Compliance Online OrientationCompliance Online...

Compliance Online OrientationCompliance Online Orientation

Compliance Orientation

To receive credit for compliance orientation, you must:

• Complete the following presentationComplete the following presentation• Review the Duke Medicine Code of Conduct, Integrity in Action*• Agree to abide by the terms set forth in the Code of Conduct

and the Duke Confidentiality Agreementand the Duke Confidentiality Agreement• Pass the compliance orientation quiz with a score of 80%

*To receive a hard copy of the Code of Conduct, please contact DUHS Compliance at py , p [email protected]

Compliance Orientation Objectives

• Explain the purpose of the Duke Medicine Compliance Program

• Describe how the Duke Medicine Code of Conduct affects your work

• Provide an example of a violation of the False Claims Act within the healthcare industry

D ib li ibiliti t D k• Describe your compliance responsibilities at Duke Medicine

Li t t t li• List ways to report compliance concerns

• Agree to abide by the Duke Confidentiality Agreement

What is Compliance ?• Following the rules and doing the right thing

• Understanding your job responsibilities and role at Duke and complying with all the laws regulations policies andcomplying with all the laws, regulations, policies and procedures that apply to your work at Duke Medicine

• Raising questions or concerns about possible non-compliance issues that should be addressed

• A compliance program creates a process to prevent, detect and correct any unwanted acts in the workplacedetect, and correct any unwanted acts in the workplaceEveryone at Duke Medicine is responsible for compliance including: medical staff, employees, students and learners, volunteers, visiting observers, vendors, contractors, and those with whom we do business

business

Benefits of a Compliance Programp g

With open lines of communication throughout our workforce our Compliance Program helps usworkforce, our Compliance Program helps usaddress compliance concerns early. And this...

Demonstrates to our community that we operateDemonstrates to our community that we operate in an ethical environment

Improves the quality of care we provide

Reduces costs associated with healthcare

Duke Medicine Code of Conduct,Integrity In Actiong y

• Duke Medicine created a Code of Conduct to give individuals a clear understanding of what is expected of them in the workplacethem in the workplace.

The Code of Conduct:• Provides general guidelines stating expectations for our

b h i i th k i tbehavior in the work environment• Reaffirms our long-term commitment to compliance and to

providing quality services to our patients and the community we serve.

• Outlines our responsibilities as we interact with our patients, staff, and others in performing our daily activities.

• Gives guidance on what to do when faced with a compliance concernconcern

• Applies to all of our workforce, including employees, medical staff, students, temporary or part-time employees, volunteers, visiting observers, as well as those with whom we do business

Compliance Orientation: Questions to Ask

Part of your duties under the Code of Conduct include asking questions and reporting compliance concerns. The f ll i ti t id h b

How would it look in the

following are questions to consider when you observe something you believe to be improper:

• Do you have all the facts?

• If you need moreinformation, how do

fi d it?

• How would it look in the local newspapers?

• Is doing nothing the best decision?you find it?

• Who can help you?

• What are the possible

decision?

• Who is affected?

• Does your action support, • What are the possibleconsequences?

y pp ,the Code of Conduct, Integrity in Action?

Fraud & Abuse

Fraud & Abuse

• The Department of Health & Human Services Office of Inspector General works to prevent, detect, and report fraud and abuse against the federal governmentfederal government

• Duke Medicine seeks to prevent and detect fraud and abuse through its policies and procedures such as the Non-Retaliation & Non-Retribution Policy and the ComplianceNon Retribution Policy and the Compliance Program

CASE Study # 1:

Meet Jane Johnson. Jane is a part-time employee who has been hired to manage the department’s federal grant funding and applications. Jane has been reporting costs and using grant funding for expenses that are not a part of the grant or research. How is this a compliance concern?

This scenario could be a violation of the False Claims ActThis scenario could be a violation of the False Claims Act. Duke Medicine workforce must provide accurate and complete documentation and recordkeeping including oncomplete documentation and recordkeeping including ongrant applications and funding, and cost management.

False Claims Act

As members of the Duke Medicine workforce, individuals must comply with the State and Federal False Claims Acts, which state:

It is a violation to knowingly submit or cause another person– It is a violation to knowingly submit, or cause another person or entity to submit, false claims for payment of government funds.

P lti i l dPenalties include: – Up to 5 years in prison and/or $25,000 in fines – Civil penalties of $5,500 or $11,000 per claim and up to triple

the damages incurred by the payor

False Claims Act

• The False Claims Act contains provisions thatThe False Claims Act contains provisions that also allow employees with actual knowledge of alleged false claims to sue on behalf of the

government.

– Employees will be protected from retaliation, e.g., harassment, demotion and wrongful termination, as a result of the employee’s lawful acts in furtherance of a false claims action.

False Claims Act Violation Examples

• Receiving a governmental-sponsored grant and charging the government for costs not related to the grantgrant

• Falsifying services or documentation leading to inappropriate coding

• Billing for medically unnecessary services such as additional tests which were not medically appropriate

• Duplicate billingp g• Charging the government for unallowable costs such

as sales and marketing• Providing substandard care• Providing substandard care

http://www.whistleblowerfirm.com/medicare-fraud/http://www.quackwatch.org/02ConsumerProtection/fca.html

Medicare/Medicaid Anti-Kickback Statute

• Under the Anti-Kickback Statute:– It is illegal to offer or receive any form of payment in exchange g y p y g

for the referral of a patientSanctions• Up to 5 years in prison and fine up to $25 000Up to 5 years in prison and fine up to $25,000• Fine up to $50,000 (Balanced Budget Act)• Exclusion from Medicare and Medicaid programs

For example, it could be a violation of the Anti-Kickback Statute for Duke HomeCare and Hospice to provide gifts to hospitals’ case p p g pmanagers.

Our ComplianceCompliance

ResponsibilitiesResponsibilities

Our Compliance Responsibilities: Recordkeeping p g

• Members of the Duke Medicine workforce have a responsibility to ensure that all information is recorded accurately and timely,

• Proper documentation and recordkeeping is necessary:For billing so that the physicians and our organization can receive– For billing so that the physicians and our organization can receive payment for the services provided.

– For healthcare operations such as creating financial reports, credentialing files and research findingscredentialing files, and research findings.

• We must always truthfully and accurately maintain paper and electronic data.

• We do not alter, falsify or manipulate any record, contract, time sheet, or other document.

Our Compliance Responsibilities:Safeguarding Our Assetsg g

• Duke Medicine employees are responsible for protecting the assets of our organization includingprotecting the assets of our organization including physical property, financial information, business strategies, and research findings.– We maintain medical records and other critical information

in a safe and secure manner for the appropriate time as required by law and Duke policy.

– We must store medical employee information in a secure location separate from personnel files.

CASE Study # 2: The Volunteer

You are a volunteer with Duke Hospital. Twoafternoons per week you volunteer making copies, filing, and performing other administrative duties for the Volunteerperforming other administrative duties for the Volunteer Services office. You usually work with Doug another volunteer. Last week Doug mentioned to you that he needed to make copies of a flyer advertising an event in which he is coordinating. You told him that you didn’t think that was a good idea since Duke paid for the paper to be usedgood idea since Duke paid for the paper to be usedfor business purposes only. Today you go to use the copier, and you see a large stack of Doug’s flyers.

What would you do?

CASE Study # 2: The Volunteer

A) Talk to Doug about not using Hospice’s resources for personal use.

B) Nothing. You are a volunteer and there is nothing you can do. You don’t have any compliance responsibilities.

C) Talk to your supervisor.

In this case, C is the best answer. Your supervisor can talk to Doug about the importance of safeguarding Duke ‘s assets and not usingabout the importance of safeguarding Duke s assets and not using the organization’s supplies for personal use.

Our Compliance Responsibilities: The Work EnvironmentThe Work Environment

• We maintain a harassment-free work environment and conduct ourselves appropriately treating each other withconduct ourselves appropriately treating each other with dignity and respect.

• We provide a safe working environment free from di ti d i i t b h idisruptive and inappropriate behaviors

• We follow all federal, state and Employment Opportunity Commission laws and regulations for recruiting and

i i lifi d lretaining qualified employees

• We take reasonable steps to keep our workplace safe and avoid hurting coworkers, patients, visitors, and ourselves through disruptive and inappropriate behaviors.

Our Compliance ResponsibilitiesAmericans with Disabilities Act (ADA)

• As a healthcare organization, Duke must comply with the ADA which means ensuring individuals with disabilities have access to:– The same excellent Duke healthcare as those individuals without

di biliti d th it f h lth iddisabilities and the same community of healthcare providers– Restrooms, telephones, registration counters, parking, and common

areas– Interpreters for patients and companions* who are deaf and request

interpreters• Duke has a responsibility to treat patients with disabilities with dignity

and respect and a legal obligation to comply with the ADA.Examples of Disability Etiquette: Hearing and Visual ImpairmentsExamples of Disability Etiquette: Hearing and Visual Impairments

– Provide sign language interpreters when necessary– Speak slowly; do not shout – Talk directly to the person with whom you are speaking y p y p g– It is appropriate to offer assistance; do not assume you know what would

be helpful* As reflected in the Conditions of Participation with the Centers for Medicare & Medicaid Services, Duke

will provide interpretive services for the patient and the patient’s companion.

Our Compliance Responsibilities:Important Contacts and Resourcesp

• If you have questions or concerns regarding compliance with federal and state regulations or working with patients with disabilities contact Duke Disability Management System (DMS) atdisabilities, contact Duke Disability Management System (DMS) at 919-668-6213 or http://www.access.duke.edu

• For questions about reasonable accommodations, contact 919-684-8247S th P ti t R l ti P f t t i f ti d• See the Patient Relations Program for contact information and information on services provided to patients including interpretation services

Other important contacts:Other important contacts:• Patient and Visitor Relations:

– Duke University Hospital: 919-681-2020– Durham Regional Hospital: 919-470-4747u a eg o a osp a 9 9 0– Duke Raleigh Hospital: 919-954-3000– DUAP Clinics: 919-668-4476– PDC Clinics: 919-684-6298

EMTALA Emergency Medical Treatment and Labor Act

• EMTALA is a federal law requiring the treatment of any patient who comes to the ED seeking carepatient who comes to the ED seeking care– “Comes to the ED” means a person is on the hospital campus

requesting or appearing to be in need of emergency care• Staff must perform a Medical Screening Exam (MSE) toStaff must perform a Medical Screening Exam (MSE) to

determine if an Emergency Medical Condition (EMC) exists and to stabilize the EMC.

– MSE is not Triage– This is a Clinical Exam provided by MD or mid-level– Exam cannot be delayed to inquire about payment or insurance– Performed in a uniform manner for all patients who present with

similar symptoms or conditionssimilar symptoms or conditions• MSE for psychiatric symptoms/substance abuse includes both:

– Medical Screening– Mental Health Screening

Mental Health Screening

EMTALA: Emergency Medical Treatment and Labor Act

If EMC i t th h it l d id t t bili• If EMC exists, the hospital and provider must stabilize the condition prior to discharge or transfer

• The ED is required to accept a patient transferThe ED is required to accept a patient transfer experiencing EMC when the hospital has the capability and capacity to treat that patient, i.e.,

R i i h it l h il bl b d d th t ff t t t– Receiving hospital has an available bed and the staff to treat the patient

– Receiving hospital has the ability to provide care that t f i h it l ttransferring hospital cannot

– See DUHS Emergency Medical Treatment and Active Labor Act (EMTALA) Policy

Red Flags RulesRed Flags Rules• Rules that require DUHS to develop and implement

an identity theft prevention program to detect and prevent identity theft

DUHS R d Fl Id tit Th ft P– DUHS Red Flags Identity Theft Program• What is a Red Flag?

A R d Fl tt ti ifi ti it– A Red Flag means a pattern, practice, or specific activity that indicates the possible existence of Identity Theft

Red Flag Rules• All staff be aware of suspicious activity concerning a

patient’s identity e.g.P ti t bl t d id tifi ti fi– Patient unable to produce identification or confirm address or date of birth

– Patient does not match identification picture– Medical record includes information not related to person

presenting• If a Red Flag is detected• If a Red Flag is detected,

– Staff should document the Red Flag--flag the record– Contact his or her supervisor to begin the investigation to p g g

determine if an identity issue exists– Contact DUHS Compliance (668-2573) if the Red Flag is

substantiated and not a clerical error

substantiated and not a clerical error

Our Compliance Responsibilities: Procurement

• As members of the Duke Medicine workforce, you may be contacted by vendors or be requested tomay be contacted by vendors or be requested to make purchasing decisions.

• Duke’s policy on procurement and vendors states:– all purchased materials and services are procured from

approved vendors, using purchase requisitions that have received management approval.

– For more information about procurement and vendors doing business or visiting Duke Medicine go to http://www.procurement.duke.edu

Our Compliance Responsibilities: Conflict of Interest & Gifts

• A Conflict of Interest can arise when our activities, associations, or positions influence the way we , p yperform our work at Duke Medicine.

• Duke Medicine employees should avoid any position of financial interest in any organization which couldof financial interest in any organization, which could improperly influence or appear to influence their workplace decisions.

• See the Conflict of Interest policySee the Conflict of Interest policy

• Duke Medicine employees should not accept any gifts, favors, or hospitality from vendors.

• See the Gifts and Courtesies policy

Let’s see an example . . .

28

Gifts Policy Examples

• A patient has provided a department with a gift basket of perishable food May the department accept this gift?perishable food. May the department accept this gift? – It is acceptable under the Gifts and Courtesies policy for a

department or division to accept a perishable gift e.g. food or flowers from an individual patient or patient’s family when it isflowers from an individual patient or patient s family when it is shared with all employees in a department, unit or division.

– For questions on gifts, contact your supervisor or the DUHS Compliance OfficeCompliance Office

• A vendor has brought bagels for staff to a lunch and learn session when they are educating staff on a new product. Is this okay?– No, the department cannot accept any gifts from vendors

including food.g

Compliance Orientation: ReportingCompliance Orientation: Reporting

Compliance concerns can be reported in several ways:

– You may talk to your manager or supervisor

– Contact the Compliance Officer for your facility or the DUHS (668 2573) SOM/SON (684 2144) or PDCDUHS (668-2573), SOM/SON (684-2144), or PDC Compliance Office (668-5161)

– Call the Duke Medicine Integrity Line for anonymous and fconfidential reporting

Duke Medicine Integrity Line

• A separate company specializing in managing compliance hotlines operates the Integrity Line; allcompliance hotlines operates the Integrity Line; all hotline calls are report to the DUHS Compliance Office

1-800-826-8109Integrity Line calls are:g y

• Confidential

• Anonymous if the caller wishes

• Not recorded or traced

• Thoroughly investigated

Non-Retaliation/Non-Retribution Policy

• Duke has a non-retaliation/non-retribution policy to ensure compliance reporting in an open environment that encourages communication and is free from retaliationcommunication and is free from retaliation.

The policy states:• There will not be any retaliation or retribution as a result of

reporting in good faith*, regardless of whether or not a violation is found to have occurred

• Retaliation is a violation of the Compliance Program and will not be tolerated and must be reported

• Reports of retaliation will be investigated thoroughly and quickly and can result in disciplinary action, up to and including q y p y p gtermination of employment

*Good faith means the person reporting the problem truly believes that a problem exists

Violations of the Code of ConductViolations of the Code of Conduct

• Violations of the Code of Conduct will be subject to the appropriate disciplinary action

• When appropriate, disciplinary action may include termination

KEY POINTS TO REMEMBER

• Compliance is Following the Rules and Doing the Ri ht ThiRight Thing

• Compliance is Everyone’s Responsibility

• Everyone has a Duty to Report Compliance Concerns

F ti t t th DUHS C li Offi• For questions, contact the DUHS Compliance Office at 668-2573 or [email protected]

CONFIDENTIALITY AGREEMENT

I agree to protect the confidentiality, privacy and security of patient, student, personnel, business, and other confidential or proprietary information of Duke University, Duke University Health System and the Private Diagnostic y, y y gClinic (collectively, “Duke”) from any source and in any form (talking, paper, electronic). I understand that the kinds of confidential or proprietary information that I may see or hear on my job and must protect include the following, among others:

• PATIENTS AND/OR FAMILY MEMBERS (such as patient records, conversations and billing information)

• EMPLOYEES, VOLUNTEERS, STUDENTS, CONTRACTORS, PARTNERS (such as salaries, employment records, disciplinary actions)(such as salaries, employment records, disciplinary actions)

• BUSINESS INFORMATION (such as financial records, research or clinical trial data, reports, memos, contracts, computer programs, technology)

• THIRD PARTIES (such as vendor contracts, computer programs, technology)• OPERATIONS IMPROVEMENT, QUALITY ASSURANCE, MEDICAL OR

PEER REVIEW ( h t t ti lt )PEER REVIEW (such as reports, presentations, survey results)

For examples of breaches of confidentiality, click here

35


I AGREE THAT:1. I WILL protect Duke confidential or proprietary information in any form. I WILL follow Duke

policies, procedures and other requirements on privacy and security.2. I WILL NOT post or discuss any Duke information, including sensitive information, (e.g., patient

information, patient pictures or videos, Duke financial or personnel information) on my personal social networking sites such as Facebook or Twitter. I WILL NOT take any pictures of patients for personal use with my cell phone or similar methods. I WILL NOT post sensitive information or patient pictures on Duke-sponsored social networking sites without the appropriate patient authorization in accordance with management approval and Duke policies and procedures.

3. I WILL keep current on all required training on the privacy and security of confidential or proprietary information.proprietary information.

4. I WILL ONLY access information that I need for my job or service at Duke.5. I WILL NOT access, show, tell, use, release, e-mail, copy, give, sell, review, change or dispose of

confidential or proprietary information unless it is part of my job or to provide service at Duke. If it is part of my job or to provide service to do any of these tasks I will follow the correctit is part of my job or to provide service to do any of these tasks, I will follow the correct procedures (such as shredding confidential papers before throwing them away).

6. When my work or service at Duke ends, I will not disclose any confidential or proprietary information and I will not take any of this information with me if I leave or am terminated.

36

CONFIDENTIALITY AGREEMENTI AGREE THAT:I AGREE THAT:7. If I must take confidential or proprietary information off Duke property, I will do so only with my

supervisor’s permission. I will protect the privacy and security of the information in accordance with Duke policies and procedures and I will return it to Duke.

8 If I have access to Duke computer system(s) I WILL follow their Secure System Usage Memos8. If I have access to Duke computer system(s), I WILL follow their Secure System Usage Memos, which are available from the System’s Information Security Administrator(s).

9. I WILL NOT share my USER ID (NET ID) and password with anyone.10. I WILL keep my computer password secret and I will not share it with anyone.11 I WILL d* d h i l 180 d I ill h11. I WILL create a strong password* and change it at least every 180 days. I will change my

password at once if I think someone knows or used my password. I will ask my supervisor if I do not know how to change my password.

12. I WILL tell my supervisor and OIT or DHTS if I think someone knows or may use my password of if I am aware of any possible breaches of confidentiality at Duke.

13. I WILL NOT use anyone else’s USER ID (NET ID) and password to access any Duke System(s).

14. I WILL log out or secure my workstation when I leave my work area.g y y15. I WILL ONLY access confidential or proprietary information at remote locations with consent

from my supervisor.16.If I am allowed to remotely access confidential or proprietary information, I AM RESPONSIBLE

for ensuring the privacy and security of the information at ANY location (e g home office etc )

37

for ensuring the privacy and security of the information at ANY location (e.g., home, office, etc.).


I AGREE THAT:17. I WILL NOT store confidential or proprietary information on non-Duke systems.18. I UNDERSTAND that my access to confidential or proprietary information and my

Duke e mail account may be auditedDuke e-mail account may be audited.19. If I receive personal information through Duke e-mail or other Duke systems, I AGREE

that authorized Duke personnel may examine it, and I do not expect it to be protected by Duke.

20. I UNDERSTAND that Duke may take away or limit my access at any time.

*Strong Computer Passwords• Must be at least six characters.• Must contain at least two letters and one number.• Must have at least one capital letter and one lower case letter.• Must be changed at least every 180 days or if it is believed or known to have been

compromised.• Must not be a word in the dictionary.• May not be re used for at least 3 years

38

• May not be re-used for at least 3 years.


I understand that my failure to comply withI understand that my failure to comply with this agreement may result in the termination of my relationship with Duke and/or civil orof my relationship with Duke and/or civil or criminal legal penalties.

39

Acknowledgment of Content Statement

I acknowledge that I have reviewed the Code of Conduct, Integrity in Action, and agree to abide by all the terms set forth in this module.

and

I acknowledge that I have read, understand, and will comply with all of the terms set forth in the Confidentiality Agreement.y g

Signature:

*If you would like a personal copy of the Code of Conduct, Integrity in Action booklet you can contact the DUHS Compliance Office at 668-2573.

Note:

If you do not agree to abide by the terms set forth in the Code of Conduct, you will not be permitted to come to Duke University Hospital & Clinics, as an affiliate.

Compliance Online OrientationCompliance Online...

Documents

Transcript of Compliance Online OrientationCompliance Online...