1. Rockcastle Regional Compliance Program
Compliance Officer
Carrie Mullins, ext or
(also Office Manager at RockPeds)
Compliance Team
Graduated law school 1997, licensed and practiced law in state of KY for 15 years
6 ½ years ago was asked to come and work at Rockcastle Pediatrics, by my sister Dr. Callie Shaffer,
1 month ago was asked by RRH to take over Compliance Officer duties, and so that is how I cam to be with you here today. New to this position, and hospital has made a commitment to the area of compliance
Currently I work part time as hospital’s compliance officer, and part time as RockPeds office manager.

2. Rockcastle Regional Compliance Program
What is “Compliance” and why do we have a “Compliance Program”?
Compliance is following the laws and regulations passed by official regulating bodies (Congress, Federal agencies, State agencies), as well as following general ethical principles.
We have a Compliance Program to:
Demonstrate to our patients, the community, our employees, the government, and third-party payors our commitment to honest and fair dealing.
Centralize and intensify our efforts in preventing and detecting illegal, unethical or dishonest behavior.

3. Rockcastle Regional Compliance Program
Where to find information on our compliance responsibilities as employees of RRH:
Code of Conduct - establishes standards of performance for all employees to conduct business with honesty and integrity – reviewed and signed as new employee
Employee Conflict of Interest Statement – reviewed an signed every year
RRH Policies (both in Employee Handbook, and Online Policy Manager)
Federal and State Laws and Regulations

4. Rockcastle Regional Compliance Program
Our Commitment to You
We promote an environment where potentially improper or fraudulent activities are prevented, detected, and reported.
We assure employees, without fear of retaliation, that their reported concerns will be reviewed, addressed, and resolved
We aim for staff who are seeking compliance guidance, education, and/or incident reporting, to have easy access to this information and tools
We will monitor adherence to applicable federal, state, and local laws, regulations, guidelines and program requirements

5. Rockcastle Regional Compliance Program
False Claims Act
Federal statute that establishes liability for knowingly presenting a false or fraudulent claim for payment to the United States government or to a government contractor.
Violation of the False Claims Act is a serious crime.

6. Rockcastle Regional Compliance Program
False Claims Act - Violation
Result in monetary penalties of $5,500 to $11,000 for EACH false claim submitted.
May be required to pay three times the amount of damages sustained by the U.S. Government
Can be excluded from participation in Medicare and Medicaid
State law penalties as well as sanctions from governing professional affiliation.

7. Rockcastle Regional Compliance Program
False Claims Act – Recent KY Examples:
EX: Ashland Cardiologist “Paulus performed invasive heart procedures on patients who did not need them.  In order to justify these unnecessary procedures, Paulus falsified patients’ medical records, exaggerating their medical condition and making it appear that the heart procedures were necessary and qualified for payment.  From 2006 to 2012, Paulus billed Medicare for more heart procedures than any other cardiologist in Kentucky, and was fifth in the nation in terms of amount paid by Medicare for stent procedures. Paulus’s sentence was based on stents he placed in seventy-one patients whose blockages were significantly less than 70 percent, where Paulus recorded them at or near 70 percent in the records, in order to be paid for the procedures.  These medically unnecessary procedures were performed during his tenure at King’s Daughters Medical Center in Ashland.           
In addition to his term of imprisonment, Paulus must pay $1.1 million in restitution to Medicare, Medicaid, and other private insurers who were financial victims of his scheme.  Under federal law, Paulus must serve 85 percent of his prison sentence and will be under the supervision of the U.S. Probation Office for three years following release.”

8. False Claims Act – Recent KY Examples:
EX: Multiple Docs, Opiod RX: ”Dr. Mohammed A.H. Mazumder of Prestonsburg, who owned Appalachian Primary Care, is charged with telling his employees, who were not doctors, to receive patients at the clinic when he was not there. The indictment says a medical technician evaluated patients, then two receptionists called pharmacies with prescription orders for opioids and other controlled substances under Mazumder’s name. The clinic then submitted claims to Medicare and Medicaid as if Mazumder had examined the patients and ordered the prescriptions.”
NOTE: These are CHARGES that have not yet been proven, he has not yet been convicted and is presumed innocent.

9. Rockcastle Regional Compliance Program
Anti-Kickback Statute (AKS)
Federal Statute that prohibits any knowing and willful conduct involving the solicitation, receipt, offer or payment of any kind of “remuneration” in return for referring an individual or for recommending or arranging the purchase, lease, or ordering of an item or service that may be wholly or partially paid for under a federal health care program (Medicare/Medicaid)
Ex: Doctor who prescribed pain cream received payments for “hourly work” from compounding pharmacy; payments for the “hourly work” were not actually for work, but in actuality were illegal kickback payments.
In plain terms: we can’t pay money to someone to send business/patients to us; and others can’t pay money to us for us sending business to them.
AKS – can go more in-depth as to requirements of this law here (not yet in policies or code of conduct) :
Employees are prohibited from knowingly/willfully soliciting or receiving, or offering or paying, any remuneration (including any kickback, bribe, forgiveness of debt or rebate), directly or indirectly, overtly or covertly, in cash or in kind, in return for or as an inducement to:
referring an individual to a provider for the furnishing of, or arranging for the furnishing of, any item or service for which payment may be made under a federal health care benefit program; or
purchasing, leasing, ordering, arranging, or recommending purchasing, leasing, ordering, of any good, facility, service or item for which payment may be made in whole or in part by a federal health care benefit program;
submitting or causing to be submitted claims to Medicare or Medicaid for patients who were referred to the hospital pursuant to contracts and financial or business arrangements that were designed to induce such referrals;
entering into financial or business arrangements with hospital-based physicians that are designed to provide inappropriate remuneration to the hospital, for example compensating physicians for less than the fair market value of services they provide to the hospital or requiring them to pay more than market value for services provided by the hospital, (i.e. token or no payment for Part A supervision and management services; requirements to donate equipment to the hospital; and excessive charges for billing services) in return for the physician’s ability to provide services to federal health care benefit program beneficiaries at that hospital;
entering into financial or business arrangements with physicians that result in the physician receiving, for example, excessive payment for medical directorships, free or below market rents or fees for administrative services, and interest-free loans and excessive payment for intangible assets in physician practice acquisitions; or
otherwise influence or attempt to influence the decision making process surrounding a transaction in an illegal, unethical, or abusive manner.
• Safe Harbor Exemptions: It is important to remember that there are a significant number of specifically drafted exemptions (often referred to as “safe harbors”) to the Anti-Kickback prohibition. The safe harbors essentially permit certain conduct that would otherwise be prohibited by the statute. However, because these exceptions are narrow in scope, and are accompanied by numerous requirements, employees may not agree to, or engage in any transaction, that involves any form of potentially prohibited remuneration without approval from the CEO or Compliance Officer.

10. Rockcastle Regional Compliance Program
Anti-Kickback Statute (AKS) (Cont’d)
At RRH, employees cannot give or receive gifts/money/services with the expectation of influencing the judgement of any purchaser, supplier, customer, government official or other person (including patients).
At RRH, employees are prohibited from having any personal financial dealings with any person, form or corporate entity which furnishes services, supplies, property or other merchandise to the Hospital. Prohibited inurement would include, but not be limited to loans, commissions, royalties and property shares.
Code of Conduct, Std. 5.1 and 5.4
Conflict of Interest Statement #2, #3

11. Rockcastle Regional Compliance Program
Anti-Referral Statute (no self-referral) Stark Law
Stark Law applies to physician referrals –if a doctor or immediate family member has a financial relationship with an entity that provides designated health services then the physician may not make a referral for any health service that is reimbursable by Medicare/Medicaid, and the entity that provides services may not bill Medicare for the services provided as a result of the prohibited referral.
Ex: physician owns a lab, and refers all his patients, including those with Medicare/Medicaid coverage, to that lab for lab testing. This arrangement would violate Stark Law.
In plain terms: can’t refer patients to your own business/business of a family member
Stark Law – go more in-depth as to requirements of this law here (not yet in policies or code of conduct) :
The anti-referral statute often referred to as “Stark” is designed to prevent possible conflicts of interest related to patient referrals made by physicians and the resulting claims for reimbursement. Anti-Referral Statute “Stark I & II” (42 U.S.C.§1395nn). Accordingly,
RRH physicians shall not make a referral for a designated health service to an entity in which he or she (or an immediate family member) has a financial relationship.
RRH shall not knowingly submit or cause to be submitted a bill or claim for reimbursement for services provided pursuant to such a prohibited referral. For purposes of this prohibition, the term “financial relationship” includes:
(a) Ownership or investment interest through equity, debt, or other means including an interest in an entity holding an ownership or investment interest in any entity actually furnishing the designated health services; or
(b) Compensation arrangement involving any remuneration to physician or immediate family member.
For purposes of this prohibition, "designated health services" include: (a) Laboratory services (b) Physical therapy services (c) Occupational therapy services

12. Rockcastle Regional Compliance Program
Anti-Referral Statute (no self-referral) Stark Law (Cont’d)
At RRH, no employee shall refer patients for services to an entity in which the employee (or immediate family member of employee) has any financial relationship.
See: Employee Conflict of Interest Statement, #3.

13. Rockcastle Regional Compliance Program
Emergency Medical Treatment and Labor Act (EMTALA)
Federal Law that prohibits patient ‘dumping’ -  requires anyone coming to an emergency department, with an emergency medical condition, to be stabilized and treated, regardless of their insurance status or ability to pay. If the hospital does not have the specialized capabilities required to stabilize the patient, the hospital must arrange for an appropriate transfer.
RRH Policy: Medical Screening, Treatment, Stabilization and Transfer of Patients to Another Facility
EMTALA:

14. Rockcastle Regional Compliance Program
Patient Confidentiality/HIPAA
Behavior Standard – Privacy
RRH Policy: HIPAA Privacy, HIPAA Security
Bidding Processes
RRH Policy: Purchasing Policy
Includes purchasing code of ethics, bidding guidelines, conflict of interest, gratuities and kickbacks
HIPAA/Patient Confidentiality: 3 points from Behavior Standard on Privacy
1. ALWAYS Patient records must be kept confidential
2. ALWAYS Use discretion when conducting telephone conversations with customers
3. ALWAYS Do not discuss our customers in public areas (i.e. elevators, hallways, cafeteria, etc.)
You will receive more in-depth coverage of HIPAA in other parts of your orientation.

15. Rockcastle Regional Compliance Program
Resources
RRH Employee Handbook: Corporate Compliance Policy, V-28; Conflict of Interest Policy, V-6; Personal Conduct Guide, V-27; RRH Policies (not already mentioned): Organizational Ethics Statement; Fair Billing Practices; Statement of Ethical Business Practices; Inpatient Pharmacy Fraud, Waste and Abuse Compliance; Chart/Charge Audit Committee; Purchasing Policy; Behavior Standards;
RRH Employee Conflict of Interest Statement
RRH Code of Conduct
US Department of Health and Human Services, Office of Inspector General (HHS OIG) website

16. Rockcastle Regional Compliance Program
Your Responsibility
RRH employees are expected to deal fairly and honestly with patients and their families, suppliers, third-party payors, and their professional associates.
Follow the Code of Conduct and Conflict of Interest Statement, and RRH Policies, comply with state and federal laws, ask questions.
As an employee of RRH, you are obligated to promptly report any conduct that you are aware of, that you in good faith believe is illegal or unethical.

17. Rockcastle Regional Compliance Program
Examples of Reportable Incidents. Employees should promptly report any conduct they are aware of, that they in good faith believe is illegal or unethical.
Potential issues/areas of concern include, but are not limited to:
Breach of patient confidentiality (HIPAA)
Inaccurate record keeping
Inappropriate billing activities (False Claims Act)
Documenting treatment not performed (False Claims Act)
Kickbacks/Illegal Remuneration (Anti-Kickback Statute and Civil Monetary Penalties Statute)
Self Referral (Stark Law)
Bid Rigging

18. Rockcastle Regional Compliance Program
How to make a good faith report of suspected illegal or unethical conduct:
Report to your supervisor. Employees are encouraged to first discuss any concern with their manager/supervisor. Your manager/supervisor is normally the best source of information and it is their job be diligent in cooperating with you and addressing issues and concerns. This should be the routine way of reporting concerns, but there are other ways to report as well.
Report to the Compliance Officer at ext. 4225, or Employees are always permitted to make inquiries or report misconduct directly to the Compliance Office.
Report by calling the 24 hour Compliance Hotline at This is an independent hotline, not operated by RRH. Employees can report anonymously 24 hours per day, 7 days per week.