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Healthcare Compliance

At ProMedica, and its subsidiaries,we are proud of the values that drive our success. These values shape an environment and culture that nurture the highest standards in business ethics and personal integrity. We are also committed to carrying these high standards into our relationships with vendors, contractors, agents, and other entities. To that end, we have implemented a Compliance Plan through which we educate and monitor in order to ensure ongoing compliance. To view ProMedica policies that have a direct impact on vendors, contractors, and/or agents, please follow the links below.

Compliance for Vendors Policy

False Claims Policy

If you have further questions or comments about our corporate compliance policies, please feel free to call the ProMedica Audit & Compliance department at 419-291-0230 or the anonymous Compliance Hotline at 419-824-1815 or 800-807-2693.

False Claims Act (FCA/FERA)

The False Claims Act (FCA) includes both civil and criminal provisions used in the enforcement of the law, which makes it an offense for any person or entity to present a false claim to the United States government. The elements necessary to establish a civil FCA violation are (1) presentation of a claim, (2) to the United States government or any program funded by government money, (3) with actual knowledge that the claim is false/fraudulent or with reckless disregard or deliberate ignorance of the truth or falsity of the claim.

Tax-exempt Status

All 501(c)(3) non-profit organizations may not pay more than “reasonable” compensation to a private individual or entity from which it purchases services or items. Likewise, it may not provide items or services for less than fair market value. If these rules are violated, ProMedica could lose its tax-exempt status and/or the IRS may impose a monetary penalty on the persons responsible.

Medicare and Medicaid Anti-kickback Statutes

This statute makes it a crime for anyone (normally a doctor) to knowingly and willfully solicit or accept payment or other remuneration for referring a patient to another for the furnishing of any item or service for which payment may be made in whole or in part by the Medicare or Medicaid programs. The statute also makes it a crime to knowingly and willfully offer or pay remuneration to “induce” such a referral. An “inducement” is any act intended “to exercise influence over the reason or judgment of another in an effort to cause the referral or program-related business.”

Health Insurance Portability and Accountability Act (HIPAA)

HIPAA, also known as the Administrative Simplification Act, details and provides for the enforcement of a patient’s privacy rights and standards for the electronic transmission of healthcare data. The legislation is sub-divided into four categories.

  • Transaction standards for the transmission of claims, enrollment, eligibility, premium payments, claim status, referrals and the coordination of benefits.
  • Code set standards for diagnosis codes, medical procedure codes, national drug codes, and dental procedure codes.
  • Privacy standards that require all individually identifiable health information be kept private and not disclosed without the patient’s permission.
  • Security standards that require processes be implemented to ensure data integrity, confidentiality and availability.

Fraud

Fraud is defined as an intentional, false representation or concealment of a material fact intended to induce another to act in a particular way resulting in his or her injury.

Fair and Accurate Credit Transaction Act (FACTA)

The purpose of this law as it applies to healthcare is to detect, prevent and mitigate identity theft in connection with patient financial accounts. ProMedica strives to prevent the intentional or inadvertent misuse of patient names, identities and medical records; to report criminal activity relating to identity theft and theft of services to appropriate authorities; and to take steps to correct and/or prevent further harm to any person whose name or other identifying information is used unlawfully or inappropriately.

Stark I, II and III

Stark laws prohibit doctors from referring Medicare and Medicaid patients to a hospital or other entity for the provision of “designated health services” if the doctor or immediate family member has a financial relationship with that entity. Financial relationships are defined as both ownership/investment interests and compensation relationships. Designated health services include physical and occupational therapy, radiology services (including MRI, CT scans, and ultrasound services), radiation therapy, durable medical equipment, orthotics and prosthetic devices, home health services, outpatient prescription drugs, and inpatient and outpatient hospital services.

Vendor Policies

Additionally, ProMedica is committed to carrying our expectations and high standards into our relationships with vendors/contractors/agents/etc.

To view ProMedica policies that have a direct impact on vendors, contractors, and/or agents, please follow the links below.

Compliance for Vendors Policy

False Claims Policy

If you have further questions or comments, you may call the ProMedica Audit & Compliance department at 419-291-0230.

If your company is seeking to do business with ProMedica, please contact the ProMedica Supply Chain Division / Contracting Section at 419-291-3450.

Compliance Hotline

Additionally, an anonymous hotline is available to all ProMedica employees and vendors, or anyone affiliated with the system. The hotline is answered by voice mail with an option to dial out to the Audit & Compliance Department. If you have questions or concerns about any aspect of ProMedica’s business relationships, call the anonymous Compliance Hotline at 419-824-1815 or 1-800-807-2693.

HIPAA Compliance

The Health Insurance Portability and Accountability Act (HIPAA) protects the privacy of all ProMedica patients. For more information about patient privacy information, please visit the HIPAA and Patient Privacy page.

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