CoxHealth/ Oxford HealthCare

CoxHealth/
Oxford HealthCare
Home Care
Compliance Training
Module 1
(Oxford is synonymous with CoxHealth in this presentation)
Year 5 CIA Compliance Training

You are now completing year 5 of our Corporate
Integrity Agreement (CIA) training.

We have had great success with this training
each year resulting in a completion rate of 98%
or better.

Your continued support and dedication during
this process has been greatly appreciated.
Year 5 CIA Compliance Training
This compliance training will provide
you with an overview of…
 Why compliance is important
 Your responsibility and how to report a concern
 Role of the Corporate Integrity Department (CID) and
CID’s Structure to educate and monitor compliance
 Key policies that make up the compliance program
Year 5 CIA Compliance Training
Let’s start out with meeting your
President and Chief Executive Officer
and
Corporate Compliance Officer and
Privacy Officer
Year 5 CIA Compliance Training
We are proud of our long tradition and
commitment to quality care.
Our success is a testimony to the dedication of
our employees, medical staff, volunteers and
Board members to improve the lives of others.
Meet Betty Breshears,
VP & Corporate Compliance Officer
and Privacy Officer for CoxHealth
including Oxford HealthCare
Year 5 CIA Compliance Training
CoxHealth is:
 An organization rich in traditions, history and integrity
 An organization whose mission is to improve health of the
communities we serve
 An organization that recognizes it is only as good as its Board,
employees, medical staff, volunteer and the companies that
we select to do business with
 Therefore we select those individuals and companies carefully
 And train everyone annually on the importance of compliance
and the culture at CoxHealth/Oxford HealthCare.
Year 5 CIA Compliance Training
Why is Compliance training
important at CoxHealth?
It is important to advise employees of the Federal
and State Laws and Regulations that govern
practices at CoxHealth -- you can not follow the
“rules” if you do not understand the “rules”.
Year 5 CIA Compliance Training
 Meet the federal and state regulations that
govern healthcare practices
 Prevent Fraud, Waste and Abuse
 Detect, correct and prevent errors that might
result in a violation
Year 5 CIA Compliance Training
What do we do at CoxHealth?

We work to prevent fraud, waste and abuse
by creating a program designed to detect,
correct and prevent errors in healthcare.

Our core program for compliance is the
Compliance Program and Code of Conduct.
Year 5 CIA Compliance Training
Everyone doing business with CoxHealth





Physicians
All Staff (including management)
Vendors
Contractors
Board
Year 5 CIA Compliance Training
Making false statements or false representations of
material fact to…

Obtain some benefit or payment

For which no entitlement would otherwise exist
Includes obtaining something of value through…

Misrepresentations or

Concealment of material facts
Year 5 CIA Compliance Training
Abuse describes practices that:
 result in unnecessary costs
 are not medically necessary
 are not professionally recognized standards
 are not fairly priced
Year 5 CIA Compliance Training
How does Oxford
HealthCare address
compliance with all the
rules and regulations?
Year 5 CIA Compliance Training
Through its employees, medical staff members,
board members, volunteers and vendors…
…all of you are working diligently every
day to do the right thing - in your work,
in how you conduct yourselves and in your
working relationships.
Thank you!
Year 5 CIA Compliance Training
One tool that CoxHealth provides to
help you remain compliant and “be the
best that we can be for those who need
us” is the Corporate Integrity Program.
The Program CORE is:
Code of Conduct
•This policy defines expected behaviors of those who work within the
CoxHealth /Oxford HealthCare facilities
The Program STRUCTURE is:
Corporate Compliance Program
•This program/policy is administered by the Corporate Integrity Department
Year 5 CIA Compliance Training
Let’s start with
an overview of the
CODE OF CONDUCT
You can review the entire policy in your Orientation Manual
or requesting a copy from Quality Management at the
National Office.
Year 5 CIA Compliance Training
 Today, more than ever in this challenging business
environment, we need to maintain our strong
reputation in the community by achieving our vision
“to be the best for those who need us”.
 By following our Code of Conduct, we will make sure
that our business practices and business decisions
reflect our corporate mission, vision and values.
Year 5 CIA Compliance Training
 We should never take advantage of anyone
through unfair, unlawful, or unethical
business practices.
 We must all be committed to conducting
business practices with honesty and
integrity and in full compliance with all
laws and regulations.
Year 5 CIA Compliance Training
The Code of Conduct covers a
variety of business practices…
Access to Care: All patients have a right to access
to care regardless of their ability to pay
Compliance with Antitrust Laws: Sharing pricing,
cost or profit information with competitors or from
one vendor to another is inappropriate.
Year 5 CIA Compliance Training
All company records
shall be accurate:
 We create many documents, reports, and records during our normal
course of business. Documentation in these company records must
be accurate and complete.
 For example: documentation in the patient medical record should
accurately reflect the services provided and by who...
 All other records should be accurate such as patient admission
records, time and attendance records, invoices, and any other kind of
record you might be documenting in…
 Corrections in records must be made appropriately so that the original
document is not deleted, and it is clearly replaced or updated.
Year 5 CIA Compliance Training
Appropriate Billing, Charging
and Coding for services shall:
• Accurately reflect the services provided
• NOT include medically unnecessary
services…this could be viewed as false
claim billing
Year 5 CIA Compliance Training

We must maintain the confidentiality of all patient medical records,
other forms of patient information and all other company records

HIPAA - prohibits the use or disclosure of patient information
unless it is for work related reasons

Employees may not access family, friends,
or co-workers medical records

Inappropriate access and disclosure of patient
information is a HIPAA violation according to
the Office of Civil Rights (OCR) and is strictly prohibited
Year 5 CIA Compliance Training
Code of Conduct

Appropriate use of Corporate Assets:
 Remember that assets of CoxHealth (such as; equipment,
materials, and supplies) are NOT to be used for personal
use. We must all do our part to hold down the cost of
operations.

Unbiased Decision Making:
 At CoxHealth we do not accept or solicit gifts, bribes,
kickbacks, gratuities or other forms of payment which could
influence a business decision.
Year 5 CIA Compliance Training
Code of Conduct
Adherence to Conflict of Interest Policy:
 At Cox we value ethical decision making and trust employees to
make choices in the best interest of CoxHealth, our customers,
and others we do business with.
 You must not use your employment with CoxHealth for personal
benefit or to ensure that Cox does business with a relative. It is
inappropriate to receive payment or gift in exchange for a
favorable recommendation to purchase items or services.
Year 5 CIA Compliance Training
Code of Conduct
Maintain a Safe Working Environment:
•
•
•
At CoxHealth we strive to adhere to OSHA standards
We encourage and train staff on proper disposal of medical
waste and hazardous materials. If unsure about how to
dispose of medical waste and hazardous materials
appropriately, ask
Know and understand the proper use of equipment and
cleaning supplies
Year 5 CIA Compliance Training
Code of Conduct
Harassment…
CoxHealth will not tolerate actions, comments,
physical contact, sexual advances or any other
conduct that is intimidating, uncomfortable or
otherwise offensive or hostile.
Harassment can be in the form of:
 Creating an uncomfortable work environment
 Heckling or bullying a co-worker
 Inappropriate sexual comments
Year 5 CIA Compliance Training
Code of Conduct
Discrimination…
CoxHealth will not tolerate any form of illegal
discrimination
 Discrimination based on race, color, religion, sex, ethnic
origin, age, disability, financial status or source of
payment is prohibited.
 Forms of discrimination could be making a hiring, firing,
promotion or counseling decision based on national
origin or religion…
Year 5 CIA Compliance Training
Code of Conduct
A Work Environment Free From Retaliation:
CoxHealth will not tolerate any form of retaliation against
you because you, in good faith, reported a suspected
violation of the Code of Conduct, any laws or regulations,
or any other CoxHealth policy.

Retaliation is any act designed to cause harm to another
when it is used to “get even” for a perceived offense, or
other action

Retaliation against any person who, in good faith, reports a
concern to the Corporate Integrity Department is strictly
prohibited.
Year 5 CIA Compliance Training
Code of Conduct
How do you report a concern
of retaliation??
Contact:

Corporate Integrity Office (417-269-7655)

Corporate Integrity Office Toll Free (888-340-5297)

Legal Department (417-269-6577)

Anonymous Hotline 269-5297 (COX-LAWS)
Year 5 CIA Compliance Training
Code of Conduct
Patient’s have the right to…
•
Receive considerate care that protects their
dignity and privacy
•
Choose and be involved in their care
•
Practice their religion and beliefs
•
Make the decision to discontinue treatment
CoxHealth has an Ethics Review Team who will work with the
patient’s clinical team, the patient and the patient’s family when
dealing with patient rights
Year 5 CIA Compliance Training
Code of Conduct
Cooperation with Government Officials…
 CoxHealth will fully cooperate with regulatory
officials
 Oxford departments and/or employees must
notify Administrative Staff if contacted by a
government official while on duty
Year 5 CIA Compliance Training
Centers for Medicare &
Medical Services (CMS)
STATE
DOJ
OIG
DHHS
ZPICs
MACs
MICs
RACs
Regional Offices
•
•
•
•
•
•
•
Survey & Certification
Courts
Attorney’s General
Medicaid
Health Boards
Local Governments
Licensure
FDA
Regional Home Health
Intermediaries
CoxHealth
DOT
DEA
OSHA
AHRQ
FBI
SEC
IRS
EPA
DOL
FTC
FCC
HRSA
CDC
Treasury
TJC
This diagram provides a visual of just how many government
entities are watching healthcare providers at any given
time…that’s a lot of arrows coming at us!!!
Year 5 CIA Compliance Training
Code of Conduct
Gifting from Patients:
It is inappropriate for employees of Oxford
HealthCare staff to accept gifts from a patient.
 Refer to Code of Conduct Policy for more detailed
information or call Administrative Staff or Quality
Management
Year 5 CIA Compliance Training
Code of Conduct
Disruptive behavior is prohibited especially in
the healthcare setting. It interferes with patient care…
 Staff are hesitant to bring a possible issue to
their supervisor’s attention if they’re afraid of
getting yelled at or made to feel that their question
is inappropriate
 Overall employee morale is affected
 High staff turnover occurs
 Productivity is undermined
Year 5 CIA Compliance Training
Code of Conduct
When disruptive behavior that should be reported:
 Criticizing caregivers in front of a patient
 Belittling or berating others
 Use of profanity or disrespectful language
 Racial, ethnic or socioeconomic slurs
 Raising your voice or yelling or shouting in a hostile manner
One way to report your concerns is by
calling the hotline or reporting to Quality Management
Year 5 CIA Compliance Training
Code of Conduct
Violations of the Code of Conduct will result in
disciplinary action…
 Violations must be reported
 Depending on the circumstances, violations may
also be reported to the appropriate government
agency as required by law.
Year 5 CIA Compliance Training
The full policy can be reviewed by calling the
Quality Management Dept.
Year 5 CIA Compliance Training
To establish a mechanism to:
 Detect, correct and prevent errors which could result
in violations of the laws and regulations governing
health care
 Report possible violations of the laws and regulations
or CoxHealth policies
Year 5 CIA Compliance Training
Year 5 CIA Compliance Training
Betty Breshears
Vice President of Corporate
Integrity- Corporate Compliance Officer
and Privacy Officer
The Corporate Integrity Department is
located on the 4th floor of the Hulston
Cancer Center
Betty can be reached at 417/269-8806
Year 5 CIA Compliance Training
At CoxHealth we have multiple committees that review
compliance and billing concerns…

Board of Directors - subcommittee for compliance

Executive Compliance Committee - leadership at Cox

Billing Compliance Committee


Includes staff from all appropriate departments of CoxHealth
Reviews billing, coding, documentation, regulations
Year 5 CIA Compliance Training
 HIPAA Compliance Committee: Monitors the rules and
regulations related to privacy & security of patients
protected health information
 Contract Compliance Committee: Reviews contracts and
leases that CoxHealth has entered into
 Cox Monett Hospital Compliance Committee: Reviews
contracts and leases that CoxHealth has entered into
Year 5 CIA Compliance Training

Home Parenteral Svcs/Home Support Compliance Committee:
Reviews the billing rules and regulations for Durable Medical
Equipment (DME) and Home Parenteral Services

Oxford Compliance Committee: Reviews compliance with
Home Health billing rules and regulations

Institutional Review Board: Monitors all Human Subject
Research conducted at CoxHealth

CoxHealth Branson Audit and Compliance Committee:
Reviews billing, coding, documentation, regulations
Year 5 CIA Compliance Training
The Committee Structure is supported by:
• Audit and Compliance Department
• Corporate Integrity Department
Year 5 CIA Compliance Training
Board Compliance
Committee
Affiliate Entities’ Boards
Steve Edwards
President and CEO
Executive
Compliance
Committee
Betty Breshears
VP of Corporate Integrity
Compliance Officer
Billing Compliance
Committee
HIPAA Compliance
Committee
Audit and Compliance
Department
Research Compliance
Contract Compliance
Compliance Structure at CoxHealth
Year 5 CIA Compliance Training
Affiliate Entities’
Compliance Committees
Employees are responsible for reporting concerns to:
 Anyone in Management
 Corporate Integrity Department-Compliance Officer
 On-line Incident Reporting
 Anonymous Hotline 269-5297 or 888-340-5297
 Legal Department
 Oxford HealthCare Administration or Director QM
Year 5 CIA Compliance Training
• Annual compliance training for all employees,
physicians, board members and vendors
• Annual HIPAA training
• Billing and Coding training
• Training regarding Stark and Anti-kickback
Year 5 CIA Compliance Training
 CoxHealth develops an Annual Audit Plan…
based on review of OIG work plan/CMS updates
 Audit and Compliance Department conducts
provider audits/hospital service audits
 Coding audits are conducted by…
outside consultants for HIM coding practices
 Audits of access to Protected Health Information...
Health Information Management Dept. (HIM)
Year 5 CIA Compliance Training

The Corporate Compliance Program states employees of
CoxHealth will be disciplined if they are aware of a
compliance concern and do not report.

Employees of CoxHealth will be disciplined for not
completing annual compliance training

Retaliation against others who report an issue in good
faith is strictly prohibited
Year 5 CIA Compliance Training
Concerns are investigated by the Corporate
Integrity Department (CID)
 Investigations may include multiple departments
 Investigations could include the legal department
Year 5 CIA Compliance Training
Investigation Steps
1. Open a Compliance File - assign tracking number
2. Interview/audit as deemed appropriate
3. Evaluate regulations/policies, perform audits
4. Determine corrective action needed, if any
Year 5 CIA Compliance Training
Investigation Steps Cont.
5. Implement or make recommendations as appropriate
6. Perform follow-up audit, if necessary
7. Report to the Executive Committee/Board
8. Maintain the confidentiality of the person reporting
Year 5 CIA Compliance Training
 Corporate Compliance Program
 Code of Conduct
 Compliance with the Stark & Anti-Kickback Laws
 Prohibition of False Claims
 Detection of Individuals and Entities Excluded from Government
Programs
 Policies are all available from the QM Director at Oxford
HealthCare
Year 5 CIA Compliance Training
You have completed your review of the
Code of Conduct and the Corporate
Compliance Program.
Now let’s review some other policies that
govern healthcare practices…
Year 5 CIA Compliance Training
Other policies that govern
healthcare practices…
 Prohibition of False Claims Act
 Stark and Anti-kickback Physician Referral Laws
 Detection of Individuals or Excluded from
Government Programs
Year 5 CIA Compliance Training
Defines:
• Federal False Claims Act
• State False Claims Act
• Whistleblower Provisions
• Protection Against Retaliation
Year 5 CIA Compliance Training
 It is illegal to submit a false bill or claim
to a state or federal agency
 A provider who violates the False Claims
Act (FCA) may be fined
Year 5 CIA Compliance Training
• A Whistleblower is an employee, former employee, or
member of the organization who reports misconduct to
people or entities that have the power to take corrective
action. Generally the misconduct is a violation of law, rules,
regulations and/or a direct threat to public interest. Fraud,
health, safety violations, and corruption are just a few
examples.
• A Whistleblower is protected from retaliation. An employer
cannot retaliate when an employee reports in good faith.
Year 5 CIA Compliance Training
• State/Federal regulations imposes a civil liability on any person
who knowingly submits, or causes to be submitted a false or
fraudulent claim
• Federal fines: $11,000 per false claim; up to triple damages for
the billed amount
• State fines: $5,000 to $10,000; plus 3 times the damages amount
Year 5 CIA Compliance Training
 Known as the “Physician Self-Referral Law”
 Prohibits providers from referring Medicare beneficiaries' for…
• Certain designated health services (lab, x-ray, admit)
• To an entity in which the physician (or an immediate family member) has:
a) an ownership/investment interest in
b) a compensation arrangement or financial relationship, such as: Contract;
Employment Agreement; Lease or Rental; or giving anything of value
 UNLESS certain EXCEPTIONS apply
Year 5 CIA Compliance Training
“Anything of value” for a physician could include things such as:
 Tickets to a cardinal game
 $2 Cox Bucks
 Lunch for a birthday
 Payment for speaking at a seminar
CoxHealth is required to track all non-monetary compensation/other
financial interest in order to be compliant with the Stark regulation.
Year 5 CIA Compliance Training
The Anti-Kickback Statute Prohibits
knowingly and willfully…
 Offering, paying, soliciting, or receiving remuneration
 Inducing or rewarding referrals of items/services
reimbursable by a Federal health are program
There are certain Safe Harbors within this statue
CoxHealth cannot offer anything of value or accept anything
of value to induce either party to do business with the other.
Detection of Individuals or
Entities Excluded from
Government Programs
Year 5 CIA Compliance Training
CoxHealth verifies that all employees, medical staff,
board members, vendors, and volunteers have not
been excluded from participation in government
programs prior to initiating services/employment.
Year 5 CIA Compliance Training
You should report any concerns that you have to the Corporate Integrity
Department. Your concerns are important to us. You can report by:
Calling 269-7655 (call can be anonymous)
Complete an Incident Report (label it “Corporate Integrity Concern”)
Calling the Hotline 269-5297 or 888-340-5297
Discuss with someone in Adminsitration or QM Director
You can also report your concern to a government agency:
State or Federal Department of Health and Human Services
Office of Inspector General
The Joint Commission - www.jointcommission.org
Year 5 CIA Compliance Training
This concludes Module 1 of your
Corporate Integrity training
Year 5 CIA Compliance Training