by the Patient Protection / Affordable Care Act (PPACA), 2010
Enforced by the federal Department of Health and Human Services’ Office of Inspector General
Healthcare fraud is a federal crime!
Conservative estimates that over $100 Billion is lost to healthcare fraud each year ($273 M / day!)

3. SSH Compliance Program
What is the purpose of the SSH Compliance Program?
To promote honest, ethical behavior in every day operations
To identify, correct and prevent illegal conduct
Compliance applies to EVERY “workforce member” (employees, contractors, vendors, everyone!)

4. SSH Compliance Program
Eight Essential Requirements:
Code of Ethical Conduct / Standards of
Conduct
Compliance program policies and procedures
Designating a compliance officer
Internal monitoring and auditing
Training and education of staff
Open lines of communication, including allowing for anonymous reporting
Responding to detected offenses and developing corrective action
Enforcing disciplinary standards

5. Several Risk Areas of OIG Concern:
Billing for Services not rendered
Providing medically unnecessary services
Upcoding / “DRG creep”
Duplicate Billing
Stark physician self-referral law
HIPAA violations
Improper payments (“Kickbacks”)
Fraud, abuse, waste
Notes to Instructor
Ask if there are any questions, or comments.
End on a positive note. Encourage participants to feel good about your hospital’s commitment to compliance.

6. What is Your Role and Responsibility?
You are our first line of defense in detecting and preventing violations
Know the rules. Complying with them at all times
Reporting any violations or suspicious activity
Comply with all policies and standards of the hospital
Accept accountability for your role in compliance

7. What Do We Mean By Standards of Conduct ?
Always obey the law
Carefully bid, negotiate, and perform contracts
Generate accurate billing and claims
Maintain the integrity of physicians, agents, consultants and representatives
Promote a positive work environment
Protect confidentiality
Refuse bribes, kickbacks, and inappropriate referrals
Notes to Instructor
We will always conduct our business in accordance with all applicable laws and regulations.
If you are involved in proposals, bid preparations or contract negotiations, you must be certain that all statements, communications and representations to prospective partners or suppliers are accurate and truthful.
All bills and claims will accurately reflect the services rendered. We will never make or present improper, false, fictitious or fraudulent claims to any government or private healthcare program, employee, department or agency.
We will treat our patients and each other with respect.
We will never compromise the confidentiality of our patients’ medical records, or patient and employee information of any kind.
We will never knowingly offer, pay, solicit, or receive compensation in connection with the referral of patients or the acquisition of items for services.

8. Compliance Action Rules
(1) As a general rule, you should use the chain of command whenever possible (2) Speak to your immediate supervisor/manager first, when possible, if you have a question or concern (3) If circumstances exist that prevent you from doing so (such as your concern is with your immediate supervisor, or your immediate supervisor is unavailable) then contact the next level of management (4) Contact the SSH Compliance Officer
Notes to Instructor
The following compliance action rules should assist you to act appropriately in particular compliance situations, such as Medicare violations.
These action rules are intended to provide simple, step-by-step guidelines to inform people of what they should do if they have a question or concern with regard to compliance matters.
Refer to sample wallet card and posters.

9. Consequences: For SSH penalties on False Claims may include:
Treble damages of amount sustained by government
Fines of between $5,500 - $11,000 per false claim
Exclusion from Federal health care programs (Medicare, Medicaid)
For “Workforce Members”:
Any workforce member who violates compliance standards is subject to disciplinary action up to and including termination of employment or contract and referral for criminal prosecution
Healthcare fraud is a FEDERAL crime!

10. Principles of Compliance (aka: Everything I ever learned I learned in kindergarten!)
Honesty
Integrity
Respect
Trust
Responsibility
Citizenship
Notes to Instructor
Review the principles of compliance.
Open a discussion with the class, or smaller breakout groups. Ask the participants to consider how these principles should make their jobs better. How will patients benefit? What are the challenges? What is each individual going to do to be in compliance?
After listening to the conclusions, remind students, that while being in compliance may mean making some changes, the ultimate goal of compliance is to offer high quality medical care in an environment that is respectful, responsible and professional.
Compliance is everyone’s responsibility.

11. What Will We Do?
Stanislaus Surgical Hospital is fully committed to obeying all laws.
Stanislaus Surgical Hospital has zero tolerance for fraud and abuse.
Compliance is not optional, but the way we will operate as an organization.

12. Thank You!

13. Compliance Program Questions:
Which government agency oversees / enforces the federal compliance program?
The Department of Health and Human Services’ Office of Inspector General
What is the estimated annual dollar amount lost due to healthcare fraud in the United States?
$100 Billion / year
If you suspect fraudulent activity, what actions should you take?
Report it!
Follow your chain of command
If necessary, report incident to higher level or Compliance Officer

14. Compliance Program Questions:
Name 3 of the 8 key risk areas identified by the OIG mentioned in the presentation:
Billing for services not rendered
Providing medically unnecessary services
Duplicate billing
HIPAA violations
Stark physician self-referring
Upcoding / DRG “creep”
Fraud, abuse, waste
Improper payments (“Kick backs”)

15. Compliance Program Questions:
Who is included in the term “SSH workforce”?
All SSH part time, full time, PRN employees
All SSH contracted labor and consultants
All SSH vendors
What is the overriding purpose for the SSH Compliance Program?
To promote honest, ethical behavior in every day operations
To identify, correct and prevent illegal conduct