Objectives

1. Define the components of corporate compliance

2. Discuss problem resolution

3. Discuss the DirectLine number 1-800-500-0333 for reporting

4. Discuss the Fraud, Abuse & False Claims Act

5. Recognize topics that involve ethical decision-making.

6. Describe the function of the MMH Medical Ethics Committee

Corporate compliance programs are important for various reasons, but the most important reason is that it is a statement by the organization that we are committed to doing the right thing. This not only means we are striving to comply with all legal responsibilities, but ethical responsibilities as well.

OUR MISSION

MMH is a not-for-profit community hospital dedicated to creating a healthcare environment where quality of life and service excellence is experienced by our patients, their families, the medical staff and community.

CORE VALUES

There are core values that are part of corporate compliance and these include respect for all persons, integrity, service, excellence & trust. We all have a responsibility to everyone we come in contact with and our community. We must act in a manner consistent with this statement, the values & principles it expresses and its supporting policies. 

This code of conduct is a broad guideline which is supported in greater detail by policy & procedure throughout the organization. 

Elements of the code of conduct deal with several areas of business conducted throughout the organization. 

Quality of Care—Providing quality care is our central focus & the organization is committed to providing services that exceed patient expectations, while focusing on continuous quality improvement.

��Respect

�� Dignity

�� Courtesy

�� High-quality care & service

�� Services that are medically necessary

�� Services provided by properly licensed or

       credentialed professionals

�� No discrimination for any reason

�� Protection of their health, safety, security,

       well-being & comfort

�� Information on treatment alternatives & risk

       factors

�� No delay in emergency treatment regardless of

      ability to pay

Human Resources—All employees, regardless of job classification, belong to a knowledgeable & skilled health team that contributes to patient care. We want a nurturing & positive environment, free of discrimination & harassment with fair treatment & opportunities for professional development.

�� Honest in our duties

�� Tactful

�� Diplomatic

�� Fair

�� Working in a drug & alcohol free environment

�� Helping to maintain a harassment free environment

�� Supported in equal employment opportunity for… 

o Hiring

o Advancement

o Compensation

o Without regard to race, color, religion, gender, national origin, age, disability

�� Continually developing our skills & knowledge

�� Exercising good judgment & objectivity in performing our duties

�� Properly trained & qualified for the position they hold

Environmental Considerations—MMH is committed to operating in a safe & healthy environment.

�� Strive to protect employees, patients & the environment from

exposure to hazardous & infectious waste.

�� Unsafe storage of hazardous material must be promptly reported

to the appropriate officials.

�� Report any unsafe practice or condition that you observe to your supervisor.

�� Be familiar with institutional safety & health procedures & use them.

�� Report all unusual events or accidents in a timely manner.

�� Report equipment problems or malfunctions to the Biomedical or

Maintenance department immediately.

�� Use required safety equipment such as personal protective devices or needle safe products.

�� Attend all safety training.

Regulatory Compliance—MMH strives to comply with all rules & regulations governing the healthcare industry.

�� Commit to comply with all federal, state & local laws, licensure laws & accreditation standards.

�� Accurately account for all patients transferred into & out of our facility.

�� Disclose current, accurate & complete cost & pricing data where such data are required by law.

�� Ensure that filed cost reports accurately reflect

appropriate costs incurred for furnishing healthcare

services to the best of our knowledge.

�� Contractual/financial arrangements with physicians, vendors or other referral sources will be structured to ensure compliance with all laws & regulations, fulfill the mission of MMH & serve the best interests of the organization & the people we serve.

�� Not supply sensitive business information to any of our competitors.

Conflicts of Interest—Employees should conduct the business of MMH to the best of their ability & for the benefit of the organization & its patients. Employees must be careful not to create any appearances of a conflict of interest.

�� Avoid engaging in any activity that may interfere or appear to interfere with the exercise of sound judgment, or might conflict with the interest of MMH

�� Safeguard all confidential information

�� Receive proper approval before traveling to workshops for the purpose of equipment acquisition

�� Follow policy on acceptance of gifts from patients and vendors. (Meditech Policy1 HR Personnel Policies #49 Gifts or Gratuities)

Safeguarding Resources/Assets—MMH expects resources to be used wisely & in the best interests of the corporation.

�� Protect our assets & the assets of others entrusted to us, including property or proprietary information from loss, theft, destruction, misappropriation & misuse.

�� Use computer access as authorized and take all

reasonable steps to protect such systems & the

information.

�� Operate a records management system that ensures appropriate retention & access to confidential records.

�� Exercise reasonable care for our own protection and for that of our personal property while on company premises and while away on official business.

�� Be responsible & accountable for the proper spending of funds & for the use of property entrusted to us.

Billing & Coding—MMH is committed to accurate coding, billing and reimbursement.

�� Maintain honest & accurate records of all our activities.

�� Commit to ensuring that billing practices comply with all laws, regulations, guidelines and policies.

�� Not knowingly file a claim or bill for services that were not rendered or were not rendered as described on the claim form or statement.

�� Ensure that diagnoses are properly coded, billed correctly & supported by medical necessity requirements.

�� Promptly refund overpayments discovered.

�� Inform the payer & correct the bill if inaccuracies are discovered in bills that have been submitted.

�� Assure that all payments and other transactions are properly authorized by management & properly documented.

�� Accurately represent the nature of services provided for billing purposes.

Questions to ask when you observe something you believe to be improper or violates patient safety.

1. Do I have all the facts?

2. If I need more information, where do I find it?

3. Are there any laws, regulations, policies or

procedures that apply to the situations?

4. Have I followed normal procedures to try to

resolve my concern? (Chain of command)

1. Contact your direct supervisor/manager unless there are circumstances that prevent you from doing so.

2. If you have raised an issue and you do not think it is getting proper attention or if your supervisor/manager cannot find the answer in a timely manner you may relate your concerns to the next level of management.

3. Seek guidance from the Human Resources Department and/or the appropriate Executive Staff member.

4. Discuss the issue with the Corporate Compliance Officer, Paul Westbrock at Ext. 1581.

If you still need assistance, you may contact the Corporate Compliance DirectLine.

1-800-500-0333

•  Call the DirectLine when your concerns are not addressed through the standard resolution process

•  Calls are taken by individuals trained in DirectLine protocol.

•  Caller anonymity & confidentiality will be protected to the limit of the law.

•  Memorial has a policy of no retribution against anyone who calls the DirectLine.

•  Calls may be recorded for quality purposes, but there is an option to choose if you do not want your call recorded.

• All information is thoroughly investigated.

Fraud, Abuse Claims Act

Our employees are dedicated to ensuring that we create accurate and truthful patient bills and submit accurate claims for payment from any payer. This includes Medicare, Medicaid, commercial insurance and patients.  Ethical coding and billing is required by our Corporate Compliance Program, not to mention federal and state law. 

The federal False Claims Act (31 USC 3729 to 3733) makes it a crime for any person or organization to knowingly make a false record or file a false claim with the government for payment.  “Knowing” can include deliberate or reckless ignorance of facts that make the claim false.  The state of Ohio has similar provisions codified as state law which include civil and even criminal penalties for false claims and statements (ORC Sections 124.341, 2913.40, 2913.401 and 2921.13).

Examples of possible False Claims include someone knowingly billing Medicare for services that were not provided, or services that were not ordered by a physician, or for services that were provided at sub-standard quality where the government would not pay. 

A person who is aware of False Claims filed for payment can file a lawsuit in Federal or State Court on behalf of the government and, in some cases, receive a reward for bringing original information about a violation to the government’s attention. 

Anyone who files a False Claim lawsuit is protected from being fired, demoted, threatened or harassed by their employer for filing the suit.  If a court finds that the employer retaliated, the court can order the employer to rehire the employee and to pay the employee twice the amount of back pay that is owed, plus interest and attorney’s fees.

Our Corporate Compliance Program supports compliance with the False Claims Act by: 

•      Monitoring and auditing to prevent or detect errors in coding and billing.

•      Educating employees about reporting concerns including the opportunity to report through our anonymous DirectLine service.

•     Investigating all reported concerns and correcting any billing errors discovered.

•      Protecting employees for doing the right thing through our Non-retaliation policy, with our promise to investigate any allegation of retaliation against an employee for reporting concerns.

Ethics

The definition of ethics is principles of right and wrong, which govern a group.  There are some key concepts that are associated with ethics. The most prominent of these concepts is beneficence or doing that which is good. The next concept is non-maleficence or not doing that which would cause harm.

Another important concept is patient autonomy or letting the patient make decisions concerning their care. 

Most days in the course of our patients’ care there are no issues that arise which cannot be resolved through discussion with the patient, family or physicians. However, when situations arise where those involved cannot come to an agreement, the ethics committee will review the situation and make a recommendation.

The ethics committee was formed in 1998 & began reviewing cases in 2001. The ethics committee was established by the hospital administration to ensure one level of monitoring the standards outlined in the Hospital’s statement of Organizational

Ethics. The committee only has advisory status offering recommendations. Recommendations made by the committee would be directed to the administration of the hospital and the involved parties. The committee exists for the purpose of serving as a resource to the hospital, physicians, staff, patients & families. The committee is made up of members from administration, medical staff, social services, nursing, specialty services, pastoral care, oncology, risk management, and the community.

The committee chair is appointed by administration & the Medical Ethics Committee designates the co-chair. The chair has oversight responsibilities for all functions and the co-chair serves as a backup. The committee has established

guidelines for service, committee continuity and objectivity and they meet monthly.

The Ethics committee will review cases concerning:

• Patient autonomy

•  Informed consent--the legal and moral requirement that a physician must obtain permission to perform any medical procedure.

•  Competence--a review to determine the ability of a patient to make or articulate wise, appropriate, logical choices concerning medical matters.

• Healthcare provider rights of conscience--the right of a healthcare provider to ask to be removed from participating in a treatment for a patient they in good conscience are not comfortable with performing.

•  Medical futility—the belief or conclusion that a particular medical treatment or therapy would be of no benefit to a patient and that it should not be prescribed or carried out.

• Surrogate decision-making—a person who makes healthcare and end-of-life choices on behalf of another individual.

• Allocation of resources—the process by which physicians, institutions, and public policy makers determine how, where, when and for whom limited funds are expended, to provide the greatest good to those in need of healthcare services.

•  Confidentiality—the professional, legal and moral obligation not to obtain or divulge private information.

The Medical Ethics Committee will not review cases concerning:

• Organizational ethics

• Human resource issues

• Legal opinions  

Following is the process for handling problems & the flow of information.