Montefiore Medical Center Compliance Program Welcome House Staff Orientation
The Healthcare Industry Government is largest payor. Perception that $100 Billion Dollars per year lost because of on healthcare fraud and abuse. Also perception that medicine is not practiced safely in all instances and that conflicts of interest abound. Increasing resources devoted to audits and investigations at all levels of government and in private industry. Media and the public is supportive of these enforcement efforts.
Who Regulates Hospitals?
LAW PROHIBITS PENALTY Anti-Kickback (SSA 1128B) kickback, bribe or rebate directly or indirectly in return for referring a person Exclusion; fines; jail False Claims Act (31 USC 3729) false or fraudulent claims for payment actual knowledge; deliberate ignorance or reckless disregard of truth or falsity qui tam Damages civil penalties up to $11,500 per claim Physician Self- Referral Prohibition ( Stark ) (SSA 1877) Prohibits physicians from ordering designated health services for patients from entities with which the physician or an immediate family member has a financial interest Civil penalty of $15,000 for each bill & $100,00 for each scheme
Other Laws False Statements EMTALA OSHA Civil Rights HIPAA
MMC s Compliance Program Establishes a culture that promotes integrity and ethical behavior consistent with our mission. Provides assistance in complying with complex governmental regulations. Identifies issues of concern and detects and prevents patterns of improper conduct from developing and occurring.
Hotline Usage MMC s hotline is available to address concerns relative to noncompliance that can not be addressed through other channels 24 Hour Hotline 1-800-MMC-8595 Labor and Employment issues should be addressed through your department or by contacting Human Resources at 718-920-4998
Rights and Responsibilities All associates have a duty to report any suspected violations of the Code of Conduct. Anyone who reports conduct that he or she sincerely believes is improper will be protected from retaliation The Federal False Claims Act includes qui tam or whistleblower provisions that allow private persons (a.k.a whistleblowers or relators ) to sue on behalf of the United States If the qui tam action succeeds, the whistleblower is entitled to receive a percentage of the settlement, penalty or fine collected Whistleblowers are also granted protection under the law from discriminatory actions taken by employers MMC strongly encourages associates to report compliance concerns to the Compliance Department and to allow reasonable time for investigation of the concerns before contacting a government agency
What is a Conflict of Interest? A personal interest which could inappropriately influence business judgments Not always financial May be actual or perceived May be dependent on position May not be negative, but disclosure and management are key
How Are Conflicts Managed? Avoiding situations that create conflicts Decision-maker should not have conflict and should make decisions fairly and in accordance with policy (RFP s, due diligence) Use judgment to avoid or alleviate conflict or appearance of conflict Disclosure May fulfill responsibility Allows assessment of conflict, potential bias
Vendor Relationships New policy to be rolled out limiting pharma /device /dme vendors activities. No vendor sponsored lunches; no gifts of any kind. Only approved reps allowed on site. Vendors should not be detailing or soliciting business from Residents.
Compliance Office Contacts Lynn Stansel, Vice President & Counsel, Compliance (718) 920-6624 Laurie Radler, Director of Compliance & Information Privacy Officer (718) 920-7059 Mark Goodman, Manager Corporate Compliance (718) 920-6351 Maria Matzoros, Associate Vice President, Billing Compliance (718) 920-8995 Michelle Miller, Associate Director, Billing Compliance (718) 920-8207