CORPORATE COMPLIANCE PROGRAM STRUCTURE AND GUIDELINES

Finger Lakes Health (“FLH”) has adopted a Corporate Compliance Program (the “Program”) to demonstrate our commitment to complying with all federal and state laws and regulations, including Federal health care program requirements.

The purpose of the Program is to provide a framework that reduces the likelihood of non-compliance, and provide a process for detection of and effective resolution of regulatory compliance issues. Program revisions will be made as deemed appropriate to achieve this purpose.

To obtain further information or guidance about applicable laws and regulations we urge you to contact your supervisor or FLH contact, or our Corporate Compliance Officer.

Program Structure and Oversight Authority

FLH has adopted a structure to establish oversight authority for the Program. There is an oversight committee of the Board of Directors (the Audit & Finance Committee), a Corporate Compliance Officer, and a Corporate Compliance Committee consisting of management. All of these individuals or groups are firmly committed to supporting you, our employees and other agents in meeting the standards set forth in this Program.

Role of the Corporate Compliance Officer  

The Corporate Compliance Officer is primarily responsible for the day-to-day operation of the Program and oversight of regulatory compliance for all services provided by the organization’s Personnel. The Corporate Compliance Officer maintains current regulatory resources, chairs the Corporate Compliance Committee, and is responsible for ensuring that all elements of the Program described herein are in effect and are fully operational. The Corporate Compliance Officer reports directly and is accountable to the President & Chief Executive Officer and the Board of Directors.

Role of the Corporate Compliance Committee

The Corporate Compliance Committee consists of members of management. The Corporate Compliance Committee monitors the operation of the Program and assists the Corporate Compliance Officer in overseeing and executing various aspects of the Program. The Corporate Compliance Committee is responsible for coordinating with the Corporate Compliance Officer to ensure that FLH is conducting business in an ethical and responsible manner, consistent with the Program.  The Corporate Compliance Committee also directly reports and is accountable to the President & Chief Executive Officer and the Board of Directors.   

The individuals serving on the Corporate Compliance Committee are listed in Attachment A, which is updated by the Corporate Compliance Officer as necessary.

Role of Outside Legal Counsel

Outside legal counsel shall assist the Board, Committees of the Board, Administrative Team, President & Chief Executive Officer, Corporate Compliance Officer and Corporate Compliance Committee as needed to identify and interpret federal and state laws and regulations, maintain the Program, and provide legal advice to FLH with respect to any aspect of the Program.

Outside legal counsel may be notified at the discretion of the Corporate Compliance Officer of incidents that have a reasonable cause to support the assertion of non-compliance, at which time the Corporate Compliance Officer will be responsible for facilitating an investigation at the direction of legal counsel of the facts of the reported incident. The results of the investigation will be used by legal counsel to provide legal advice to the Corporate Compliance Officer, Corporate Compliance Committee and FLH.

Role of the Board of Directors

The Board has designated the Audit & Finance Committee of the Board to support, monitor and oversee the activities and effectiveness of the Program. All decisions by the Audit & Finance Committee shall be reported to the Board of Directors at least twice a year.

Formal Policies  

The Corporate Compliance Program document, Reporting Requirements/Code of Ethics and Business Conduct, Whistleblower Policy, Corporate Compliance Program Disciplinary Policy, Standards and Procedures, Compliance Policy and Procedures, Compliance with Applicable Federal and State False Claims Act and Compliance Committee Charter have all been formalized in writing, approved and adopted by the Audit & Finance Committee.  The Corporate Compliance Officer will no less than annually, review these documents to determine if they (i) have been implemented; (ii) are being followed by Personnel; (iii) are effective and (iv) require any updates.  

The written Compliance Policies and Procedures and the Code of Ethics and Business Conduct are designed to:

• articulate FLH’s commitment and obligation to comply with all applicable federal and state standards;
• describe compliance expectations as embodied in the Code of Ethics and Business Conduct Standards;
• document the implementation and operation of the Program;
• provide guidance to Personnel on dealing with potential compliance issues;
• identify the methods and procedures for communicating compliance issues to appropriate compliance personnel;
• describe how potential compliance issues are investigated and resolved;
• include a policy of non-intimidation and non-retaliation for good faith participation in the Program;
• establish disciplinary standards for Personnel who fail to comply with the written policies and procedures, standards of conduct, or state and federal laws, rules and regulations; and
• include all requirements listed under the Federal Deficit Reduction Act of 2005 regarding disseminating information as to false claims laws and whistleblower protections.

Ongoing Education and Training

FLH’s compliance training and education program is designed to train and educate our Personnel, including the Corporate Compliance Officer, the President & Chief Executive Officer, and all affected individuals. Our training and education covers, among other things, compliance issues/risk areas, expectations, disciplinary standards and the operation of the Compliance Program. The training is also intended to incorporate compliance concepts and updates of regulatory information needed to ensure that Personnel are current in their knowledge. 

At a minimum, such training will take place annually and will be made part of the orientation for all new employees upon hire and upon new appointment of a manager, corporate compliance officer, chief executive or governing board member. New employees will be provided with such training within the first 30 days of their employment. In the areas of coding and billing, required annual training will be provided in the submission of accurate bills for services rendered to Medicare and/or Medicaid patients, the personal obligation of each individual involved in the billing process to ensure that such billings are accurate, the applicable reimbursement rules and statutes, the legal sanctions for improper billings, and in proper and improper billing practices.

Participation in compliance training is mandatory for all Personnel. It is the responsibility of Department Directors to maintain department-specific records related to continuing education such as attendance, agendas, etc. The Corporate Compliance Officer has a process in place to track attendance for scheduled mandatory compliance trainings. 

Effective Lines of Communication

FLH has established and implemented effective lines of communication, ensuring confidentiality, between the Corporate Compliance Officer, members of the Corporate Compliance Committee and FLH’s employees, mangers and governing board.  The lines of communication are accessible to all Personnel and all patients/residents receiving services from FLH.

FLH’s website contains information regarding the Program, including the Code of Ethics and Business Conduct. 

• Reporting Requirements.  All Personnel are required to report suspected misconduct or possible violations of the Code of Ethics and Business Conduct as they are identified to the Corporate Compliance Officer, another member of senior management, or their supervisor.   Personnel may also report issues to the Integrity Helpline, which is available 24 hours a day, seven days a week.   
• Anonymous and Confidential Reporting.  Personnel may report anonymously, if they so choose (by way of the Integrity Helpline).  The identity of Personnel reporting will be kept confidential, whether requested or not, unless the matter is subject to a disciplinary proceeding, referred to or under investigation by the NY State Medicaid Fraud Control Unit (MFCU), the Office of Medicaid Inspector General (OMIG) or law enforcement, or if disclosure is a requirement in connection with a legal proceeding.  

Disciplinary Standards to Encourage Good Faith Participation in the Compliance Program

FLH has established well-publicized disciplinary standards to encourage good faith participation in the Program by all affected individuals. 

Personnel will be subject to disciplinary action, ranging from verbal warnings to termination of employment or contract, regardless of their level or position, if they fail to comply with any applicable laws or regulations, or any aspect of the Program. This includes, but is not limited to, disciplinary actions for:
 

• Failure to report suspected problems; 
• Participation in non-compliant behavior; 
• Encouraging, directing, facilitating or permitting non-compliant behavior;
• Failure by a violator’s supervisor(s) to detect and report a compliance violation, if such failure reflects inadequate supervision or lack of oversight;
• Refusal to cooperate in the investigation of a potential violation; 
• Refusal to assist in the resolution of compliance issues; and
• Retaliation against, or intimidation of, an individual for their good faith participation in the Compliance Program.

The System for Routine Monitoring and Identification of Compliance Risk Areas

FLH has established a system for the routine identification and assessment of compliance risk areas relevant to its operations.  This process includes internal, and, as appropriate, external reviews, audits, and other practices to evaluate FLH’s compliance with Federal health care program requirements (e.g., the Medicare and Medicaid Programs) and the overall effectiveness of the Program.

• Monitoring and Auditing.  The Corporate Compliance Officer (or designees) will ensure that internal and external audits, as appropriate, are conducted by auditors with expertise in Federal health care program requirements and applicable laws, rules and regulations, or have expertise in the audit subject areas.   The Corporate Compliance Officer and Corporate Compliance Committee will also audit and monitor the operation of the Program to determine its effectiveness. 
• Specific Risk Areas.  The Corporate Compliance Officer, or designees, will monitor areas where there is potential for fraud, waste or abuse.  This includes, but is not limited to, reviews of FLH’s’ business practices; coding, billing and documentation and payment practices; issues relating to quality of care and medical necessity of services; the credentialing process; compliance with mandatory reporting requirements;  governance standards; contractor oversight and other potential compliance risk areas that may arise from complaints, risk assessments, or that are identified by specific compliance protocols or through other means.   Supervisors, Managers, Directors and Vice Presidents are encouraged to request specific reviews or audits of their department's compliance activities. To ensure that important duties under FLH's Program are properly delegated, the Corporate Compliance Officer shall maintain documentation of all significant requests for reviews or audits relating to the Program. Requests by department personnel shall be reviewed and approved in advance by the Corporate Compliance Officer. For requests of a recurring nature (i.e., periodic audits), the audit may be incorporated into the annual compliance Work Plan.
• Exclusion Screening. FLH will make diligent efforts to ensure that it does not employ or contract with individuals or entities who are ineligible to participate in Federal health care programs, including conducting queries to the Office of Inspector General https://exclusions.oig.hhs.gov), the Office of the Medicaid Inspector General (https://apps.omig.ny.gov/exclusions/ex_search.aspx) and the System for Award Management (SAM) (https://sam.gov/content/exclusions)  prior to hiring or contracting and monthly thereafter.
• Risk Assessment and Annual Work Plan.  The Corporate Compliance Officer, together with the Corporate Compliance Committee, will formulate an annual Compliance Work Plan based on the developments arising from internal reviews, departmental risk assessments and identified issues of concern as well as external areas of compliance concern. The annual Work Plan will be reviewed and approved by the Audit & Finance Committee of the governing board.   

The System for Promptly Responding to Compliance Issues

FLH has established and implemented procedures and a system for promptly responding to compliance issues as they are raised, investigating potential compliance problems as identified in the course of self-evaluations and audits, correcting such problems promptly and thoroughly to reduce the potential for recurrence, and ensure ongoing compliance with the Federal health care program requirements (e.g., the Medicare and Medicaid Programs).

• Investigations. All compliance issues, however raised (i.e., whether reported or discovered through audits/self-evaluations), must be brought to the attention of the Corporate Compliance Officer.  The Corporate Compliance Officer will oversee or conduct an inquiry into the issue, consulting with outside counsel, consultants and/or others if necessary. Personnel are expected to cooperate in such investigations.
• Corrective Action and Responses to Suspected Violations. All Personnel are also expected to assist in the resolution of compliance issues.   Corrective action will be implemented promptly and thoroughly and may include: conducting training; revising or creating appropriate forms; modifying or creating new policies and procedures; conducting internal reviews, audits or follow-up audits; imposing discipline, as appropriate;  and making a voluntary disclosure or refund to appropriate governmental agencies   (e.g., the Department of Health, Office of the Medicaid Inspector General,  the Office the United States Department of Health and Human Services, Office of Inspector General or the Centers for Medicare and Medicaid Services) or other appropriate parties.  Corrective Action Plans and other corrective actions will continue to be monitored after they are implemented to ensure that they are effective.

Policy of Non-Intimidation and Non-Retaliation.

• Intimidation and Retaliation Are Prohibited. We expect all Personnel to comply with this Program, including the reporting of any potential misconduct, illegal conduct or other compliance-related concerns. Retaliation or intimidation in any form against an individual who in good faith reports potential compliance issues or for other good faith participation in the Compliance Program is strictly prohibited and is itself a serious violation of the Code of Conduct.  Acts of retaliation should be immediately reported to the Corporate Compliance Officer and, if substantiated, will be disciplined appropriately.