* SAMPLE * COMPLIANCE PROGRAM

[NOTE: This is a sample compliance plan based on OIG Compliance Program

Guidance. Groups should modify it as appropriate to fit their circumstances]

* SAMPLE *

COMPLIANCE PROGRAM

GROUP PRACTICE

(Revised 11/12)

SAMPLE COMPLIANCE PROGRAM i

GROUP PRACTICE

COMPLIANCE PROGRAM

Table of Contents

Page

Purpose and Overview .................................................................................................................... 1

General Standards of Conduct ................................................................................... __

Governing Board Responsibilities............................................................................... __

Administrator Responsibilities ..................................................................................... __

Compliance Officer Responsibilities ........................................................................... __

Compliance Committee Responsibilities .................................................................... __

Employee Responsibilities .......................................................................................... __

Medical Staff Responsibilities ..................................................................................... __

Education and Training ............................................................................................... __

Communication About Compliance Issues ................................................................. __

Auditing and Monitoring .............................................................................................. __

Investigation and Response ....................................................................................... __

Medical Necessity for Lab and Diagnostic Procedures .............................................. __

Billing Responsibilities ................................................................................................ __

COMPLIANCE PROGRAM: PURPOSE AND OVERVIEW

___________ (“PRACTICE”), its Governing Board, and its administration are committed to

quality and efficient patient care; high standards of ethical, professional and business conduct;

and full compliance with all applicable federal and state laws affecting the delivery or payment of

health care, including those that prohibit fraud and abuse or waste of health care resources.

The purpose of this Compliance Program and its component policies and procedures is to

establish and maintain a culture within PRACTICE that promotes quality and efficient patient

care; high standards of ethical and business conduct; and the prevention, detection and

resolution of conduct that does not conform to PRACTICE’s standards and policies, applicable

law, and health care program or payor requirements. The Compliance Program applies to all

PRACTICE personnel, including but not limited to its Governing Board, administration,

physicians and other practitioners, employees, volunteers, and other entities providing services

on behalf of PRACTICE (collectively “PRACTICE personnel”). The Compliance Program

includes the following elements:

1. Written standards, policies and procedures which promote PRACTICE’s commitment to

compliance with applicable laws and regulations.

2. The designation of a Compliance Officer and Compliance Committee charged with the

responsibility of implementing and monitoring the Compliance Program.

3. Regular, effective education and training programs for all affected PRACTICE personnel

as appropriate to their functions.

4. A process to receive complaints concerning possible Compliance Program violations,

procedures to protect the anonymity of complainants to the extent possible, and policies

that protect complainants from retaliation.

5. A process to respond to allegations of improper activities and the enforcement of

appropriate disciplinary action against PRACTICE personnel who have violated

PRACTICE policies, laws, regulations, or health care program requirements.

6. Periodic audits or other methods to monitor compliance and assist in the reduction of

problems in any identified areas.

7. A process for investigating and resolving any identified problems.

As demonstrated by the signatures below, the Compliance Program is enacted at the direction

and with the support of the Governing Board, administration, and owners of medical staff

PRACTICE.

APPROVED BY:

Chairman, Governing Board

Date

Administrator

Date

Compliance Officer

Date

COMPLIANCE PROGRAM: General Standards of Conduct

POLICY PRACTICE personnel shall adhere to high standards of ethical conduct and will

comply with and assist PRACTICE in complying with all applicable laws and

regulations and third-party payor program requirements.

PROCEDURE

PRACTICE personnel shall comply with the following policies and standards:

1. Ethical and professional standards. PRACTICE personnel shall comply with and perform

their services consistent with high ethical and professional standards. They shall treat

patients, co-workers, and others in a professional manner with honesty, fairness, dignity

and respect.

2. PRACTICE policies and procedures. PRACTICE personnel shall comply with all

applicable PRACTICE policies and procedures, including but not limited to those policies

and procedures relevant to the Compliance Program.

3. Laws, regulations, and program requirements. PRACTICE personnel shall comply with

all applicable federal and state laws, regulations, and third-party payor program

requirements.

4. Non-discrimination. PRACTICE personnel shall not discriminate against other

PRACTICE personnel, patients, or others on the basis of race, color, sex, religion, age,

national origin, ancestry, disability, or sexual orientation.

5. Offering or receiving items of value to induce referrals. Federal and state laws prohibit

paying, offering or receiving anything of value to induce referrals for healthcare business

unless certain conditions are met. PRACTICE personnel shall not offer, solicit, pay or

accept anything of value in exchange for healthcare referrals without first obtaining

approval from the Compliance Officer. This applies to offering or receiving any money,

gifts, free or discounted items or services, professional courtesies, or other arrangements

with the intent to induce referrals. This applies to any such transactions involving

potential referral sources, including transactions with other health care providers,

vendors, or patients. Violations may subject the PRACTICE and its personnel to criminal

and administrative penalties.

6. Financial relationships with physicians and other referral sources. Federal and state

laws affect contracts, agreements, and other financial relationships with physicians,

practitioners, vendors and other referral sources.

a. PRACTICE personnel shall not enter any contract or other financial arrangement

with, or give or receive anything of value to or from, an outside physician, a

physician’s family member, or other referral source without the prior approval of

the Compliance Officer.

b. If PRACTICE has a contract or other financial relationship with an outside

physician or a member of the physician’s family, PRACTICE personnel shall not

bill Medicare for any items or services referred by that physician without the prior

approval of the Compliance Officer.

c. PRACTICE personnel must strictly comply with the terms of any approved

contract or other financial arrangement with outside physicians, their family

members, or referral sources. Failure to perform or improper modifications of

such contracts or arrangements may violate applicable laws.

7. Improper inducements to Medicare or Medicaid beneficiaries. Inducements to Medicare,

Medicaid, or other government beneficiaries may violate applicable law. PRACTICE

personnel shall not waive or discount government beneficiary co-pays unless such

discount complies with PRACTICE’s charity care policy. PRACTICE personnel shall not

offer any other discount, gift, free items or service, or other inducements to government

beneficiaries without first obtaining approval from the Compliance Officer.

8. Professional courtesies. PRACTICE personnel shall not offer or receive any free or

discounted items or services to or from other health care providers, their family members,

or their office staff unless such offer is consistent with PRACTICE’s Professional

Courtesy Policy or the offer has been approved by the Compliance Officer.

9. Improper billing activities. PRACTICE personnel shall not engage in false, fraudulent,

improper, or questionable billing practices. Such improper activities include, but are not

limited to:

a. Billing for items or services that were not actually rendered.

b. Billing for or rendering items or services that were not medically necessary.

c. Submitting a claim for physician services when the services were actually

rendered by a non-physician, or where a physician failed to provide the level of

supervision required by applicable laws or regulations.

d. Submitting a claim for payment without adequate documentation to support the

claim.

e. Signing a form for a physician without the physician’s authorization.

f. Improperly altering medical records.

g. Prescribing medications and procedures without proper authorization.

h. Using a billing code that provides a higher payment rate than the correct billing

code (i.e., “upcoding”).

i. Submitting bills in fragmented fashion to maximize reimbursement even though

third-party payors require the procedures to be billed together (i.e., “unbundling”).

j. Submitting more than one claim for the same service (i.e., “duplicate billing”).

If PRACTICE personnel have a question about the proper standard or procedure for

documenting or submitting a claim, they should contact the Compliance Officer as

described below.

10. Unfair competition and deceptive trade practices. Federal and state antitrust laws

prevent certain anti-competitive conduct, including collusive agreements among

competitors to set prices; divide patient care or services; boycott other entities; etc.

PRACTICE personnel should not engage in collusive discussions with competitors over

such things as prices, employee wages, services to be rendered or eliminated, or division

of patients or patient services without the Compliance Officer’s prior approval. Similarly,

PRACTICE personnel should not discuss exclusive arrangements with third-party payors,

vendors, and providers without first discussing the matter with the Compliance Officer.

Finally, PRACTICE personnel should not engage in any deceptive acts or practices

relating to PRACTICE.

11. Privacy and confidentiality. PRACTICE personnel shall maintain the confidentiality of

patients’ protected health information as required by PRACTICE’s privacy policies and

applicable law, including but not limited to the Health Insurance Portability and

Accountability Act (“HIPAA”) and its accompanying regulations, 45 C.F.R. part 164.

PRACTICE personnel should not access patient information unless they have a need to

access the information because of their job duties. To the extent feasible and allowed by

law, PRACTICE personnel shall maintain the confidentiality of communications and

records containing confidential information concerning co-workers; communications and

records relating to PRACTICE’s confidential financial or business operations, trade

secrets, credentialing or peer review actions; documents prepared in anticipation of

litigation; and communications with legal counsel for PRACTICE. This section shall not

be construed to prohibit activity protected by the National Labor Relations Act.

12. Entities that contract with PRACTICE. PRACTICE personnel shall ensure that vendors

and other entities which contract with PRACTICE comply with the Compliance Program

and cooperate with PRACTICE’s compliance efforts. If a contract or arrangement with

an outside entity implicates any of the compliance concerns discussed above,

PRACTICE personnel should refer the contract or matter to the Compliance Officer for

review. Nothing in this policy or Compliance Program shall be construed as an

undertaking by PRACTICE to inspect, assume liability for or guarantee the performance

of work or activities by independent contractors or other agents.

13. Questions concerning the Compliance Program. PRACTICE personnel shall seek

clarification from or approval by the Compliance Officer before engaging in actions or

transactions if there is any question concerning whether the action or transaction

complies with applicable laws, regulations, program requirements, or PRACTICE

policies.

14. Report suspected violations. PRACTICE may have an obligation to promptly repay

money it improperly receives from third party payors within 60 days. it is essential that

PRACTICE personnel:

a. Comply with applicable laws, regulations, and policies; and

b. Immediately report suspected violations or compliance concerns to their

supervisor, department leader, or the Compliance Officer as set forth in the

COMPLIANCE PROGRAM: Communication About Compliance Issues Policy,

number CP 009. Anonymous reports may be made by depositing the report in

the designated compliance report lock box. The failure to report a suspected

violation may subject PRACTICE personnel to appropriate discipline.

15. Non-retaliation. PRACTICE personnel shall not retaliate against any person for reporting

a suspected violation of any law, regulation, program requirement or PRACTICE policy

relevant to the Compliance Program.

All PRACTICE personnel shall be required to review these Standards of Conduct and sign below

confirming that they have reviewed the Standards as set forth below.

____________________________________________________________________________

PRACTICE PERSONNEL ACKNOWLEDGEMENT OF

GENERAL STANDARDS OF CONDUCT

Owner, Employee, or Contractor Name: ____________________________________

I hereby acknowledge that I have received and reviewed PRACTICE’s Standards of Conduct, I

have had any questions I had answered, and that I agree to be bound by and shall comply with

the Standards of Conduct. I understand that failure to comply with the Standards of Conduct or

other PRACTICE policies may subject me to immediate adverse action, which may include

suspension or termination of employment or loss of clinical privileges.

Signed: ______________________________________

Date: _________________

COMPLIANCE PROGRAM: Governing Board Responsibilities

POLICY The Governing Board of PRACTICE is responsible for ensuring that PRACTICE

has an effective Compliance Program; appointing a qualified Compliance Officer

and members of the Compliance Committee; and receiving regular reports and

taking appropriate action to ensure that PRACTICE is following the Compliance

Program.

PROCEDURE

In addition to any other actions that may be necessary and appropriate to fulfill the purpose of

this Compliance Program, the Governing Board shall:

1. To the extent applicable, comply with the COMPLIANCE PROGRAM: General Standards

of Conduct Policy, number CP 001.

2. Appoint an appropriate Compliance Officer.

3. Organize and appoint appropriate members of the Compliance Committee.

4. Authorize reasonable and appropriate funding and staff to implement the Compliance

Program, including but not limited to that which is necessary to allow the Compliance

Officer and Compliance Committee to reasonably perform their responsibilities. In so

doing, the Governing Board shall give due consideration to the recommendations of the

Administrator.

5. Receive and review reports from the Compliance Officer on a quarterly basis, or more

frequently as deemed necessary by the Governing Board, Administrator, or Compliance

Officer.

6. Take appropriate action on any compliance issues brought before it consistent with this

Compliance Program and applicable bylaws, rules and regulations, including but not

limited to ensuring that compliance issues are appropriately investigated and resolved

consistent with the requirements of applicable law; that remedial efforts are implemented

to avoid or correct compliance concerns; and that PRACTICE personnel are disciplined

as appropriate.

7. Participate in periodic training concerning issues relevant to the Compliance Program as

set forth in the COMPLIANCE PROGRAM: Education and Training Policy, number

CP 008.

8. Maintain the confidentiality of any compliance issues brought before it consistent with

applicable PRACTICE policies, laws and regulations.

COMPLIANCE PROGRAM: Administrator Responsibilities

POLICY The Administrator of PRACTICE is responsible for supporting the Compliance

Program; and, in coordination with the Compliance Officer and Compliance

Committee, overseeing compliance activities at PRACTICE.

PROCEDURE

In addition to any other actions that may be necessary and appropriate to fulfill the purpose of

this Compliance Program, the Administrator shall:

1. Comply with the COMPLIANCE PROGRAM: General Standards of Conduct Policy,

number CP 001.

2. Develop an appropriate job description for a Compliance Officer.

3. Serve as a member of the Compliance Committee.

4. Supervise the Compliance Officer and, in cooperation with the Compliance Officer and

Compliance Committee, oversee all compliance activities.

5. Identify and delegate appropriate responsibilities to such other PRACTICE personnel as

necessary to implement and maintain an effective Compliance Program.

6. Receive and, where appropriate, act on reports from the Compliance Officer and/or

Compliance Committee.

7. Support departmental corrective actions as recommended by the Compliance Officer

and/or Compliance Committee.

8. In the event of a potential violation of any state or federal law or regulation, ensure

appropriate steps are taken to respond to the alleged violation, including but not limited

to consulting with counsel on behalf of PRACTICE where appropriate.

9. Participate in periodic training concerning issues relevant to the Compliance Program as

set forth in COMPLIANCE PROGRAM: Education and Training Policy, number CP 008.

10. Maintain the confidentiality of any compliance issues brought before the Administrator

consistent with applicable PRACTICE policies, laws and regulations.

COMPLIANCE PROGRAM: Compliance Officer Responsibilities

POLICY PRACTICE shall have a Compliance Officer. The Compliance Officer shall report

directly to the Administrator and, as appropriate, the Governing Board. With the

assistance of the Compliance Committee, the Compliance Officer shall be

responsible for implementing, monitoring, and coordinating such action as is

necessary and appropriate to facilitate an effective Compliance Program.

PROCEDURE

1. Appointment. The Compliance Officer shall be selected and appointed by the Governing

Board.

2. Duties. In addition to any other actions that may be necessary to fulfill the purpose of this

Compliance Program, the Compliance Officer shall:

a. Comply with the COMPLIANCE PROGRAM: General Standards of Conduct

Policy, number CP 001.

b. Oversee, monitor, and coordinate the implementation and maintenance of an

effective Compliance Program.

c. Serve as the Chairperson of the Compliance Committee.

d. Report directly to the Administrator and the Compliance Committee concerning

compliance activities.

e. Report directly to the Governing Board concerning compliance activities on a

quarterly basis, or more frequently as deemed necessary by the Governing

Board, Administrator, or Compliance Officer. The Compliance Officer shall have

authority and the responsibility to report directly to the Governing Board if he/she

believes the Administrator is not adequately addressing compliance concerns.

Among other things, the reports should summarize the results of compliance

investigations, reviews or audits.

f. Periodically revise the Compliance Program as necessary to meet the needs of

PRACTICE and comply with relevant laws, regulations, and third-party payor

program requirements.

g. In cooperation and coordination with Human Resources, develop and direct

programs that educate and train PRACTICE personnel concerning the

Compliance Program and the requirements of relevant laws, regulations, and

program requirements as set forth in the COMPLIANCE PROGRAM: Education

and Training Policy, number CP 008.

h. Ensure that contracts, financial arrangements, marketing initiatives, or other

transactions that may implicate fraud and abuse laws and regulations are

reviewed for compliance.

i. Take reasonable steps to ensure that independent contractors and agents who

furnish health care services or related services to PRACTICE are aware of and/or

act consistently with applicable laws, regulations, and PRACTICE policies,

including the Compliance Plan. In the event that the Compliance Officer

becomes aware of a violation of applicable laws, regulations or policies by

independent contractors or agents, the Compliance Officer shall take appropriate

steps to address the situation, including, where appropriate, modifying or

terminating the relationship. Nothing in this policy or Compliance Program shall

be construed as an undertaking by PRACTICE to inspect, assume liability for or

guarantee the performance of work or activities by independent contractors or

other agents.

j. Coordinate with Human Resources or other appropriate PRACTICE personnel to

ensure that PRACTICE does not employ, contract with, grant privileges to, or bill

for services rendered by entities excluded from government health programs.

The National Practitioner Data Bank and Cumulative Sanction Report must be

queried:

i. Before offering employment, granting or renewing privileges, or

contracting or renewing a contract with any person or entity providing

health care services.

ii. At least biannually thereafter for each such entity.

k. Coordinate with Human Resources or other appropriate PRACTICE personnel to

ensure that appropriate background checks are performed so that PRACTICE

does not employ persons who have been recently convicted of a felony or a

criminal offense related to health care or health care fraud and abuse.

l. Work with PRACTICE managers and the Compliance Committee to establish

appropriate internal compliance reviews and evaluation procedures for relevant

departments. Among other things, the reviews may, but are not necessarily

required to, address items such as:

i. Statistical samples that disclose variations from established baselines.

ii. Reserves established to repay government programs.

iii. The Compliance Program to ensure that its elements have been

implemented and are being followed.

iv. Certain practices that have been identified by federal enforcement

agencies as “risk areas” for waste, fraud and abuse, including:

(1) Compliance with laws governing kick-back arrangements and

physician self-referrals.

(2) Compliance problems that may develop in the claim development

and submission process, including but not limited to the improper

billing practices referenced in the COMPLIANCE PROGRAM:

General Standards of Conduct Policy, number CP 001, and

confirmation of the determination of medical necessity and

reasonable necessary services.

(3) Documentation that satisfies third-party payor requirements.

Such compliance risk areas are identified in the OIG Compliance Program

for Individual and Small Group Practices (2000), 65 F.R. 59434, and on

the OIG’s Fraud Detection and Prevention Website,

http://oig.hhs.gov/fraud.asp.

m. Develop policies and procedures that encourage and allow PRACTICE personnel

to report suspected compliance violations and other improprieties without fear of

retaliation. Where possible, provide a method for anonymous reporting.

n. Take appropriate action on matters that raise compliance concerns, including but

not limited to reports or complaints of suspected violations. The Compliance

Officer shall have flexibility to design and coordinate internal investigations and

any resulting corrective action with relevant PRACTICE departments, providers,

agents and, if appropriate, independent contractors.

o. Promptly report any apparent intentional violation of any state or federal

regulation by any staff or employee to the Administrator. The Administrator may

notify legal counsel and, if appropriate, coordinate any appropriate disclosure to

the appropriate government agency.

p. In coordination with Human Resources or the appropriate manager and upon the

approval of the Administrator, promptly initiate appropriate disciplinary or

corrective action against any PRACTICE personnel for violations of the

Compliance Program as the circumstances warrant. The Compliance Officer

shall review applicable bylaws, policies, procedures and contracts to ensure that

the action taken is consistent with applicable standards and processes, if any.

q. If any systemic errors have resulted that would violate the Compliance Program

or applicable laws and regulations, recommend appropriate corrective action to

the Administrator.

r. Establish and maintain a record of every complaint received involving a potential

violation of any law or regulation related to health care fraud and abuse, which

record shall include the following information:

i. the date received;

ii. the manner in which the report was received (e.g., by anonymous report);

iii. a brief statement of the facts alleged;

iv. notes detailing and documenting a timely investigation and response; and

v. a summary of the action taken and the date the action was taken.

s. Maintain records of substantive contact with any government agency relevant to

the Compliance Program, including but not limited to decisions, guidance, or

advisory opinions concerning PRACTICE’s compliance. If the government

agency refuses to provide such guidance, the fact shall be documented.

t. Maintain the confidentiality of any compliance issues brought before the

Compliance Officer consistent with applicable PRACTICE policies, laws and

regulations.

3. Funding. The Compliance Officer shall be afforded sufficient funding and staff to enable

him or her to reasonably perform his/her responsibilities.

4. Access. Except as prohibited by applicable laws or regulations, the Compliance Officer

shall have authority to review all documents and other information relevant to compliance

activities, including but not limited to patient records; billing records; marketing records;

and agreements with other parties such as employees, staff professionals, independent

contractors, suppliers, agents, PRACTICE-based physicians, etc.

5. Legal Counsel. Government regulators recognize that assertions of fraud and abuse

raise numerous complex legal and management issues that should be examined on a

case by case basis and, therefore, the Compliance Officer should work closely with legal

counsel, who can provide guidance regarding such issues. See 63 F.R. 8995 (2/23/98).

COMPLIANCE PROGRAM: Compliance Committee Responsibilities

POLICY PRACTICE shall have a Compliance Committee. The Compliance Committee

shall be responsible for assisting and advising the Compliance Officer in

implementing, monitoring, and coordinating such action as is necessary and

appropriate to facilitate an effective Compliance Program.

PROCEDURE

1. Appointment. The members of the Compliance Committee shall be appointed by the

Governing Board, and shall consist of:

a. The Compliance Officer, who shall serve as Chairperson of the Compliance

Committee.

b. The Administrator or his or her representative.

c. The Chief Financial Officer or his or her representative.

d. Representatives from appropriate PRACTICE departments such as:

i. Billing

ii. Clinical staff

iii. Human Resources

iv. Medical Records

e. Other PRACTICE personnel as appropriate and appointed by the Governing

Board.

f. Legal counsel, as appropriate and determined by the Administrator.

2. Duties. In addition to any other actions that may be necessary or appropriate to fulfill the

purpose of this Compliance Program, the Compliance Committee shall do the following:

a. Comply with the COMPLIANCE PROGRAM: General Standards of Conduct

Policy, number CP 001.

b. Meet quarterly or more frequently as deemed necessary by the Governing Board,

Administrator, or Compliance Officer.

c. Advise and assist the Compliance Officer in implementing and monitoring the

Compliance Program throughout PRACTICE.

d. Assist the Compliance Officer and department leaders in identifying, analyzing,

and prioritizing specific areas of concern in relevant departments.

e. Assist the Compliance Officer and department leaders in developing,

implementing, monitoring and evaluating standards, policies and procedures to

ensure compliance in specific departments.

f. Assist the Compliance Officer in developing procedures to promote the detection

of compliance problems through, e.g., employee reports; employee complaints;

employee hotlines; etc.

g. Assist the Compliance Officer in developing procedures to evaluate and respond

to complaints and problems dealing with compliance issues.

h. Participate in periodic training concerning issues relevant to the Compliance

Program as set forth in the COMPLIANCE PROGRAM: Education and Training

Policy, number CP 008.

i. Maintain the confidentiality of any compliance issues brought before the

committee consistent with applicable PRACTICE policies, laws and regulations.

COMPLIANCE PROGRAM: PRACTICE Personnel Responsibilities

POLICY Each PRACTICE member, employee, or contractor is responsible for complying

with and, as appropriate to the employee’s position and responsibilities, assisting

PRACTICE in its compliance activities. No person will be subject to any

retribution or disciplinary action for reporting a suspected violation of the

Compliance Program or applicable law or regulation in good faith. The failure to

report a suspected violation of which the employee has information may subject

the employee to discipline.

PROCEDURE

1. Compliance. Each PRACTICE employee shall:

a. Comply with the COMPLIANCE PROGRAM: General Standards of Conduct

Policy, number CP 001.

b. Cooperate with and, as appropriate to the employee’s position and

responsibilities, assist PRACTICE in implementing, maintaining, and monitoring

the Compliance Program.

c. Report all suspected violations of the Compliance Program, laws, regulations, or

third-party payor program requirements as set forth in the COMPLIANCE

PROGRAM: Communication About Compliance Issues Policy, number CP 009.

d. Report all cases in which any PRACTICE personnel or any entity with whom

PRACTICE contracts has been excluded from participation in government health

care programs.

e. Refrain from retaliating against any person for reporting suspected violations of

the Compliance Program or laws, regulations, and third-party program

requirements.

f. Participate in initial and periodic training concerning issues relevant to the

compliance program as set forth in the COMPLIANCE PROGRAM: Education

and Training Policy, number CP 008.

2. Evaluation. Adherence to the provisions of the Compliance Program shall be an element

in the evaluation of each employee’s performance standards.

3. Violations. Violation of the Compliance Program and its associated policies and

procedures, or of any law, regulation, or third-party payor program requirement, shall be

grounds for employee discipline as set forth in this Compliance Program and the

PRACTICE Employee Handbook.

COMPLIANCE PROGRAM: Education and Training

POLICY PRACTICE will provide relevant training to PRACTICE personnel concerning

compliance issues, including but not limited to applicable laws, regulations, third-

party payor program requirements, and PRACTICE policies.

PROCEDURE

1. New governing body members and employees. All new PRACTICE personnel (including

employees, contracted personnel, members or shareholders, and Governing Board

members), as part of an initial orientation, will receive training appropriate to the person’s

position and responsibilities concerning the Compliance Program. The training will

include:

a. PRACTICE’s commitment to compliance and high standards of ethical,

professional and business conduct.

b. An overview of the Compliance Program.

c. A copy of the COMPLIANCE PROGRAM: General Standards of Conduct Policy,

number CP 001.

d. Instructions on how to receive answers to questions concerning the Compliance

Program or compliance issues.

e. Instructions on how to report suspected violations of laws, regulations, third-party

payor program requirements and PRACTICE policies, and an explanation that

persons will not be subject to retaliation for making such reports.

f. Potential sanctions for violation of the Compliance Program, including the failure

to report suspected violations.

g. An opportunity to ask questions and receive answers.

h. The person will sign a form verifying that they have received training concerning

the Compliance Program and describing the training received.

2. Periodic training. PRACTICE personnel will receive periodic or updated training

concerning the Compliance Program appropriate to the person’s position and

responsibilities. Such training shall occur as often as appropriate, but at least once every

two years.

a. The training will include:

i. The basic subjects covered in the initial orientation.

ii. Changes in relevant laws, regulations, or third-party payor program

requirements.

iii. Changes in relevant portions of the Compliance Program or relevant

policies or procedures.

iv. As appropriate and to the extent that disclosure would not jeopardize an

applicable privilege, a discussion of compliance issues or problems

discovered by PRACTICE since the last training relevant to the

employee’s position and responsibilities.

v. An opportunity to ask questions and receive answers.

b. The Compliance Committee shall determine the frequency of the formal

compliance training programs for PRACTICE personnel as appropriate to

PRACTICE’s needs, which training may vary by department but should be

conducted at least annually. Notwithstanding the foregoing, compliance

education should be an ongoing process and compliance issues should be a

regular part of department meetings.

c. Persons who have received compliance education or training will sign a form

verifying that they have received training. In addition, as part of formal

compliance programs, employees will be asked to confirm that they have

disclosed all suspected violations, if any, of laws, regulations, program

requirements and PRACTICE policies pursuant to their obligations under the

COMPLIANCE PROGRAM: Communication About Compliance Issues Policy,

number CP 009.

3. Additional training for certain departments. PRACTICE officers, managers, employees,

or contractors whose actions affect the validity and accuracy of claims submitted to the

federal or state government (including personnel involved in coding, billing, cost

reporting, and marketing processes) shall receive additional specialized training

appropriate for their position and responsibilities, including training concerning the

following:

a. General prohibitions on paying or receiving remuneration to induce referrals.

b. Government and private payor reimbursement principles.

c. Other improper billing practices, including those referenced in the COMPLIANCE

PROGRAM: General Standards of Conduct Policy, number CP 001.

4. Compliance Officer. The Compliance Officer shall, with the assistance of the

Compliance Committee and relevant department leaders:

a. Stay current on laws, regulations, third-party payor program requirements, and

advisories relevant to compliance issues, including “fraud alerts” issued by the

Office of Inspector General.

b. Notify appropriate PRACTICE personnel of relevant changes in laws, regulations

or program requirements that affect compliance. The Compliance Officer may

request a report from the department leader as to whether the behavior detailed

in the alert is likely to be of concern to the PRACTICE.

c. Work with Human Resources and other PRACTICE leaders to develop periodic

training sessions as necessary and appropriate to employees’ positions and

responsibilities.

5. Human Resources Director. The Human Resources Director or their designee will:

a. Work with the Compliance Officer to coordinate and conduct appropriate training

sessions concerning the Compliance Program.

b. Maintain documentation of Compliance Program training for a period of seven (7)

years, including attendance logs and materials distributed at training sessions.

6. Compliance issues relating to education. All compliance-related educational sessions

involving an outside entity or vendor must be coordinated through and approved by the

Compliance Officer. All persons scheduling educational programs at PRACTICE must

be aware of the potential for a conflict present in:

a. vendor-sponsored educational programs,

b. vendor “grants” for training or education,

c. vendor donations to PRACTICE-sponsored events,

d. security of prescription medication, and

e. accuracy of drug billings.

COMPLIANCE PROGRAM: Communication About Compliance Issues

POLICY PRACTICE shall maintain an open line of communication between PRACTICE

personnel and the Compliance Officer or other appropriate representative to

ensure successful implementation of the Compliance Program and reduce any

potential for fraud, abuse and waste. No person shall be subject to any

retribution or disciplinary action for good faith reporting under this program, even

if allegations are found to be groundless.

PROCEDURE

1. Questions. PRACTICE personnel may seek clarification from the Compliance Officer,

members of the Compliance Committee, or supervisor if they have questions with regard

to an applicable law, regulation, third-party payor program requirement, or PRACTICE

policy or procedure. Significant questions and responses should be documented and

dated and, if appropriate, shared with other PRACTICE personnel so that standards,

policies and procedures can be updated and improved to reflect necessary changes or

clarifications.

2. Reporting suspected violations. PRACTICE personnel are required to report suspected

violations of the Compliance Program or any law, regulation, or third-party payor program

requirement relevant to the Compliance Program. The reports must be made as soon as

reasonably possible to ensure that PRACTICE complies with appropriate deadlines for

responding to suspected compliance concerns. PRACTICE personnel may choose any

of the following reporting options:

a. Report to supervisor or member of the Compliance Committee. PRACTICE

personnel may report concerns about a compliance issue directly to their

supervisor, the Compliance Officer, the Administrator, or other member of the

Compliance Committee. If the person making the report has reason to believe

that their legitimate concerns are not being addressed, they shall bring their

concerns directly to the Compliance Officer, Administrator, another member of the

Compliance Committee, or a member of the Governing Board.

b. Receipt of report. Persons receiving a complaint shall forward the report directly

to the Compliance Officer. Such persons are not to initiate any investigation nor

discuss the concern with any person other than the Compliance Officer unless

directed by the Compliance Officer. Complaints forwarded in this manner will be

processed by the Compliance Officer as set forth in the COMPLIANCE

PROGRAM: Investigation and Response Policy, number CP 011.

c. Compliance lock box. The Compliance Officer will make available one or more

locked boxes for depositing anonymous reports of suspected compliance

violations. PRACTICE personnel who wish to remain anonymous may deposit

their report into the box

d. Response by Compliance Officer. Upon receiving a compliance complaint, the

Compliance Officer shall investigate and respond as detailed in the

COMPLIANCE PROGRAM: Investigation and Response Policy, number CP 011.

3. Preserving confidentiality. Where known, PRACTICE will strive to keep the identity of

PRACTICE personnel who make a report confidential; however, PRACTICE cannot

guarantee that the information will remain confidential, e.g., if government entities

become involved.

4. Non-retaliation. No person will be subject to any retribution or disciplinary action by

PRACTICE for good faith reporting under this program, even if allegations made in good

faith are found to be groundless. Persons who engage in retaliatory conduct in violation

of this policy shall be subject to discipline.

5. Documentation. The Compliance Officer or their designee will log, investigate, and file

every complaint or report received. Records of complaints and investigations will be

maintained for seven (7) years after the investigation is closed. At the end of the seven-

year period all files will be destroyed by shredding, burning or some other method in

keeping with their confidential nature, provided that the records shall not be destroyed if

there is reason to suspect that the documents may be subject to an ongoing or future

investigation.

6. Reports. The Compliance Officer shall report significant or verified complaints of

suspected violations to the Compliance Committee, Administrator, and/or Governing

Board as appropriate. All persons receiving such reports shall maintain their

confidentiality to the extent consistent with applicable laws, regulations, and PRACTICE

policies.

7. Privileges. All such reports or the subsequent investigation and resolution may be

privileged from disclosure to certain entities. PRACTICE does not waive and specifically

reserves the right to assert appropriate privileges, including but not limited to the work-

product and peer review privileges.

8. Fraud alerts. If the Compliance Officer receives a Fraud Alert, Advisory Bulletin or other

publication from CMS, the OIG, or other government entity that may implicate practices

at PRACTICE, the Compliance Officer shall immediately investigate.

a. The Compliance Officer may send the Fraud Alert or other publication to the

appropriate department for review and comment on PRACTICE’s compliance.

b. In cases where a Fraud Alert or other publication does uncover potential

compliance issues at PRACTICE, the Compliance Officer and appropriate

department leaders will take immediate steps to correct the situation. In addition,

the Compliance Officer will make a report to the Administrator and/or Governing

Board as appropriate detailing:

i. the issues raised by the alert or other publication;

ii. the findings of the Compliance Officer or department leader;

iii. the corrective action taken; and

iv. the monitoring activities established to ensure ongoing compliance.

c. In cases where a Fraud Alert or other investigation uncovers evidence of an

actual violation of civil or criminal law or the rules and regulations of a federally-

funded health care program, the Compliance Officer will inform the Administrator,

who may contact legal counsel and, if appropriate, the appropriate government

authority.

COMPLIANCE PROGRAM: Auditing and Monitoring

POLICY PRACTICE will implement a self-assessment program to monitor and evaluate

the compliance program. Evidence of ongoing monitoring will be maintained by

the Compliance Officer and periodic reports will be given to the Administrator and

Governing Board.

PROCEDURE

1. Department Responsibilities. The Compliance Officer and Compliance Committee shall

ensure that each PRACTICE department with responsibilities that implicate compliance

issues establishes an appropriate policy and process for monitoring ongoing compliance.

The policy and processes may vary according to the department’s needs and

compliance risks.

2. Methods. The Compliance Officer and Compliance Committee shall work with the

department to identify the appropriate monitoring and auditing processes, which may

include the following as appropriate to the department:

a. Periodic review of departmental practices or actions relevant to compliance

issues, including but not limited to—

(1) Claims for payment generated or submitted by the department;

(2) Contracts with potential referral sources relevant to the department;

(3) Advertising or marketing initiatives by the department;

(4) Gifts or inducements to program beneficiaries;

(5) Necessity, quality, and propriety of care rendered.

b. Receipt of and response to compliance questions, concerns, or complaints.

c. Review of government survey or inspection results.

d. Review of new government guidance or directions.

e. Review of claim denials.

f. Interviews of employees concerning possible or potential compliance issues,

including exit interviews of employees who leave PRACTICE employment.

g. Discussion of compliance issues in regularly scheduled department meetings.

h. Confirmation that department employees have been properly trained concerning

compliance issues relevant to their job duties.

i. Review of significant deviations in processes or payments.

j. As authorized by the Compliance Officer, formal auditing by an internal or

external professional of compliance-related issues.

3. Frequency. The frequency and extent of the monitoring shall depend on the needs and

potential for compliance violations in the department, provided that the following shall

apply to specific departments:

a. Billing and coding. Departments that are involved in coding and billing for claims

will, on at least a quarterly basis, review a sample of bills and underlying

documentation to confirm ongoing compliance with applicable laws, standards,

and payor requirements governing billing, coding, and claim submission.

b. Clinical services. Departments that render and document clinical services will, on

a quarterly basis, review a sample of charts and related documents to confirm

ongoing compliance with applicable laws and standards concerning patient care

services, medical necessity, appropriate documentation, and proper coding of

services rendered.

4. Reports. At least once each year, each department with responsibilities that implicate

potential compliance concerns shall prepare and submit an appropriate confidential

report to the Compliance Officer summarizing the department’s monitoring activities

during the preceding year. The report shall include, e.g.:

a. A brief description of the department’s ongoing monitoring activities and the

results of such monitoring.

b. A brief description of any compliance issues or concerns that were identified, and

the resolution of those concerns.

c. A brief description of training provided concerning compliance issues or

concerns.

d. Any other items relevant to the Compliance Officer’s duties.

5. External Audits. The Compliance Officer, with Administrator approval, may at anytime,

direct that an external audit of any department be conducted by qualified PRACTICE

personnel or an outside contractor. An external audit may be appropriate where, e.g.,

internal reviews or complaints raise the possibility of a significant compliance issue; new

guidance has been received from regulators; it is necessary to establish a baseline to

confirm compliance or provide training; or simply to confirm ongoing compliance in

departments which face significant compliance issues. If an audit is employed, it may

follow this protocol:

a. The Compliance Officer, with the assistance of the Compliance Committee,

determines the need for and scope of the audit.

b. The Compliance Officer, with the assistance of the Compliance Committee, will

develop a checklist of particular items and records to be audited.

c. The Compliance Officer or a member of the Compliance Committee may meet

with department leaders to discuss the need for and scope of the audit.

d. The chosen auditor is assigned tasks by the Compliance Officer or member of the

Compliance Committee.

e. The auditor meets with the department leader to conduct the audit with the

assistance of the department leader.

f. The auditor may elect to share preliminary findings with the Compliance Officer,

assigned representatives of the Compliance Committee, and/or department

leader.

g. The auditor prepares and presents to the Compliance Officer a report with

appropriate examples of substantiating material.

h. The Compliance Officer and auditor meet with department leaders to review and

discuss the report. The department leader may be given an opportunity to

respond to the report.

i. The Compliance Officer will present the report and relevant information to the

Administrator and, as appropriate, the Compliance Committee and Governing

Board.

6. Violations of law. In cases where department monitoring, reviews or audits reveal

evidence of an actual violation of civil or criminal law or the rules and regulations of

government health care programs (e.g., Medicare or Medicaid), the department leader

shall immediately notify the Compliance Officer. If the Compliance Officer determines

that the concern is valid, the Compliance Officer will immediately notify the Administrator,

who may consult with legal counsel and, as appropriate, notify the relevant government

authority. The Governing Board will be apprised of findings and actions taken.

7. Over/under payments. In cases where department monitoring, reviews, or audits reveal

evidence of the receipt of overpayments or underpayments from any third-party payor,

the department leader shall notify the Compliance Officer. The Compliance Officer or his

or her designee may consult with legal counsel and, if determined appropriate,

immediately notify the third-party payor and refund any overpayment or seek payment for

any underpayment. The Administrator will be informed of significant underpayments or

overpayments.

COMPLIANCE PROGRAM: Investigation and Response

POLICY The Compliance Officer or their designee will direct investigations concerning

alleged compliance problems and report relevant findings. The fact that a

complaint was filed does not necessarily establish wrongdoing, but does serve as

an opportunity to evaluate the compliance program and make any appropriate

changes.

PROCEDURE

1. Record. Upon receiving notice of a potential compliance problem, the Compliance

Officer shall create a record as referenced in the COMPLIANCE PROGRAM:

Compliance Officer Responsibilities Policy, number CP 004. The record shall contain the

following information:

a. the date received;

b. the manner in which the report was received (e.g., by anonymous report);

c. a brief statement of the facts alleged;

d. notes detailing and documenting a timely investigation and response; and

e. action taken and the date the action was taken.

2. Investigation. The Compliance Officer, or an appropriate designee, shall promptly

investigate the issue. Among other appropriate actions, the Compliance Officer or their

designee may, as the circumstances warrant:

a. Review documents and statistical data to determine whether there are systemic

or clerical errors by, e.g., checking for analytical or transcription errors or

statistical outliers.

b. Review relevant policies and procedures relating to the compliance problem to

determine the extent of the problem.

c. Review documentation and witnesses to determine if there was intentional

wrongdoing as evidenced by intentionally erroneous policies; altered records; etc.

3. Report. Upon completion of the investigation, the Compliance Officer or their designee

will prepare a final report summarizing the investigation and recommended actions to be

taken, if any. Additional actions may include, but are not necessarily limited to, providing

additional training; modifying or correcting procedures; disciplining employees; repaying

overpayments or requesting payment for underpayments; etc.

4. Errors resulting in noncompliance. If the investigation discloses unintentional errors or

mistakes by PRACTICE personnel, the Compliance Officer shall report the conclusions

to the Administrator and, as appropriate, the Compliance Committee and/or Governing

Board. Legal counsel may be contacted to determine whether disclosure or repayment

to the appropriate government entity should be made. According to the OIG Self-

Disclosure Protocol, matters involving exclusively overpayment or errors that do not

suggest that violations of law have occurred should be brought to the attention of the

government contractor, and need not be reported to government agencies. (63 F.R.

58400.)

5. Violations of law. If the investigation discloses what appear to be intentional violations of

applicable civil or criminal laws, the Compliance Officer shall immediately report the facts

to the Administrator. Legal counsel may be contacted to determine whether disclosure or

repayment to the appropriate government should be made. If possible, disclosure should

be made within 60 days from the time that the errors were discovered.

6. Repayments. Federal and state laws generally require that PRACTICE report and repay

overpayments received from government health care programs within, e.g., 60 days.

Compliance Officer shall work with appropriate departments and, as appropriate, legal

counsel to comply with all such laws.

COMPLIANCE PROGRAM: Medical Necessity for Lab and Diagnostic Procedures

POLICY Medical necessity is the primary determining factor in ordering tests and

diagnostic procedures. The physician is responsible for determining medical

necessity. Peer review procedures at PRACTICE will include utilization review.

Instances of improper use of diagnostic or laboratory procedures will be grounds

for medical staff disciplinary review. PRACTICE will not provide services for

testing that is not diagnosis-related.

PROCEDURE

1. Laboratory and diagnostic procedures will be performed only with an appropriate

physician order.

2. Orders for outpatient tests must include a narrative diagnosis or diagnosis code.

3. Tests must be ordered individually unless part of a recognized multi-channel test series

or an organ or disease panel.

4. Tests for which Medicare reimbursement is anticipated must be medically necessary for

diagnosis or treatment and not for screening purposes.

5. Patients must be notified prior to the performance of a test not justified by diagnosis or

diagnosis code that reimbursement may be denied and that the patient is liable for

payment. The patient must acknowledge responsibility for payment in writing.

6. All physicians at PRACTICE will be provided copies of the following on an annual basis:

a. PRACTICE’s medical necessity policy;

b. The individual components of laboratory profiles;

c. A contact person in PRACTICE’s billing department with whom to discuss issues;

and,

d. A reminder that governmental agencies may take civil and/or criminal action

against any party ordering medically unnecessary tests.

COMPLIANCE PROGRAM: Billing Responsibilities

POLICY PRACTICE will ensure that all claims submitted for payment are accurate and

correctly identify the services ordered. PRACTICE will not:

a. Bill for services not provided;

b. Bill for services not properly ordered

c. Misrepresent a patient’s diagnosis to justify services;

d. Knowingly apply for duplicate payment or payment from duplicate payors

for the same service;

e. Unbundle charges;

f. Misrepresent the services rendered, the amounts charged, the identity of

the person receiving the service, or the identity of the person actually

providing the service;

g. Utilize the billing number for a provider who did not actually provide the

service;

h. Bill as if services rendered one day were rendered on different days; or

i. Take other action that is false or in violation of applicable laws or

regulations.

PROCEDURE

1. Clinical providers and the billing department are responsible for ensuring the

appropriateness of codes for any tests ordered.

2. Questions about code selection should initially be presented to the supervisor; the

ordering practitioner will be contacted if necessary.

3. If questions remain after discussing with the ordering practitioner, the department should

refer the matter to the Compliance Officer.

4. Billing Office personnel must be particularly vigilant in billing for services that involve:

a. Coding;

b. Claim rejections, in which case notify supervisor for problem identification and

correction;

c. Inappropriate unbundling/bundling of services.

5. CPT and HCPCS codes will be reviewed annually upon receipt of the CPT code manual

for the year. Significant code changes will be communicated in writing to practitioners as

appropriate.

6. Bulletins from third-party payors will be reviewed and initialed by the head of the Billing

Office. Coding changes made or changes in reimbursement levels will be communicated

to all practitioners as needed.

7. Coding change instructions and transmittals will be retained for a period of seven (7)

years from the date they are effective.

8. Ordering practitioners will ensure that the codes used are those which most accurately

describe the ordered test. Codes will never be selected solely to maximize

reimbursement.

9. PRACTICE will not:

a. Use diagnostic information provided from earlier dates of service, except in cases

where approved standing orders are utilized;

b. Use prepared sheets that provide diagnostic information which has been found to

be successful in maximizing reimbursement in the past;

c. Use any computer-based or other programs which automatically insert diagnosis

codes without receipt of current diagnostic information from the practitioner; or,

d. Assume or “make up” diagnostic information for claims submission purposes.

10. PRACTICE will not bill Medicare beneficiaries for uncovered tests unless a beneficiary

acknowledgment executed by the patient prior to the performance of the test is on file.

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