Compliance Policy #910
Boulder Community Hospital will take reasonable steps to achieve compliance with applicable laws and with the Hospital's compliance standards by utilizing monitoring and auditing systems reasonably designed to detect criminal or other improper conduct by its employees and other agents.
Audit and Review of Operational Activities
The Hospital shall conduct regular audits and/or reviews of its operations to assure that it is complying with its own compliance standards and with applicable laws and regulations. The following procedures shall apply to
audits and reviews of the Hospital's operations:
1. Each compliance standard adopted by the Hospital shall state how compliance with that standard will be verified and shall identify the person responsible for making that verification and reporting regularly, but no less than annually, to the Compliance Officer. The Compliance Officer may conduct anyadditional audits, monitoring or investigation deemed necessary to verify compliance with the Hospital's standards.
2. In addition to verification of compliance with Hospital standards, the Compliance Officer or Compliance Committee shall adopt on an annual basis an audit and review plan, which shall be presented to the Chief Executive Officer and Board of Directors. The plan shall specify the following:
a. Specific areas of the Hospital's operations which will be audited or reviewed during the year. Areas subject to audit or review may include, as appropriate, any of the following: activities which create exposure for potential violation of applicable laws, including without limitation, physician relationships; activities which may
trigger laws prohibiting kickback arrangements; coding; claims development and submission; cost reporting; reimbursement; and marketing; compliance with specific rules and polices which have been the focus of
attention on the part of government agencies, fiscal intermediaries/carriers or law enforcement; and
areas of concern specific to the Hospital that have been identified internally or by any governmental entity, law enforcement agency or third party payor.
b. The persons or entities responsible for conducting the audit or review.Audits and reviews shall be conducted by persons who have knowledge of health care compliance requirements in the specific area. Persons responsible for conducting audits or reviews may be employees of the Hospital who are independent of the function subject to audit or review or individuals or entities outside the Hospital.
c. A general description of the methods for conducting the audit or review (e.g., sampling of claims, chart review, employee interviews, document review, etc.). The individual or entity responsible for conducting the audit or review shall have discretion, after consultation with the Compliance Officer, to design specific techniques to conduct the audit or review in an effective manner.
d. A general timeline for the audit or review.
3. The person or entity conducting the audit or review shall submit a written report to the Compliance Officer and Chief Executive Officer. Such report shall include the results of the audit or review, as well as any
recommendations for corrective action or modifications of the Hospital's compliance standards or polices, if necessary.
Monitoring Adherence to the Compliance Program
The Hospital shall regularly monitor the Hospital's adherence to its compliance policies to verify whether such policies are being followed and effectively enforced. Such review shall include, but is not limited to, thefollowing:
1. The Compliance Officer shall meet with department directors, managers and members of senior management at least annually and shall review at least the following areas as applicable to the operations of the Hospital which are under the direction or authority of the director, manager or member of senior management: the education and training programs conducted for Hospital employees and agents; reports and/or investigations of compliance- related misconduct of employees or agents and the results of the investigation, including any disciplinary
action taken; a summary of actions taken to verify adherence to the Hospital's compliance standards and the results of such actions; identification of any areas in which compliance standards should be developed or existing standards modified; and any recommendations for improvement with respect to compliance.
2. The Compliance Officer and/or Compliance Committee shall conduct periodic spot checks of various aspects of the Hospital's compliance program to assessadherence to the Hospital's compliance standards and policies. The Compliance Officer and Compliance Committee shall determine which areas to review. Such reviews may include any of following: interviews with or written questionnaires to employees and agents to determine knowledge of and adherence to compliance standards; examination of records documenting compliance; verification of dissemination of documentation of compliance activities; examination of education and training programs and attendance lists; examination of the Hospital's contracts with physicians and other independent contractors; review of employee screening procedures; and assessment of any other procedures or protocols established to assure compliance.; and other methods as determined by the Compliance Officer.
3. The Compliance Officer and Committee may utilize, as necessary, any additional means of assessing the effectiveness of the Hospital's compliance program, including the use of outside auditors and consultants.
Results of Audit and Monitoring Activities
All audit and monitoring activities shall be conducted in such a manner as to maintain any appropriate legal privileges, including the attorney-client, work product, quality management and self-evaluative privileges, as applicable. Legal counsel shall be consulted, as necessary, with respect to audit and monitoring activities. The results of all audit and monitoring functions shall be provided to the Compliance Officer, who shall report such results to the Compliance Committee, Chief Executive Officer and Board of Directors on a regular basis, but no less frequently than annually. In the event any audit or review reveals potential violations or areas for improvement, the Compliance Officer shall take any appropriate action in accordance with the Hospital's compliance policies, including without limitation, conducting an investigation, imposition of disciplinary action if warranted, development of a corrective action plan, modification of the Hospital's compliance standards and policies, reporting to applicable government agencies and submission of
any overpayments made to the Hospital, if applicable.
The Compliance Officer shall keep the Chief Executive Officer and Compliance Committee informed of all audit and review activities. The Chief Executive Officer and/or Compliance Officer shall report the results of the audits and reviews to the Board of Directors as necessary, but no less than annually.
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