Valuing Integrity Corporate Compliance October 2006 Anne Adams Chief Compliance Officer

1. Valuing Integrity Corporate Compliance October 2006 Anne Adams Chief Compliance Officer Emory Healthcare and Emory Medical Care Foundation Sue Dale Administrator, Gynecology and Obstetrics Emory University School of Medicine and The Emory Clinic

2. What is Compliance ? • Complying with applicable Federal and State laws and regulations. • Following all Emory and departmental policies and procedures. • Doing the right thing!

3. Compliance Program • Committed to conducting business in compliance with all federal, state, and local laws. • Committed to preventing and detecting non- compliance . • “Standards of Conduct” and other policies to guide our activities.

4. Elements of a Compliance Program • Compliance Standards & Procedures • Chief Compliance Officer • Employee Training • Monitoring & Auditing • Reporting Process • Response & Prevention • Enforcement & Discipline

5. Role of the Compliance Office • Establish, oversee implementation, and revise the Compliance Program • Provide oversight for organization’s compliance activities • Provide education • Provide advice and guidance • Develop compliance policies • Investigate reports of non-compliance • Monitor compliance with rules & regulations • Coordinate response to external investigations • Oversee corrective actions

6. WhyDo Organizations Need a Compliance Program? • Government focus/enforcement • Risk of prosecution/penalties • Protect system resources/reputation • Health Insurance Portability and Accountability Act (HIPAA) • Grants and Contracts • Research/IRB/FDA/OHRP • Sarbanes/Oxley • Healthcare Industry Fraud and Abuse

7. Who Are the Players? • Centers for Medicare & Medicaid Services (CMS) • Office of Inspector General (OIG) • Department of Justice (DOJ) • Federal Bureau of Investigation (FBI) Financial Crimes Section • Georgia Bureau of Investigation (GBI) • Medicare/Medicaid Fraud Unit • Office of Civil Rights (OCR)

8. Your Responsibility • To know the rules that apply to your section/department. • Follow the rules, help find and report potential violation and problems. • Actively participate in and promote compliance.

9. Main Areas of Risk • Teaching physician presence. • Billing for items or services not rendered (or documented). • Providing medically unnecessary services. • Upcoding/ Unbundling. • Failure to properly use modifiers (25, 26, 59, etc.). • Consultations/New vs. established. • Misrepresenting diagnosis to justify service. • Billing for a non-covered service as covered. • Research misconduct • Research Effort Reporting

10. Non-Retaliation Policy • It is the policy of EMORY that individuals making good-faith reports of compliance concerns will not experience any form of retaliation. • If you experience or witness retaliation, report it to the Compliance Office immediately. • Incidents of retaliation will have serious consequences.

11. Are We Getting Our Voluntary Compliance Program Right?

12. Are compliance efforts impacting employee and organizational activity? • Enhance – to improve quality/to make greater. • Culture – social behavior patterns typical of a population or community at a given time. • Education. • Resources. • Awareness/Open communication. • Influence positive behavior. • Meet requirements of the Federal Sentencing Guidelines. • We have a solid foundation and we want to build on that foundation and reaffirm our commitment.

13. Strengths • Leadership • Physicians committed to patient care • Encourage open communication/questions with managers • Employee commitment • Excellent internal consultants

14. A blended program value based – awareness of key organizational principles; prevention; core principals are offered; employees are individually accountable to values; encourage employees to question decisions before taking action. rules based – do’s and don'ts; general deterrence of bad conduct though emphasis on punishment and avoidance. Must continue to have leadership support – words and resources.

15. The Role of Management • Management serves as the primary example and the primary source of information for our employees. • Management fosters open communication regarding compliance and answers questions raised by employees. • Management is accountable for their own actions as well as the actions of those they supervise.

16. Compliance is a team effort – Everyone is responsible for making a winning team. • No room for behavior not geared to professionalism, integrity, compliance and excellence. • “Off Messages” that are inconsistent with a culture of compliance risks our reputation of excellence. • Lead by example - we have set clear expectations for documentation and coding compliance. • Emory goes beyond compliance.

17. We must maintain a culture of professionalism, integrity and compliance at Emory. • Current culture is healthy, but want to continue to maintain/improve health and wellness – continue to ask questions and raise compliance concerns. • Don’t want to leave organization, employees and physicians vulnerable to not meeting regulations/ government inquiry. • Accurate documentation, coding and billing are critically important functions. • Non-compliance by a few puts Emory at risk.

18. Integrity and Ethics – physicians, administrators, staff, board members are all involved and it reaches across all functions. • Ultimately enhancing our culture of compliance goes to integrity strategy – compliance plays a role/faciliate, but managers at all levels and across functions are involved in the process. • Physician/Management Driven. • Must have a willingness to seek solutions within framework of values. • Values are integrated into the normal channels of managements. • Support and reinforce organizational values.

19. Commitment to Compliance • Follow applicable rules and regulations. • Ask questions if the rules are unclear. • Act when your instincts tell you something is wrong. • You must report potential violations. • Be a part of the solution if a problem is found.

20. Reporting Potential Problems • Who do I go to? • Supervisor or Manager • Compliance Department 404-778-2757 • Emory Healthcare Trust Line • 1-888-550-8850 (Anonymous Reporting 24/7) • What will happen? • Determination who will handle issue • Investigation • Action

21. Administrator’s Perspective • Most difficult challenge is the task of influencing physicians to adopt compliance as an integral part of our standard operating procedures. • This is not Monopoly – there is not a get out of jail free card • “Teaching physicians suffer from mural dyslexia”(Fast Tracking Compliance Training in Academic Practices article MGMA) • Cannot see the handwriting on the wall • Why are we spending money on compliance? • Compliance is a control program

22. Expecting Reactions To Compliance • Typical Reactions to Compliance: • Great men can’t be ruled • What rules? When did this start? • Glassed over eyes – asleep • Must not be talking to me • Administrator’s Reaction: • Never react back or will be seen as the evil one • Use positive arguments • Use a physician champion

23. What are the Physicians’ Expectations • Communication: • Communicate both good and bad news; communicate regularly • Honor confidentiality • Share data • Allow venting of frustrations • Stay on their side – avoid defensiveness • Use examples • Consistency • And…..be cheerful, confident, and optimistic

24. Best Practice – Consistent Themes • Physician-to-physician communication that compliance is not optional – based on integrity • Staff need to hear and see that leadership has taken a stance in favor of ethnical business practices. • Train physicians and staff in small specialty specific groups – more relevant and makes it practical application easier.

25. Best Practice – Consistent Themes • Use numerous examples from their own notes and specialty to demonstrate the point and use as examples. • Make the education and training interactive. • Have a sense of humor. • Recent documentation - The lab test indicated abnormal lover function; The patient is still under our car for physical therapy; The patient is numb from her toes down; Patient was alert and unresponsive; When she fainted her eyes rolled around the room; Patient seen in the ED, examined, x-rated and sent home.

26. Compliance Programs Questions? Emory Healthcare Compliance Program 404-778-2757 or Extension 8-2757 Anne Adams, MS, JD Chief Compliance Officer Emory Healthcare Emory Medical Care Foundation Emory Trust Line 1-888-550-8850

27. Questions regarding Research Compliance Kristin H. West, J.D. Assoc. V.P. & Director Emory University Office of Research Compliance 1784 N. Decatur Road, Suite 510 Atlanta, GA 30322 Phone: (404) 727-2398; FAX: (404) 727-2328 Emory Trust Line 1-888-550-8850

28. Helpful Resources http://www.cms.hhs.gov Centers for Medicare and Medicaid Services (CMS) http://www.georgiamedicare.com/ Georgia Medicare Part A http://www.gamedicare.com/ Georgia Medicare Part B http://www.cms.hhs.gov/hipaa/ CMS - HIPAA Main Page Teaching Big Shots to Behave and other Human Resource Challenges By Stephen M Paskoff, Esq. (Visit the OCP web-site to see more resources)

29. Compliance Office Motto