2015-2016 Corporate Compliance Training Welcome to Northside Hospital s Annual / New Hire Compliance Training 1 of 35
Goals of Session 1. Review Northside s Compliance Program and Code of Conduct 2. Emphasize the importance of Northside s Compliance Program 3. Review the role of the Compliance Department Helps you to understand: The standards described in the Compliance Program. The application of those standards to you. Your role in compliance. The importance of complying with the Compliance Program. The Compliance Department s commitment to helping you understand the Compliance Program and answering your compliance related questions. 2 of 35
Northside s Compliance Program Who must comply with the Compliance Program? Northside remains committed to compliance and strives to conduct its operations in compliance with applicable laws and regulations. Northside s comprehensive Compliance Program assists the organization in those efforts. Everyone!!! Employees Management Administration Board members Medical staff Contractors and vendors Volunteers 3 of 35
Elements of Northside s Compliance Program 1. Compliance Committee and Chief Compliance Officer 2. Written Policies and Procedures 3. Compliance Training and Education 4. Open Lines of Communication 5. Compliance Monitoring and Auditing 6. Corrective Action Process 4 of 35
No. 1 Compliance Committee and Chief Compliance Officer Northside s Chief Compliance Officer Jorge Hernandez Northside s Compliance Committee: Jorge Hernandez, Chair (Vice President of Administrative Services and Chief Compliance Officer) Catherine Butler (Director, Legal Services) David Converse (Director, Information Systems) Bridget Green (Director, Human Resources) Debbie Mitcham (Vice President of Finance and Chief Financial Officer) Robert Skip Putnam (Vice President of Administration and Northside Forsyth CEO) Mary Shepherd (Vice President of Clinical Operations) Susan Sommers (Vice President, Legal, Risk Management and Ancillary Services) Carl Waller (Vice President, Supply Chain Management) 5 of 35
No. 2 Written Policies and Procedures COMPLIANCE MANUAL Contains Northside s Code of Conduct Compliance Program Policies and Procedures Available on Lucidoc All employees are responsible for being familiar with and complying with the Code of Conduct and these Policies and Procedures 6 of 35
Code of Conduct Northside s Code of Conduct is a summary of the most important ethical and legal standards that guide our behavior. Please Read Code Now Please click here to read Northside s Code of Conduct This step is mandatory and will take 15-20 minutes to review Code of Conduct If you would like to print a copy of the Code of Conduct for further review click on the print icon when the file is opened. 7 of 35
Patient Care Is Paramount Legal And Regulatory Compliance Northside s No. 1 priority is to provide the highest level of care to our patients and our community while maintaining the highest level of integrity. We pledge compassionate support, personal guidance and uncompromising standards to our patients in their journeys toward health of body and mind. We provide care without discrimination based on gender, race, color, age, religion, national origin, sexual orientation or disability. We know our legal and ethical obligations and we create policies to help us comply with these responsibilities. We work throughout the Northside system to understand how ethical, moral and legal standards apply to our operations. We require you to understand the basic legal obligations that pertain to your job function or the services that you provide to Northside. 8 of 35
Relationships with Other Providers Avoidance of Conflicts of Interest Northside monitors its business dealings to structure relationships with physicians and other healthcare providers consistent with relevant federal and state laws in furtherance of Northside s mission. Northside trains appropriate personnel on the restrictions governing the manner in which Northside transacts business and its relationships with physicians and other healthcare providers. Northside understands that any private activities or interests that influence (or could appear to influence) an individual s ability to objectively perform his or her work must be avoided. Northside employees and agents should disclose to their supervisor, the Chief Compliance Officer or the Legal Services Department any situation that could be a conflict of interest with Northside as well as any financial interest or other position with a Northside vendor, supplier, competitor or other business relation that could create a conflict of interest with Northside. 9 of 35
Strong Relationship with Payors Lobbying and Political Activity Northside strives to accurately bill all payors, including public and commercial insurance payors. Northside monitors its practices to prevent inaccurate claim submissions and to promote accurate cost report practices. Northside refrains from lobbying and engaging in political activity that may jeopardize its federal and state tax exempt status. Northside resources and funds shall not be used to contribute to political campaigns or in furtherance of political activity. Officers and employees may personally participate in or contribute to political organizations or campaigns but must do so as individuals, and not as representatives of Northside. 10 of 35
Government Contracts Northside is committed to conducting business with all Government agencies Federal, State, Local and Foreign. Northside has developed a Code of Business Conduct and Ethics for Government Contracts. Specialized training will be provided to employees and contractors who will be working on and supervising those who work on a Government contract or subcontract. Employees who are not working directly on a Government contract should take special note of the sections concerning employment of former government employees, restrictions on gifts and gratuities, and the procurement integrity policy. 11 of 35
Gifts of Cash or Cash Equivalents Ineligible Persons Northside employees are not permitted to accept or solicit, or to pay or provide, gifts of cash (or cash equivalents) based on the individual s position or association with Northside or related to any Government contract or subcontract, or the prospect of such contract. Northside has mechanisms in place to detect and prevent the employment or engagement of any individual or entity excluded or discharged from participation in Federal healthcare programs. Prospective and current employees and contractors shall disclose any debarment, exclusion or other suspension from participation in Federal healthcare programs or any conviction of a criminal offense related to the provision of healthcare items or services. 12 of 35
Responding to Government Investigations In the unlikely event a government investigation is conducted: Immediately notify the Chief Compliance Officer or the Legal Services Department. Do not attempt to interfere with the government s investigation. Do not destroy, delete, hide, alter, or otherwise dispose of any documents, e-mails, or other information relating to the subject of the investigation. Any attempt to hide or destroy documents sought in an investigation is a serious violation of law and Northside s Compliance Program. Do not discuss the investigation or the events under investigation except at the direction of the Chief Compliance Officer or Legal Services Department. 13 of 35
Responding to Government Investigations If a government agent or investigator contacts you or requests an interview (either at Northside or your home), you should immediately notify the Chief Compliance Officer or the Legal Services Department. You should also contact your own personal counsel (if you have counsel), before answering any questions or submitting to an interview. Always keep in mind, however, that you have no obligation to consent to an interview. You should obtain the following information from the investigators: the name, agency affiliation, business telephone number, and business address of all investigators, and the reason for the visit. 14 of 35
Confidential Information Safeguarding Patient Information Northside has developed systems to maintain the integrity and privacy of documents, records, images and other information. Northside employees are required to safeguard and not disseminate all such information. If you are unsure of the protections that apply to a document or record, please ask your supervisor or the Chief Compliance Officer. Northside maintains policies that apply specifically to financial information and patient information. Northside also maintains policies that apply to third party information that Northside has obtained under an obligation of confidentiality and Government contractor bid and proposal and Government source selection information Northside is committed to maintaining the integrity and security of patient health information and has developed policies and procedures governing the use and disclosure of this information. Northside strongly encourages you to report any issues or concerns you have about the security or integrity of patient information. If you observe or suspect any inappropriate or suspicious activity, it is your responsibility to report it to your supervisor, the Privacy Officer 404-845-5653, the Security Officer 404-303-3630 or the HIPAA Hotline 404-845-5534. 15 of 35
HIPAA Federal and state laws contain privacy and security rules that govern the use and disclosure of patient health information. For example, a federal law, the Health Insurance Portability and Accountability Act ( HIPAA ), has standards to protect the use and disclosure of protected health information ( PHI ). 16 of 35
What is PHI? PHI consists of patient identifiable information delivered via paper, verbal communications or electronic means. Examples include: Patient name Date of birth Medical record number # Address Email address SS # PHI may be shared among caregivers for the purposes of: Treatment, Payment or Healthcare Operations ( TPO ). Healthcare Operations include: QA/QI, Utilization Review, Disease Management, Credentialing, Auditing, etc. Requests for uses or disclosure of PHI for non-tpo purposes should be submitted to the Privacy Officer, 404-845-5653. 17 of 35
Using PHI Use or disclosure of PHI should be on a need to know basis. Access to a system does not imply that it is appropriate to search any patient information at will. In other words, never look at patient information unless it is necessary to do your job. Only use the absolute minimum necessary patient information. Employees must read and sign a Confidentiality of Information & Computer Access Code Agreement, which explains your responsibility to keep information confidential and secure. 18 of 35
PHI Security Do not leave any PHI data displayed on your monitor or unprotected at your workstation when you are away. Always log out of an application before leaving your workstation. Lock your computer and secure PHI when you leave your workstation. Always place monitors in a location that prevents others from viewing information on the screen. Use screen savers to help ensure confidentiality. Make sure laptops and PCs are monitored and secure. Never send PHI via email or the Internet without using encryption that is approved by the IS department. Call the IS Help Desk at 404-851-8883 if you suspect a PC is infected with a virus or under any other sort of electronic attack. 19 of 35
Usernames and Passwords Never share your username or password with anyone. Memorize your password, do not write it down. Do not use family members or pets names, phone numbers, birth dates or other easily guessed information as your password. Change your password periodically (at least every 90 days). If you suspect your password has been compromised, change your password immediately. 20 of 35
No. 3 Compliance Training Northside maintains an active compliance training program. All employees are required to participate in this annual compliance training. In addition to this annual compliance training, Northside employs various other methods to train you on relevant compliance matters. 21 of 35
No. 4 Open Lines of Communication Northside has established a toll-free hotline for all individuals to anonymously report suspected violations of the Compliance Program Northside Hotline No: 404-845-5907 Northside will not take disciplinary action against anyone because they submit a compliance concern. 22 of 35
No. 4 Open Lines of Communication Northside encourages you to ask questions. All employees have an affirmative obligation to report even suspected misconduct. You may make a report through the anonymous hotline, your supervisor or the Chief Compliance Officer. Failure to communicate a known compliance concern through an established reporting mechanism will be considered a violation of the Compliance Program. 23 of 35
No. 5 Compliance Monitoring Northside takes steps to maintain compliance with its standards and procedures by utilizing monitoring and auditing systems. Northside s Internal Audit Department works closely with the Compliance Department to conduct audits of potential risk areas. 24 of 35
No. 6 Corrective Action If a violation of Northside s Compliance Program occurs the Chief Compliance Officer, working with the Compliance Committee, will determine the appropriate corrective action to take. Appropriate corrective action may include, but is not limited to: (a) training (b) re-billing claims (c) fixing system errors; and/or (d) disciplinary action (up to and including termination). 25 of 35
Expectations Click here if you are an employee Click here if you are a manager Managers are employees with oversight responsibility, including executive management, administrators, directors, managers and supervisory personnel Click here if you are a medical staff member Click here if you are a contractor, agent, vendor or volunteer 26 of 35
Employee Expectations Think about how the Compliance Program applies to your work and rely on the Code of Conduct and the other policies and procedures to guide your decisions. If you have a question or concern: Speak with your supervisor; Speak with the Chief Compliance Officer, 404-851-6378; or Call the anonymous hotline, 404-845-5907 27 of 35
Employee Expectations Receive compliance training. Read the Compliance Program Manual and Code of Conduct. Sign an affirmation statement stating that you understand and agree to abide by Northside s Code of Conduct and Compliance Program Policies and Procedures. Be familiar with compliance risk areas. Report suspected misconduct. If you are not sure ASK. 28 of 35
Manager Expectations Maintain Northside s culture of compliance. Lead by example Encourage employees to ask questions and voice concerns Work with the Chief Compliance Officer and Compliance Committee Consider compliance when evaluating and rewarding employees Prevent compliance issues. Identify risk areas and propose appropriate policies and procedures Educate your employees of relevant policies and procedures Respond to potential compliance problems. Notify the Chief Compliance Officer Pursue appropriate, prompt corrective action Take appropriate disciplinary action when necessary 29 of 35
Manager Expectations (cont d) If you have questions about the Compliance Program, policies or procedures, or need guidance in responding to a question: Speak with your supervisor; Call the Chief Compliance Officer, 404-851-6378; or Call the anonymous hotline, 404-845-5907 30 of 35
Medical Staff Expectations Participate in compliance activities Raise potential compliance issues and assist in possible solutions Raise questions and issues: Call the Chief Compliance Officer: 404-851-6378 Call the anonymous hotline: 404-845-5907 31 of 35
Expectations of Contractors Contractors, agents, vendors, and volunteers should: Read and understand the Code of Conduct and the Compliance Program Policies and Procedures Participate in compliance activities Raise questions or concerns by: Speaking with a Northside manager Speaking with the Chief Compliance Officer, 404-851-6378 Contacting the anonymous hotline, 404-845-5907 32 of 35
Compliance with the Program and Code of Conduct Compliance with the Compliance Program and Code of Conduct is very important and will be considered in your performance evaluation Failure to follow the Code of Conduct may lead to discipline as outlined by Northside s Disciplinary and Non-Retaliation Policy 33 of 35
Summary of Expectations Understand and follow the Compliance Program and Code of Conduct Seek assistance and ask questions Raise concerns promptly Cooperate with the Compliance Department 34 of 35
The End - Thank you! Thank you for your participation and your continued dedication to the Northside Compliance Program! You may contact Jorge Hernandez, Chief Compliance Officer at 404.851.6378 should you have any questions about this Annual / New Hire Compliance Training. To complete this course you must select Take Test to complete the acknowledgement located in the left panel to submit your acknowledgement stating that you have read and understood this training course. 35 of 35