statement of corporate policy:
It is the policy of McBride Orthopedic Hospital (hereafter referred to as McBride) to comply in all respects with laws that affect the activities of McBride and its employees. The Mission of McBride is to serve the communities of Oklahoma City by providing access to excellence in orthopedic care, in an environment designed to efficiently and effectively deliver consistently superior patient outcomes. McBride has adopted a Compliance Program to familiarize employees with the requirements of applicable law and regulations. The Board of Directors is responsible for the implementation of the Compliance Program through delegation of that responsibility to Administration and the Compliance Officer.
McBride will provide educational and training opportunities regarding the Compliance Program and applicable law. Employees have access to a copy of the Compliance Program and Code of Conduct on the intranet. New Employees will sign the Code of Conduct during Orientation. Employees are expected to fully comply with these policies and the provisions of the Compliance Program and Code of Conduct. Failure to do so will be grounds for disciplinary action, including termination when appropriate. Any employee may discuss any question regarding the Compliance Program with the Compliance Officer and, if appropriate, the CEO. It is the duty of each employee to report any act of non-compliance to the Compliance Officer. The Board of Directors has designated the Vice President of Revenue Cycle Management to serve as Compliance Officer. The Compliance Officer will notify the CEO of any such reports. If incident involves the Compliance Officer, the employee should notify the CEO of the relevant issues.
The Compliance Officer and/or the CEO will report all acts of non-compliance to the Board of Directors. At the request of the employee, any report may be made on a confidential basis. No report made in good faith will affect the status or be grounds for disciplinary action or dismissal of the reporting employee.
The term "affiliates", as used in this document, means medical staff and independent contractors and agents. Affiliates are notified of McBride's Compliance Program, including without limitation, its policies with respect to the specific areas of documentation, coding, billing, and competitive practices.
The following is the Code of Conduct that McBride has adopted which binds employees and affiliates:
- McBride employees and affiliates must cooperate fully and completely with McBride's Compliance Program.
- McBride employees must comply with McBride's policies and procedures; which are located on the intranet.
- Employees and affiliates must immediately report violations or suspected violations of the Compliance Program and/or McBride's policies and procedures to the Compliance Officer or the CEO. The Compliance Officer or the CEO will investigate reports promptly, as appropriate under the circumstances.
- All treatment provided or recommended by McBride will be medically necessary or will be billed as screening or preventative services in compliance with the payer's applicable rules and requirements.
- McBride employees and affiliates will not directly or indirectly pay or receive from any person or any entity any payment for patient referrals or for arranging for the purchase or lease of any item or service in violation of State or Federal law. Except for certain exceptions, it is illegal or unethical to offer or solicit any financial inducement, gift or other thing of value to prospective patients or others in order to encourage patients to be treated at McBride.
- McBride will not refer patients to entities with which McBride employees or affiliates have an ownership or other financial interest, except as permitted by the Federal Self-Referral Law and any other applicable restrictions on self-referrals. Employees and affiliates are obligated to inform the Compliance Officer promptly of financial or other interests that they have with any other person or entity with which McBride does business, pursuant to the Conflict of Interest and Related Matters section of this document.
- Except for the occasional expressions of gratitude from patients, McBride employees should refuse gifts, loans or anything of value offered by outside individuals or companies, including McBride's affiliates, unless gifts are of nominal value.
Quality of Care
- Patients will be treated with respect and dignity. McBride will provide quality care at a medically appropriate level and without regard to race, color, national origin, age, disability, or sex.
- McBride will make no distinction in the care provided based on ability to pay except as medically, legally, and ethically appropriate. Each patient, no matter what the payment source or level of reimbursement will be provided with the same high level of superior care and cost-effective treatment.
- Informed consent will be obtained for all treatment, as appropriate and required under the circumstances.
- Patients and their representatives will be accorded appropriate confidentiality, privacy, counseling and opportunities for resolution of complaints.
- McBride employees and affiliates will be licensed, credentialed, or skilled at the services they perform as appropriate and required by law.
- McBride will comply with all laws and regulations regarding patient rights and privacy.
- Patient billing inquiries will be referred to an appropriate person in a timely manner.
- The Compliance Committee will review the Code of Conduct and Compliance Program annually.
Records and Other Property
- McBride's records and documents are confidential. Except as required or authorized by law, they will not be disclosed or discussed with anyone not employed or affiliated with McBride without written permission of McBride or the written authorization of the relevant patient or patient representatives, as appropriate. Employees and affiliates will take reasonable precautions to ensure that their conversations and other communications safeguard patient confidentiality.
- No property belonging to McBride may be removed from McBride locations without the permission of McBride Administration.
- Except as expressly permitted in writing, by McBride, no employee or affiliate may use or disclose any trade secrets or other confidential or proprietary information belonging to McBride.
- Upon separation, no employee or affiliate may take or retain any McBride papers, patient lists, fee books, patient records, files or other documents. Copies of any such materials may only be taken or retained as specifically authorized as part of a written agreement.
- No edits should be made to hospital documents unless the edit is properly undertaken in accordance with documentation guidelines.
- It will be the responsibility of Administration and the Business Office Director to ensure that all provider agreements, provider manuals, and provider billing and coding instructions and bulletins are maintained in a centralized, well-organized manner.
- Administration or designee will coordinate with the billing personnel to ensure that information is shared appropriately with all personnel whose position requires access.
Certain Reporting, Survey, and Other Requirements
- Employees and affiliates must immediately report to the Compliance Officer any inquiry, investigation, proceeding, charge, or complaint involving any court of law, administrative tribunal, or state or federal agency that is related to McBride.
- Employees and affiliates must immediately notify the Compliance Officer if he or she becomes the subject of any request for information, inquiry, investigation, or proceeding, the outcome of which could result in suspension or revocation of his or her licensure, any professional membership or certification.
- Employees and affiliates must immediately notify the Compliance Officer if he or she is excluded, suspended, debarred, or removed, whether voluntarily or involuntarily, from any government or commercial payer plan or program.
- In most instances the Compliance Officer will communicate directly with employees. The Board of Directors or designee will communicate compliance matters with the physicians.
Governmental and Other Inquiries or Communications
- McBride will respond truthfully and accurately to any governmental, payer, or patient inquiries as required by law.
- During a governmental investigation, no person will conceal, destroy, or alter documents; knowingly make any false statements to the government's representatives; or attempt to cause another person to fail to provide accurate information or obstruct the inquiry.
Maintenance of Compliance Plan Documents
- A copy of the current Compliance Program is located on the intranet.
- It is the responsibility of the Compliance Officer to audit compliance with this requirement at least once each year.
- McBride's Medical Staff Office, Human Resources, and Accounting Department will check the Lists of Excluded Persons maintained by the Office of the Inspector General and/or through the AMA Physician Profile and/or the National Practitioner Data Bank to ensure that no provider of care has had sanctions placed on him/her by any federal programs.
- Any provider of care must immediately notify the Compliance Officer in writing if a federal program places any sanctions on them.
Billing - General Matters
- McBride will take reasonable efforts to ensure that the federally funded health care programs and all other payers are billed appropriately. McBride will not direct practitioners towards higher level procedure codes or diagnoses codes that will support third party payer coverage. Coding and Billing policy and procedures have been developed and established and should be referred to for matters in question.
- McBride will take reasonable steps to ensure that claims for reimbursement are accurate and complete. McBride uses recognized coding compliance software to ensure appropriate coding.
- Claim forms will be submitted in a timely manner taking all reasonable steps to ensure the accuracy of the date of service, the nature of the service, the persons or entities that provided the service, and all other information, including the signatures used.
- McBride will take reasonable steps to ensure that services are documented appropriately as required by the applicable billing and coding requirements.
- If McBride intends to bill for a service that is likely to be denied as not reasonable and necessary by the payer, the patient will be informed as will sign an Advance Beneficiary Notice (ABN) form (also known as waiver of liability form) before the service is provided. The form will state why this specific service is likely to be denied and that the patient will be financially responsible for the service(s). The patient may be billed for the service after payer has denied payment. It is not appropriate to use ABN forms for all non-covered services.
- Except in connection with the coordination of benefits, duplicate bills will not be submitted to a third party payer or until such time as the payer has indicated that the prior bill is lost or otherwise unavailable. The third party's statements regarding the status of the prior bill should be documented and maintained.
- Claims for services, items, and for the administration of drugs will not be issued until the service, item, or drug is actually provided or dispensed.
- No payment will be sought for pharmaceuticals provided to McBride as a free sample not intended for resale.
- Claims to third party payers will not be submitted for missed appointments unless the applicable payer reimburses for such services.
- If any employee or affiliate receives any fee or other form of compensation for hospital services performed during his or her employment or affiliation with McBride, the employee will remit such payment to McBride if requested.
- McBride will obtain patient written consent to bill and collect for services on an assigned basis before the billing of any third party payers, unless allowed otherwise by law.
- It will be the responsiblity of Admissions personnel to verify the presence of such consent in the patient's medical record at the time of each patient visit.
Local Medical Review Policies
- Medicare and other carriers issue Local Coverage Determination (LCD) that explains the ability of providers to bill certain services unless certain enumerated conditions, signs, symptoms, or diagnoses are present.
- McBride will maintain online accessibility that includes copies of all such LCD that are issued by payers and which are applicable to services or items offered by McBride.
- Unless McBride disagrees in good faith with an LCD and articulates a reasonable basis for that disagreement, it will only bill such a payer in accordance with the requirements of such policy.
- Where McBride disagrees in good faith with an LCD of a payer, McBride will take steps to document in a communication with the applicable payer the nature and the reasons for McBride's disagreement with the policy.
- Under no circumstances will procedures or diagnosis codes be used that are not accurate in effort to circumvent any LCD.
Conflicts of Interest and Related Matters
- McBride and affiliates will report to the Compliance Officer any actual or potential conflict of interests that arise in connection with McBride.
- McBride and affiliates will cooperate in resolving actual or potential conflicts of interests.
Integrity of Financial Reporting and Funds Control
- McBride will take steps to ensure that assets and liabilities are accounted for properly, in compliance with tax and financial reporting requirements, and in accordance with generally accepted accounting principles.
- McBride will not permit assets, payments, or funds to be mischaracterized or misrepresented on its financial records.
- Any marketing and advertising activities used to educate the public, increase awareness of services, or to recruit colleagues will present only truthful information to comply with state professional misconduct laws.
Integrity of Data Systems
- McBride will establish procedures for maintaining the integrity and security of electronic data systems including but not limited to: regular back-ups, regularly scheduled virus and malware scans, and real-time perimeter intrusion prevention scans.
- McBride will develop procedures to prevent unauthorized access and disclosure of confidential electronic data in accordance with the federal security standard of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 "HIPAA".
Compliance Officer: Rick Smith, 405-230-9116
Compliance Hotline: 405-486-2527