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Cherry Health
Compliance Program
10/2/14; 10/1/15; 12/1/16; 10/4/18; 7/9/19; 3/10/20; 1/21/21; 5/13/21; 6/9/22
Table of Contents
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Glossary 3
Seven Elements of Compliance Program 4
I. Commitment to Compliance 5-7
II. Designation of Compliance Team 7-8
Quality Oversite Committee 8-9
III. Conducting Effective Training & Education 9-10
IV. Developing Effective Lines of Communication 10
V. Disciplinary Guidelines 10-11
VI. Auditing & Monitoring 11-12
VII. Responding to Detected Offenses & Developing
Corrective Action Initiatives 12-13
VIII. Compliance Policies and Procedures 14-17
Glossary
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Billing: The term billing as it is used throughout this document is intended to mean any
coding practices and documentation used to support coding. It is not intended to refer
to the setting of fees, charges or review of organizational pricing practices.
Compliance Program: A system of standards developed to assure compliance with the
conformity to all payer guidelines and regulatory requirements governing health and
behavioral health care practice.
Compliance Team: The individuals assigned to oversee the implementation and
operation of the Corporate Compliance Program. It reviews the results of internal
audits, makes recommendations for improvements to the Corporate Compliance
Program and reports its activities to the Board of Directors and through the Patient
Services Committee of the Board via the Quality Oversight Committee dashboard
reports.
HIPAA: The Health Insurance Portability and Accountability Act of 1996, including all
past or future amendments and all regulations now or in the future under its authority.
Non-Compliance: The failure to document or bill according to federal regulations
applicable to the services of Cherry Health, or a material failure to properly code the
service, or material failure to comply with HIPAA.
Provider: A provider of medical, dental, vision or behavioral services.
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Cherry Health
Corporate Compliance Program
Cherry Street Service, Inc., DBA Cherry Health, voluntarily implements a Corporate
Compliance Program aimed at the prevention of fraud, abuse and waste, compliance
with rules, regulations and laws while simultaneously improving quality patient care.
Our compliance efforts are aimed at preventing, detecting, and resolving variances, as
well as working in collaboration with other departments to assure new initiatives are
implemented within the organization to maximize quality and effectiveness of patient
care.
The seven elements of Cherry Health’s Corporate Compliance Program are:
I. Commitment to Compliance
A. Standards of Conduct
B. Reasonable and Necessary
C. Billing
D. Compliance with applicable HHS Fraud Alerts
E. Anti-Kick Back/Inducements
F. Retention of Records/Documentation
G. Implementation of Regulatory Initiatives
II. Designation of a Compliance Committee
III. Conducting Training and Education Programs
IV. Communication
V. Disciplinary Guidelines
VI. Auditing and Monitoring
VII. Corrective Action
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I. COMMITMENT TO COMPLIANCE
A. Standards of Conduct
Cherry Health promotes adherence to the Corporate Compliance Program as a major
element in the performance evaluation of all staff members, officers and agents.
Adherence to the program is woven through the organization’s policies and procedures.
Cherry Health staff members, officers and agents are bound to comply, in all official acts
and duties, with all applicable laws, rules, regulations, standards of conduct, including,
but not limited to, laws, rules, regulations, and directives of the federal government and
the state of Michigan, and rules, policies and procedures of Cherry Health. These
current and future standards of conduct are incorporated by reference in this Corporate
Compliance Program.
All candidates for employment will undergo a prudent background investigation
including: a reference check, exclusion check and criminal record. Due care will be used
in the recruitment and hiring process to prevent the appointment to positions with
substantial discretionary authority, persons whose record (professional licensure,
credentials, prior employment and any criminal record) gives reasonable cause to
believe the individual has a propensity to fail to adhere to applicable standards of
conduct. Once hired, monthly exclusion checks are done to ensure no employee,
contractor, board member or vendor is barred from participating in federal programs.
All new staff members receive orientation and training in compliance policies and
procedures including CMS Fraud, Waste and Abuse and ethics as part of new staff
orientation. Participation is required as a condition of employment. All staff receive
training in compliance policies, procedures and CMS Fraud, Waste and Abuse on an
annual basis. Failure to participate in required training may result in disciplinary actions,
up to and including termination of employment.
Every employee receives periodic training updates regarding compliance protocols as
they relate to the employee’s individual duties. This is done through articles in the
organization newsletter, presentations at staff meetings and general consultations.
Board members receive compliance training annually.
Non-compliance with the program or violations will result in progressive discipline of the
employee(s) involved, up to, and including, termination of employment.
B. Reasonable and Necessary Services
Cherry Health will take reasonable measures to ensure that only claims for services that
are reasonable and necessary, given the patient’s condition, are billed.
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Documentation will support the determinations of reasonable and necessary when
providing services.
Cherry Health is aware that Medicare will only pay for services that meet the Medicare
coverage criteria and are reasonable and necessary to treat or diagnose a patient.
Therefore, Cherry Health’s clinical staff will use prudent ordering practices.
In requesting diagnostic procedures or tests, Cherry Health’s clinical staff will determine
that the tests or procedures are within the guidelines of reasonable and necessary
services, and documentation will support the findings and diagnoses with regard to the
tests or procedures ordered. A diagnosis will be submitted for all tests ordered.
C. Billing
All claims for services submitted to Medicare or other health benefits programs will
correctly identify the services provided. Only those services provided by authorized
clinicians that are performed and that meet Medicare’s or the health benefits program’s
criteria will be billed.
Intentionally or knowingly upcoding (the selection of a code to maximize
reimbursement when such code is not the most appropriate descriptor of the service
provided) will result in disciplinary action which may include immediate termination of
employment. The clinical staff must provide documentation to support the CPT, DSM V,
and/or ICD-10 codes used based on medical findings and diagnoses.
D. Compliance with Applicable HHS Fraud Alerts
The Corporate Compliance Team or designee will review the Medicare Fraud Alerts. The
Corporate Compliance Team or designee will immediately terminate any conduct
deemed inappropriate by the Fraud Alert by implementing corrective actions and taking
reasonable actions to ensure that future violations do not occur. Documentation will be
kept regarding review of the alerts and action taken.
E. Anti-Kickback/Inducements
Cherry Health will not participate in nor condone the provision of inducements or
receipt of kickbacks to gain business or influence referrals. All of Cherry Health’s clinical
staff will consider the patient’s interests in offering referral for treatment, diagnostic, or
service options.
Any employee involved in promoting or accepting kickbacks or offering inducements will
be subject to disciplinary action which may include immediate termination of
employment.
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F. Retention of Records/Documentation
Cherry Health will ensure that all records required by funding source, federal and/or
state law are created and maintained. All records will be maintained for the period
specified by federal and state law and by the funding source.
Documentation of compliance efforts will include staff meeting minutes, memoranda
concerning compliance protocols, problems identified, and corrective actions taken, the
results of any investigations and documentation supportive of assessment findings,
diagnoses, treatments and program of care.
G. Implementation of Regularity Initiatives
The Corporate Compliance Team will work collaboratively with other departments in the
understanding and implementation of regulatory initiatives with the goal of improved
care for patients.
DESIGNATION OF A CORPORATE COMPLIANCE TEAM AND COMPLIANCE
COMMITTEE
While compliance is the responsibility of all Board members, staff, volunteers, students,
interns, contractors, patients, vendors and business associates, the Corporate
Compliance Team is the focal point of the Corporate Compliance Program and should be
accountable for all compliance responsibilities.
Cherry Health designates The Director of Quality and Informatics, The Risk
Management Specialist and the Compliance Analyst to coordinate compliance activities.
Director of Quality and Informatics will oversee and monitor the implementation of the
Corporate Compliance Program.
• Report in a timely manner either directly or via the Quality Oversight Committee
to the organization’s Chief Officers on the progress of implementation and
assisting the practice in establishing methods to improve efficiency and quality
of services and to reduce the vulnerability to allegations of fraud, abuse and
waste.
• Develop and distribute all written compliance policies and procedures to all
affected staff members.
• Periodically revise the program considering changes in the needs of the
organization and in the law including changes in policies and procedures of
government and private payer health programs.
• In coordination with The Workforce Development manager will Develop,
coordinate, and participate in a multifaceted educational and training program
that focuses on the elements of the Corporate Compliance Program and seeks to
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ensure that all staff members are knowledgeable of, and comply with, pertinent
federal, state, and private payer standards.
• Ensure that all service providers are informed of Corporate Compliance Program
standards with respect to coding, billing and documentation, etc.
• Assist in coordinating internal compliance review and monitoring activities
including annual reviews of policies.
• Independently coordinate investigation and action on matters related to
compliance including the flexibility to design and coordinate internal
investigations.
• Develop policies and programs that encourage managers and staff members to
report suspected fraud and other improprieties without fear of retaliation.
• Assist the organization in understanding the impact of complying with new,
updated and changed regulatory initiatives.
The Corporate Compliance Officer has the authority to review all documents and other
information relative to compliance activities, including, but not limited to, requisition
forms, billing information, claims information and records concerning arrangements
with patients.
Quality Oversight Committee:
Cherry Health recognizes and supports the very close working relationship between
quality and compliance. In order to foster the most efficient manner for these two to
maintain that close working relationship, Cherry Health designates a team consisting of
staff with decision making authority representing areas of the organization that are
most directly impacted by the regulatory environment, (for example, CFO, COO, CMO,
CHRDO, Director of Reimbursement, Director of Quality and Informatics, Compliance
Officer, Director of Pharmacy or their designees) called the Quality Management
Oversight Committee to advise the Compliance Officer, assist in the implementation of
the Corporate Compliance Program as needed and address the quality issues that arise
from the operations of the organization.
The functions of the Quality Oversight Committee include:
• Analyze the organization’s regulatory environment, the legal requirements with
which it must comply and specific risk areas resulting in an annual risk
assessment.
• Assess existing policies and procedures and standards that address risk areas for
possible incorporation into the Corporate Compliance Program.
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• Work with the organization’s standards of conduct, policies and procedures to
promote compliance.
• Recommend and monitor the development of internal systems and controls to
implement standards, policies and procedures as part of the daily operations.
• Determine the appropriate strategy/approach to promote compliance with the
program and detection of any potential problems or violations.
• Monitor new and ongoing quality improvement efforts to determine
effectiveness.
III. CONDUCTING EFFECTIVE TRAINING AND EDUCATION
Cherry Health requires all staff members, students and interns to attend specific training
in the areas of confidentiality, HIPAA (and all associated regulations), Fraud, Waste and
Abuse (the CMS version), Ethics and Corporate Compliance policies and procedures
upon hire, and on an annual and as-needed basis thereafter. This includes training in
federal and state statutes, regulations, program requirements, policies, and ethics. The
trainings emphasize the organization’s commitment to compliance with these legal
requirements and policies.
The training programs include sessions highlighting the organization’s Corporate
Compliance Program, summaries of fraud and abuse laws, discussions of coding
requirements, claim development, claim submission processes and how to report
compliance issues.
The Workforce Development Manager provides this training at new staff orientation
and annually thereafter via the automated educational system. Documentation of
attendees, the subjects covered, and any materials distributed at the training sessions
are maintained.
Basic trainings include:
• Government and payer reimbursement principles.
• General prohibitions on paying or receiving remuneration to induce referrals.
• CMS Fraud, Waste and Abuse, Office of Inspector General exclusions, Michigan
Mental Health Code and Substance Abuse Treatment confidentiality rules.
• Only billing for services ordered, performed and reported.
• Duty to and how to report misconduct.
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Training may also occur at departmental staff meetings, either as a topic presented by
the supervisor or through a visit from the compliance team. This type of training will be
documented in the minutes of the meeting along with participants in attendance.
Staff receive reminders and updates about the topics they have been trained on or
information about new or changing topics through entries in the agency newsletter, the
Heartbeat. These reminders come from both the IT and compliance departments. The
reimbursements department assists in training staff in the areas of documentation
through presentation at provider staff meetings and through provision of helpful tools
keeping staff abreast of the required elements of documentation.
IV. DEVELOPING EFFECTIVE LINES OF COMMUNICATION
Cherry Health protects whistle blowers from retaliation.
Cherry Health has established a procedure so that staff members may seek clarification
from the Corporate Compliance Team in the event of any confusion or questions
regarding a policy or procedure.
A hot line (844.305.1504) has been established so that staff members, patients or others
may anonymously consult with the Corporate Compliance Officer or designee with
questions, or report violations. A compliance email box,
(compliance@cherryhealth.com) was established and may be used to communicate
information regarding compliance and compliance activities. A staff feedback portal has
been established via Google so that staff may communicate with Compliance
anonymously. Any staff member may collect information of a compliance nature from
patients or others and share that with the Compliance team.
Any potential problem or questionable practice which is, or is reasonably likely to be, in
violation of, or inconsistent with, federal or state laws, rules, regulations, directives or
Cherry Health rules, procedures or policies relative to the delivery of healthcare
services, or the billing and collection of revenue derived from such services, and any
associated requirements regarding documentation, coding, supervision, and other
professional or business practices must be reported to the Compliance Team.
Any person who has reason to believe that a potential problem or questionable practice
is or may be in existence should report the circumstance to the Compliance Team. Such
reports may be made verbally or in writing and on an anonymous basis.
The Corporate Compliance Team promptly documents and investigates reported
matters that suggest violations of policies, regulations, statutes or program
requirements to determine their veracity. The Corporate Compliance Team will
maintain a log of such reports including the nature of the investigation and its results.
The Corporate Compliance Team works closely with legal counsel who can provide
guidance regarding complex legal and management issues.
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V. DISCIPLINARY GUIDELINES
All Cherry Health staff, volunteers and students are held accountable for failing to
comply with applicable standards, laws, policies and procedures. Supervisors and/or
managers are held accountable for the foreseeable compliance failures of their
subordinates.
The supervisor or manager is responsible for taking appropriate disciplinary actions in
the event an employee fails to comply with applicable regulations, procedures or
policies. The disciplinary process for violations of the Corporate Compliance Program is
administered according to organization policies and procedures depending upon the
seriousness of the violation. The Compliance Officer, as well as legal counsel, may be
consulted in determining the seriousness of the violation.
If the deviation occurred due to legitimate, explainable reasons, the Corporate
Compliance Officer and supervisor or manager may limit disciplinary action or take no
action. If the deviation occurred because of improper procedures, misunderstanding of
rules, including systemic problems, the organization will take immediate actions to
correct the problem.
When disciplinary action is warranted, it should be prompt and imposed according to
organization policies and procedures.
Within 30 working days after receipt of an investigative report, the supervisor and/or
the Chief Medical or Oral Health Officer and/or CEO (or designee) of the organization
shall determine the action to be taken upon the matter. The action may include,
without limitation, one or more of the following:
1. Dismissal of the matter.
2. Coaching conversation.
3. Documented discussion, written reminder, a letter of admonition or a letter of
reprimand.
4. Entering and monitoring a corrective action program. The corrective action
program may include requirements for individual or group remedial education
and training, consultation, monitoring, and/or concurrent review.
5. Reduction, suspension, or revocation of clinical privileges.
6. Suspension or termination of employment.
7. Modification of assigned duties.
8. Reduction in the amount of salary compensation.
The Chief Medical or Oral Health Officer shall have the authority to, at any time,
suspend summarily the involved employee’s clinical privileges or to summarily impose
consultation, concurrent review, monitoring, or other conditions or restrictions on the
assigned duties of the involved provider to reduce the substantial likelihood of violation
of standards of conduct.
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VI. AUDITING AND MONITORING
The Corporate Compliance Team or designee will conduct ongoing evaluations of
compliance processes through monitoring and reporting to the Board of Cherry Health.
Compliance reporting will be included in program dashboard reports shared with the
Client Services Committee. Annually, the Director of Quality and Informatics will report
through the Executive Committee of the Board.
The Corporate Compliance Team or designee will develop audit tools designed to
address the organization’s compliance with laws governing documentation, coding and
billing, claim development and submission, reimbursement, reporting and record-
keeping. Internal audits will be conducted on a regular basis.
As part of the exit interview of employees, compliance questions will be included to
solicit information concerning potential problems and questionable practices. The
answers to those questions will be shared with the Corporate Compliance Team. The
Corporate Compliance Team or designee may follow up with the former employee
regarding the report of potential problems or questionable practices.
VIII. RESPONDING TO DETECTED OFFENSES AND DEVELOPING CORRECTIVE ACTION
INITIATIVES
Violations of Cherry Health’s Corporate Compliance Program, failure to comply with
applicable state or federal law, other requirements of government, private health
programs, funding sources, accreditation bodies, and other types of misconduct may
threaten the organization’s status as a reliable, honest, and trustworthy provider
capable of participating in federal health care programs. Detected, but uncorrected,
misconduct may seriously endanger the mission, reputation and legal status of the
organization. Consequently, upon reports of reasonable indications of suspected
noncompliance, the Corporate Compliance Officer must initiate an investigation to
determine whether a material violation of applicable laws or requirements has
occurred.
The steps of the internal investigation may include interviews and a review of relevant
documentation. Records of the investigation should contain documentation of the
alleged violation, a description of the investigative process, copies of interview notes
and key documents, a log of witnesses interviewed, and the documents reviewed, the
results of the investigation and the corrective actions implemented.
If an investigation of an alleged violation is undertaken and the Corporate Compliance
Team believes the integrity of the investigation may be hampered by the presence of
staff members under investigation, those staff members should be removed from their
current work activities pending completion of that portion of the investigation. These
staff members will be suspended, with pay, pending the outcome of the investigation.
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Additionally, the Corporate Compliance Team must take appropriate steps to secure or
prevent the destruction of documents or other evidence relevant to the investigation.
If the results of the internal investigation identify a problem, the response may be
immediate referral to criminal and/or civil law enforcement authorities, development of
a corrective action program, or a report to the government and submission of any
overpayments, if applicable. If potential fraud or violations of the False Claims Act are
involved, the Corporate Compliance Officer should report the potential violation to the
Office of the Inspector General or the Department of Justice.
When making a repayment for an overpayment, Cherry Health should inform the payer
of the following:
1) The refund is being made pursuant to a voluntary Corporate Compliance
Program.
2) A description of the complete circumstances prompting the overpayment.
3) The methodology by which the overpayment was determined.
4) Any claim-specific information used to determine the overpayment.
5) The amount of the overpayment.
The CEO of Cherry Health will have the authority and responsibility to direct repayment
to payers and the reporting of misconduct to enforcement authorities as is determined,
in consultation with legal counsel, to be appropriate or required by applicable laws and
rules.
If the CEO of Cherry Health discovers credible evidence of misconduct and has reason to
believe that the misconduct may violate criminal, civil, or administrative law, then the
Corporate Compliance Officer will promptly report the matter to the appropriate
government authority within a reasonable time frame, but not more than 60 days after
determining that there is credible evidence of a violation.
Office of Inspector General Hotline: 1.800.HHS.TIPS (1.800.447.8477)
When reporting misconduct to the government, the Corporate Compliance Team should
provide all evidence relevant to the potential violation of applicable federal or state
laws and the potential cost impact.
This Corporate Compliance Program may be altered or amended in writing only with the
concurrence of the CEO of the organization.
Corporate Compliance Policies and Procedures
The following policies and procedures are included in the Corporate Compliance
Program as the foundation of the program. The procedures provide guidance to the
workforce and Board of Directors in working within an organization that is committed to
compliance or when confronted with issues that relate to compliance.
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Policies:
1. Corporate Compliance Program
The mission of Cherry Health is to improve the health and wellness of individuals by
providing comprehensive and integrated health care while encouraging access by those
who are underserved. In fulfilling this mission, Cherry Health is dedicated to adhering to
the highest ethical standards and accordingly recognizes the importance of compliance
with all applicable state and federal laws. To evidence this dedication, the Board of
Directors adopts and provides authorization to staff to implement the Corporate
Compliance Program.
2. Ethical Environment
Cherry Health is dedicated to the delivery of health care in an environment
characterized by strict conformance with the highest standards of accountability for
administration, clinical, business, marketing and financial management. Cherry Health’s
leadership is fully committed to the need to prevent and detect fraud, fiscal
mismanagement and misappropriation of funds, and has in place a formal Corporate
Compliance Program to ensure ongoing monitoring and conformance with all legal and
regulatory requirements.
This program emphasizes:
• Development and distribution of a written code of ethics and conduct, as
well as written policies and procedures that address the various components
of the Corporate Compliance Program and addresses principal risk areas.
• Designation of Compliance Team and a Quality Management Oversight Team
charged with the responsibility of operating and monitoring the Compliance
Program.
• Development and implementation of regular, effective education and
training programs for Cherry Health employees, Board members, members
of the medical staff, contractors and volunteers.
• Maintenance of an effective and well publicized protocol for reporting or
raising conduct or ethical concerns without fear of retaliation.
• Development of disciplinary standards to clarify and respond to conduct
prohibited by the Code of Ethics and conduct and pursue equitable
enforcement of standards with regard to employees who violate law or
regulation according to the Compliance Program.
• Development of criteria and protocol for ensuring that no individual who has
engaged in illegal or unethical behavior or who has been convicted of health
care related crimes shall hold positions that exercise discretionary authority.
• Maintenance of effective auditing and monitoring systems to evaluate
compliance with laws, regulations, federal health care programs, and the
standards developed in the compliance plan; to assist in the prevention of
compliance program violations; and to maintain the effectiveness of the
compliance program.
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• Investigate, respond, and prevent identified noncompliance, including the
establishment of appropriate and coordinated corrective action measures.
Procedures:
1. Corporate Compliance Program
The Corporate Compliance Program is intended to become a part of the fabric of the
Organization’s routine operations. The organization endeavors to communicate to all
personnel the intent to comply with applicable laws through the Corporate Compliance
Plan. In addition, the Corporate Compliance Program will:
• Assess Cherry Health’s business activities and consequent legal risks.
• Educate all personnel regarding compliance requirements and train
personnel to conduct their job activities in compliance with state and federal
law and according to the policies and procedures of the organization.
• Implement monitoring and reporting functions to measure the effectiveness
of the plan and to address problems in an efficient and timely manner.
• Include enforcement and discipline components that ensure that all
personnel take their compliance responsibilities seriously.
Overall responsibility for the operation and oversight of the Corporate Compliance
Program belongs to the Board; however, the day-to-day responsibility for operation and
oversight of the program rests with the Director of Quality and Informatics. The Director
of Quality and Informatics will be assisted in these duties by the Quality Oversight
Committee.
No members of the organization have authority to act contrary to any provision of the
Corporate Compliance Program or to condone any such violations by others. Anyone
with knowledge of information concerning a suspected violation of law or violation of a
provision of the Corporate Compliance Program is required to report promptly such
violations in accordance with the Corporate Compliance Program and Duty to Report
Compliance Issue procedure.
Members of the organization who violate any provision of the Corporate Compliance
Program, including the duty to report suspected violations, will be subject to disciplinary
measures as set forth in the Corrective Action policy and procedure. Cherry Health will
take steps to investigate all reported violations and will endeavor through constant
vigilance to ensure that the Corporate Compliance Program is effective in preventing,
detecting and eliminating violations of the law. In addition, promotion of and adherence
to the Corporate Compliance Program will be part of the job performance evaluation
criteria (Integrity section) for all organization members.
Cherry Health reserves the right to change, modify or amend the Corporate Compliance
Program as deemed necessary. If changes, modification or amendments are made to
the program, members of the organization will be informed as soon as possible after the
changes, amendments or modifications are approved by the Board.
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Should members of Cherry Health have any questions or uncertainties regarding
compliance with applicable state or federal law, or any aspect of the Corporate
Compliance Program, including related policies or procedures, they should seek
immediate clarification from their supervisor, the Corporate Compliance Officer, or
through the Compliance Hotline.
2. Corporate Compliance Coordination and Quality Oversight Committee
Cherry Health will designate a Director of Quality and Informatics to serve as the
coordinator of all compliance activities and a Quality Oversight Committee to advise the
Corporate Compliance Officer and assist in the implementation of the Corporate
Compliance Program as needed.
The responsibilities and scope of authority of the Director of Quality and Informatics and
Quality Oversight Committee are included in the Corporate Compliance Program and
position description.
3. Compliance Reporting to the Board of Directors
Compliance reporting will be included in program dashboard reports to the Client
Services Committee of the Board of Directors on a regular basis. If an issue is deemed to
be of a serious nature it will be reported to the Board at its next regularly scheduled
meeting after the issue arises.
4. Duty to Report Compliance Issues
Duty to Report: All staff, patients/families, members of the board and business
associates are expected to report any activity that appears to violate applicable laws,
rules, regulations and/or applicable Cherry Health policies and procedures without fear
of retaliation or retribution.
As much as possible, the confidentiality of the reporting person will be protected.
However, during the investigation of the claim, the identity of the reporting person may
be deduced or indirectly disclosed.
Non- Retaliation or Retribution: Staff, members of the board or business associates are
not permitted to engage in retaliation, retribution, punishment or any form of
harassment against another employee or associate for reporting compliance-related
concerns made in good faith through established reporting methods. Any retribution,
retaliation or harassment will result in disciplinary action.
How to Report a Concern: Generally, compliance concerns involve the potential for
fraud, abuse and waste, confidentiality violations or noncompliance with policies or
procedures. Examples of compliance concerns include (but are not limited to):
• Submitting inaccurate or misleading claims for services provided.
• Making false statements or representations to obtain payment for services.
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• Offering or giving something of value to patients to encourage them to use or
purchase health care services.
• Sending a statement of account (billing statement) which includes protected
health information (PHI) to the wrong address or person.
• Unintentionally sharing PHI inappropriately.
Those with a compliance concern have several options to report or obtain additional
information and assistance.
• Whenever possible, resolve the issue within the department. It is an expectation
to raise concerns first with the manager or direct supervisor if that approach is
appropriate.
• If discussing the concern with the manager or supervisor is inappropriate, the
employee may contact the Corporate Compliance Team directly by phone or
email. The employee may report to any supervisor, manager, administrator,
utilize the compliance email box, the staff feedback portal or call the Compliance
Hotline.
• The Compliance Hotline is available for anyone to use to raise an issue. The
hotline can be used either anonymously, or if a response is desired the person
should identify themselves.
• Concerns regarding employee performance should be directed to Human
Resources and addressed through the Problem Resolution process.
After a Concern Has Been Reported:
• The Corporate Compliance Team will investigate all concerns reported. If the
concern relates to a process or procedure of another department, and is not a
compliance issue, the Corporate Compliance Officer will refer that concern to
the appropriate department for resolution. There will be a determination of
whether a formal investigation, by an outside party, is warranted.
• The Corporate Compliance Team will notify the reporting individual (if known)
that the concern has been received and is either resolved or being investigated
further.
• If a complaint warrants formal investigation by an outside party, the Executive
Committee of the Board of Directors will engage and receive the report from the
outside party.
5. Billing Integrity Audits
Billing Integrity Audits (BIA) will be conducted by Corporate Compliance staff or
designee on a regular basis and prior to the submission of bills to the payers.
A random selection of an adequate number of patient records will be used. The BIA will
verify the accuracy of claims and services provided by a comparison of the patient
record to the requirements of the payer and the remittance advice.
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The BIA will include that services provided are documented in accordance with
appropriate requirements, are coded correctly, billed appropriately, and payment is
applied appropriately. Exceptions noted will be documented on a spreadsheet that will
indicate the date of service, the provider of the service, description of the exception,
and are reported to the CMO, program supervisors and providers.
Ongoing monitoring will continue to ensure repeated errors do not occur by updating
reports, which will indicate errors made by individual staff as well as by program, the
corrective action recommended and when the corrections were made within the
timelines established in the recommendation of the auditor. Additional documentation
will be kept that indicates if the corrective actions were successful. The outcome of the
BIA will be the improvement of procedures and processes to assure efficient and
accurate billing of services.
The BIA will be made available to auditors per contract or agreement as appropriate.
