Corporate Compliance

The CMH Corporate Compliance program serves to address and resolve known or suspected illegal or unethical matters within the organization.

Columbia Memorial Hospital Guidelines on Ethical Conduct (Policy 8610-315)

The policy on the following pages has been adopted by the Board of Trustees of Columbia Memorial Hospital as our hospital’s Code of Ethics and Business Conduct. It summarizes the virtues and principles that are to guide our actions in the delivery of health care. We expect our agents, consultants, contractors, representatives and suppliers to be guided by them as well.

There are numerous resources available to assist you in meeting the challenge of performing your duties and responsibilities. There can be no better course of action for you than to apply common sense and sound judgment to the manner in which you conduct yourself. However, do not hesitate to use the resources that are available whenever it is necessary to seek clarification.

Any questions you may have regarding this policy or the Compliance Program can be addressed to your department manager, the corporate compliance officer, or any member of the Compliance Committee.

Columbia Memorial Hospital Compliance Program Overview

The elements of Columbia Memorial Hospital’s Compliance Program which impacts all employees are outlined below. In addition to this overview, the Compliance Program contains policies associated with specific services that will be communicated to the personnel to whom they pertain.

I. Commitment to Lawful and Ethical Behavior

Columbia Memorial Hospital’s (“CMH”) Board of Trustees has adopted a Corporate Compliance Program to support CMH’s longstanding commitment to the provision of health care services in full compliance with all federal, state and local laws and regulations, and to set forth CMH’s Compliance Program for proactively preventing, detecting, and reporting violations of the laws and regulations which govern this organization and the services we provide. The guiding principles for the provision of those services are summarized in the CMH Guidelines on Ethical Conduct (Policy 8610-315).

The Compliance Program describes the mechanism by which management exercises due diligence in seeking to prevent and detect any behavior contrary to those principles. Perhaps most important, it supports the existence of a corporate culture that places the highest value on integrity in the achievement of its mission.

II. Standards of Conduct and Compliance Policies

In addition to the Guidelines on Ethical Conduct that applies to all employees, standards of conduct pertinent to some of the services provided by CMH have been developed, as well as written policies addressing specific areas of potential fraud, such as claims development and submission processes, coding accuracy, and financial relationships with physicians and other health care professionals. The objectives of those standards of conduct and policies are to (1) establish the high values expected of employees; (2) provide explicit guidelines for employees to follow; (3) ensure all employees understand what is expected; (4) ensure employees are implementing those standards as a daily practice; (5) enhance a corporate culture supporting compliance with federal and state law, and federal, state and private payor health care program requirements, as well as CMH’s ethical and business policies; and (6) build trust in the community using CMH’s services. Special attention is given to those health care services and activities that represent the most significant exposure to fraud and abuse of laws and regulations that govern federally funded programs.

The Guidelines on Ethical Conduct policy and the Compliance Program Overview will be made available to and in a form that is understandable by all employees. Annually, each employee will be required to complete and sign an attestation that he/she has received and understands the Guidelines on Ethical Conduct policy and the Compliance Program Overview. The Compliance Program will be regularly updated as the policies and regulations addressed in the Program are modified.

III. Compliance Program Oversight

A Corporate Compliance Officer (CCO) is responsible for developing compliance policies, standards and procedures; overseeing and monitoring the implementation of those policies, standards and procedures; and assessing the effectiveness of the Compliance Program for CMH. The CCO is delegated sufficient authority to undertake and comply with their respective responsibilities and shall have open access to senior management and the Board of Trustees.

Responsibility for the oversight of the Compliance Program is vested in the Compliance Committee, which consists of the CCO and the managers of the following departments: Laboratory, Patient Accounts, Health Information Management, and Information Services. Other department managers will participate on the Compliance Committee as necessary.

IV. Standards and Methods for Delegating Authority

CMH will exercise due care not to delegate substantial discretionary authority to individuals whom the organization knew, or should have known, through the exercise of due diligence, had a propensity to engage in illegal activities. This will be accomplished by conducting a reasonable and prudent background investigation, including a reference check, as part of every such employment application.

CMH prohibits the employment of individuals who have been convicted of a criminal offense related to health care or who are listed by a federal agency as debarred, excluded or otherwise ineligible for participation in federally funded health care programs. Employees who are charged with criminal offenses related to health care or proposed for exclusion or debarment will be removed from direct responsibility for or involvement in any federally funded health care program. If resolution results in conviction, debarment or exclusion of the individual, CMH will terminate its employment of that individual.

V. Effective Communication of Standards and Procedures

The compliance policies and standards contained in the Compliance Program will be effectively communicated on a regular basis to those employees and other agents to whom they pertain through training programs or publications that explain in a practical manner what is required. Communications with employees will emphasize (1) CMH’s commitment to compliance; (2) the importance of complying with the laws and regulations governing the services which CMH provides; (3) the specific requirements of the regulations as they relate to an individual’s job; and (4) the obligation of each employee to behave in a manner consistent with the principles articulated in the Guidelines on Ethical Conduct and the Compliance Program.

VI. Monitoring and Auditing Systems

CMH will take reasonable steps to assess the effectiveness of the Compliance Program by utilizing audits and other evaluation techniques to monitor compliance and assist in the resolution of problems identified. The results of those monitoring and auditing activities will be reported on a regular basis to Administration and the Board of Trustees. Particular attention will be paid to those areas targeted by the Office of Inspector General of the Department of Health and Human Services, such as medical records coding, billing, laboratory services, home health services, physician referrals, and other services. A detailed report on the results of all monitoring and auditing activities will be maintained by the CCO.

VII. Internal Reporting and Responding to a Suspected Violation

CMH is committed to providing an environment that encourages and allows employees to seek and receive prompt guidance before doing anything that may violate the Guidelines on Ethical Conduct, and to report conduct that a reasonable person would suspect to be a violation of internal compliance policies, applicable statutes, regulations, or federal health care program requirements. Columbia Memorial Hospital absolutely prohibits retaliation against any employee who makes a good faith report of a compliance issue.

A toll-free telephone number (1-800-560-6938) is provided for employees and agents of CMH as an optional mechanism to report any activity and/or conduct they suspect is not in adherence to the CMH Guidelines on Ethical Conduct or Compliance Program. Information received will be used to investigate and verify whether or not improper activity has occurred, and to correct and prevent inappropriate conduct. To the extent possible and appropriate, CMH will endeavor to conceal the identity of anyone reporting a possible violation. Complete confidentiality, however, cannot be guaranteed.

VIII. Investigations

When the Compliance Officer or management personnel learn of a potential violation or misconduct the matter will be promptly investigated. Employees are expected to cooperate in the investigation of possible violations but should NOT try to investigate by themselves without involving the compliance officer. Investigations may raise complex legal issues and CMH could lose important privileges if an investigation is carried out without legal advice. Also, an investigation may lead to judicial, administrative, or legislative action, for which CMH needs legal representation at the earliest stage.

If any person who identifies himself or herself as a government investigator approaches a Hospital employee the employee should contact Administration immediately. An appropriate representative of Administration will verify the credentials of the investigator, determine the legitimacy of the investigation, and ensure that proper procedures are followed for cooperating with the investigation.

Employees contacted by persons presenting themselves as government investigators outside of the work place, during non-work hours, or at home, should not feel pressured to talk with the person under such circumstances without contacting Administration or their personal attorney. It is the legal right of employees to contact legal counsel before responding to questions by an investigator.

During a government investigation employees must never conceal, destroy, or alter any documents, lie, or make misleading statements to government investigators. All efforts to cooperate with the government should be coordinated through Hospital legal counsel.

IX. Corrective Action

If an investigation reveals misconduct did occur corrective action will be immediately initiated. CMH will take all reasonable steps to respond appropriately to the offense and to prevent further similar offenses, including any necessary modification of the Guidelines on Ethical Conduct and/or the Compliance Program. If an investigation reveals that CMH received payments to which it was not entitled, CMH will make prompt restitution of such sums to the appropriate federally funded health care program.

The responsibility for investigating, reporting and correcting problems that have been identified lies with the CCO and others involved in management of CMH.

X. Enforcement and Disciplinary Action

Disciplinary action will be initiated against individuals who have failed to comply with the Guidelines on Ethical Conduct and Compliance Program, thereby impairing CMH’s status as a reliable, honest, trustworthy provider.

Location
Main Campus

Contact Information:
Karen Flint
karen_flint@columbiamemorial.org
503-325-4321 x3409