Corporate Responsibility

1. Corporate Responsibility Regulatory Compliance “Systems that ensure all students are aware of laws and regulations and act in accordance of those regulations”

2. Corporate Responsibility Why is this important to me?

3. Compliance Goal Provena Health is committed to compliance with all federal and state laws and regulations. The goal of Provena Health’s compliance efforts is to ensure all business is conducted ethically, honestly and in accordance with all rules, regulations and standards

4. Office of the Inspector General • Office of the Inspector General (OIG) • The enforcement arm of the Department of Health and Human Services. • Primary goal is to investigate suspected health care fraud and abuse, specifically: Medicare & Medicaid

5. Risk A large portion of the OIG regulations focus on Risk Assessment At Provena Health our highest risk areas are: • Coding • Billing • Documentation/Charting • Chain of Command issues • Quality of care- Substandard Care • Patient/Resident Privacy (HIPAA)

6. OIG - Recommendations Due Diligence Recommendations • Standards of Business Conduct education for all employees • Senior Oversight of Compliance Programs • Background checks, on all employees, vendors, and volunteers before hire and biannually • Create a culture of awareness and establish reporting mechanisms. • Compliance monitors and audits performed on a regular basis • Standards and Compliance procedures for all employees

7. The Provena Health Corporate Responsibility Plan • Provena Health’s Standards of Behavior are based on the Provena Health Values of: Respect Integrity Stewardship Excellence It is the expectation of all Provena Health students that they act with integrity, honesty, and they approach all customer interactions ethically and confidentially

8. The Provena Health Corporate Responsibility Plan • Senior Oversight Meghan Kiefferserves as Provena Health’s System Corporate Responsibility and Compliance Officer The Provena St. Mary’s Hospital Corporate Responsibility Liaison is Theresa Barnes 815-937-3500

9. The Provena Health Corporate Responsibility Plan • Due Diligence in Hiring Criminal background checks are performed on all new employees. We additionally check the Excluded Provider list to assure that our employees, medical staff and vendors have not been excluded from participating in any federally funded health care programs.

10. The Provena Health Corporate Responsibility Plan • Student Awareness and Training All Provena Health students are required to participate in annual Corporate Compliance training. All new employees are required to receive Corporate Compliance in New Employee Orientation

11. The Provena Health Corporate Responsibility Plan • Monitors and Audits At Provena Health, systems are in place to continuously monitor the accuracy of our coding, billing, and documentation. These systems are designed to reasonably detect errors and problems. • CHAN (Catholic Health Audit Network) is Provena Health’s internal auditor

12. The Provena Health Corporate Responsibility Plan • Discipline Any violations of corporate compliance istaken very seriously and appropriate and consistent disciplinary action is take for all violations, regardless of title, position, or affiliation.

13. The Provena Health Corporate Responsibility Plan • AlertLine 1-800-93-ALERT • A confidential and anonymous vehicle to report compliance issues. • Outsourced to Global Compliance and reporting is free of retaliation • Our preference is that you initially follow the standard chain of command when faced with a compliance issue Supervisor>local Compliance Liaison>System Compliance Officer, then to the AlertLine

14. The Provena Health Corporate Responsibility Plan • Whenerrors are detected, we must take reasonable steps to respond appropriately, determine the root cause, and prevent similar errors in the future • Stop the process, protocol or billing if necessary • Determine the cause of the error • Develop a protocol to prevent future errors • Communicate and implement protocol • Continuously monitor the protocol

15. False Claim Act This Act provides a legal tool to counteract fraudulent billing turned into the Federal Government Claims under the Act are filed by persons with inside knowledge of the false claim (“whistle blowing”)

16. False Claim Act False claims can occur with documentation issues that turn a legitimate claim into a false claim. Problem Areas: • No documentation • Incomplete or incorrect documentation • Documenting on delivery of care that you did not deliver personally or witness being delivered. • Missing signatures • Missing or backdated dates

17. False Claim Act High Risk Areas: Billing • Supplies or services not delivered • Services not medically necessary • Billing for a non-covered service, as if covered • Outpatient services that should have been included as part of an inpatient stay

18. False Claim Act Risk Areas (cont.) • Up-coding • Misrepresenting a diagnosis to justify services • Unbundling • Duplicate billing

19. Your Responsibility Conflict of Interest Students who are in a position of trust that have competing professional or personal interests. Conflict of Interest arises when anyone has 2 duties that conflict • Students must not use their positions to profit personally. • Students must not share confidential Provena Health information for personal gain • Students must disclose in interest in business that you or a family member have if that business: Buys/sells goods or services to/from Provena Health Competes with Provena Health Is in a position to benefit from patient referrals

20. Your Responsibility Gifts, Honoraria and Gratuities Students cannot accept gifts or gratuities from patients/residents/clients or vendors. Must never accept • Money • Loans • Gift Certificates Acceptable • Candy, Fruit, or food that can be shared If unsure , ask your compliance officer or call the Alert-Line

21. Your Responsibility • Know all the laws and regulations that affect your job responsibilities • Bring to your supervisor’s attention any suspected issues/concerns as a condition of employment. • Avoid and report any suspected conflicts of interest • Complete your annual education requirements

22. Your Responsibility It is the expectation of Provena Health that all students exhibit the Standards of Behavior, know what is right, and do what is right. If you see something that does not look or feel right, contact your supervisor or the Corporate Responsibility Liaison or call the Alert-Line

23. Your Resources • Provena Health Corporate Compliance and HIPAA Policies can be found on Dovenet http://dovenet.provena.org/ • Local Compliance Liaison • Alert-Line Web page photo