Corporate compliance

Claxton-Hepburn Medical Center/Claxton Medical, P.C. ("CHMC") recognizes the problem that fraud and other deliberate or accidental misconduct in the healthcare industry pose to society. CHMC seeks to eliminate misconduct through the Corporate Compliance Program. CHMC is committed to maintaining an effective Corporate Compliance Program in accordance with applicable law and guidance from state and federal healthcare authorities. The provisions of this Compliance Plan have been developed to create an effective Corporate Compliance Program. This Compliance Program is designed to prevent errors or misconduct; to detect errors or misconduct if they occur; and to enhance the reputation of CHMC and its employees as ethical providers of healthcare services. Service in healthcare is the highest calling. Integrity and trust are essential to our services. Our patients are entitled to rely on that trust. They are to be treated at all times with respect and dignity.

The Corporate Compliance Program at CHMC is a mandatory, self-monitoring program to ensure our compliance with all federal, state and local laws applicable to healthcare.

Our program is required to:

• Heighten awareness of compliance and ethical issues through education.
• Oversee the activities of CHMC and its employees with regard to compliance with laws, regulations, policies and code of conduct.
• Provide mechanisms for detection, correction and prevention of improper conduct.
• Provide employees with avenues for addressing compliance and ethical issues.

Regulations (laws)

Federal/State Government–Health & Human Health Services (HHS):

• EMTALA—"patient anti-dumping law."
• Deficit Reduction Act.
• False Claims Act.
• HIPAA.
• NYSDOH regulations.
• Patient Protection and Affordability Care Act.
• Public Health Law.
• Social Security Act.
• Any other applicable regulation.

We deal with issues related to:

• Fraud and abuse—(Deficit Reduction Act, Social Security Act, False Claims Act).
• Regulatory standards and laws—Department of Health and DNV.
• Billing and coding requirements.
• HIPAA.
• Medical necessity.
• Patient documentation.
• Information requests.
• EMTALA—"patient anti-dumping law."

This plan applies to all members of the board of directors, administration, employees, volunteers, medical staff, agents and vendors.

Any shortcomings are to be reported to a supervisor, the corporate compliance officer or the chief executive officer so that they can be dealt with appropriately. If you have a question or concern, please call the corporate compliance officer at 315.713.5100 or email us at compliance@chmed.org.

Claxton-Hepburn Medical Center/Claxton Medical, P.C. corporate compliance policy

It is the policy of Claxton-Hepburn Medical Center/Claxton Medical, P.C. ("CHMC") to comply with all applicable federal, state and local laws and regulations, both civil and criminal, as well as those pertaining to CHMC as a tax-exempt, charitable institution.

In addition to complying with the law, it is also the policy of CHMC to comply with the compliance code of conduct and applicable policies and procedures addressing standards of conduct, which are adopted from time to time by the board or a committee thereof, the chief executive officer or the CORE Compliance Committee.

No employee, agent or medical staff appointee of CHMC has any authority to act contrary to the provisions of the laws, the code of conduct or applicable policies addressing standards of conduct or to authorize, direct or condone violations by any other employee, agent or medical staff appointee.

Any employee, agent or medical staff appointee of CHMC who has knowledge of activities that he or she believes may violate the law or CHMC's compliance code of conduct and/or applicable policies has an obligation, promptly after learning of such activities, to report the matter to his or her immediate supervisor, the chief executive officer or to the corporate compliance officer. Reports may be made anonymously and employees will not be penalized for truthful reports. Failure to report known violations, failure to detect violations due to negligence or reckless conduct, and making false reports shall be grounds for disciplinary action, including termination. Any reports of retaliation, harassment or other workplace-related problems shall be referred to Human Resources.

CHMC communicates its standards and procedures to all employees and agents, through mandatory training programs by dissemination of information that explains, in a practical manner, what is required. This includes dissemination of the compliance code of conduct as well as an Acknowledgment of Education by each employee via the HealthStream electronic education module. Compliance policies and procedures are also available on CHMC's intranet.

CHMC achieves compliance with its standards by utilizing monitoring and auditing systems reasonably designed to detect errors or misconduct by its employees and agents and by having in place and publicizing a reporting system whereby employees, medical staff and other agents can report errors or misconduct by themselves or others within the organization without fear of retribution.

Employees, agents or medical staff appointees may report potential compliance issues to the corporate compliance officer by phone, email, mail or face-to-face. CHMC utilizes a hotline to report compliance issues for those who wish to remain anonymous. The corporate compliance officer has an obligation to act on all reported issues. Unresolved issues are taken to the highest authority in the organization for resolution.

After a violation has been detected, CHMC will take all reasonable steps to respond appropriately, timely and accordingly. Modifications to systems and processes may be necessary to prevent and detect future violations.

This corporate compliance policy is intended to communicate current provisions regarding compliance. The board reserves the right to change, modify or waive all provisions herein. If any employee has a question concerning a particular provision contained herein or concerning any practice not addressed in this document, he or she should consult with the corporate compliance officer.

Any shortcomings are to be reported to a supervisor, the corporate compliance officer or the chief executive officer so that they can be dealt with appropriately. If you have a question or concern, please call the corporate compliance officer at 315.713.5104 or email us at compliance@chmed.org

Related policies: Please contact our Corporate Compliance Office for these or other compliance-related policies.