AMG CORPORATE COMPLIANCE
PROGRAM
It’s About Doing
The Right Thing...
Revised-8/2016
AMG COMPLIANCE PROGRAM
Established to ensure the company operates in accordance with laws and regulations
The Program is designed to:
PREVENT/DETER any accidental and intentional violations of laws
DETECT violations if they occur
CORRECT any future non-compliance
1. STANDARDS AND PROCEDURES - Code of Ethics and Business Conduct, the foundation of the Compliance Program
2. OVERSIGHT – The designation of Corporate Compliance Officer
3. EDUCATION AND TRAINING - Ensures our workforce can perform job functions in compliance with rule and regulations
4. AUDITING AND MONITORING- Ongoing review and risk assessment
5. REPORTING – Hotline and communication without fear of retaliation
6. ENFORCEMENT AND DISCIPLINE – Ensure disciplinary actions are imposed for non-compliance 7. RESPONSE AND PREVENTION – Respond and develop corrective action
SEVEN PILLARS OF COMPLIANCE
EVERYONE’S RESPONSIBILITY
Compliance is EVERYONE’S Responsibility RESPONSIBILITY OF WORKFORCE MEMBERS:
UNDERSTAND how the Compliance Program applies to your job and ask questions when necessary
REPORT any suspected violations
Actively PARTICIPATE in compliance activities (Training)
RESPONSIBILITY OF SUPERVISORS AND MANAGERS:
CREATE and MAINTAIN a culture of compliance
PREVENT, DETECT, RESPOND to compliance problems
PREVENT RETALIATION against employees who report violations in good faith
HEATHCARE REGULATORY
ENVIRONMENT
Healthcare is a government enforcement
priority because of the potential for fraud and
abuse
FRAUD AND ABUSE
FRAUD - making material false statements or representations of facts that an individual knows to be false or does not believe to be true in order to obtain payment or other benefit to which we would otherwise not be entitled
ABUSE –practices that directly or indirectly result in unnecessary costs or improper payments for services which fail to meet recognized professional standards of care
Fraud and Abuse Explanation Fraudulent activity is an action that is done for one’s own benefit or for the benefit of another. The activity can be knowing, willful, reckless, or unintentional. Fraudulent activity may involve false statements or representations of facts in order to benefit or obtain payment. Abuse involves practices that result in unnecessary increased costs or use of medical services or products.
Examples of Fraud and Abuse:
Billing for Services not provided Billing for Services not medically necessary Falsifying records Substandard quality of care Restriction of patient choice Offering, soliciting, giving or receiving
anything of value for a patient referral
SIGNIFICANT LAWS
Healthcare is an industry with strict standards and regulations that are aimed at reducing fraud, waste and abuse. These laws are to prevent financial motive from influencing medical judgment. The laws seek to protect patients, improve the quality of care delivered, and in turn reduce cost.
LAW THESE LAWS:
False Claims Act Deficit Reduction
Act Fraud and
Enforcement Recovery Act (FERA)
Fight fraud and abuse
Encourage reporting by whistleblowers
Outlaw retaliation against whistleblowers
Aim to reduce rising healthcare spending
Establish liability for presenting false claim
FALSE CLAIMS ACT
Providers can be prosecuted for a wide variety of conduct that leads to the submission of false claims. Such conduct includes: Falsifying records
Knowingly making false statements
Double-billing for items or services
Submitting bills for services never performed
Potential penalties for violating the False Claims Act are severe and include: Civil or monetary penalties ranging from $10,781 to $21,563 per claim
Criminal prosecution, including imprisonment
Exclusion from federal healthcare programs
The False Claims Act includes a “qui tam” or
whistleblower provision to
encourage people to come forward
and report wrongdoing
without retaliation
ANTI-KICKBACK STATUTE
LAW THIS LAW: Anti-Kickback Statute Prohibits the offer or receipt of certain
remuneration in return for referrals Includes any kickback, bribe, or rebate Defines a violation as a criminal offense
Potential Penalties for Violation:
$50,000 civil monetary penalty per violation
Criminal penalties of up to $25,000 in fines and/or up to 5 years in prison
Exclusion from federal healthcare program
LAW THESE LAWS:
Health Insurance Portability and Accountability Act (HIPAA)
American Recovery and Reinvestment Act (ARRA)
Health Information Technology for Economic and Clinical Health Act (HITECH)
Omnibus Rule
Provide insurance portability
Establish Standards for privacy and security of patient information
Strengthen HIPAA privacy and security standards and penalties for breaches of information
HIPAA PENALTY TIERS
HIPAA Violation Civil Monetary Penalty
CAUSE $ AMOUNT
Violation was not known $100-$50,000 per violation
Due to reasonable cause and not to willful neglect
$1,000-$50,000 per violation
Due to willful neglect, but is corrected
$10,000-$50,000 per violation
Due to willful neglect and is not corrected
$50,000 per violation
Questions regarding HIPAA and any other privacy or
security questions should be directed to Susan Wallis, RHIT,
CHC- Privacy Officer [email protected] or 337-269-9566. Full HIPAA
training is available on Medline U for reference.
All Privacy or Security related events should be immediately
reported to the Privacy Officer
STARK LAW
LAW THIS LAW: The Stark Law is also referred to as
the Physician Self-Referral Law
Prohibits physicians from referring Medicare patients for certain services to an organization with which the physician or a member of the physician’s immediate family has a financial relationship unless an exception exists.
Prohibits an entity from presenting (or causing to be presented) a bill or claim to anyone for a service furnished as a result of a prohibited referral.
Potential Penalties for Violation: $10,000 for each failure to report when required by statute $15,000 for each item or service subject to improper
referral $100,000 for each circumvention scheme Exclusion from Medicare/Medicaid Programs Possible False Claims Act Liability
PPACA
LAW THIS LAW:
Patient Protection and Affordable Care Act (PPACA)
Supports healthcare reform Establishes health insurance
exchanges Provides new tools to fight
fraud and abuse Increased Criminal and civil
penalties Expansion of Recovery Audit
Contractors (RAC)
Government Resources
The Office of Inspector General (OIG) uses 5 strategies to prevent healthcare fraud, waste and abuse:
1 Enrollment: Scrutinize provider applicants
2 Payment: Use reasonable, responsive methods
3 Compliance: Assist providers to comply
4 Oversight: Monitor for fraud, waste, and abuse
5 Response: Punish fraud, remedy vulnerabilities
HEALTHCARE FRAUD PREVENTION AND
ENFORCEMENT ACTION TEAM (HEAT)
The HEAT Team makes fighting Medicare fraud a Cabinet-level priority for Health
and Human Services and the Department of Justice (DOJ). The Medicare Fraud Strike Forces include teams from the
following:
DOJ- Criminal Division FBI CMS HHS’ Office of Inspector
General
AMG COMPLIANCE PROGRAM BASICS
To be Proactive NOT REACTIVE
STANDARDS AND PROCEDURES
The AMG Code of Ethics and Business Conduct requires you to follow federal and
state regulations for fraud, waste and abuse as well as
company compliance policies. It requires that you behave in
a way that helps the organization keep a good
reputation in the communities in which we
serve
CODE OF ETHICS AND BUSINESS CONDUCT
Every member of the workforce must do their job ethically and with professionalism
Workforce members MUST:
Follow AMG Policies and Procedures Comply with Federal, State, and Local
regulations Commit to reporting any compliance
concerns/violations Read and sign that you understand the
Code Follow the Code in your daily activities Contact Stephen Devall at 337-269-9566
with questions regarding the Code
CONFLICT OF INTEREST
All workforce members, including but not limited to employees, vendors, medical staff, leadership, and governing board members, must disclose any situation which would potentially be a conflict of interest with AMG.
Workforce members MUST disclose:
Any employment arrangement; Financial interest; Official position; Ownership interest; Loan to or from; Guarantee of any obligation; and/or Any other relationship that such employee (or
MEMBER OF HIS/HER IMMEDIATE FAMILY) has with AMG’s customers, vendors, competitors, or other business relation that could potentially be a conflict of interest at the time of hire/contracting/appointment and per policy thereafter
Immediate Family Member: spouse, child or spouse of a
child, brother, sister, or spouse of a brother or sister, mother-in-law, father-in-law, brother-in-law or sister-in-law.
CONFLICT OF INTEREST – continued
Financial interest does not include ownership of an immaterial amount of stocks or bonds in a publicly held company
No person shall be permitted
to participate in the decision-making process with respect to a transaction in which such person may have a conflict of interest
PROHIBITED BEHAVIOR
Behavior that is prohibited under the AMG Code of Ethics and Business Conduct
Behavior that is prohibited: Billing for services that are not medically necessary Retaliation Sexual harassment or workplace violence Using company property for personal use without supervisory
approval Destroying or altering company records beyond what AMG
policy allows Falsification of mileage or timesheets Improper billing of services Engaging in activity that is a conflict of interest for AMG Inappropriately accessing patient information without a “need to
know” Inappropriately disclosing patient health information Discrimination based on race, color, religion, gender, national
origin, sexual orientation, disability, or age Offering or paying a referral source anything in exchange for a
referral Contracting, employing, or billing services rendered by an
individual or company that is excluded from participation in federal healthcare programs
Disregard of company policies and procedures
OVERSIGHT
The AMG Corporate Compliance Officer is
STEPHEN DEVALL
For questions or concerns the Compliance Officer may
be reached at 337-269-9566
EDUCATION AND TRAINING
Every workforce member will be trained
Training will be provided:
Upon hire Annually When there is a significant
change in regulation determined by the Compliance Officer
AMG COMPLIANCE RISK AREAS
Summary of AMG Key Compliance Risk Areas:
The federal Anti-Kickback Statute HIPAA Privacy and Security Rules Risk identified by the Office of Inspector General and other government agencies Submission of accurate claims and the federal False Claims Act The referral-based statutes listed in the Stark Law (Physician Self-Referral Law) Coding and Documentation Disclosure of Physician Ownership Hospital Readmissions Substandard Care
COMPLIANCE AUDITING AND MONITORING
ACTIVITIES:
The AMG Compliance Committee assesses risk and oversees
company wide mitigation of risks. An ongoing auditing and
monitoring program is maintained to monitor adherence to AMG
policies and procedures , including state and federal laws. The
Government also performs audits through various programs.
AUDITING AND MONITORING
The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) calls for auditing and monitoring as “an ongoing evaluation process (that) is critical to a successful compliance program.”
The OIG states that auditing and monitoring should be:
an ongoing process; thorough with regular reporting on it to
senior officials, including the board; regular, periodic audits by qualified people
focusing on programs with substantive exposure to government enforcement actions; and
ensuring compliance with specific federal, state, and internal rules and policies.
RESPONDING TO GOVERNMENT REQUESTS
All government audit requests such as ADR, RAC, MAC, CERT,
Probe, ZPIC, OIG, OCR, etc., should be sent to the Corporate office for
review and instruction.
CMS
OIG
OCR
ENFORCEMENT AND DISCIPLINE
Always do the right thing! Failure to follow the AMG Compliance program may
result in: • Disciplinary Action • Termination • Criminal Prosecution • Monetary Fines • Exclusion from Federal
Healthcare Programs
WORKFORCE RESPONSIBILITY
All Workforce members should: Disclose conflicts of interests Report suspected compliance violations, without
the fear of retaliation, including, but not limited to, violations of:
AMG Code of Ethics and Business Conduct Policy and procedure Patient Safety and Quality
Concerns State or Federal law/regulations
HOW TO REPORT VIOLATIONS
There are several ways to report a potential Compliance violation including:
Notifying your Supervisor or department manager Via the “File a Compliance Report Online” link on the AMG website at
www.amgihm.com under “Contact Us” Contacting the Corporate Compliance Officer, Stephen Devall, at 337-269-
9566 Via mail at 101 La Rue France, Suite 500, Lafayette, LA 70508 Anonymously via the Compliance Hotline at 844-523-2091
RESPONSE AND PREVENTION
INVESTIGATION/RESPONSE/CORRECTIVE ACTION:
All reported concerns are investigated confidentially and expeditiously. No
retaliation or disciplinary action will be taken against any individual for reporting
an issue or concern in “good faith”. Anyone who retaliates against an
individual for reporting a compliance concern will be subject to disciplinary
action, up to and including termination. If the reported concern is validated through
investigation the Company will appropriately respond and implement
corrective action to prevent future non-compliance
Please see the AMG Non-Retaliation Policy #015 for more information
QUESTIONS
FOR QUESTIONS REGARDING THIS TRAINING PLEASE CONTACT STEPHEN
DEVALL, CORPORATE COMPLIANCE OFFICER AT 337-269-9566