GBMC Ethics and Compliance Program

MISSIONHealth. Healing. Hope.

The Mission of GBMC HealthCare is to provide medical care and service of the highest quality to each patient leading to health, healing and hope.

VISIONMedical sophistication with personalized service.

The Vision of GBMC is to be the preferred medical center in Maryland for the best physicians, nurses and staff by providing medical sophistication with personalized service, enhanced by clinical education and research with the guiding principle that “the patient always

comes first.”

VALUESThe Values of GBMC are GREATER Values of Respect, Excellence, Accountability, Teamwork, Ethical Behavior and Results.

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Definitions

• Compliance– Conformity; acting according to certain accepted standards

• Ethics– The study of: moral values and rules; right and wrong

conduct– Contemporary Ethics focuses on Choices

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Compliance & Ethics

• Taken together, they define the essence of the GBMC Ethics and Compliance Program:– A values-based culture that guides our actions in the

workplace so that our daily activities are performed with honesty, integrity, and in support of the organization’s

Mission, Vision and Values.

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Ethical Corporate Culture

• Benefits– Ethics plays an important role in deterring fraud and abuse in

organizations. The overall goal of an effective compliance program is to create an ethical corporate culture.

– An ethical corporate culture reduces the chance that fraud and abuse will occur; or, if it does occur, it reduces the chance that it will go undetected.

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Definitions

• Fraud– Intentional deception, misrepresentation or perversion of

truth in order to damage another or to obtain personal gain

• Abuse (in healthcare compliance terms)

– “Honest” mistakes or errors that organizations should have known were mistakes or errors; Culpable Ignorance – a lack of knowledge for which one can be blamed and held accountable (not an excuse for non-compliance)

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Fraud and Abuse

• Consequences– 40-60 million Americans cannot afford or are not offered

access to health insurance. The main barrier to coverage is cost and the biggest single contributor to unnecessary spending is fraud and abuse.

– The price tag for fraud and abuse is estimated at $100 billion each year. The losses caused by fraud and abuse are passed on to individuals through increased insurance premiums, reduced wages, and increased taxation to fund government programs.

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Government’s Response

– Virtually every week, a story appears in the news concerning the government's investigation of a health care provider or organization. Behind violent crime and terrorism, health care fraud has been targeted as the number one white-collar priority of federal prosecutors.

– Since 1996, Congress has significantly increased the funding for health care fraud and abuse enforcement efforts. Additionally, Congress has created powerful new criminal and civil enforcement tools that have enabled the government to expand and intensify the fight against health care fraud and abuse.

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Government’s Response

– Along with these increased investigations, comes the ability of the government to impose significant fines and penalties on healthcare organizations and individuals, including disqualification from health care programs and even prison.

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Government’s Response

– The Office of the Inspector General (OIG) believes that significant reductions in fraud and abuse liability can be accomplished through the use of compliance programs. An effective compliance program can minimize the consequences resulting from a violation of the law and may, in some cases, convince a prosecutor not to pursue criminal action.

– The OIG has provided the healthcare industry with model compliance program guidance. There are specific elements that the OIG requires organizations adopt to be considered as having an effective compliance program.

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GBMC’s Response

– Voluntary development of an Ethics and Compliance Program based on the OIG’s requirements that ensures that corporate policies, practices, and culture foster the understanding of, and compliance with, applicable legal requirements.

– The purpose of our Ethics and Compliance Program is to:

o Prevent violations of the law,o Detect violations of the law,o Document our efforts in the event violations exist that are not

detected.

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Elements of Ethics & Compliance Program

“Tone at the Top”

Ethical Corporate Culture

GBMC Board of DirectorsReinforcement of GBMC’s Commitment to Compliance

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Elements of a Compliance Program (OIG)

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Element #1 Standards & Procedures

• The organization must have established compliance standards and procedures to be followed by its employees that are reasonably capable of reducing the prospect of unlawful activity.

– We have developed and continue to develop policies and procedures to address many legal and regulatory requirements. However, it is impractical to develop policies and procedures that encompass the full body of applicable law and regulation that affects our industry. Obviously, those laws and regulations not covered in organization policies and procedures must be followed. GBMC has a range of expertise within the organization, including legal counsel and numerous functional experts who should be consulted for advice concerning human resources, legal, billing, tax, and other regulatory requirements.

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• One of the most critical components that supports the OIG requirement for standards and procedures is the GBMC Code of Business Ethics (the “Code”). The purpose of the Code is to articulate GBMC’s message of fair competition and ethical business practices. It addresses some of the complex legal and business ethical issues we face every day and provides guidance for handling some specific compliance scenarios. The Code should be used in conjunction with GBMC policies to provide guidance on regulatory matters.

Element #1 Standards & Procedures

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• The Code is divided into 6 Guiding Principles which are closely aligned with GBMC’s objectives, goals and service excellence behaviors. They are:

o “We Strive to Provide Outstanding Service to Our Patients”

o “We Strive to Abide by the Law and Maintain High Ethical Standards in Our Business Decision Making”

o “We Strive to Maintain a High Standard of Accuracy and Completeness in Our Records”

o “We Strive to Maintain a Professional and Safe Work Environment”

o “We Take Personal Responsibility for Protecting the Organization’s Resources and Achieving Our Ethical Goals”

o “We Report Our Compliance Concerns by Using the Appropriate Chain of Command”

Element #1 Standards & Procedures

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• These Guiding Principles are defined more thoroughly in the Code, along with examples of compliance-related practices that we are required to follow in furtherance of those principles. Please take the time to review the Code prior to taking the online test at the end of this section. The Code of Business Ethics may be obtained electronically via the Compliance Web Page on the InfoWeb.

Element #1 Standards & Procedures

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• Specific individual(s) within high-level personnel of the organization must be assigned overall responsibility to oversee compliance with such standards and procedures

Element #2 High Level Oversight

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• The Audit and Compliance Committee of the Board of Directors is responsible for the oversight of the Ethics and Compliance Program.

• Heather Hill, Compliance Officer, is responsible for day-to-day Ethics and Compliance Program activities; as Compliance Officer, she reports to the President & CEO, with an administrative reporting relationship to the EVP&CFO; the Compliance Officer has direct access and provides periodic reports to the Audit Committee.

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• The organization must have used due care not to delegate substantial discretionary authority to individuals whom the organization knew, or should have known through the exercise of due diligence, had a propensity to engage in illegal activities.

o GBMC conducts pre-employment screening, including background checks, on employees.

o The GBMC Compliance Department performs monthly checks against a Federal Government database to ensure no sanctions have been imposed against GBMC employees and physicians that would expose GBMC to any financial risk.

Element #3 Trustworthy Individuals

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• The organization must have taken steps to communicate effectively its standards and procedures to all employees by requiring participation in training programs or by disseminating publications that explain in a practical manner what is required.

o GBMC has incorporated Ethics and Compliance Program training into the mandatory annual competency plan (THAT’S WHY YOU’RE HERE !!).

o The New Employee Orientation Program contains 30 minutes of training on the Ethics and Compliance Program.

o Specialized training is provided on specific compliance areas on an as-needed basis throughout the year by the Compliance Department.

Element #4 Education

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• The organization must take reasonable steps to achieve compliance with its standards, e.g., by utilizing monitoring and auditing systems reasonably designed to detect inappropriate conduct by its employees and by having in place and publicizing a reporting system whereby employees can report compliance concerns without fear of retribution.

o Every year, the Compliance Department develops an annual compliance audit plan which outlines the areas that will be audited to ensure compliance with internal policies, laws, regulations, and contracts. Audit areas are determined based on a risk assessment process that considers the likelihood and impact of noncompliance.

o Departments throughout GBMC perform various auditing and monitoring activities to ensure compliance, e.g., the Coding department, Medical Records, etc.

Element #5 Monitoring & Auditing

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• Employees are educated about the resources available to them to report compliance concerns including:– Supervisor or Chain of Command

– Compliance Officer, Teresa Schorr: 443-849-2358

– Compliance Office email: compliance@gbmc.org

– Compliance Page on the InfoWeb

– Compliance Hotline, a confidential reporting service operated 24 hours a day, 7 days a week at 1-800-299-7991; anonymity of the person placing the report is protected to the extent possible as dictated by federal and state law.

Element #5 Monitoring & Auditing

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• The standards must have been consistently enforced through appropriate disciplinary mechanisms, including, as appropriate, discipline of individuals responsible for the failure to detect an offense. Adequate discipline of individuals responsible for an offense is a necessary component of enforcement; however, the discipline that will be appropriate will be case-specific.

o GBMC has a progressive disciplinary policy in place to deal with individuals who do not comply with internal polices, laws, and regulations. The Compliance Department’s responsibility is to present the facts of the case and provide supporting documentation and details as necessary. The Human Resources Department is ultimately responsible for disciplinary procedures as they deem appropriate. All employees have a duty to report instances of non-compliance in good faith. Individuals who report in good faith will be protected from retaliation.

Element #6 Enforcement & Discipline

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• After an offense has been detected, the organization must have taken all reasonable steps to respond appropriately to the offense and to prevent further similar offenses.

o GBMC requires that issues of noncompliance be responded to in writing by the appropriate management. This response must outline the corrective action to be taken, by whom, and in what timeframe to deter against the possibility of re-occurrence. Corrective action plans are followed up on by the Compliance Department.

Element #7 Response & Prevention

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Areas Where Compliance Risk May Exist

• Patient Information – We collect information about the patient’s medical condition, history, medication, and family illnesses to provide quality care. We realize the sensitive nature of the information and are committed to maintaining its confidentiality. Consistent with HIPAA, we do not use, disclose or discuss patient-specific information with others unless it is necessary to serve the patient or required by law. This also applies to situations where our fellow employees become patients.

• Relationships with Physicians – Federal and state laws and regulations govern the relationship between hospitals and physicians who may refer patients to our facilities. It is important that all arrangements with physicians be properly structured to comply with laws such as Stark, Anti-Kickback and IRS regulations. Due to the complexity of these relationships, it may be appropriate to seek guidance from internal resources such as the Compliance or Legal Department. The two fundamental principles we should all keep in mind are that we do not pay for patient referrals, nor do we accept payments for referrals we make.

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• Licensure and Certification Renewals – GBMC staff who hold positions which require professional licenses, certifications, or other credentials are responsible for maintaining the current status of their credentials and for complying with any federal or state requirements applicable to their roles. GBMC does not allow any colleague, independent contractor, or practitioner to work without valid licenses or credentials.

• Billing Practices – GBMC will bill only for services actually rendered. Services rendered must be accurately and completely documented and coded to ensure both proper billing and the integrity of the medical record. Billing must comply with the requirements of state and federal payers and conform to all payer contracts and agreements. There are federal and state laws that make it illegal to receive payment for false claims. Hospitals that engage in practices that violate the False Claims Act could face fines and penalties. GBMC has processes in place that support the detection and prevention of fraud and abuse including, external and internal billing and coding audits, billing compliance committees, monthly monitoring and employee education.

Areas Where Compliance Risk May Exist

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• Conflicts of Interest – A conflict of interest may occur if your activities or personal interests appear to or may influence your ability to make objective decisions required of your job at GBMC. We try to minimize these situations, but if they do occur, we disclose them to management. A good rule of thumb that a potential conflict of interest may exist is any time an objective observer might wonder if your actions are motivated solely by your responsibilities to GBMC or because you stand to reap some personal benefit from the situation.

• Receiving Gifts and Business Courtesies – GBMC has straightforward, clear cut guidelines outlined in policy regarding what types of courtesies are appropriate for GBMC staff to accept from a person or organization that does business or may want to do business with GBMC. No member of GBMC may ever accept cash or a cash equivalent (e.g., gift certificates) from anyone in a position to do business with GBMC, regardless of amount or whether it is directed at an individual or department. There are ways that vendors can extend business courtesies to our employees that are appropriate and in accordance with policy. If you are unsure as to the appropriateness of a gift or courtesy, ask.

Areas Where Compliance Risk May Exist

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Reporting Concerns

• Resources for Guidance– To obtain guidance on a compliance issue or to report a

concern, individuals may choose from several options:• We encourage human resources-related issues to be handled by the

Human Resources Department experts.

• As an expected good practice, when you are comfortable in doing so and think it appropriate under the circumstances, raise concerns first with your supervisor.

• If you are uncomfortable in going to your supervisor or it is inappropriate considering the situation, you may contact another member of management, the Compliance Office, or use the GBMC Business EthicsLine. All of these resources are clearly defined in the Code along with corresponding contact information.

• Employees should never feel that they have no where to go when they want to discuss a compliance-related concern.

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GBMC Ethics & Compliance Program

• Final Thoughts– Compliance impacts all functional areas of the hospital. It is not

just a Billing or Finance problem. We all have a responsibility to carry out our activities in a manner that is ethical, legal and in support of the behaviors outlined in the Code of Business Ethics. Some of us have jobs that are subject to greater levels of compliance scrutiny and we should be familiar with those requirements.

– The GBMC Ethics and Compliance Program does not need to be perfect as long as it demonstrates due diligence. That is why it is an active, evolving process and not simply a static document. We can never say that we have finished complying. The very nature of the healthcare environment eliminates any possibility of a final compliance product. Laws and rules change constantly and GBMC has positioned itself to be able to respond and react to the rapidly changing regulatory environment.

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We hope this Computer-Based Learning course has been both informative and helpful.

Feel free to review this course until you are confident about your knowledge of the material presented.

Click the Take Test button on the left side when you are ready to complete the requirements for this course.

Click on the My Records button to return to your CBL Courses to Complete list.

Click the Exit button on the left to close the Student Interface.

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GBMC Ethics & Compliance Program