Kickback
No False Claims It is illegal to submit false claims for reimbursement. Cape Cod Healthcare (CCHC) strictly prohibits any employee, provider or representative from knowingly presenting—or causing to be presented—a false or fraudulent claim to patients, Medicare, Medicaid, other government health programs or private payors. Likewise, no false statements or records may be used to obtain reimbursement. Standards for Claims All claims must: • Be submitted only when services were actually provided and medically necessary. • Accurately reflect charges for services rendered. • Properly document the procedures performed. • Comply with all applicable regulatory requirements. Examples of Violations • Billing for services not rendered or inaccurately described. • Billing for services that were not medically necessary or appropriate. • Falsifying plans of care or Certificates of Medical Necessity. • “Upcoding” diagnoses or entering false/misleading information to obtain excessive or impermissible payments. Training and Reporting • Personnel involved in preparing or submitting claims will receive ongoing training, including mandatory annual updates. • If you suspect improper claims are being submitted to Medicare, Medicaid, other government programs or private payors (e.g., Blue Cross), you must report the concern to the Chief Compliance Officer.
Research Compliance
Cape Cod Healthcare (CCHC) participates in Medicare, Medicaid and other government healthcare programs, and must comply with strict federal and state laws governing referrals and financial arrangements.
CCHC is committed to advancing medicine and medical technologies while ensuring strict compliance with ethical and legal standards. (A) Research Misconduct • All employees, medical staff, students, fellows, guest researchers and collaborators must report observed, suspected or apparent research misconduct immedi- ately to the Chief Compliance Officer. • If uncertain whether an incident qualifies as miscon- duct, consult the Chief Compliance Officer. • Cooperation in reviews, investigations and corrective actions is required. (B) Institutional Review Board (IRB) The IRB oversees all human subject research at Cape Cod Hospital, Falmouth Hospital, affiliated practices and ancillary facilities. Responsibilities include: • Ensuring compliance with applicable laws and regulations. • Providing education and training on ethical require- ments and CCHC research policies. • Managing conflicts of interest for IRB members and investigators. • Acting as the Privacy Board for research conducted within CCHC. Medicare and Billing Compliance • Medicare has specific requirements for coverage of clinical trial services. • The Chief Compliance Officer works with research staff, coders and patient accounts to ensure billing practices meet Medicare and other payor requirements. • Regular reviews prevent submission of claims for: - Items/services paid for by research sponsors. - Non-covered items under Medicare. - Trials that do not qualify as “qualified clinical trials.”
Anti-Kickback Laws • These laws prohibit offering, soliciting or receiving money or any benefit in exchange for patient referrals or to induce the purchase of goods or services. CCHC policy strictly forbids: • Offering or receiving anything of value to induce patient referrals or purchases. • Routine waivers of co-payments or deductibles. • Any arrangement that could be perceived as a bribe, kickback or rebate.
Prohibited Practices Examples of violations include: • Paying physicians or referral sources to induce patient referrals. • Compensating physicians for duties not actually performed. • Failing to require contracted physicians to devote time to agreed duties. • Paying compensation above fair market value. • Terminating contracts based on referral volume. • Providing grants, directorships, consulting or marketing agreements intended to generate referrals. Oversight and Documentation • All agreements involving compensation or referrals must be in writing and approved by CCHC’s legal counsel before becoming binding. • Arrangements are subject to periodic review to ensure compliance and fair market value. Guidance and Reporting Because this is a complex area of law, employees must exercise caution in transactions involving referral sources, healthcare providers or suppliers. Consult CCHC policies, the Chief Compliance Officer or the Chief Legal Officer for guidance. If you suspect an improper arrangement or violation of law, report it immediately to the Chief Compliance Officer or Chief Legal Officer.
Stark Law (Physician Self-Referral) The Stark Law prohibits:
• Physicians from referring patients for certain desig- nated health services to entities in which they or their family members have a financial interest. • Entities like CCHC from billing for services provided as a result of prohibited referrals. • CCHC requires strict compliance with the Stark Law in all physician financial arrangements.
7 | Cape Cod Healthcare
Code of Conduct | 8
Made with FlippingBook - Online catalogs