Compliance Training

for ApolloMD and Groups

Revised December 09 2015

Our Corporation is

Committed to Compliance

• ApolloMD is committed to legal and ethical conduct.

• Our compliance efforts are designed to establish a culture that promotes prevention, detection

and resolution of instances of conduct that do not conform to Federal and State law, and

Federal, State and private payer health care program requirements, as well as the company's

ethical and business policies.

• As part of our Compliance Program, we have developed:

– A Compliance Plan

– Compliance Training

– A Compliance Committee

– Ongoing Audits

– Methods for Reporting Non-Compliance

– A Compliance Bulletin Board

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This Training Covers:

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What is the Corporation’s

Compliance Program?

Can reports be made

anonymously?

How does all of this apply

to ApolloMD employees?

Who serves on the

Compliance Committee?

How can one contact the

Compliance Officer?

What is HHS?

What is the LEIE

Database?

What is OIG?

What constitutes

fraud? Abuse?

What laws are

applicable to billing?

What is HHS?

• HHS is the acronym for the Department of Health and Human Services (the acronym is also

often listed as DHHS).

• It is the United States government’s principal agency for protecting the health of all Americans

and providing essential human services, especially for those who are least able to help

themselves.

• HHS is comprised of the Office of the Secretary and 11 operating divisions. The agencies

perform a wide variety of tasks and services, including research, public health, food and drug

safety, grants and other funding, health insurance, and many others.

• It represents almost a quarter of all federal outlays, and it administers more grant dollars than

all other federal agencies combined. HHS’ Medicare program is the nation’s largest health

insurer, handling more than one billion claims per year. Medicare and Medicaid together

provide health care insurance for one in four Americans.

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What is the OIG?• OIG is the acronym for the Office of the Inspector General, which is part of HHS.

• Established in 1976 , the OIG’s mission is to protect the integrity of HHS programs by fighting

waste, fraud and abuse.

• A majority of the OIG's resources goes toward the oversight of Medicare and Medicaid —

programs that represent a significant part of the Federal budget and that affect this country's

most vulnerable citizens.

• The OIG develops and distributes resources to assist the health care industry in its efforts to

comply with the Nation's fraud and abuse laws and to educate the public about fraudulent

schemes so they can protect themselves and report suspicious activities.

• The OIG conducts audits, investigations, and evaluations. It makes cost-saving or policy

recommendations for decision-makers and the public, and it assists in the development of

cases for criminal, civil and administrative enforcement.

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Administration & OversightThe OIG is charged with investigations of suspected fraud and abuse:

FRAUD

• A deception deliberately practiced in order to secure unfair or unlawful gain; or

• Knowingly and willfully executing or attempting to execute a scheme to defraud any health care benefit

program or to obtain by means of false or fraudulent pretenses, representation or promises any of the

money or property owned by or under the custody of any health care benefit program.

ABUSE

• To use wrongly or improperly;

• An action that results, directly or indirectly, in unnecessary costs to programs;

• Accepting payment for services that fail to meet professionally recognized standards of care;

• Providing services that are medically unnecessary; or

• Accepting payment for items or services when there is no legal entitlement to that payment and the

provider has not knowingly or intentionally misrepresented facts to obtain payment.

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Examples of Fraud & Abuse

• Billing for medical services not actually performed, known as phantom billing

• Billing for a more expensive service than was actually rendered, known as upcoding

• Billing for several services that should be combined into one billing, known as unbundling

• Billing twice for the same medical service

• Dispensing generic drugs and billing for brand-name drugs

• Giving or accepting something in return for medical services, known as a kickback

• Knowingly retaining overpayment

• Bribery

• Providing unnecessary services

• False cost reports

• Embezzlement of recipient funds7

What is Compliance?

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• As it relates to the OIG, compliance means adhering to applicable Federal and State laws and the

program requirements of Federal, State, and private health plans.

• The OIG has developed a series of voluntary compliance program guidance documents directed at

various segments of the health care industry, such as third-party billing offices.

• These documents encourage the development and use of internal controls to monitor adherence to

applicable statutes, regulations, and program requirements.

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Applicable Federal Laws

Some of the major federal laws specifically applicable to healthcare programs and providers are

set forth below. Each employee should have a working understanding of these laws:

• The Health Insurance Portability and Accountability Act of 1996 (Pub.L.No. 104-191) (Usually

referred to as "HIPAA")

• Medicare/Medicaid False Claims

• Additional Provisions of U.S. Criminal Code, as Expanded by the New Criminal Provisions of

the 1996 Act [18 U.S.C. 1 et seq.].

• Qui Tam (Often Referred to as "the Whistleblower's Act")

We will look at each law individually.

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The Health Insurance Portability

and Accountability Act• The Health Insurance Portability and Accountability Act of 1996 (Pub.L.No. 104-191) is often

referred to simply as "HIPAA.”

• This law amended the Public Health Service Act, the Employment Retirement Income Security

Act ("ERISA"), and the Internal Revenue Code to provide for improved portability and

continuity of healthcare coverage.

• It also established or strengthened a number of fraud and abuse provisions such as mistaken,

reckless, or false claims.

• Now, fraud and abuse provisions apply to any healthcare benefit program that, through

insurance or otherwise, is directly funded by the federal government or any state healthcare

program. Federal and state efforts are coordinated to facilitate enforcement.

The Corporation offers a separate

training specific to HIPAA.

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• The Centers for Medicare & Medicaid Services (CMS) is a branch of the U.S. Department of

Health and Human Services. CMS is the federal agency that administers the Medicare program

and monitors the Medicaid programs offered by each state.

• Medicare basics

• In relation to Medicare/Medicaid false claims, we define here ten statutes:

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The Relevance of Compliance to

Medicare & Medicaid

1. The False Claims Act

2. Anti-kickback Law

3. Ethics in Patient Referrals Act of 1989

4. Health Care Fraud

5. Criminal Wire and Mail Fraud

6. Criminal False Statements Related to Health Care Matters

7. Criminal False Statement Act

8. Civil False Claims Act

9. Theft and Embezzlement

10. Obstruction of Criminal Investigations of Healthcare Offenses

Medicare Basics

• Established as part of the Social Security Act of 1965.

• Federally funded health insurance program for:

– people age 65 or older,

– people under age 65 with certain disabilities, and

– people of all ages with End-Stage Renal Disease (permanent kidney

failure requiring dialysis or a kidney transplant).

• Consists of 4 parts:

– Part A – Hospital Insurance (Institutional providers including inpatient care)

– Part B – Medical Insurance (Services provided by suppliers, generally outpatient)

– Part C – Medicare Advantage Plans (Managed care services that include Parts A and B and also

wellness and preventative health programs)

– Part D – Prescription Drug Plans (Prescription benefits for anyone with Part A or Part B; Part D coverage

is not standardized, meaning patients choose which drugs or classes of drugs they wish to cover, at what level or tier they

wish to cover it)

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Medicaid Basics

• Established as part of the Social Security Act of 1965.

• Provides healthcare coverage and services for those with low income and resources.

• Covers one in seven people, more than any other public or private insurer in America.

• Medicaid is administered by states. State participation in Medicaid is voluntary, but all states

participate.

• States receive an entitlement (receive federal matching payments for all state spending on

covered services). Thus, Medicaid is jointly funded by both the Federal and state governments.

• Each state sets its own guidelines regarding eligibility and services.

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Medicare/Medicaid Statutes

1. The False Claims Act [42 U.S.C. subsection 1320a-7b(a)].

The False Claims Act prohibits a person from knowingly and willfully making or causing to

be made any false, fraudulent, or fictitious statement, representation of material fact, and

prohibits a person from making a claim or application for benefits with such knowledge and

fraudulent intent and from retaining healthcare benefit program funds which have not been

properly paid.

• The act does not require proof of a specific intent to defraud the government.

• Among the actions subject to this provision are fraudulent billing, double billing, upcoding, unbundling, and failure to refund overpayments. Conspiring to defraud a governmental agency or healthcare benefit program is also prohibited.

• Penalties include criminal prosecution, exclusion from participation in federally-funded programs, and civil penalties, plus damages.

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2. Anti-kickback Law [42 U.S.C. subsection 1320a-7b(b)]

This statute prohibits a person from knowingly and willfully soliciting, or receiving any remuneration, either directly or indirectly, overtly or kind, in return for:

(i) Referring an individual to a person for the furnishing, or arranging for the service for which payment or any other economic benefit may be made, in any federal healthcare program; or

(ii) Purchasing, leasing, ordering, or arranging for, or recommending the ordering of, any good, facility, service, or items for which payment may under any federal healthcare program.

Violation of this law is a felony punishable by fines

and/or imprisonment.15

Medicare/Medicaid Statutes

3. Ethics in Patient Referrals Act of 1989 [42 U.S.C. subsection 1395nn]

(Sometimes known as the "Patient Referral Act" and also referred to as "Stark I" and "Stark

i. The Patient Referral Act prohibits a person (who does not meet an or compensation relationship, from referring any patient in need of any which payment may be made under Medicare or Medicaid to such entities financial relationship. (Stark I)

ii. This law was expanded in 1993 to apply to referrals for a list of outpatient services, home health services, durable medical equipment, physical and outpatient services in which the referring person has an economic relationship. This new expansion is known as "Stark II".

Sanctions include denial of payment, refund of payment, civil monetary Medicare and Medicaid.

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Medicare/Medicaid Statutes

4. Health Care Fraud [18 U.S.C. subsection 1347].

This statute prohibits the knowing and willful execution of, or attempt to artifice:

i. To defraud any healthcare benefit program, or

ii. To obtain, by means of false or fraudulent pretense, representation, property owned or under the custody or control of any healthcare connection with the delivery of, or payment for, healthcare benefits,

5. Criminal Wire and Mail Fraud [18 U.S.C. subsection 1341].

This statute makes it a crime for a person to use the U.S. Postal Service, telephone lines in furtherance of any scheme to defraud a governmental benefit program.

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Medicare/Medicaid Statutes

6. Criminal False Statements Related to Health Care Matters [18 U.S.C. subsection 1035]

This statute makes it a crime for any person to knowingly and willfully make fraudulent statements, representations, writing, or documents regarding a the delivery of, or payment for, healthcare benefits, items, or services, and to falsify, conceal, or cover up a material fact by any trick, scheme, or device.

7. Criminal False Statement Act [18 U.S.C. subsection 1001].

This statute makes it a crime for a person to knowingly and willfully make any fictitious statement to a governmental agent or healthcare benefit program.

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Medicare/Medicaid Statutes

8. Civil False Claims Act [31 U.S.C. subsection 3729(a)].

This statute prohibits a person:

i. from knowingly filing a false or fraudulent claim for payments to a benefit program.

ii. from knowingly using a false record or statement to obtain payment on a governmental agent or healthcare benefit program; or

iii. from conspiring to defraud a governmental agency or healthcare benefit a false or fraudulent claim paid.

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Medicare/Medicaid Statutes

9. Theft and Embezzlement [18 U.S.C. subsection 660].

This statute makes it a crime for any person to knowingly and willfully misapply any of the monies, property, or other assets of a healthcare benefit

10. Obstruction of Criminal Investigations of Healthcare Offenses [18 U.S.C. subsection 1518]

This statute prohibits a person from willfully preventing, obstructing, to prevent, obstruct, mislead, or delay the communication of information or violation of a federal offense to a criminal investigator.

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Medicare/Medicaid Statutes

The Deficit Reduction

Act of 2005 (DRA)

• Signed into law on February 8, 2006

• Affects any employer who receives >$5 million per year in Medicaid payments

• Requires employers to provide information on:

– The Federal False Claims Act

– Any Applicable State False Claims Act

– (See Appendix for state-specific False Claims Act links)

– Whistleblower Rights & Protection

– Fraud & Abuse Policies

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Civil Monetary Penalties Act• The Social Security Act authorizes the Secretary of HHS to seek civil monetary penalties (CMPs) and

assessments for many types of misconduct. The Secretary of HHS has delegated many of these CMPs to

the OIG.

• The OIG may seek CMPs against any person who:

– Presents or causes to be presented claims to a Federal health care program that the person knows or

should know is for an item or service that was not provided as claimed or is false or fraudulent.

– Violates the anti-kickback statute by knowingly and willfully: (1) offering or paying remuneration to induce

the referral of Federal health care program business; or (2) soliciting or receiving remuneration in return

for the referral of Federal health care program business.

– Presents or causes to be presented a claim that the person knows or should know is for a service for

which payment may not be made under 42 U.S.C. § 1395nn, the physician self-referral or "Stark" law.

• The OIG is authorized to seek different amounts of CMPs and assessments based on the type of violation at

issue.

• The OIG may also seek exclusion from participation in all Federal health care programs.

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Additional Provisions of U.S. Criminal Code (as Expanded by the New Criminal Provisions of the 1996 Act

[18 U.S.C. 1 et seq.])

Definitions Relating to Federal Healthcare Offenses:

i. "Federal healthcare offense" means a violation of, or a criminal conspiracy to violate, any of the specific provisions of

the United States Code if the violation or conspiracy "relates to a healthcare benefit program.“

ii. A "healthcare benefit program" is defined as: any public or private plan or contract, affecting commerce, under which a

medical benefit, item, or service is provided to any individual, and includes any individual or entity who is providing a

medical benefit, item, or service for which payment may be made under the plan or contract. A "Healthcare benefit

program" includes all forms of private insurance, HMO coverage, and self insurance.

iii. Even overpayments that were unintended when billed or accepted can be converted into a felony. "Whoever, having

knowledge of the occurrence of any event affecting… his initial… right to any payment… conceals or fails to disclose

such event…" shall be guilty of a felony.

iv. The recent criminalization of transactions involving healthcare, healthcare providers, and healthcare benefit programs

has further increased potential exposure for the provider. This is now one of the greatest risk areas for providers.

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Qui Tam (Often Referred to as "the Whistleblower's Act")

• This statute is found in a section of The False Claims Act. It allows private citizens to initiate a

lawsuit in the name of the U.S. government, charging fraud against a government contractor

that receives or uses government funds, and allowing the citizen to share in any money

recovered. As a result of this law, enforcement is not limited to government officials. Private

individuals ("whistleblowers") may bring "qui tam" actions in the name of the U.S. government.

• The False Claims Act provides that anyone who presents a false or fraudulent claim to the

government is potentially liable for a civil penalty claim, plus damages.

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With so many laws to follow,

who is policing compliance?

• Department of Health and Human Services in conjunction with the Office of the Inspector

General

• Office of the Attorney General / The United States Department of Justice (DOJ)

• Federal Bureau of Investigation (FBI)

• Centers for Medicare and Medicaid Services (CMS)

• State Medicaid Fraud Units

• Office of Civil Rights

25But before any of these agencies, we are!

What is the Purpose of our

Compliance Program?

• Demonstrate our Corporation's commitment to sincere, ongoing efforts to comply with all

applicable laws;

• Revise and clarify current policies and procedures in order to enhance compliance;

• Enhance communications with governmental entities with respect to compliance activities;

• Empower all responsible parties to prevent, detect, and resolve conduct that does not conform

with applicable laws, regulations and the program; and

• Establish mechanisms for employees to raise concerns about compliance issues and ensure

that those concerns are appropriately addressed.

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7 Areas Addressed in Our

Compliance Plan (As Suggested by the OIG)

• Written Policies and Procedures

• Designation of a Compliance Officer and a Compliance Committee

• Training and Education

• Effective Communication

• Consistent Enforcement of Standards

• Auditing and Monitoring

• Appropriate Response to Detected Offenses

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Corporation’s Compliance Officer

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• The Compliance Officer serves as the focal point for the company’s privacy-related

initiatives.

• The Corporation’s current Compliance Officer is Preston Smith, ApolloMD’s Chief Revenue

Officer, who may be reached:

Phone - (770) 874-6902

Email - psmith@apollomd.com

Mail - 5665 New Northside Drive, Suite 320 Atlanta, Georgia 30328

• If an employee is uncertain whether specified conduct is prohibited, that employee should

contact the Compliance Officer prior to engaging in such conduct. Likewise, an employee

should report to the Officer any potentially non-compliant behavior of other employees.

Corporation’s

Compliance Committee

o The Corporation’s current Compliance Committee includes: • Preston Smith (the Compliance Officer), ApolloMD’s Chief Revenue Officer (770) 874-5432 /

rmurray@apollomd.com

• Joan Catalano-Parker, Corporate Counsel

(770) 874-5482 / jcatalano@apollomd.com

• Dave Afshar, Chief Financial Officer

(770) 874-5426 / dafshar@apollomd.com

• James Dale, Chief Technology Officer

(770) 874-5420 / jdale@apollomd.com

• Joel Koppenhaver, Chief Information Officer

(770) 874-5490 / jkoppenhaver@apollomd.com

• Thea Dellinger, Vice President of Human Resources

(770) 874-5485 / tdellinger@apollomd.com 29

The Compliance Committee will, under the guidance of the Compliance Officer, be responsible for

implementing the Company’s Compliance Program and otherwise coordinating and supervising the

Company’s compliance efforts.

How can you help?

• Learn how your job is critical to the Corporation’s compliance efforts

• Be familiar with and follow the Corporation’s policies and procedures

• Ask questions when uncertain

• Be proactive in suggesting changes

• Regard auditing and monitoring of your work as opportunities for improvement

• Know and abide by all aspects of the Compliance Plan

• Report to the Compliance Officer anything that looks suspicious or just feels wrong

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Exclusions Program:

LEIE DatabaseOIG is required by law to exclude from participation in all

Federal health care programs individuals and entities

convicted of the following types of criminal offenses:

1. Medicare or Medicaid fraud, as well as any other

offenses related to the delivery of items or

services under Medicare, Medicaid, SCHIP, or

other State health care programs;

2. Patient abuse or neglect;

3. Felony convictions for other health care-related

fraud, theft, or other financial misconduct; and

4. Felony convictions relating to unlawful

manufacture, distribution, prescription, or

dispensing of controlled substances.

The OIG maintains a list of all currently excluded individuals and

entities called the List of Excluded Individuals and Entities (LEIE).

Anyone who hires an individual or entity on the LEIE may be subject

to civil monetary penalties (CMP).31

Reporting Suspected Noncompliance

• We want to know! The Corporation is committed to ensuring that we do things “by the

book.” If you see or suspect noncompliance, we want to address the issue.

• It is each employee's duty and obligation to report any suspected noncompliance with the

Corporation’s Compliance Program or suspected violations of law.

• Employees may contact the Compliance Officer or any member of the Compliance

Committee by utilizing their personal contact information previously discussed (which is

also posted on the Compliance Bulletin Board at the Corporate office).

• The Corporation assures employees that there will be no retribution for reporting conduct

that a reasonable person acting in good faith would have believed to be erroneous or

fraudulent.

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Hotline Information

• The Telephone Helpline/Hotline is a simple, risk-free way for employees to report activities that may involve compliance violations.

• Callers to the helpline/hotline can seek advice about their own compliance-related situations and they can report suspected violations by others.

• This number rings directly to the Compliance Officer. Callers who wish to remain anonymous will be provided with an identification number. This number may be used by the caller to identify him or herself when calling back to report additional information or if further questioning by the Compliance Officer is necessary.

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Telephone Helpline/Hotline 1 (855) 343-3799

Email Helpline/Hotline compliance@apollomd.com

• The Email Helpline/Hotline serves the same purpose as the telephone helpline/hotline.

• This email box is monitored by the Compliance Officer.

• The OIG’s “Report Fraud” poster lists means

by which individuals can contact the OIG

directly to report fraud or suspected

misconduct.

• The Corporation posts a copy of this

document on its Compliance Bulletin Board.

Filing Reports with the OIG

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Resources

• U.S. Department of Health & Human Services: http://www.hhs.gov/

• Office of Inspector General: http://oig.hhs.gov/

• Centers for Medicare & Medicaid Services: http://www.cms.gov/

• Medicare: http://www.medicare.gov/

• The United States Department of Justice: http://www.justice.gov/

• Federal Bureau of Investigation: http://www.fbi.gov/

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• Alabama: Does not have a false claims act at the state level.

• Arkansas: http://falseclaimsactblog.com/static/false_claims/arkansas.html

• Arizona: Does not have a false claims act at the state level.

• Colorado: http://www.taf.org/colorado-fca-6-2010.pdf

• Florida: http://falseclaimsactblog.com/static/false_claims/florida.html

• Georgia: http://falseclaimsactblog.com/static/false_claims/georgia.html

• Illinois: http://falseclaimsactblog.com/static/false_claims/illinois.html

• Indiana: http://falseclaimsactblog.com/static/false_claims/indiana.html

• Kentucky: Does not have a false claims act at the state level.

• Louisiana: http://falseclaimsactblog.com/static/false_claims/louisiana.html

• Mississippi: Does not (yet) have a false claims act at the state level. (Note:

Senate Bill No. 2136 was introduced in January 2010 and then referred to motion was made for the bill to die in committee; the motion passed).

• Missouri: Does not have a false claims act at the state level.

Appendix*State-specific False Claims Act links

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• New York: http://falseclaimsactblog.com/static/false_claims/newyork.html

• North Carolina: http://falseclaimsactblog.com/static/false_claims/north-

carolina.html

• Ohio: Does not (yet) have a false claims act at the state level.

• (However, Senate Bill No. 143 was introduced March 7, 2011. A copy of the read at http://www.legislature.state.oh.us/bills.cfm?ID=129_SB_143).

• Pennsylvania: Does not (yet) have a false claims act at the state level.

• (However, Senate Bill No. 1113 was introduced in October 2009 and then the proposed legislation may be read at http://www.legis.state.pa.us/CFDOCS/Legis/PN/Public/btCheck.cfm?txtType=PDF&sody=S&billTyp=B&billNbr=1113&pn=1483).

• South Carolina: Does not (yet) have a false claims act at the state level.

• (However, Senate Bill No. 320 was introduced in January 2009 and referred to a February 2009. A copy of the proposed legislation may be read at 2010/bills/320.htm).

• Tennessee: http://falseclaimsactblog.com/static/false_claims/tennessee.html

• Texas: http://falseclaimsactblog.com/static/false_claims/texas.html

• Virginia: http://www.taf.org/virginiafca.htm

• West Virginia: Does not have a false claims act at the state level.

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Appendix*State-specific False Claims Act links

38

Conclusion

This concludes our general compliance training. You will now need to complete a brief

assessment. Please answer each question to the best of your ability.

Thank you for your commitment to compliance.