Compliance Program Training

Compliance Program
May 7, 2014
Presented by: Compliance Department
Banner Health Network’s (BHN) Mission, Vision and
Culture of Compliance
Ethics – Do The Right Thing!
Compliance Program Basics
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
How Do I Know What Is Expected Of
The BHN Code of Conduct state compliance expectations and the
principles and values by which an 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
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
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
Written Policies And Procedures And
Standards Of Conduct
Banner Health Network (BHN) has corporate policies and procedures
(P&Ps) that address laws that affect all BHN associates, such as the Code
of Conduct, reporting suspected non-compliance and HIPAA.
Business departments and delegates/vendors are required to develop and
distribute P&Ps that address the laws specific to their business functions.
P&Ps should include the legal citations for the compliance requirements.
P&Ps should be reviewed and updated as needed, but no less than
annually, to assess compliance with any current requirements. P&Ps
should be reviewed when changes are made in business activities that
may impact compliance or when new compliance requirements are
Compliance Leadership And Structure
BHN has designated the leadership and defined a structure to oversee
implementation and maintenance of the Compliance Program.
Appropriate compliance committees are charged with the responsibility
and authority to direct and monitor components of the Compliance
The Compliance Department reports monitoring results, regulator audits,
and compliance issues and concerns to these committees.
Compliance Leadership And Structure
The purpose of the Compliance Department is to assist the company to be
compliant with all laws and to monitor compliance to identify compliance
Some of the key responsibilities of the Compliance Department are:
Interpret new laws and assist business departments to implement
compliant processes
Complete a compliance risk assessment and conduct compliance
oversight activities
Assist business departments to understand existing compliance
requirements and develop and maintain compliant processes
Coordinate audits and responses and any subsequent CAPs
Monitor the Integrity Line and investigate and triage calls
Effective Training And Education
BHN has regular compliance education and training programs for all
Training programs
Formal training
Initial and annual compliance training programs
required for all associates.
Specialized training in compliance requirements for
specific business functions, such as claims payment,
medical management and service center.
Focused training as needed
Informal and ongoing training
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 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 questions.
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
Auditing And Monitoring
BHN monitors compliance to identify compliance deficiencies so that the
deficiencies can be corrected.
The Compliance Department conducts a risk assessment, at least annually,
to establish priorities for monitoring.
The Compliance Department uses a variety of methods to monitor
compliance that include, but are not limited to:
Reviews critical documents used by business departments, including
but not limited to policies, template letters, and provider & member
communication to evaluate correct interpretation of compliance
Auditing And Monitoring (cont’d)
Collects results of compliance metrics. Metrics are most often used for
reportable data, such as turnaround times and report rates. The
Compliance Department monitors metrics submitted by the business
Conducts compliance assessments on processes that are not easily
measured by data and activities that are not audited by Internal Audit
Priorities for assessments may be identified:
During the risk assessment.
During implementation or transition of implementation of
new laws.
As part of Corrective Action Plans or monitoring
Auditing And Monitoring (cont’d)
Compliance monitoring is not just the responsibility of the Compliance
Department. Business departments and delegates/vendors are expected to conduct
ongoing compliance monitoring, too.
Appropriate compliance monitoring and reporting activities should be developed
and implemented during implementation of any new or changed requirements.
The ability to produce evidence of compliance often requires some method of
ongoing compliance monitoring to ensure that processes remain compliant and
corrective actions are taken when deficiencies are identified.
The Compliance Department is available to discuss compliance monitoring
activities upon request during implementation or at any time a department or
delegate/vendor would like to initiate a new monitoring activity or review the
effectiveness of an existing monitoring activity.
Auditing And Monitoring (cont’d)
Business departments and delegates/vendors should be able to provide
evidence of compliance at all times. Evidence of compliance may be
requested for many reasons, including regulatory audits, market conduct
requests, legal requests, or concerns about compliance.
Evidence of compliance is documentation that can be produced on a
periodic basis, or as requested, to demonstrate that a business department
and delegate/vendor is maintaining sustained compliance with a regulatory
Evidence of compliance often requires evidence of compliant outcomes,
such as claims payment, not just processes, such as P&Ps.
Enforcement Of Compliance Standards
BHN has implemented disciplinary mechanisms to consistently enforce
standards and address dealings with sanctioned and other specified individuals.
BHN’s P&Ps provide disciplinary guidance for associates who fail to comply with
the Compliance Program or with compliance requirements.
BHN’s policy requires a reasonable and prudent background investigation to
determine whether prospective associates, sub-contractors, agents or providers were
ever criminally convicted, suspended, debarred or excluded from participation in a
federal program.
Procedures And System For Prompt
Response To Compliance Issues
BHN has P&Ps about responding to detected compliance offenses, to initiate
corrective action to prevent similar offenses, and to report to Government
authorities when appropriate.
Compliance issues should be reported to the Compliance Department.
Compliance issues may initially be reported by an associate to their
supervisor and then escalated/reported to Compliance, as appropriate.
Business departments with an identified compliance issue are required to
develop and implement a corrective action plan (CAP). The Compliance
Department will review and monitor the CAP until the compliance issue is
The Compliance Department will determine when a compliance issue must
be reported to a Government authority and will facilitate the report.
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
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, Banner Health Network 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.
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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