Question

Write a memo, as the chief compliance officer of your health care organization, outlining a broad proposal, specific to your type of organization, suggesting to the Board of Governors an overall plan of compliance. Rather than just parroting any guidelines, try to tailor them to your organization and make it understandable to all the Board members, some of whom may not know much of healthcare business and billing practices.

Entailing a compliance program such as code of conduct, billing compliance , credential compliance

Answer 1

To

Chief compliance officer

St Johnson Hospital

I would like to share my thoughts on implementing compliance and guidelines, Hospital must be committed to ethical and lawful behavior. In order to achieve our passion and purpose, we have an obligation to establish a framework by which our organization and our employees are able to know about and comply with the ever-changing regulatory environment of health care. To that end, we have established the Regional Corporate Compliance Program (the Program). The Program applies to but is not limited to all who work for, or at, Regional Health Care System and its subsidiaries Employees, including: administrative, exempt and non-exempt staff, and professionals; Contracted personnel; Physicians on staff but not employed by Regional, residents; Volunteers, students; Vendors; All clinic and satellite locations; Physicians and employees involved in any 501(a) either partly or wholly funded by Third party billing companies and/or any party performing services on behalf of Regional. The Program is intended to complement, not replace, other Regional policies and is designed to comply with all federal, state, and local laws and regulations. PROGRAM STRUCTURE The Corporate Compliance Program is intended to demonstrate the absolute commitment of the organization to the highest standards of ethics and compliance and to establish accountability for the adherence and maintenance of the Corporate Compliance Program policies and procedures. Our commitment applies to all levels of the organization. The Compliance Officer has primary responsibility for ensuring the Compliance Program is current, and that our standards are met. The Board of Directors has oversight authority along with the President/Chief Executive Officer.

The Board has authorized a Corporate Compliance Officer to establish, maintain, and monitor the effectiveness of the Corporate Compliance Program. The Compliance Officer will sponsor, oversee, coordinate and deliver continuing education on a variety of compliance topics. The Compliance Officer will chair the Department Level Compliance Committee and will report to the Finance Committee of the Board of Directors at least quarterly. Management’s Responsibilities under the Corporate Compliance Program Management throughout the organization is responsible for setting the example, ensuring that everyone is provided with appropriate resources, and that they are consistently holding 3 themselves and Regional employees accountable for their actions. Specifically, Management will establish and distribute policies and procedures and provide training and education regarding compliance, as appropriate.

Employees’ Responsibilities under the Corporate Compliance Program All employees have an obligation to assure that the Corporate Compliance Program is successful. Employees can help to achieve that success by completing the following actions:

1. Read and regularly review the Code of Conduct and the policies that support it in order to learn the compliance requirements that apply to individual responsibilities.

2. Participate in organization-wide and department specific training designed to help understand employee obligations under the Code of Conduct.

3. Abide by the requirements set forth in the Code of Conduct.

4. Ask questions and seek assistance when uncertain about the proper course of action. 5. Know the Corporate Compliance Officer, and how to reach him/her. 6. Support employees who report suspected violations of the Code of Conduct. Recognize that retaliation against persons who report suspected violations is not permitted.

7. Be alert to situations that could result in illegal or unethical conduct and encourage other employees to consult with supervisors or the Corporate Compliance Officer if it appears that they may be in danger of violating the law or the Code of Conduct. 8. Report suspected violations of the Code of Conduct or the Compliance Program Regional’s commitment to compliance with all applicable laws, rules and regulations applies to everyone at all levels of the organization. As part of the Compliance Program, Regional routinely takes actions to help everyone to comply with legal and ethical requirements, including the following actions: Developing and implementing written policies and procedures Having an empowered Compliance Officer; Conducting ongoing education and training programs; Maintaining an organizational structure that supports the Compliance Program; Conducting ongoing auditing and monitoring activities; Identifying, investigating and responding appropriately to potential compliance issues; Verifying that those with whom we do business and employ are trustworthy; Protecting people who raise compliance issues in good faith from retaliation; Maintaining open channels for reporting compliance concerns; and Reporting results of compliance activities to the governing body and senior

CODE OF CONDUCT This Code of Conduct provides the groundwork for each of us to act with the highest level of integrity and in accordance with ethical and legal standards. Compliance is everyone’s responsibility at Regional. The Code of Conduct is a critical component of Regional’s overall Corporate Compliance Program. We have developed the Code of Conduct to ensure we provide quality patient care and meet our ethical and legal standards. The Code of Conduct and Regional’s Compliance Program applies to all who work for, or at, Hospitals and its subsidiaries: employees, including: administrative, exempt and non-exempt staff, and pr ofessionals; contracted personnel; physicians on staff but not employed by Regional, residents; 5 volunteers, students; vendors; all clinic and satellite locations; physicians and employees involved in any 501(a) either partly or wholly funded by Regional; third party billing companies and/or any party performing services on behalf of Regional, as well as the corporate board of directors.. If you have any questions regarding our expectations of you, the Code of Conduct or Regional’s Compliance Program, feel free to contact your supervisor, the Regional Compliance Officer, or call our Compliance Hotline at 940-764- 2990. Regional is committed to conducting all of our business dealings in compliance with the applicable laws and regulations and avoiding any impropriety, dishonesty, or wrongdoing. We believe adhering to the guiding principles in the Code of Conduct and the Regional Compliance Program will allow us to create and reinforce a corporate culture of embracing compliance and maintain a reputation as a leader in providing innovative, comprehensive, and quality health care to our patients. Regional has resources to help you understand expectations related to compliance and to assist you with any questions you might encounter.

Best,

David brenda, RN