CORPORATE

COMPLIANCE POLICY

TABLE OF CONTENTS

CHAPTER 1 Introduction to Your Compliance Program

Compliance Mission Statement

Code of Conduct

CHAPTER 2 Auditing and Monitoring

CHAPTER 3

Establishing Practice Standards and Procedures

CHAPTER 4 Designation of a Compliance Officer/Contact

Job Description for Compliance Officer

CHAPTER 5

Conducting Appropriate Training and Education

CHAPTER 6 Responding to Offenses and Corrective Action Initiatives

CHAPTER 7

Developing Open Lines of Communication

CHAPTER 8 Enforcement and Other Considerations

CHAPTER 9

Professional Courtesy

Chapter 1

Introduction

In October 2000, the Office of Inspector General of the Department of Health and Human Services issued its own “Compliance Program Guidance for Individual and Small Group Physician Practices.” This is the first formal guidance from the government addressed directly at group practices. While characterized as a guide for solos and smaller groups, the OIG guidance is, in fact highly relevant to almost any physician practice, regardless of size. Although the new OIG guidance emphasizes that formal compliance programs are not required, it makes equally clear that the OIG strongly encourages and recommends that all physician practices adopt pro-active measures to further compliance. The mere fact that the government has developed formal guidance on compliance program development for group practices sends a strong signal to physicians on the extent to which the OIG encourages voluntary actions. The government has also developed enforcement policies that favor organizations that have previously developed voluntary compliance programs. Thus, in the case of a federally sponsored health plan and the OIG, whether a health care billing entity has a corporate compliance program in place may determine whether a violation of a federal requirement is treated as an innocent mistake or as a fraudulent act. Sublette County Rural Health Care District has chosen to take a pro-active position and develop their own compliance plan based on the 7 core elements of the OIG Guidelines. These elements are discussed in detail within the following chapters. We support our Compliance Mission Statement and believe all employees, including directors, providers, and managers will conduct themselves with honesty, integrity, and fairness.

COMPLIANCE MISSION STATEMENT SUBLETTE COUNTY RURAL HEALTH CARE DISTRICT

It is the corporate policy of Sublette County Rural Health District to comply with all federal, state, and local laws and regulations governing the provision of health care items and services. All employees, agents, and contractors are expected to conduct themselves with honesty, integrity and fairness. Accordingly, Sublette County Rural Health Care District has implemented a Corporate Compliance Program to ensure, to the extent reasonable possible, that all employees invoke a high degree of business honesty and integrity required of a health care provider. In addition, this program has been instituted as a means of preventing fraud, abuse, and false billings to any third-party payer. Strict adherence to the compliance program is expected of all employees, including corporate directors, officers, providers, managers, and those hired to work as independent contractors.

CODE OF CONDUCT

1. Certain rules and regulations governing employee behavior are necessary for the orderly operation of Sublette County Rural health, and for the protection of the rights and safety of employees and patients. Statements of the following are not all inclusive but provide basic guidelines for professional.

2. Employees must project a professional, mature, courteous and friendly attitude toward patients, visitors and co-workers, unaffected by race, color, religion, national origin, sex, age, or disability.

3. Employees are responsible for conducting themselves in a manner consistent with the highest standards of care and service to the patient.

4. No patient, visitor or co-worker should be kept waiting while employees engage in personal conversation. Conversations must be conducted in low tones and pertain only to business matters.

5. Offensive, abusive, or improper language during working hours is prohibited. 6. Disorderly conduct during working hours is prohibited. This includes fighting, scuffling,

horseplay, or abusing other employees. 7. Under no circumstances is the business or medical affairs of our patients or the District

to be discussed outside of the District. 8. Unauthorized disclosure of patient information is prohibited. 9. Falsifying or alteration of medical records, reports and other documents is prohibited. 10. Each employee should keep his/her work area clean, neat, and orderly. 11. Employees should keep equipment assigned to them in clean working condition.

Problems should be immediately reported to the Supervisor. 12. Willful holding back, slowing down, hindering or limiting work effort in any way is

prohibited. 13. Employees are responsible for performing job duties efficiently and completely. Every

effort must be made to comply with the Supervisor’s direction regarding job related activities.

14. Employees are responsible for knowledge and familiarity with procedures governing fire evacuation and patient emergencies.

15. Employees must not be discourteous to or criticize co-workers, particularly in the presence of patients. Careless remarks, when made in the presence of other employees or visitors, often result in poor relations.

16. Employees must be non-discriminating, fair and friendly in dealing with fellow employees. Cooperation in helping each other ensures pleasant working conditions. A good attitude toward fellow employees enhances the efficiency of the District. Avoid all idle or malicious talk.

17. Fraudulent statements of any nature are prohibited. 18. If contacted by the press or other media, employees must refer these contacts to the

Chief Executive Officer or the Chief Financial Officer. 19. Sublette County Rural Health Care District, stationery and envelopes shall be used for

business mail only. 20. Falsification of time records is prohibited.

21. An employee working directly or indirectly for a competitor of this District is prohibited. 22. Any personal project that utilizes Sublette County Rural Health Care District equipment

and materials must be approved by management. 23. Unauthorized possession, removal or use of any District property or prescription blanks

is in violation of the Code of Conduct. 24. Employees who are charged and/or found guilty of offenses impacting on employment,

including but not limited to, illegal drug activities, shoplifting, drunken driving, and manslaughter, may be considered in violation of this Code of Conduct.

25. Off the job, illegal drug use that may adversely affect the employee’s job performance may be proper cause for dismissal.

CHAPTER 2

AUDITING AND MONITORING Audits are one means of determining whether a group’s compliance measures are working, and of detecting both individual and systematic problems so they can be corrected. They are most commonly used in compliance programs to review the accuracy and completeness of documentation, coding, and billing records as a way to protect the District against the submission of claims that could be construed as false or fraudulent, and to identity overpayments received by the District from payers or patients that should be refunded. The OIG believes both billing and clinical personnel should be involved in self audits. These audits can take two forms: (a) a standards and procedures review; and (b) a claims submission review. It is useful to audit existing billing and related policies and procedures before auditing actual claims. This can detect systemic problems that increase the likelihood of claim problems; e.g., billing software with various biases built in or forms used in the coding process that bias codes selected. With respect to claims submission review, the OIG advocates a “baseline audit” of actual claims to establish parameters on existing problems, identify the most urgent needs for training and new standards, and set goals for improvement. This approach, known as “benchmarking,” can assist the District as they go forward to determine whether they are making progress in their efforts to submit accurate claims. The OIG recommends that a baseline audit review of claims submitted and paid during the initial three months after implementation of the compliance program. After that, it is recommended that periodic audits be conducted at least once a year or more often if necessary based on the initial baseline. The OIG sets a basic review guideline of five (5) or more randomly selected records per federal payer or five (5) to ten (10) records per provider. There is both art and science to designing an appropriate audit, documenting it and responding to its findings. Audits will be used to determine, among other things, whether: (a) bills are accurately coded and accurately reflect documented services provided; (b) proper documentation is completed; (c) services or items provided are reasonable and necessary; and (d) any incentives for unnecessary services exist. We have chosen to perform “Pre-Claim Submission Audits” rather than “Retrospective Audits.” We believe that pre claim audits will provide the District with coding and documentation parameters without the possibility of filing an inaccurate claim. The frequency of audits at Sublette County Rural Health Care District will be determined after a baseline is established and evaluation of whether appropriate follow-up is required for potential problems. If a problem area should surface during an audit, then additional audits will be performed until the problem is satisfactorily resolved, and the compliance risk is eliminated.

Once any problem area is satisfactory resolved the District will annually review a minimum of ten charts for each provider to verify compliance with reimbursement and billing requirements. In selecting the charts there should be a reasonable proportion charts included of the District’s top ten denials. If after completion of the District audit a provider is found in non-compliance, the Compliance Committee will take appropriate action to assure the provider is in compliance for the future. Repeated violations may result in corrective action.

Chapter 3

Establishing Practice Standards and Procedures

Sublette County Rural Health Care District strives to comply fully with all applicable federal and state laws, including laws which prohibit the filing of false or fraudulent claims with the government. This commitment is an integral part of the organization’s mission, and all employees are expected to support the organization in this commitment. Employees will be evaluated in part on their contribution to ensuring that the organization meets the commitment. Our District standards address four core areas: (a) Coding and Billing; (b) Reasonable and Necessary Services; (c) Documentation; and (d) Improper inducements, Kickbacks, and Self-Referrals. Like most physician practices, we recognize the following as the specific regulatory risks most frequently subject to investigation and audit:

Billing for items or services not rendered as claimed;

Submitting claims for supplies and services that are not reasonable and necessary;

Double billing;

Billing for non-covered services;

Failure to properly use coding modifiers;

“clustering”; (use of few codes – example 99213)

“upcoding”;

“unbundling” (separate billing codes for services that have an aggregate code);

Inappropriate balance billing (billing Medicare beneficiaries for the difference between the total provider charges and the Medicare Part B allowable payment);

Routine waiver of co-payments and billing third-party insurance only;

Discounts and professional courtesy;

Improper billing for incident-to services;

Improper reassignment of physician billing numbers;

Failure to refund credit balances due patients and payers; and

Billing for services provided by unqualified or unlicensed clinical personnel. With respect to reasonable and necessary services, the OIG reminds practices that Medicare will only pay for services that meet the definition of reasonable and necessary. Accordingly, a provider should only bill for reasonable and necessary services. A physician practice; however, is permitted to bill for services that may not be reasonable and necessary in order to receive a denial required for payment from the secondary payer.

Accurate and complete documentation is one of the most important aspects of a compliance program. This is because documentation serves as verification that the bill is accurate and the services have been provided. Specifically, the documentation can validate: (a) the site of services; (b) the appropriateness of the services provided; (c) the accuracy of the billing; and (d) the identity of the service provider. For clinical information, providers should continue to rely on CMS and E&M and Coding and Documentation Guidelines. The OIG sets forth the following examples of internal documentation guidelines practices may use to ensure proper documentation:

The medical record is complete and legible;

The documentation of each patient encounter shall follow CMS Guidelines to include the reason for the encounter; any relevant history; pertinent physical examination findings; relevant diagnostic test results; assessment, clinical impression or diagnosis; plan of care; date and legible identity of the provider;

If not documented, the rationale for ordering any ancillary services can be easily inferred by an independent reviewer or third party who has appropriate medical training;

CPT and ICD-9 codes used for claims submission are supported by documentation and the medical record; and

Appropriate health risk factors and changes in treatment or diagnosis are identified. The OIG also instructs physician practices to closely monitor the completion of the CMS-1500 form by: (a) linking the diagnosis code with the reason for the visit or service; (b) using modifiers appropriately; and (c) providing Medicare with information about a beneficiary’s other insurance coverage.

Chapter 4

Designation of a Compliance Officer/Contact

After the audits have been completed and the risk identified, ideally a member of the physician team and the Certified Coder needs to accept the responsibility of developing a corrective action plan if necessary, and oversees the District adherence to the plan. The Certified Coder has agreed to accept the position of Compliance Officer. The Coder will work in collaboration with the Medical Director of each Practice site and with the CEO of the Health Care District. The Coder will be in charge of all Corporate Compliance activities for the District. The Compliance Officer is responsible for overseeing the implementation and day to day operations of the Compliance Plan. It is acceptable for the District to designate more than one person with Compliance monitoring responsibility. For example, the Certified Coder Compliance Officer would be responsible for arranging periodic audits and insuring that billing questions are answered appropriately while the Medical Directors at each Practice site would work with the CEO directly if there were the need to address corrective action concerns. According to the OIG, the responsibilities of the Compliance Officer and of the Compliance Committee include:

Developing compliance policies and procedures;

Coordinating personnel issues to ensure that all clinicians have current licenses and certifications and that all employees have been screened for prior health care related convictions and exclusion from government programs;

Developing and coordinating compliance education and training;

Designating and coordinating compliance audits and reviews;

Establishing a system for receiving confidential reports of alleged wrong doings and investigating their merit;

Implementing disciplinary measures and system changes where necessary; and

Evaluating the success of the compliance program. As the designated Compliance Officer, the Certified Coder will have access to the group’s contracts, proprietary data, patient information, allegations and evidence of any wrong doing, and sensitive personnel information. The Certified Coder must have the respect and confidence of both clinical and administrative employees and must have the full backing of the governing body. The Certified Coder will establish the authority and credibility of the program in the eyes of rank and file employees. At Sublette County Rural Health Care District, our focus is on the audit process and alignment with the OIG guidelines. This is not to be a punitive program, but rather a program of education and adhering to a Code of Conduct.

Corporate Compliance Officer Job Description Sublette County Rural Health Care District

Reports to: Chief Executive Officer Education: MD, DO, PA, NP, and/or Certified Coder Qualifications: Individual and the team must be able to perform each essential duty

satisfactorily. Summary: Contributions to the fulfillment of the District’s compliance mission by implementing and maintaining a Corporate Compliance Program. This may involve coordinating compliance training and education, arranging and/or conducting internal audits, identifying compliance issues and trends, investigating and resolving compliance complaints and promoting an awareness and understanding of the positive ethical and moral principles consistent with the mission, vision and values of the District and those required by federal law. Essential Duties and Responsibilities:

Establishes a Compliance Manual, describing all aspects of the compliance program, as well as compliance policies and procedures for each component. Maintains and supplements the manual as necessary.

Affirms internal systems and controls to carry out the District’s standards, policies and procedures, as part of its daily operations.

Arranges and coordinates appropriate compliance training and education programs for all employees. Ensures an understanding of the District’s commitment to comply with all applicable laws and regulations, as well as the District’s internal policies, procedures and ethical requirements.

Conducts or arranges and coordinates internal audits for the purpose of monitoring and detecting noncompliance with applicable laws and requirements. If any noncompliance is detected, recommends a solution and follows up to ensure that the recommendations have been implemented.

Formalizes and monitors systems to enable employees to report instances of noncompliance or suspicious activity without fear of retribution. Ensures that the system is adequately publicized and that allegations of noncompliance are investigated and responded to promptly.

Ensures the maintenance of the “Compliance Report Log” and works with the Corporate Compliance Committee on the commencement and outcomes of internal investigations.

In consultation with the Chief Executive Officer, helps ensure that there is a mechanism in place for disciplining instances of noncompliance, appropriate to the nature and extent of the deviation, and ensures consistency in the application of disciplinary action.

Works with the Managers and Supervisors to ensure a workforce with high ethical standards, including the establishment of minimum standards for conducting appropriate background/reference checks on both potential and existing employees.

On a continual basis works to improve the prevention/detection of any noncompliance.

Prepares Compliance Reports for the Chief Executive Officer and keeps him/her generally informed of compliance issues and developments.

Chapter 5

Conducting Appropriate Training and Education This is one of the most important elements of any compliance program, and one of the most difficult to implement successfully. Regulatory requirements, particularly those in the Medicare billing area, are complex, frequently confusing and ever changing. Our Compliance Program demonstrates diligence in attempting to stay abreast of these requirements and in communicating them to clinical and administrative employees. The training program at Sublette County Rural Health Care District has been developed to educate clinical and administrative employees about applicable laws, regulations, and policies as well as about the District Compliance Program itself. It is important for employees to understand the purpose, and the need for, a compliance plan, as well as the consequences of violating the plan. The OIG recommends and Sublette County Rural Health Care District agrees that all the employees be trained on the Compliance Program at least annually an d all new hires as soon as practical after their hire date. Additionally, the OIG specifically recommends annual training in coding and billing for employees involved in those areas. Such training should include:

a) Coding requirements; proper CPT and ICD-9 usage; b) Processes for claim development and submission; c) Signing forms for providers without the provider’s authorization; d) Proper documentation of services; and e) Standards for submitting bills for services provided to Federal Health Care program

beneficiaries, including the legal sanctions resulting from deliberately false or reckless billings.

Training for compliance issues will be combined with other employment related training. Additional training will be provided when there is a major change in government requirements such as new Medicare documentation requirements for evaluation and management services. All individuals in the group with the authority to enter into leases and contracts on behalf of the District will receive training regarding the restrictions imposed by the federal anti-kickback and self-referral laws, which may impact their choice of vendors or suppliers for the items and services they prescribe to Medicare beneficiaries, and how contract relationships are structured. All employees receiving compliance training will sign an attendance sheet which will be maintained as evidence of training. Employees will also be asked to sign an acknowledgement that they have reviewed and understand the group’s compliance-related policies. All providers will also be asked to sign an acknowledgement that they have reviewed and understand the group’s compliance policies. Attendance and participation in training sessions will be a condition of continued employment.

The District will maintain updated ICD-9, HCPCS, and CPT manuals and carrier bulletins within manuals and will make them available to employees. A loose-leaf notebook will be available for this purpose. Employees will be asked to initial key regulatory circulars as evidence they have read them.

Chapter 6

Responding to Offenses and Corrective Action Initiatives Violations of the District’s compliance program, significant failures to comply with applicable federal or state law and other types of misconduct threatens the District’s status as a reliable, honest, and trustworthy provider of healthcare. Consequently, upon receipt of reports or reasonable indications of suspected noncompliance the Compliance Officer will be begin investigation of the report. Internal investigations are crucial to the compliance process. The investigation may be prompted not only by a report from an employee but as the result of a regularly scheduled internal audit. The OIG suggests a set of warning signals that should trigger an internal review that would include the following:

a) Significant changes in the number and/or types of claim rejections; b) Correspondence from carriers and insurers challenging the medical necessity or validity

of claims; c) Illogical patterns of CPT-4, HCPCS or ICD-9 code utilization; and d) High volumes of unusual charge or payment adjustment transactions.

For all reports of possible violations, the OIG recommends that a full internal assessment of the situation be provided. In this way, the program can avoid the appearance of ignoring reports of possible wrongdoing. In addition to reviewing the problem the District will evaluate if the compliance program should be modified to prevent reoccurrence of the problem. The investigative procedure and findings will be documented, and summaries of significant investigations will be reviewed with the Chief Executive Officer. All investigations are extremely confidential and will be handled in a discrete manner. There is no template or formula for measuring the disciplinary action sanctioned that is appropriate in each incident, as each case has its own distinguishing characteristics. However, the employer will strive to apply similar disciplinary measures to similar offenses. Wyoming is an “Employment at Will” state and the Compliance Committee will exercise appropriate disciplinary action to protect the District’s reputation. The most significant consideration in determining the appropriate discipline, if any, is the nature of the employee misconduct. Intentional or reckless noncompliance will subject transgressors to significant sanctions.

Chapter 7

Developing Open Lines of Communication An employee Corporate Compliance reporting system has been developed at Sublette County Rural Health Care District. It is our goal that employees feel comfortable reporting without retribution or fear of job termination. Confidentiality is maintained as an absolute priority. According to the OIG meaningful and open communication will include some or all of the following:

The requirement that employees report conduct as a reasonable person, would in good faith believe to be erroneous or fraudulent;

The creation of a user friendly process, such as an anonymous drop box for effectively reporting such conduct, which we will use here at the Sublette County Rural Health Care District.

Provisions in the standards of procedure stating that a failure to report such conduct is a violation of the compliance program;

The development of a simple procedure to process such reports;

The utilization of a process to maintain, to the extent possible the anonymity of the persons involved in the reported possible erroneous or fraudulent conduct and the person reporting the concern; and

Provisions in the standards and procedures that there will be no retribution in reporting such conduct.

Procedures have been established for documenting reports and for conducting investigations. If a preliminary review of the matter suggests that a substantial violation of applicable law or of the requirements governing private or government sponsored health plans may have occurred, a “full blown” investigation will be promptly conducted to determine its veracity. Subsequent investigations will be conducted to ensure that the problem is corrected.

Chapter 8

Enforcement and Other Considerations A compliance program needs teeth if the government is to recognize it as being effective. When real wrongdoing is discovered, through audits or otherwise this District will strive to correct the problem and take steps to ensure that the problem does not reoccur. If problems of a criminal nature are uncovered, the District will be prepared to refer them to law enforcement authorities, and cooperate fully with law enforcement personnel. When clear overpayments are discovered, prompt refunds will be made to carriers or the patient. Sublette County Rural Health Care District realizes there is often a borderline between innocent mistakes and intentional wrongdoing. For that reason our compliance plan uses a graduated corrective plan. For example, a chart audit may turn up documentation problems. Our first response may simply be more training of the individuals involved. A second round of problems may call for some financial repayment to Medicare, and some financial penalty to the offending individual. A third round may call for more serious discipline, if not discharge. In conclusion, just as immunizations are given to patients to prevent them from becoming ill, the District views the implementation of a voluntary compliance program as a comparable form of preventive medicine for the District. This voluntary compliance plan is intended to assist the District in developing and implementing internal controls and procedures that prompt adherence to federal health care program requirements. These efforts will streamline and improve the business operations within the District and therefore help to inoculate against future problems.

Other Considerations Although not specifically included in the OIG’s Group Clinic Compliance Guidelines, it is an important element in the Federal Sentencing Guidelines. The District wishes to incorporate this step into their compliance plan.

Recruiting personnel standards – At a minimum the District will verify the licensing of physicians and other potential employees and check whether they have been sanctioned by the government in the past. The OIG’s list of previously excluded individuals can be accessed via the Internet at: http://www.hhs.gov/oig. Existing employees will also be screened and physician employment contracts and shareholder agreements will be reviewed.

1) Adherence to the compliance plan will be an element of each employee’s evaluation;

2) Appropriate action will be taken against anyone who has engaged in any illegal activity;

3) Employees are expected to report evidence of possible wrongdoing to the compliance officer;

4) Employees are expected to cooperate fully with the compliance plan in investigating potential areas of concern; and

5) Employee reports of alleged wrongdoing will be kept confidential whenever possible, and employee reports made in good faith will not be grounds for discipline or adversely affect performance evaluation, even if the report turns out to be unsubstantiated.

How far to go in screening prospective employees and monitoring the existing workforce is a matter that is decided by the Board of Directors. No system is foolproof in preventing a group from making an occasional “bad hire,” and the compliance plan is not defective simply because one slips through.

Documentation and assessment of the compliance program – In the eyes of the government, compliance work is like clinical care; if it is not documented it was not done. The copies of policies and procedures along with the compliance plan will be maintained in a central notebook.

1) The District will record the frequency of billing and contract reviews and training

sessions that have been held. 2) The compliance plan will be reviewed annually to assure the program is

functioning in operation as promised on paper.

Voluntary disclosure – As noted elsewhere having an effective compliance program requires a willingness to correct identified problems. Correction can entail simple

refunds to payers without detailed explanation or it can involve more substantial disclosure to payers.

1) If in doubt whether to disclose, always disclose; 2) If in doubt about how much to disclose, disclose more rather than less; 3) If in doubt about when to disclose, disclose sooner rather than later; 4) If in doubt about whom to disclose; disclose to the OIG or other law

enforcement agencies not just the payer. The OIG has developed a detailed Voluntary Disclosure Program, but a provider making a disclosure under this program is not given any guarantees of protection from criminal prosecution or even the imposition of civil fines or penalties. This Voluntary Disclosure Program’s protocol can be accessed via the Internet at: www.hhs.gov/oig under the “Electronic Reading Room” library. The risk of voluntary disclosure is very real and the District will carefully assess the pro’s and con’s of such disclosure with a competent advisor before deciding a course of action.

Chapter 9

Professional Courtesy Phase II of Stark creates an exception allowing entities to extend “Professional Courtesy” to a physician, and members of the physician’s immediate family pursuant to several conditions. 42 CFR 411.357(s). Phase II defines professional courtesy as the provision of free or discounted health care items or services. 42 CFR 411.351. To qualify for the professional courtesy exception, the arrangement must meet the following conditions:

1. The professional courtesy is offered to all physicians in the entity’s referral area community without regard to the volume or value of referrals generated between parties

2. The health care items and services provided are of a type routinely provided by the entity

3. The entity’s professional courtesy policy is set out in writing and approved in advance by the governing body of the health care provider

4. The professional courtesy is not offered to any physician (or immediate family) who is a Federal health care program beneficiary , unless there has been a good faith showing of financial need

5. If the professional courtesy involves any whole or partial waiver of any coinsurance obligation, the insurer is informed in writing of the reduction so that the insurer is aware of the arrangement

6. The arrangement does not violate the anti-kickback statute or billing or claims submission laws or regulations. 42 CFR 411.357 (s).

In the Phase II preamble, CMS cautions that the regulations should not be construed as requiring or encouraging courtesy arrangements. CMS also reminds parties that some professional courtesy arrangements may run afoul of the anti-kickback or civil monetary penalties law. Additionally, CMS notes that although professional courtesy discounts may be covered under the employee exception, this exception does not preclude hospitals or other entities from extending their professional courtesy policies to employees, including non-physician employees, pursuant to this new exception. 69 Fed. Reg. at 16116. From a compliance perspective, entities should fully document any notification of reduction of co-insurance to insurers. This should be documented in existing Compliance Programs.