HAMILTON MEMORIAL HOSPITAL DISTRICT
COMPLIANCE PLAN

In order to comply with governmental regulations regarding Medicare/Medicaid fraud, waste, and abuse, Stark Law physician referral restrictions, Clinical Laboratory Improvement ACT (CLIA) requirements, Emergency Medical Treatment and Active Labor Act (EMTALA), Equal Employment Opportunity Commission (EEOC)  laws and regulations, National Labor Relations Board (NLRB) laws and regulations, Occupational Safety & Health Administration (OSHA) regulations, Internal Revenue Service (IRS) regulations, Health Insurance Portability and Accountability Act (HIPAA), and other applicable laws and regulations of the United States and the State of Illinois, the Hamilton Memorial Hospital District (HMHD) has developed this Compliance Program, which includes the following elements:

• Written standards of conduct for employees;
• The development and distribution of written policies that promote the hospital’s commitment to compliance with all laws and regulations and that address specific areas of potential fraud and abuse, such as billing, marketing and claims processing;
• The designation of a hospital Compliance Committee which is charged with analyzing the business and legal requirements applicable to the hospital, assessing existing policies and procedures, developing standards of conduct, monitoring internal systems and controls, approving the overall approach toward compliance taken by the organization and developing a problem resolution system;
• The designation of a Compliance Coordinator (CC) who is charged with the responsibility of operating the compliance program;
• The development and offering of education and training programs to all employees;
• The use of audits and/or other evaluation techniques to monitor compliance and ensure correction of identified problem areas;
• The use of a disciplinary process for employees who have violated internal compliance policies or applicable laws or who have engaged in wrongdoing;
• The investigation and remediation of identified systemic and personnel problems;
• The promotion of and adherence to compliance as an element in evaluating all employees with added importance for supervisors and managers;
• The development of policies addressing the non-employment or retention of sanctioned individuals;
• The maintenance of a hotline and/or other means to receive complaints and the adoption of procedures to protect the anonymity of complainants; and the adoption of requirements applicable to record creation and retention;
• Appropriate administrative, technical and physical safeguards to protect the privacy and security of protected health information;
• The best practices of the hospital safeguard this privacy and are facilitated through the Risk Management and Performance Improvement Plans;
• These are supported and further realized through workstation specific practices with additional direction provided through Access Control and Workforce Management policies and procedures.

A. PROCEDURES AND POLICIES

These policies were developed under the supervision and direction of the hospital Chief Executive Officer (CEO), the Compliance Coordinator (CC), the Compliance Plan Committee, and are provided to all employees and individuals who are affected by the specific policy at issue. These policies are maintained by the CC and updated as needed.

Standards of Conduct

The Hamilton Memorial Hospital District has developed these Standards of Conduct for all employees which clearly delineate the policies of HMHD with regard to fraud, waste and abuse, and adherence to all guidelines and regulations governing Federally and State funded healthcare programs.  If special fraud alerts issued by the Health and Human Services (HHS) Office of Inspector General (OIG) delineate conduct that is criticized or prohibited and HMHD is involved in such conduct, HMHD shall immediately take action to correct such practices.  These standards are available to and understandable by all employees and regularly updated as the policies and regulations of these programs are modified.

1. Medical Necessity

The hospital will attempt to ensure that claims are submitted to Federally and State funded healthcare programs only for treatment(s), medication(s), procedure(s), test(s), supplies, x-rays, and all other services provided that the ordering physician has reason to believe are medically necessary.  Upon request, the hospital will provide documentation containing diagnosis codes supporting the medical necessity of treatment(s), medication(s), procedure(s), test(s), supplies, x-rays, and all other services the hospital has provided and billed to the federal and State funded healthcare programs.  The hospital does not and cannot control the treatment of patients or make medical necessity determinations; however, steps will be taken to help maximize the likelihood that the Medical Staff follows the governmental guidelines and that the hospital staff only bills federal and State funded healthcare programs for treatment(s), medication(s), procedure(s), test(s), supplies, x-rays, and all other services that they believe meet the reimbursement rules for those programs.

While a physician must be able to order any treatment(s), medication(s), procedure(s), test(s), supplies, x-rays, and all other services, including screening tests, that he/she believes are appropriate for the treatment of his/her patients, the hospital has, through Medical Staff meetings, requisitions and educational programs, attempted to make physicians aware that Medicare/Medicaid will only pay for treatments, medications, procedures, tests, supplies, x-rays, and all other services that meet the Medicare/Medicaid definition of “medical necessity”.  Medicare/Medicaid may deny payment for a treatment, medication, procedure, test, supply, x-ray, and all other services that the physician believes is appropriate, but which the government decides does not meet the Medicare/Medicaid definition of medical necessity.  The hospital advises the physicians that they should only order those treatments, medications, procedures, tests, supplies, x-rays, and all other services that are medically necessary for the diagnosis and treatment of their patients. The OIG takes the position that a physician who orders medically unnecessary treatments, medications, procedures, tests, supplies, x-rays, and all other services for which Medicare reimbursement is claimed may be subject to civil penalties if the government determines lack of medical necessity.

a. Outpatient Requisitions for Laboratory:  the hospital laboratory will standardize its test and procedure offering and use common, uniform requisition forms for outpatient testing that emphasize physician choice and encourage doctors to order, to the extent possible, only those tests that they believe are appropriate and medically necessary for each patient.  The requisition forms are designed to require physicians to order tests individually (i.e., separately) unless:

• the test is specifically part of a CPT or HCPCS defined automated multichannel test series;

• the test is part of a CPT – defined “clinically relevant test grouping” such as an organ or disease panel or profile; or

• the test is part of a profile that has been customized at the request of the physician. In addition, a printed Statement will appear on every outpatient requisition form reiterating that physicians should only order tests that are medically necessary for the diagnosis or treatment of a patient, rather than for screening purposes.

b. Outpatient Requisitions for Radiology: the hospital radiology department outpatient requisitions will indicate x-rays that the treating physician or consultant believes is medically necessary.  The requisition forms require physicians to document the medical necessity for x-rays ordered by inserting a diagnosis description or ICD-9 code for tests ordered.

c. Miscellaneous Outpatient Requisitions: the hospital miscellaneous outpatient department requisition forms will indicate the treatment(s), procedure(s) or medication(s) the treating physician or consultant believes are medically necessary. The requisition forms require physicians to document the medical necessity for tests ordered by inserting a diagnosis description or ICD-9 code for tests ordered.

d. Physicians: the physicians are responsible for ordering only medically necessary treatment(s), medication(s), procedure(s), test(s), supplies, and all other services.

e. Notices to Physicians:  the hospital will provide the physician, upon request, a copy of the Medicare medical necessity policy. For treatment(s), medication(s), procedure(s), test(s), supplies, x-rays, and all other services ordered which are deemed not medically necessary Medicare may deny payment. The OIG takes the position that a physician who orders medically unnecessary medications, procedures, tests, supplies, x-rays, and all other services, for which Medicare reimbursement is claimed, may be subject to civil penalties.

f. Physician Acknowledgments:

(1) the physician understands that when ordering treatments, medication(s), procedure(s), test(s), supplies, x-rays, and all other services for which Federal or State funded program reimbursement will be sought, the physician should only order those treatment(s), medication(s), procedure(s), test(s), supplies, x-rays, and all other services which the physician believes are medically necessary for each patient;

(2) the physician has been informed that the OIG takes the position that a physician who orders medically unnecessary treatment(s), medication(s), procedure(s), test(s), supplies, x-rays, and all other services may be subject to civil penalties; and

(3) the hospital receives monthly Part B bulletins and  provides this information to the physicians for their educational benefit as well as their office staff in regards to compliance issues, proper coding, diagnosing, etc.

g. Reliance on Standing Orders:  The hospital will permit the use of standing orders

executed in connection with an extended course of treatment. However, the hospital will monitor existing standing orders to ensure their continuing validity. These are annually reviewed and updated by the individual who is authorized to order treatment(s), medication(s), procedure(s), test(s), supplies, x-rays, and all other services. ,

h. Utilization Monitoring: The hospital will take the steps described above to help

ensure that physicians will make a determination and document the medical necessity of treatment(s), medication(s), procedure(s), test(s), supplies, x-rays, and all other services billed to any Federal or State funded healthcare program, as well as any private pay programs.

The Utilization Review Department monitors the medical necessity of admission and treatment of inpatients, observation patients, and extended care patients.  The UR Coordinator monitors this with UR Committee meetings held quarterly or more often as needed. This Committee is interdepartmental with Medical Staff, Administration, Nursing, Business Office, and Health Information representation. Pertinent results of these meetings are reported at the next Medical Staff meeting.

Prior to any outpatient treatment being administered, the hospital will confirm that medical necessity has been met by comparing the physician’s diagnosis with the Medicare guidelines. If it is determined that this requirement has not been met, an Advance Beneficiary Notice is explained to the patient, obtaining his/her signature showing understanding of the possibility that Medicare may not cover the cost of the treatment about to be given.

Should the hospital have reason to believe that its physicians are ordering medically unnecessary treatment(s), medication(s), procedure(s), test(s), supplies, x-rays, and all other services, it should, through the Hospital Utilization Review Committee, determine why that behavior has occurred and what corrective action can be taken. If the hospital determines that it has in some way contributed toward that behavior, the hospital will take appropriate action and document the findings and corrective action.

Utilization Monitoring for Home Health:

The Home Health Agency monitors the medical necessity, eligibility, and appropriateness of Plan of Care for all patients admitted to the agency services. The Director monitors this through pre-admission intake/referral information given by the referral source and through case conference meetings with the staff providing the care.

Physicians signing the Plan of Care are also signing a statement that the patient is appropriate and eligible for home health services.

Should the agency believe that a patient is not eligible or appropriate for home health, the physician will be notified and the patient will not be admitted to home health services. Should the patient’s status change after/during the course of care and no longer be appropriate or eligible, the agency will notify the physician for discharge or referral orders.

Should the patient not meet Medicare qualifications for services and it is the belief of the agency that Medicare will not cover the services as ordered, the patient shall be issued an Advance Beneficiary Notice (ABN) as appropriate. The ABN shall be issued per Medicare requirements. The provision for care shall then follow the patient’s agreement/decline for services based upon the ABN. The physician shall be notified of the patient’s decision to continue or decline home health services.

Utilization Monitoring for the Nursing Center:

The Nursing Center Utilization Committee monitors the necessity and appropriateness of treatment for nursing center residents. This committee meets quarterly or more often when necessary. This committee consists of: the Nursing Center Medical Director, Nursing Center Administrator, the Nursing Center Director of Nursing, the Nursing Center Social Service Director, the Care Plan Coordinator, Dietician, the Director of Laboratory, the Nursing Center Activities Director or their designee, and the Director of Physical Therapy or their designee. Results of these meetings are reported at the next medical staff meeting.

2. Physician Relationship Issues

Physician recruitment and employment will be in compliance with federal and State anti-kickback statutes as well as complying with the Stark physician self-referral law.  Contracts and arrangements shall comply with applicable laws regarding compensation and referral.  Hospital-based physicians shall not have financial arrangements that are based on hospital remuneration in return for the physician’s ability to provide services to healthcare beneficiaries.   Contracted physicians and professional employees will be compensated at fair market value for their professional services.  No physician shall make referrals for designated healthcare services to entities in which the physician has a financial interest either through ownership or investment interest or a compensation arrangement and such financial relationship does not fit within an exception in the applicable laws.  No physician shall bill for services rendered as a result of an illegal referral. 

3. Billing

HMHD will attempt to ensure that all claims for services are accurate, properly documented, and correctly identify the services ordered by the physician (or other individual authorized by law to order services) and performed or provided by the hospital.

Monies obtained from any federal or State funded healthcare programs as well as any private pay programs, etc. that clearly represent overpayments are monies to which HMHD has no legal entitlement and will be returned to the appropriate carrier, fiscal intermediary, or individual.

a. Selection of CPT or HCPCS Codes: The CPT or HCPCS code that is used to bill Medicare or Medicaid will accurately describe and properly document the service that was ordered and performed. The hospital will choose only the code that most accurately describes the ordered treatment(s) and/or test(s). If the hospital has questions about code selection after review by the interdepartmental committee, which consists of the Business Office Director, the appropriate department director, Health Information Director, and any other applicable employee, the hospital will direct its questions to outside consultant experts. The hospital chargemaster will be reviewed on at least an annual basis by internal staff and when necessary an outside agency.

b. Interpretation of Laws and Regulations: The hospital will attempt to interpret the Medicare and Medicaid guidelines and regulations, but in all cases, encourages employees not to guess, but to ask if there is confusion or a question. Any advice or interpretation of the law or regulations the hospital requests from the government, the Centers for Medicare and Medicaid Services (CMS), or fiscal intermediary will be documented and a record of the response and person(s) providing that response maintained. The hospital/ clinics subscribe to Medicare B bulletins and receive Medicare Part A bulletins which are read with implementation of necessary changes in billing practice. Applicable billing and coding personnel will attend educational meetings as revisions in codes and billing practices are mandated.

c. Selection of ICD-9-CM DRG Codes: The hospital will only submit diagnostic information obtained from the ordering physician. The hospital will not:

(1) use diagnostic information provided by the physician from earlier dates of service (other than standing orders);

(2) use "cheat sheets" that provide diagnostic information that has triggered reimbursement in the past;

(3) use computer programs that automatically insert diagnosis codes with receipt of diagnostic information from the physician;

(4) make up diagnostic information for claims submission purposes;

(5) engage in upcoding (choosing a code that is not the most accurate description of the service provided),

(6) fragmentation (using two or more codes when a single one exists that is more appropriate but pays less);

(7) explosion (billing separate elements for treatment(s), medication(s), procedure(s), test(s), supplies, x-rays, and all other services rather than an inclusive code when appropriate), or

(8) double bill. Those employees responsible for coding diagnoses and procedures will attend inservice as well as outside educational meetings.

d. Documentation for Claims: The hospital will:

(1) contact the ordering physician to obtain diagnostic information in the event that the physician has failed to provide such information;

(2) provide services and diagnostic information supplied pursuant to a standing order executed in connection with an extended course of treatment; and

(3) accurately translate narrative diagnosis obtained from the physician to ICD-9-CM codes. Where diagnostic information is obtained from a physician or the physician’s staff, documentation of the receipt of such information will be created and maintained. Bills will only be submitted when appropriate documentation has been obtained and is maintained and available for audit and review.

e. Claims for Reimbursement: The hospital will only submit claims for treatment(s), medication(s), procedure(s), test(s), supplies, x-rays, and all other services that were documented as being both ordered and performed or administered. Prior to submitting a claim for reimbursement to Medicare, the hospital will check with the physician on any order for services that are subject to interpretation. 

f.Billing Documentation:  Patient accounts will randomly be selected to ensure charge requisitions match the billing including but not limited to CPT codes, charge codes, discharge codes, and patient name.

g. Medicare Secondary Payer (MSP): At the time of registration the hospital will have each Medicare patient complete the MSP form. The employee doing the registration will review the MSP form and make the appropriate decision as to what payer should be primary.  The hospital will make every effort to ensure that the proper payer is billed prior to Medicare being billed.  

4. Patient Care

HMHD will comply with all Federal and State regulations. Inasmuch as these regulations are under constant revision, individual managers will be responsible to update their area of responsibility in an ongoing manner to ensure that continued improvement in quality of care occurs.

5. Employment

HMHD will comply with minimum wage laws, EEOC rules and laws, NLRB laws and regulations, IRS laws and regulations, and all other federal and State laws. Any exclusions or sanctions imposed by Medicare or Medicaid or any felony conviction related to Medicare and/or Medicaid fraud and financial abuse will cause termination or exclusions from the Medical staff.  Any employee who has criminal charges related to Medicare and/or Medicaid fraud and financial abuse, sanctions, or exclusions brought against them by the federal or State government will be removed from direct responsibility for or involvement in any Federally or State funded healthcare program until such charges are resolved.  If such charges result in conviction, debarment, or exclusion, HMHD will terminate the individual’s employment.

6. Contracts

All contracts and relationships with vendors will be reviewed to ascertain that they meet the basic requirements of business ethics as well as meeting the HIPAA guidelines as they pertain to the facilities Business Associate contracts.  Employees will not seek to gain an improper advantage by offering business courtesies, favorable treatment or advantages to customers, referral sources or purchasers of the District’s services.  Contracts will not be made with any vendor, contractor or customer under sanction by the Federal Government. Any relationship failing to meet these requirements will be terminated.      

7. Compliance with Applicable HHS OIG Fraud Alerts

The hospital will require that the Compliance Committee, Compliance Coordinator, legal counsel, or other appropriate personnel carefully consider any and all fraud alerts issued by the OIG.   Moreover, the hospital will cease or correct any conducts criticized in such fraud alert, if applicable, and take reasonable action to prevent such conduct from recurring in the future.  If appropriate, the hospital will take the steps described in the Auditing and Monitoring section of this document regarding investigations, reporting and correction of identified problems.

8. Marketing

HMHD will make good faith efforts to ensure that all Physicians understand the services offered by the Hospital District and that these services will be available to the public when ordered. HMHD will also make efforts to ensure that all physicians are aware of the financial consequences of all payers, including Medicare, for all treatments, medications, procedures, tests, supplies, and any other services ordered. Marketing information that HMHD provides will be truthful and straightforward and will not be used to mislead.  Regarding anti-kickback laws, in accordance to and compliance with, 42 U.S. C. § 1320a-7b, gifts, including monetary donations received from vendors and vendor suppliers are no guarantee of current or future business in exchange for participation in or donations to specific fund raising efforts.

9. Retention of Records

All records required either by Federal law, State law, or by the compliance plan will be created and maintained in compliance with the hospital record retention policy.

10. Compliance as an Element of an Employee Evaluation

It is each individual employee’s responsibility to monitor for compliance with Hamilton Memorial Hospital District’s Compliance Plan and report any misconduct they identify to the hospital Compliance Coordinator. Failure to monitor and report policy violations may lead to disciplinary action up to and including termination.  Failure to report any complaint of misconduct or fraud and/or internal abuse to the hospital Compliance Coordinator so that an investigation can proceed and determine if indeed a violation has occurred will be considered a major breach of employee responsibility and may be grounds for immediate termination of employment.  Self-reporting by employees who have violated this policy will be considered a mitigating factor in determining disciplinary action taken.

Effective April 1, 2003 monitoring and reporting compliance plan violations will become an element in every employee’s annual evaluation.  Also, effective July 1, 2003, promotion of and adherence to the compliance program will become an element in evaluating the performance of managers and supervisors.

All HMHD employees will be informed of the Compliance Plan and any changes made to the plan will be communicated to employees.  In addition, all managers and supervisors will be required to perform the following:

(1) Discuss with all employees the compliance plan and policies and legal requirements applicable to their function.

(2) Inform all employees that strict compliance with the compliance plans and related policies is a condition of employment.

(3) Disclose to all employees that HMHD will take disciplinary action up to and including termination for violation of the compliance plan and/or other requirements or policies relating to the compliance plan.

Managers and supervisors may be disciplined for failure to adequately instruct their employees or for failing to detect non-compliance with applicable policies and legal requirements, where reasonable diligence on the part of the manager or supervisor would have led to the discovery of the problem or violation and given HMHD the opportunity to correct the problem earlier.

A. DESIGNATION OF A COMPLIANCE  COORDINATOR

The Compliance Committee under the direction of the Hospital Administration and/or their designee is responsible for developing compliance policies and standards’, ensuring the Compliance Program is being implemented, monitoring and evaluating the hospital’s compliance activities, achieving and maintaining compliance, and periodically revising the program to meet changes in the hospital’s needs and the business and regulatory environment.  The HMHD Board of Directors has given sufficient authority to the Chief Executive Officer to undertake and comply with these responsibilities. The Chief Executive Officer will develop and distribute to appropriate individuals all written compliance policies and procedures. These policies and procedures will be readily understandable by all employees. Additional responsibilities of the Compliance Coordinator include the following:

• Coordinate personnel issues with Human Resources,
• Coordinate and verify employee training in regard to the Hospital Compliance   

Plan, standards of conduct to reflect the current federal, State, and local laws and
continuing education,

• Coordinate internal auditing and monitoring activities within the hospital,
• Review contracts with independent contractors and agents to eliminate unethical

      business practices and payment issues that could violate Stark requirements,

• On a semi-annual or more frequent basis, (if a compliance issue is identified by

the Compliance Coordinator, Compliance Committee, or CEO), any compliance issues that have arisen will be reported to the HMHD Board of Directors.

B. DESIGNATION OF COMPLIANCE COMMITTEE

The Compliance Committee will be composed of the Chief Executive Officer and/or his designee, the Chief Financial Officer, the Business Office Director, and the Health Information Director/Compliance Coordinator.

C. COMPLIANCE COMMITTEE FUNCTIONS

The Compliance Committee’s functions may include, but not be limited to:

• Analyzing the organization’s business, industry environment and legal requirements with which it must comply, including specific risk areas;
• Assessing existing policies and procedures which address these areas for possible incorporation into the proposed compliance plan;
• Developing standards of conduct, policies and procedures to promote compliance with the applicable institution’s policies;
• Recommending and monitoring, in conjunction with the relevant departments, the development of internal systems and controls to carry out the organization’s standards, policies and procedures as part of its daily operations;
• Determining the appropriate approach/strategy to promote compliance with the program and detection of any potential violation; and
• Developing a system to solicit, evaluate and respond to complaints and problems.

D. EDUCATION AND TRAINING

Hamilton Memorial Hospital District’s Compliance Program requires compliance and ethics training for all employees.  This training will emphasize HMHD’s commitment to compliance with all laws, regulations, and guidelines of all Federal and State programs.  This training will be conducted on an annual basis to ensure all employees fully comprehend the implications of failing to comply with HMHD’s compliance plan and all applicable healthcare program requirements.

The education and training of employees will cover HMHD’s Compliance Plan and related policies and will reinforce to the employee that strict compliance with the law and HMHD policies are a condition of employment.  Employees will be informed that failure to comply with the law and/or Hospital District policies may result in disciplinary action up to and including termination.

Employees involved in marketing will be educated as to the fact that offering remuneration in return for referrals is prohibited and HMHD will take disciplinary action deemed appropriate up to and including termination for violations of the law or failure to report a potential violation by another employee, supervisor, or outside contractor or provider.

In addition to compliance and ethics training, the need for periodic continuing education, which may be required by law or regulations, will be provided for appropriate personnel. Continuing education programs are provided to help ensure a knowledgeable and more productive staff.  HMHD will post in common work areas and other prominent places accessible to all employees a notice reminding employees of HMHD’s commitment to compliance with all Federal and State laws and regulations.

F. COMMUNICATION

1. Access to the Compliance Coordinator

Since an open line of communication between the Compliance Coordinator and/or Compliance Committee with the employees is critical to the successful implementation and operation of the compliance program, there is an open-door, complete anonymity, non-retribution policy available to all employees to encourage communication.  HMHD, using legal resources, will attempt to clarify the gray areas of interpretation of Medicare and Medicaid guidelines and regulations, but in all cases, HMHD encourages employees not to guess, but to ask if there is confusion or a question. 

2. Hotline

A hotline and written memoranda are examples of ways employees can anonymously report suspected misconduct.  All employees have access to the Compliance Coordinator and are guaranteed that complaints can be made without fear of retribution.  Matters reported through the hotline, and written memoranda that suggest violations of compliance policies or legal issues will be maintained by the Compliance Coordinator in a log and will be investigated immediately by the Compliance Coordinator to determine their validity.  The Compliance Coordinator will report the findings to the Compliance Committee for possible further investigation of each compliance issue.    

The hospital will not penalize, discriminate, or retaliate against any employee who in good faith, individually or with another person does any of the following:

• discloses a policy or practice of the workplace that violates any law or rule that poses a risk to health or safety of the public or patient;
• initiates, cooperates or participates in an investigation done by a regulatory agency or accredited body concerning matters that the employee reasonably believes poses a risk to the health and safety of the public or patient;
• Objects to or refuses to participate in any activity, policy or practice of a hospital that violates any law or rule that a reasonable person would believe poses a risk to the health or safety of the public or patient;
• Participates in a committee or peer review process or files a report or complaint that discusses allegation of unsafe, dangerous or potentially dangerous care within the hospital.

 G. AUDITING AND MONITORING

The compliance program requires a thorough monitoring of its implementation and semi-annual reporting to members of the HMHD Board of Directors. The Hospital will have annual audits of the hospital's operations performed, with particular attention paid to billing, sales, marketing, notices and disclosures to physicians, requisition forms and pricing. These audits will be designated and implemented to ensure compliance with the hospital's compliance policies and plan, and all applicable Federal and State laws. In addition, these audits will address issues related to contracts, competitive practices, marketing materials, ICD-9, CPT/HCPCS coding and billing, information, reporting and record keeping as is appropriate for this hospital.

Performance improvement and zero tolerance of fraud and abuse is the goal of the compliance program. In attempting to ensure these goals, compliance audits will include:

• internal reviews
• interviews with personnel involved in management, operations, billing, sales, marketing, and other related activities;
• reviews of written materials and documentation used by the hospital; and
• trend analysis studies.

 

Formal audit reports will be prepared and submitted to the Compliance Coordinator and the hospital Board of Directors to ensure that management is aware of the results and can take whatever steps necessary to correct past problems and prevent them from recurring. The audit reports will specifically attempt to identify areas where corrective actions are needed. Subsequent audits or studies will be used to ensure that the recommended corrective actions have been implemented and are successful.

H. DISCIPLINARY ACTIONS

Disciplinary action will be taken against any individual who fails to comply with Hamilton Memorial Hospital District’s Compliance Plan.  Likewise, any individual who has violated Federal or State laws or has engaged in unethical practices which may damage HMHD’s reputation will be subject to discipline.  The normal step by step discipline process for employees of HMHD is as follows:

• Verbal Counseling
• Written Counseling
• Suspension of employment without pay for up to three days.
• Termination of employment.

Some infractions may be of such serious nature that suspension or discharge may be appropriate discipline for even the first offense.

Self-reporting of violations of the law may be taken into account when applying any discipline.

I. CORRECTIVE ACTION

1. Investigating, Reporting and Correcting Identified Problems:

a. Investigation:  Any and all reports of violations of HMHD’s compliance plan, violation

of State and federal laws, unethical practices, or any other misconduct that may damage or threaten HMHD’s status as a honest and reliable provider of healthcare capable of ethically participating in a healthcare program funded by the federal or State government will be investigated.  The Compliance Coordinator as well as the Compliance Committee will conduct investigations of this matter.  These investigations will be done in a prompt manner and will be conducted under advice of HMHD’s legal counsel as deemed necessary.  The purpose of such an investigation will be to determine if indeed violations have occurred that may damage or cause harm to HMHD.  If such a violation has occurred, immediate steps will be taken to remedy the violation.  This investigation may include interviews, review of relevant documents, and any other information deemed necessary to conduct a thorough investigation.  Outside auditors or legal counsel may be acquired to assist HMHD when deemed necessary.  If the presence of the employee or employees being investigated may jeopardize the investigation, this employee or employees may be suspended from their position with HMHD pending the outcome of the investigation.  Steps will be taken to prevent destruction of documents or evidence relevant to the investigation.  If at the completion of the investigation disciplinary action is required, discipline will be imposed according to the HMHD policy and any collective bargaining agreements that HMHD has entered into.

b. Reporting:  If after the investigation into misconduct, HMHD has reasonable grounds to believe that the investigated misconduct violates criminal law, constitutes a material violation of the civil law, or violates rules and regulations governing a Federally or State funded healthcare program, HMHD will follow the advice of counsel as to appropriate action to take in reporting the findings.

c. Action: If an investigation reveals misconduct did occur, corrective action will be taken

immediately.  HMHD will administer necessary disciplinary actions to any employee involved in such misconduct in an effort to correct the identified problems.  Action will also be taken to prevent similar misconduct from occurring in the future.

2. Non-Employment or Retention of Sanctioned Individuals

The Hamilton Memorial Hospital District will not employ individuals who have been convicted of a criminal offense related to healthcare or who are listed by a federal agency as debarred, excluded, or otherwise ineligible for participation in a Federally or State funded healthcare program.  In addition, individuals with criminal offenses related to healthcare pending or proposed debarment or exclusion pending will be removed from direct involvement with any federal or State funded healthcare programs in which HMHD participates.  If such pending charges result in conviction, debarment, or exclusion of the individual or company, HMHD will terminate its relationship with that individual or company.