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Annual Acknowledgement Statement

  • As approved by Beaumont Board of Directors, all Beaumont Health System employees and physicians are responsible for compliance and are required to receive Compliance education/training upon hire and annually thereafter is based on the document, Compliance Program Guidance for Hospitals, which was released by the Office of the Inspector General (OIG) in 1998. This document describes the seven basic elements of an effective compliance plan.
  • Beaumont Health System has a decentralized approach to compliance by using Department Compliance Plans (DCP). Each DCP has:
    • 7 basic elements
    • Department specific risk areas (areas where regulations apply)
    • Each department has a Department Compliance Coordinator (DCC) who is responsible for:
      • Department specific education and communication, audits, monitors and process improvement initiatives
      • Reviewing and updating the plan, annually at minimum
      • Keeping employees informed and up to date
      • The DCC is the link, who supports and acts as a liaison for their department, staff and the Corporate Compliance Office
  • Who is your Department Compliance Coordinator?
    • If you don’t know, ask your supervisor or check the Corporate Compliance website

7 Elements of Beaumont Health System Corporate Compliance Plan

  1. Written Policies and Procedures
    • At both the corporate and departmental level
  2. Official Personnel
    • Vice President, Compliance
    • Business Ethics & Corporate Compliance Committee
  3. Compliance Education and Training for all employees
    • The Corporate Compliance Office provides education on the Corporate Compliance Plan, as well as information regarding regulatory compliance related issues
    • Individual departments provide training on specific policies, rules, laws and regulations that apply to that department
    • Annual compliance education via Beaumont University’s Student Learning Center
  4. Communication of Compliance Information
    • Corporate Compliance Web Page
    • Brochures, Posters, Bulletin boards
    • Phone calls, Outlook (emails)
  5. Enforce compliance standards through investigation, education and communication and, if necessary, disciplinary actions
  6. Monitors and Audits allow the Department Compliance Coordinator and Compliance Team to support the Corporate Compliance Plan and the Department Compliance Plans
  7. Respond in a timely manner to all reports or suspicions of potential non-compliance

What is Compliance?

  • Conducting business in a legal and ethical manner
  • Following laws, rules and regulations
  • Doing our jobs in full compliance with the regulations:
  • Following Beaumont’s Code of Business and Ethical Conduct, Policy #350

Why is Compliance Important?

  • It protects patient’s rights and their privacy
  • It guards the safety of patients and employees
  • It protects employees and the community at large
  • It prevents possible errors, waste, fraud and abuse that can result in penalties or sanctions enforced upon Beaumont Health System and/or employees

How does Compliance Affect You?

  • All employees and physicians shall report compliance concerns internally to management, their department compliance coordinator, department chief, Compliance Line (1-888-495-5100) or Corporate Compliance Office, which can be done anonymously, if preferred
  • You have the right, under the law, to report any potential issues of non-compliance at Beaumont Health System to state and federal administrative agencies
  • By law, organizations are not allowed to penalize callers for reporting potential compliance issues.

What you need to know about Compliance:

  • Know and understand the “core” Compliance Program documents:
    • Corporate Compliance Plan
    • Code of Business & Ethical Conduct Policy #350 and related brochure
    • Corporate Compliance Program brochure
    • Compliance Line brochure
  • Attend compliance education and training sessions
  • Know the laws, rules and regulations that apply to your job
  • Ask questions when you are not sure
  • Report potential compliance concerns
  • Complete annual mandatory education

Policy #350: Code of Business & Ethical Conduct

  • The Beaumont Health System Code of Business and Ethical Conduct is a comprehensive policy that strongly addresses industry relations and conflicts of interest to protect patients and Beaumont Health System.
  • Policy 350 prohibits any business courtesy or other benefit that is understood by either party to be offered or provided as an inducement to refer patients or business. Any relationship with a vendor that could be interpreted as influencing a designee’s decision-making on behalf of Beaumont Health System is prohibited.
  • Beaumont Health System designees are not permitted to receive any form of payment or gift from a vendor for writing articles, speeches, presentations or attendance at conferences or programs.
  • Note- designee collectively refers to a clinician and/or non-clinician o Adherence to all provisions of Policy #350 by all Beaumont employees and physicians is expected when dealing with patients, families, the public, the business community, payors, vendors, and governmental and regulatory authorities
  • For additional information, refer to Beaumont Health System Code of Business and Ethical Conduct on the Corporate Compliance web page or call the Corporate Compliance Office at (248) 551-0224

Reasons to Comply

  • Criminal and Civil Penalties, Imprisonment or loss of License
  • Monetary penalties
  • Corporate Integrity Agreement (Government’s Compliance Program)
  • Excluded from participation in Government programs
  • Loss of Public Trust

Prevention & Detection of Fraud, Waste & Abuse

  • Beaumont promotes and conducts training programs for all employees to ensure awareness of ethical and legal standards
  • Promotes internal reporting of potential concerns
  • Investigates and resolves all reports of potential non-compliance

False Claims Acts

  • Imposes civil liability on any individual or entity that knowingly submits or conspires to submit a false claim to the federal government
  • Prohibits a person from making or presenting or causing to be made or presented a claim for payment of health care services knowing the claim to be false
  • Examples of False Claims are claims that:
    • Are based on services that were not actually rendered or costs that were not actually incurred
    • Contain information that is not accurate or is misleading about the quality or type of services or products supplied
    • Payments made, which by law, the claimant was not allowed to receive
    • Contain false or misleading pricing information

Electronic Health Record (EHR)

  • Beaumont adopted the use of the EHR systems to improve the accuracy, functionality, and accessibility of patient medial records.
  • All health care providers entering patient data into a Beaumont EHR is responsible for adhering to Electronic Health Report Copy/Paste and Template Use Policy #481.
  • Any individual entering documentation into the EHR is responsible for the entire content and accuracy of the data.
  • Plagiarism – the act of including content of a note authored by another into the note without proper reference is prohibited. o The CMS (Centers for Medicare and Medicaid Services) and the OIG (Office of the Inspector General) have identified an increased frequency in records with identical documentation across services.

Conflict of Interest

  • A need to disclose a potential conflict of interest may exist if a Beaumont designee, or any member of their immediate family, receives compensation in any form for services rendered in any capacity to any organization or individual that has any past, present, or prospective business dealings with Beaumont, if such compensation might be reasonably construed as tending to prevent the Beaumont designee from acting solely and wholly in the best interest of Beaumont
  • At any time when a Beaumont designee or their immediate family member becomes involved in a relationship that is perceived to be a conflict of interest, the Beaumont designee must complete the Conflict of Interest/Disclosure of Remuneration Questionnaire
  • If you believe you may have a potential conflict of interest, call the Corporate Compliance Office, at 248-551-0224

Fraud Risk Management Program

  • Definition
    • Fraud is defined as a false representation of a matter of fact whether by words or conduct, by false or misleading allegations, or by concealment of what should have been disclosed; that deceives and is intended to deceive another so that the individual will act upon it to his or her legal injury. Fraud is a crime and also a civil law violation.
  • Responsibility
    • The avoidance of fraudulent activity is the responsibility of everyone at Beaumont. Beaumont policies and procedures are designed to prevent and detect fraud in internal business practices. Any actual or potential instances of fraudulent behavior are dealt with swiftly and decisively. The Corporate Compliance Office, with the support of senior management, is responsible to oversee the Fraud Risk Management Program and Fraud Risk Management Policy 351. Other departments having involvement/ responsibility include Legal Affairs, Security, Internal Audit and Human Resources.

Questions or Reports about Compliance Policies

  • Compliance Policies can be found on the Corporate Compliance web page
  • Questions regarding a policy can be directed to the Corporate Compliance Office via the web site or by calling (248) 551-0224.
  • For more specific questions call:
    • Your Supervisor, Manager or Department Chief
    • Your Department Compliance Coordinator
    • The Compliance Line 1-888-495-5100 (24 hours)
  • Corporate Compliance Team
    • Vice President, Compliance
      • Edward R. Grima
      • (248) 551-5004
    • Privacy Officer
      • Doug Clarkston
      • (248) 551-5006
    • Chairman, Business Ethics and Corporate Compliance Committee
      • Mark D. Kolins, M.D.
      • 248-551-8859
    • Information Security Officer
      • Doug Copley
      • (248) 733-7337
      • ITSecurity@beaumont.edu
    • Director, Education & Coding Compliance
      • Rochelle Cooper
      • (248) 551-5120
    • Senior Corporate Counsel, Legal Affairs
      • Mary Elizabeth Derwin, JD, MS, RN
      • 248-551-0765
    • Director, Internal Audit
      • Robert A. Kinsman, CPA, CIA
      • 248-423-3752
  • All reports remain confidential and will be investigated Corporate

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