Federal law requires your facility to have a compliance program.
The program is designed to help discover, prevent, and correct illegal and unethical actions.
A strong compliance program creates benefits for healthcare facilities and the individuals they care for. These benefits include better quality of care and lower costs.
Healthcare facilities have a legal duty to send correct claims. They also need to protect individuals' health data.
A strong compliance program shows that the facility:
Report when you:
- See something that does not seem right.
- Have questions about a sensitive issue.
- Are not sure if a problem exists but have concerns.
- As a healthcare worker, you have a duty to speak up if you see or hear a concern.
- Values honest behavior.
- Encourages staff reporting.
- Seeks to discover illegal or unethical actions.
- Seeks to prevent illegal or unethical actions.
The focus of a compliance program should be on the facility-specific areas of risk.
All staff are required to take compliance training on a regular basis to keep the rules in mind.
Almost all health data is confidential. Never look up or talk about an individual’s health data unless it is part of your job.
Codes are standard numbers and letters that stand for different types of illnesses and procedures. Codes should correctly match the data that is documented in the health record.
Billing for services that were not needed or not done is illegal. All care given to individuals should be needed to improve their health. This rule also applies to medical items.
The Stark Law, or physician self-referral law, says that it is illegal:
- For doctors to make referrals for designated health services (DHS) if the doctor (or their close family member) has a financial contract with the DHS business.
- For the facility the doctor works for to send claims for those referred services.
Examples of DHS include lab tests and physical therapy.
The federal Anti-Kickback Statute says that it is illegal to give or take money or
something of value for referrals.
EMTALA is a law about care in Emergency Departments. EMTALA is sometimes called the anti-dumping law.
The law says that all people can get emergency care, even if they cannot pay for it. This includes a woman in labor.
The FCA says that a provider cannot send a claim for payment that is not true.
Examples of the FCA include:
- When a provider submits a claim for services they did not give.
- When a provider submits a claim for a higher level of service than they gave to an individual.
A conflict of interest is when a person gets personal benefit from job-related choices or actions. Check your facility’s policies and procedures before taking gifts from business partners.
Duty to Report
Federal law protects those who report in good faith.
Trying to get revenge against someone who reported a concern is illegal.
Give a detailed report of what you saw and heard.
Report names, dates, times, and locations.
Check your facility’s policies and procedures for ways to report. Here are a few options:
Talk to your manager. Talk to your compliance officer. Use your facility’s compliance hotline for reporting.
Federal law protects those who report in good faith.
Trying to get revenge against someone who reported a concern is illegal.
Give a detailed report of what you saw and heard.
Report names, dates, times, and locations.
Check your facility’s policies and procedures for ways to report. Here are a few options:
Choose the best option and select SUBMIT.
There is no right reason to take money from a person in your care. Following the coworker or telling others will not help. It is your duty to report.
If you saw a coworker take money from a person in your care, what should you do?
Assume they are taking it for safekeeping.
Follow them to see where they go.
Report what you saw to your manager.
Tell your other coworkers.
