Corporate Compliance

• Achieving our Mission of improving the health of our community depends upon our ability to establish and maintain our patients’ trust. We earn patients’ trust by treating everyone with compassion, dignity and respect.
• We also maintain our patients’ trust by protecting their right to privacy and safeguarding their health information. Each of us has a personal obligation to protect patient confidentiality by preventing inappropriate access to and disclosures of patient information. Our commitment is reinforced by our Patient Rights policy, our Service Standards, and other policies such as the Notice of Privacy Practices. 
• Anyone who has reason to believe that a patient is being or has been denied their rights shall report their concerns as described below.  

• As a charitable tax-exempt organization, we serve our community to the best of our ability, which includes providing free care programs and other community benefits. 
• Our Policy on Conflicts of Interest provides a systematic process for identifying, disclosing and resolving potential conflicts of interest. 
• We provide medical services to all individuals with an emergency medical condition.  As required by the Emergency Medical Treatment and Labor Act (EMTALA), patients presenting with an emergency medical condition will be provided with medical services and care. Their ability to pay will not be considered. 

• We cooperate with authorized governmental investigations and audits.  Our policies regarding contacts with governmental agencies ensure that we cooperate with the government in a complete and consistent manner. 
• We protect and retain all records and documents required by the government, professional and legal standards and our own policies. 

The Federal False Claims Act (FCA) and other fraud and abuse laws exist to fight fraud and reduce wasteful healthcare spending. Anyone who knowingly submits or causes the submission of false, fraudulent or misleading claims to the government may be subject to severe penalties. A claim is any request for money that we make to a government agency, insurance company or individual. Our Corporate Compliance Program describes how we prevent and detect fraud, waste and abuse. It describes our process for ensuring that coding, billing, documentation and accounting for patient care services follow federal and state laws.

• We bill only for the services that we have provided. Our services are supported by accurate and complete documentation that describes the items and services we provide. Inaccurate statements in documentation and/or billing can result in submitting a false claim. Everyone is responsible for ensuring that his or her own documentation is complete and accurate. Billing for services must be consistent with applicable policies and laws.  
• As stated in our policy on Preventing Fraud and Abuse, anyone who has reason to believe that we have done or are doing something that could result in a false claim has a duty to report as described below.  
• We engage in honest and ethical business practices.
• We do not offer or accept anything of value when the purpose is to improperly induce, influence, or reward patient referrals, or any federal health care related business. We avoid any business arrangement or practice that has the potential to interfere with clinical decisions or increase costs. Vendors who contract to provide goods and services will be selected based on quality, cost, and need for their product.
• We safeguard patients’ right to choose their own home health agency and medical equipment supplier. We respect and maintain patient privacy and confidentiality.

We are committed to Employee Engagement. We will create an environment where employee engagement flourishes and we commit our hearts and minds to meeting and exceeding the needs of customers and each other. We listen to employee feedback and promote a workplace that is free of discrimination and harassment. Employees will treat all others individually without regard to race, color, marital status, national origin, religion, age, sex, pregnancy, ethnic origin, disability, sexual orientation, gender identity, illness, HIV status, disability, veteran or National Guard status or any other protected status.  Employees will also be treated individually without regard to any protected status. An employee who observes or experiences any form of discrimination or harassment shall report his or her concerns to a leader or Human Resources, or report them confidentially as described below.    

All individuals who work within our facilities treat others and are themselves treated with courtesy, respect and dignity. We are responsible for maintaining and promoting harmonious relationships within the organization to ensure the proper environment for the considerate and successful care and treatment of patients. Joint Commission field reviews have shown that quality and safety thrive in an environment of collegiality and civility. This policy creates a mechanism by which undesirable or disruptive conduct is identified, investigated, and resolved.

Disruptive and disrespectful behavior may include, but is not limited to:

• Obstruction of the operation of the hospital
• Interference with the ability of others to do their jobs
• Creation of a “disruptive  work environment” for hospital staff (including volunteers), or medical staff
• Conduct adversely affecting or impacting the community’s confidence in the hospital’s ability to provide quality care
• Attacks (verbal, written, or physical) leveled at any member of the hospital staff, medical staff, patients or patients’ families that are personal or beyond the bounds of fair and professional conduct
• Inappropriate comments or illustrations made in patient medical records or other official documents impugning the quality of care in the hospital, or attacking specific physicians, or hospital staff
• Non-constructive criticism addressed to the recipient in such a way as to intimidate, undermine confidence, belittle or to suggest stupidity or incompetence
• Disruptive and disrespectful behavior includes statements that are generated verbally, in writing or electronically in any form including e-mail, text messages, social network sites and blogs. 

Your duty to report

Safeguarding our commitment to Integrity requires everyone’s help.  The purpose of this Code of Conduct is to encourage you to report your questions or concerns. We rely on you to tell us if you believe that someone is violating the law. We also rely on you to tell us if you believe that a process or practice violates the law. 

• All possible violations of the law, regulations, this Code of Conduct or a compliance policy must be reported.
• Staff will seek clarification from their supervisor or the Compliance Officer if they are unsure about the regulatory requirements for performing their job.  

This Code of Conduct makes all of us accountable for compliance with legal and ethical standards.  Anyone who violates such standards, including a failure to report, shall be subject to appropriate discipline.

Any retaliation or threat of retaliation against a person who reports in good faith is strictly prohibited.  Any person who believes that they are being retaliated against shall report their concerns to the Compliance Officer. Reporting in good faith means that you are reporting a concern truthfully and factually.     

How to report your concerns

You may choose how to report your concerns.  You may report:

• Your concerns to your supervisor or Human Resources
• By posting a question or concern on the Corporate Compliance page of the RRHS Portal
• By calling the RRHS/RRMC Compliance Hotline at 866.403.5245

The Hotline allows you to leave a confidential voicemail message.

Reports will be treated confidentially. You can choose to report anonymously and your identity will not be disclosed unless such disclosure is ordered by a Court or other lawful authority. The Compliance Officer will investigate all reported concerns.  Anonymous callers must provide sufficient information to allow for a reasonable investigation. When calling, you should identify your work area, describe the specific practice or behavior, and describe what you believe to be illegal about the activity.     

Any attempt to harm or slander another person through false accusations, or malicious rumors is a violation of RRHS/RRMC policy. Such attempts, if proven, shall be subject to disciplinary action consistent with RRHS/RRMC personnel or other policies, or any contracts as applicable, up to and including termination. 

The Compliance Program including the Compliance Hotline should not be used to address general disputes or grievances between co-workers or between an employee and their leader. Concerns that do not involve a potential violation of law or a specific RRHS/RRMC policy should be referred to a leader or Human Resources.     

Leaders have a major role in safeguarding our commitment to Integrity. 

• Leaders have a duty to enforce the Code and other policies consistently.
• Leaders have a duty to protect individuals from retaliation.  The leadership role includes creating an environment where employees feel comfortable and safe when raising concerns about compliance and corporate integrity.
• Leaders have a responsibility to ensure that staff has adequate information and training to comply with laws, regulations, and policies. 
• Leaders also have a duty to reasonably detect and report all compliance violations. 
• Leaders shall refer all questions and concerns about compliance issues to the Compliance Officer before beginning any investigation.  

Any physician, hospital staff member, patient or visitor may report potentially disruptive behavior. Any persons who believe they are the object of or affected by disruptive or disrespectful behavior are encouraged to let the offending individual know that their behavior is unwelcome and against hospital policy. Individuals wishing to report an incident of potentially disruptive behavior by an employee or volunteer must do so to the Vice President or Director of Human Resources. Individuals wishing to report an incident of potentially disruptive behavior by a physician must do so to the Medical Staff President or the Director of Medical Affairs. The report must be in writing and include the date and time of the incident, the circumstance surrounding the incident, a factual and objective description of the questionable behavior, the consequences, if any, to patient care or hospital operations, and any action taken to remedy the situation. Individuals may file a complaint anonymously. False or malicious reports subject the individual to disciplinary action.  For complaints that involve employed physicians, the Vice President of Human Resources, Director of Medical Affairs, and the President of the Medical Staff, and if necessary the President of the Hospital shall determine who is responsible for leading any investigation and whether to utilize the Human Resources process or the Medical Staff process or both.

SCOPE:

Rutland Regional Medical Center

PURPOSE:

The purpose of this policy is to inform employees, volunteers, members of the Medical Staff, contractors, and agents of Rutland Regional’s efforts to prevent Fraud, and Abuse so that potential concerns are immediately reported. This policy is intended to ensure that Rutland Regional provides information about the federal False Claims Act, the Vermont Medicaid fraud statute and whistleblower protections under both state and federal law, as required by section 1902 of the Social Security Act as amended by the Deficit Reduction Act of 2005.  

POLICY

1. Commitment to compliance – Rutland Regional has a Corporate Compliance Plan, Code of Conduct, and other policies that are intended to prevent, detect, and remedy fraud, waste and abuse, and other forms of noncompliance. The Code of Conduct states that the organization is committed to (1) complying with laws, regulations, and ethical standards, (2) promoting a culture of prevention, detection, and resolution of potential wrongdoing; and (3) strictly prohibiting retaliation against individuals who report concerns in good faith.
2. Education and communication – Rutland Regional provides education, training, and communication about laws such as the False Claims Act to ensure that potential concerns are immediately reported and resolved as expeditiously as possible.
3. Obligation to prevent and report – All staff are responsible for ensuring that they prevent, and report potential problems that can lead to payment errors. It is critical to identify, and respond to potential payment errors to prevent the organization from being subject to severe financial penalties.   
4. Identifying potential overpayments – The False Claims Act requires that providers identify, report, and return to Medicare or Medicaid overpayments within 60 days of identification. The failure to promptly return an identified overpayment would be considered a false claim.

4.1. The False Claims Act prohibits:

4.1.1.  knowingly presenting or causing to be presented to the federal government a false or fraudulent claim for payment or approval;

4.1.2.  knowingly making or using, or causing to be made or used, a false record or statement that is material to an obligation to pay or transmit money or property to the Government;

4.1.3.  to defraud the government by getting a false or fraudulent claim allowed or paid; and

4.1.4.  Knowingly concealing or improperly avoiding or decreasing an obligation to pay or transmit money of property to the Government.

4.1.5.  Knowingly failing to return an identified overpayment within 60 days after the overpayment was identified.

4.2. Sanctions include:

4.2.1.  Excluding the provider or individual from participating in Medicare and Medicaid;

4.2.2.  Criminal penalties including imprisonment for up to five years; and

4.2.3.  Civil monetary penalties from $5,500 to $11,000 per claim, plus triple damages;

4.3. Enforcement: The United States Attorney General may bring a civil or criminal action for violations of the False Claims Act, and the Vermont Attorney General may file a civil action for violation of the State false claims statute. The federal False Claims Act also includes a qui tam provision, which allows an individual who is the “original source” of information about the falsity of a claim to file a claim as a relator on behalf of the Federal Government, and the relator may share in the government’s recovery of damages.

4.4. Protection for “Whistleblowers”: The False Claims Act protects employees from retaliation when they pursue a False Claims Act related action. As stated in the Code of Conduct, Rutland Regional strictly prohibits retaliation of any kind.

4.5. Reporting Concerns about Potential Overpayments – The Code of Conduct requires that all staff and contractors report all possible violations of the law. If staff or a contractor has knowledge or information that may have resulted in or may result in the submission of a false claim, or the receipt of an overpayment, they shall notify their supervisor, the Chief Compliance Officer at 802.772.2557, or call the Compliance Hotline at 866.403.5245.

4.5.1. The Chief Compliance Officer is responsible for ensuring that a reasonable inquiry is conducted to determine if the organization has received any overpayments. The department that provided the service, or manages the relevant process, is responsible for providing information that is necessary to determine the potential cause of an overpayment, and implementing corrective action to prevent future errors. The Patient Financial Services and Finance Departments are responsible for assisting in the quantification, and timely repayment of all overpayments.   

4.5.2. Exception to reporting – There is no requirement to report errors that occur within the Patient Financial Services Department that are part of routine claims processing, or within the Finance Department associated with cost report issues provided that the errors are resolved promptly. 

DEFINITIONS

Abuse means practices that, either directly or indirectly, result in unnecessary costs to the Medicare or Medicaid Programs where it is not possible to establish that abusive acts were committed knowingly, willfully, and intentionally.

Fraud means the intentional deception or misrepresentation that an individual knows to be false or does not believe to be true and makes, knowing that the deception could result in some unauthorized benefit to himself/herself or some other person.

Knowingly means that a person, with respect to information: (1) has actual knowledge of the information; (2) acts in deliberate ignorance of the truth or falsity of the information; or (3) acts in reckless disregard of the truth or falsity of the information. No proof of specific intent to defraud is required.

OTHER POLICIES AND FORMS

Replaces Providing Information About the False Claims Act

Code of Conduct

Corporate Compliance Plan

Providing and Documenting Services that are paid by the Federal Healthcare Programs

REFERENCES:

42 U.S.C. § 1396a(a)(68)(Medicaid requirement for a policy on the False Claims Act)

31 U.S.C. §§ 3729-33 (False Claims Act)

31 U.S.C. §§ 3801-12 (Program Fraud Civil Remedies Act)

18 U.S.C. § 1347 (Criminal Health Care Fraud)

21 V.S.A. §§ 507-09 (Vermont health care employee whistleblower protection law)

13 V.S.A § 3016 (Vermont criminal false claim)

33 V.S.A. § 141 (Vermont Medicaid fraud)

APPENDIX – EXAMPLES THAT MAY RAISE A FALSE CLAIMS ACT CONCERN

• Billing for services that were not provided.
• Duplicate payments.
• Billing the wrong number of units.
• Misrepresenting the services that were provided as another service that carries a higher payment (often referred to as “upcoding” or “unbundling”).
  • Incorrect use of CPT codes, HCPCS codes, Modifiers, and diagnosis codes.
• Payments for noncovered services
  • Receiving payments from Medicare for a noncovered service such as a service that was inconsistent with a Local Coverage Decision (LCD), or National Coverage Decision (NCD).
  • Receiving payments from Medicaid for a noncovered services such as  service that was inconsistent with a Medicaid Medical Policy.
• Receipt of Medicare payments when another insurance had the primary responsibility for payment.
• Failing to properly document a billable service when the documentation is a condition for payment.
• Providing and billing for a service without a required physician order.
• Receiving a payment for a service with the wrong date of service such as when are patient died prior to the date of service that was reported on a claim.
• Billing for services that were performed by an unlicensed or excluded individual.
• Billing for a service that was not appropriately supervised by a physician or nonphysician practitioner.
• Billing Medicare for outpatient services provided to a resident of a skilled nursing facility where the service should have been covered as part of a SNF stay.