2. Banner Health- Compliance Training

General Compliance
May 13, 2014
Presented by: Compliance Department
BHN’s Mission, Vision and Values
Culture Of Compliance
Ethics & Compliance Program
Compliance Program Basics
Compliance Questions Answered
Compliance Attestations
Laws and Regulations
BHN Resources
Additional Resources
BHN’s Mission, Vision And Values
We exist to make a difference in people’s lives through
excellent patient care.
We will be a national leader recognized for clinical
excellence and innovation, preferred for a highly coordinated
patient experience, and distinguished by the quality of our
People Above All…by treating those we serve and each other
with compassion, dignity, and respect;
Excellence…by acting with integrity and striving for the
highest quality care and service;
Results…we show we value results by exceeding the
expectations of the people we serve, as well as expectations
we set for ourselves.
A Culture Of Compliance Within Banner
Health Network
Do the right thing
Prevents noncompliance
Detects non compliance
Corrects non compliance
Ethics – Do The Right Thing!
BHN is committed to possessing and demonstrating the
reliability, honesty, trustworthiness and high degree of
integrity expected of a leading healthcare organization and a
participant in federally funded health-care programs.
It is important that you conduct yourself in an ethical and
legal manner.
It’s about doing the right thing!
Act fairly and honestly
Comply with the letter and spirit of the law
Adhere to high ethical standards in all that you do
Report suspected violations
Ethics And Compliance Program
Banner Health Network’s (BHN) Compliance Program
provides guidance employees and delegates/vendors to
better understand and apply complex healthcare laws and
BHN's Compliance Program protects BHN, employees and
delegates/vendors against risks that could result from a
failure to comply with legal or ethical requirements
Ethics And Compliance Program (cont’d)
The Compliance Program also ensures BHN can seek
reimbursement for services provided to Medicare and
Medicaid participants.
The Compliance Program helps ensure uniformity across
BHN. The Compliance Program and the policies and
procedures that make up the Compliance Program apply
equally to employees and delegates/vendors.
Compliance Program Basics
The Office of Inspector General (OIG) has outlined 7 components of an
effective compliance program. Banner Health Network has
incorporated these into our comprehensive compliance program.
Written Policies, Procedures and Standards of Conduct;
Compliance Leadership and Structure;
Effective Training and Education;
Effective Lines of Communication;
Effective System for Routine Monitoring and Identification
of Compliance Risks; and
Enforcement of Compliance Standards;
Procedures and System for Prompt Response to Compliance
How Do I Know What Is Expected Of
The BHN Code of Conduct and Compliance Handbook state compliance
expectations and the principles and values by which the organization operates.
Each Employee and delegate/vendor must report any issue or practice that
they believe in good faith may constitute a violation of a law or BHN’s
compliance policies.
BHN strictly prohibits retaliation against any individual who in good faith
reports a suspected violation or suspected illegal or unethical conduct.
People who are found to have engaged in unlawful conduct or conduct in
violation of BHN policies, or who have failed to detect, report and/or
correct any offense, are subject to corrective action, up to and including
Effective Line Of Communication
BHN has established lines of communication for compliance issues, including
an open line of communication between the compliance department and all
associates and delegates/vendors.
The BHN ComplyLine (888-747-7989) or at
https://bannerhealthcomplyline.alertline.com are available to submit
potential ethics issues or other compliance concerns.
The Compliance Department is available to all associates and
delegates/vendors to report compliance issues or to respond to compliance
BHN has a non-retaliation policy to protect anyone who makes a report in
good faith about a potential compliance; fraud, waste and abuse; or ethics
Who Is Responsible For Compliance?
Everyone is responsible for
compliance. The Board of
Directors and Executive Leaders
have overall responsibility for the
company’s Compliance Program,
but each associate and
delegate/vendor is responsible to
know and comply with all laws
related to his/her job and to report
non-compliance to a supervisor,
the ComplyLine, and/or the
Compliance Department.
Why Is Compliance Important?
Compliance is “lights on.” BHN must be a compliant company to stay in
Being a compliant company makes good business sense. The extent to
which we are compliant affects our ability to grow our business, to
maintain a positive reputation, and to become the innovative industry
leader that we aspire to be.
Our focus on compliance underscores our core values of honesty, integrity,
transparency and accountability.
Correcting compliance problems costs money and resources and reduces
activities to grow and improve our company. If compliant programs are
implemented and sustained, BHN can focus on its business opportunities.
What Does Non-Compliance Cost?
Non-compliance costs the company many ways in the shortterm and long-term.
In the short-term, it can lead to fines, lawsuits, increased
regulatory scrutiny, bad publicity and even increased
In the long-term, non-compliance can lead to loss of business,
reputation, and revenue. Once the company is fined or
sanctioned, the story is often repeated in related articles for
many years continuing to damage the company’s reputation.
Compliance Attestation
Banner Health Network’s (BHN) triple aim goals are:
improving the patient’s experience of care, improving the
health of populations, and reducing the per capita cost of
health care. To meet these goals and our commitment to
compliance BHN must ensure that our delegates/vendors
operate in compliance with the applicable law and
regulatory guidance.
To facilitate BHN’s responsibilities of ensuring
delegates\vendors compliance with laws and regulatory
guidance. Delegate/vendors must complete a Compliance
Attestation upon contract execution and annually
CMS Offshore Attestation
The CMS Offshore Attestation is an attestation that must
be completed by delegate/vendor that intends to contract
with an offshore subcontractor who has access to BHN’s
Medicare members PHI/PII and/or fulfills their contract
with BHN through offshore employees.
Offshore is considered any country that is not one of the
fifty United States or one of the United States Territories
such as: American Samoa and Puerto Rico.
Regardless of whether the subcontractor is American or
foreign owned, if the services are performed by
employees located in offshore countries, they are subject
to complete a CMS Offshore Attestation.
Anti-Kickback Statutes
The anti-kickback statute is a federal law prohibiting
persons from willfully offering, paying, seeking or
receiving anything of value to bring about a referral
for medical services or goods payable under Medicare
or Medicaid.
Failure to obey this law can result in fines, jail or
exclusion from the Medicare and Medicaid programs.
This law prohibits kickbacks and bribes. It also
affects the way healthcare entities carry out a broad
range of ordinary business deals.
Antitrust Laws
Antitrust laws forbid companies from doing business in a
way that gives them too much control in the marketplace.
The purpose of these laws is to preserve competition.
These laws may affect your dealing with patients, doctors,
payers, suppliers and competitors.
One application of antitrust laws is price fixing. Price
fixing is an agreement between business competitors to
provide the same service at the same price. In the U.S.,
price fixing can be prosecuted as a criminal felony
offense under the Sherman Antitrust Act. Even
exchanging prices may violate the antitrust laws.
Health Insurance Portability and
Accountability Act (HIPAA)
HIPAA passed in 1996, is a law which governs the way healthrelated information is shared among healthcare providers.
Basically, the only time you can look up person’s information
if the person is your patient, or when the information is
necessary to carry out your job. Even then, you cannot discuss
that information with any one except the person without the
person’s express permission.
Information about a person’s medical condition is highly
sensitive and its confidentiality must be maintained.
No employee or delegate/vendor should ever release or discuss
personal health information with others unless it is necessary
to provide appropriate medical care, it is with the person’s
written consent, or it is required by law.
Conflict Of Interest
A conflict of interest arises whenever an employee’s
interest or that of an employee’s immediate family
conflicts or appears to conflict with the interest of
Everyone has a duty to avoid conflicts of interest or
the appearance of conflicts of interest.
Conflicts of interest can occur when employees
accept gifts, meals, sponsored training, or travel from
outside entities.
False Claims Act
The False Claims Act (FCA) became federal law in 1863
during the Civil War. Dollars and lives were being lost
because unscrupulous contractors made “false claims” against
the federal government.
The Federal False Claims Act (FCA) imposes civil liability on
any person or entity that knowingly submits, or causes to be
submitted, a false or fraudulent claim for payment to the U.S.
government. This would include fraud involving any federally
funded contract or program such as Medicaid and Medicare.
The FCA is violated when a person knowingly makes, uses, or
causes to be made or used, a false record or statement to get a
false or fraudulent claim paid or approved by the federal
False Claims Act (cont’d)
“Knowingly” may be defined as:
A person has actual knowledge of the falsity of
the information.
A person acts in deliberate ignorance of the truth
of falsity of the information.
A person acts in reckless disregard of the truth or
falsity of the information.
A “claim” includes any requests or demand for
money that is submitted to the U.S. government or is
False Claims Act (cont’d)
To provide consistent enforcement throughout the
country, the Deficit Reduction Act of 2005 (DRA)
encourages each state to have its own False Claims
Act that is comparable to the federal False Claims
The Program Fraud Civil Remedies Act (PFCRA)
provides administrative remedies against any person
who makes, or causes to be made, a false claim or
written statement to various federal agencies,
including the Department of Health and Human
Stark Law
Civil law
It owns penalties and connected to the False Claims
Prohibits certain referrals
Prohibits billing Medicare for items and services that
are the result of certain services
Strict Liability Law
No billing Medicare or patient during disallowance
period/non-compliance period
Intellectual Property
Intellectual property includes patents, trademarks,
service marks, trade secrets, copyrights, proprietary
information and inventions or techniques.
Intellectual property is protected by federal and state
laws. Violations of the intellectual property laws may
result in personal civil damages or criminal charges.
During the course of employment or contractual
relationship you may have access to intellectual
property owned by other businesses. This information
is private and should not be disclosed to others.
BHN Resources
Kathy Harris, CHC, CPC
BHN Compliance Officer
[email protected]
BHN Code of Conduct
BHN Compliance Handbook
Additional Resources
Social Security Act:
Title 18
Code of Federal Regulations*:
42 CFR Parts 422 (Part C) and 423 (Part D) and 425 (ACO)
CMS Guidance:
HPMS Memos
CMS Contracts:
Private entities apply and contracts are renewed/non-renewed each year
Other Sources:
OIG/DOJ (fraud, waste and abuse (FWA))
HHS (HIPAA privacy)
Additional Resources
Title XVIII of the Social Security Act
Medicare Regulations governing Parts C and D (42 C.F.R. §§ 422, 423 and
Offshore Attestation Guidance 2008 CMS Call Letter issued 4/19/2007
HPMS Offshore Attestation memos dated 7/23/2007, 9/20/2007 and
Civil False Claims Act (31 U.S.C. §§ 3719-3733)
Criminal False Claims Statute (18 U.S.C. §§ 287,1001)
Anti-Kickback Statute (42 U.S.C. § 1320a-7b(b))
Antitrust Laws (15 U.S.C. §§ 1-7) (15 U.S.C. § 12-27)
Stark Law Statute (Physician Self-Referral Law) (42 U.S.C. § 1395nn)
Intellectual Property Law (U.S. Patent and Trademark Office)
Exclusion entity instruction (42 U.S.C. § 1395a-7)
The Health Insurance Portability and Accountability Act of 1996 (HIPAA)
(Public Law 104-191) (45 CFR Part 160 and Part 164, Subparts A and E)
OIG Compliance Program Guidance for the Healthcare Industry:

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