TABLE OF CONTENTS Page Introductory Letter by David Howes 4 Compliance Program Components – Written Compliance Guidelines 5 Code of Ethics 5 Mission, Vision, Values & Customer Promise 6 Quality of Care & Services 6 Compliance with Laws & Regulations 6-7 Privacy 7 Confidentiality 7 Social Media 8 Federal Contracts & Procurement 9 Workplace Conduct & Employment Practices 9 Excluded/Sanctioned Individuals 9-10 Information Technology 10 Coding, Billing & Collection 10 Financial Relationships with Vendors & Referral Sources 10 Gifts & Gratuities 10-11 Environmental & Safety Considerations 11 Conflict of Interest 11 Protecting Martin’s Point Assets 11-12 Political Activities & Contributions 12 Policies & Procedures 12
Board of Directors, Chief Compliance Officer, Medicare
Compliance Officer and Committees 12-13 Training and Education 13-14 Effective Communication 14-15 Enforcement of Standards/Disciplinary Guidelines 15 Monitoring and Auditing 15 Responses to Detected Offenses and Corrective Action Plans 16 Approval Process of Compliance Program and Code of Ethics 16-17 Definitions 18 Exhibit A
Quality, honesty and integrity in everything we do are important values to all of us who are associated with Martin’s Point. As a not-for-profit, we are committed to providing affordable, quality health care and services that align with our mission and values while driving healthy business performance so we can continue to make a difference in the communities we serve for a long time to come.
We live in a world of constantly changing regulations and requirements. We are committed to adhering to these laws, government regulations, third party payor agreements and our own policies. To this end, we have implemented a Corporate Compliance Program and Code of Ethics to assist with this process. A key element of the Compliance Program is our Code of Ethics. Itis rooted in our mission and values, and re-affirms the values and professional standards that already exist among all who are associated with Martin’s Point.
Our Code of Ethics was designed to serve several purposes:
To educate our staff about the importance of compliance with laws, regulations, standards of care, ethical business practices and the basic standards expected in the workplace;
To communicate the commitment of ethical decision-making by Martin’s Point management to all staff members; and
To ensure that all employees understand their responsibility for keeping Martin’s Point in full compliance with these laws and regulations and specifically their responsibility as part of the Compliance Program.
Our Code of Ethicsand our Compliance Program have the full endorsement of the Board of Directors, as well as the management team. Please familiarize yourself with this document. It provides an overview of the Martin’s Point compliance program. While this document does not cover the specifics of every situation that you may encounter, it does provide guidance to resources available when you have questions. The management team stands ready to answer your questions about this document and the Compliance Program in general.
You should speak with your supervisor anytime you have a question regarding a possible violation of our Code of Ethics. Should you not receive a satisfactory response from your supervisor in a reasonable amount of time, continue raising your concern to your Human Resources Business Partner, Senior Manager/Director and/or the President/CEO. Additionally, we have appointed a Chief Compliance Officer and established a toll-free Compliance Hotline as further resources to help resolve such issues. Reports can be made anonymously to the Compliance Hotline at 1-800-297-8616.
I can assure you that management will not tolerate retaliation for reporting issues to management, the Chief Compliance Officer or the Compliance Hotline. You should feel free to contact the Chief Compliance Officer at any time whether or not you have first contacted your supervisor, Human Resources or Senior Manager/Director. Compliance questions and inquiries can also be directed to your Compliance Business Partner.
The Board of Directors and management team of Martin’s Point join me in pledging our full commitment to upholding our Compliance Program and Code of Ethics as we fulfill our mission of health care excellence.
David Howes, MD, President and Chief Executive Officer
Introduction The Martin’s Point Health Care (Martin’s Point) Compliance Program and Code of Ethics apply to all Martin’s Point employees, board members, volunteers, student interns and other individuals authorized to act as representatives of Martin’s Point. The effectiveness of the Compliance Program is predicated on our corporate culture and the implementation of our corporate values. Martin’s Point strives to do the right thing for our members, ourselves, each other and our community while personifying honesty, integrity and quality. This document represents a set of practices and procedures that reflect the company’s commitment to do the right thing at the right time while implanting effective management steps to ensure full compliance with applicable state and federal laws, regulations, contracts and other legal requirements that govern our organization. We all work together toward our mission—to create a healthier community through authentic relationships built on trust. In support of that mission, we expect that all of us will behave according to this Code and we want and need to hear about any suspected violations, irregularities, or questions about what to do. You can voice concerns through your immediate supervisor, the Chief Compliance Officer or Medicare Compliance Officer, or the Compliance Hotline, 1-800-297-8616.
Compliance Program Components
The Martin’s Point Compliance Program is based on the seven elements detailed in the Federal Sentencing Guidelines.
Written Compliance Guidelines – Code of Ethics and Policies & Procedures
The Martin’s Point Health Care Code of Ethics articulates the company’s values and mission statement, as well as the company’s expectations of employees, including the employees of first tier, downstream and related entities, to act in an ethical and compliant manner. The Code of Ethics encourages employees, management, and board members to report violations of law and policy to the Chief Compliance Officer, the Medicare Compliance Officer, appropriate governmental entities or their responsible designees (such as MEDICs) and/or to law enforcement. The Code of Ethics also specifies the disciplinary actions that can be imposed for non-compliance, including written warnings, reprimands, suspensions and terminations.
We recognize that our employees are the key to providing high-quality health care experience for both clinical and non-clinical business activities. We also recognize that we must act in accordance with our Code of Ethics, policies, procedures, laws and regulations. We are aware that failure to do so can result in serious consequences for individual employees, medical staff members, Martin’s Point and the people and communities we serve. Each employee has an affirmative duty to report a compliance issue and failure to do so could result in termination. Our Compliance Program and Code of Ethics apply to all Martin’s Point employees.
While our Code of Ethics is designed to provide overall guidance, it does not address every situation. More specific guidance is provided in the Martin’s Point Policies & Procedures. If there is no specific policy, our Code of Ethics becomes the policy. If a policy and our Code of Ethics provision conflict, the Code of Ethics takes precedence. The Code of Ethics is a “living document” that is updated periodically to respond to changing conditions. Questions regarding our Code of Ethics, or any issue, should be raised by the employee to his or her immediate supervisor, to the Martin’s Point Chief Compliance Officer, the Medicare Compliance Officer or Martin’s Point management. Issues can also be reported confidentially and anonymously to the Compliance Hotline, 1-800-297-8616.
The term “we,” as used in this document, is meant to refer collectively to Martin’s Point employees, board members, providers, volunteers, student interns and externs, temporary and per diem employees, and other individuals that are authorized to act as representatives of Martin’s Point, both inside and outside Martin’s Point facilities.
Our mission is our organizational why—a statement of why we do what we do. The mission of Martin’s Point Health Care is to create a healthier community through authentic relationships built on trust. We are People caring for People.
VISION Trusted for care. Chosen for service. Uniting the community in affordable health. VALUES
Our business strategy is guided by our values of helping each other, acting as owners of the business, taking care of ourselves, learning better ways to do things, trusting each other and having fun doing it.
CUSTOMER PROMISE Our Customer Promise enhances and supports our commitment to our Code of Ethics. Through our Customer Promise, we aspire to fulfill our mission, vision and values to our internal and external customers through our core Customer Promise objectives.
Care - We are here for you when and how you need us.
Trust - You can trust us to act with honesty and integrity.
Hope - You will be met with optimism and compassion.
Guide - You will have a partner in making decisions that best fit your life.
QUALITY OF CARE & SERVICES
We provide high quality care and skilled, courteous, compassionate, reliable service to all patients and members and others. We will respect the dignity, comfort, and privacy of every individual, member, patient, and employee, while providing them with consideration, courtesy and respect.
We will provide appropriate and timely care by qualified health care professionals to all patients without regard to race, religion, disability, age, gender, national origin, sexual orientation or ability to pay for such care.
We will adhere to Martin’s Point’s statement of patient rights and we respect the choices of our members and patients expressed in advance directives.
We will maintain complete and thorough records of patient information and protect the privacy of our patients’ and members’ health records to fulfill the requirements set forth in our policies, accreditation standards, applicable laws and regulations.
COMPLIANCE with the LAWS & REGULATIONS
We follow all applicable federal, state, and local laws and regulations using high standards of ethics, integrity and timeliness.
We provide health care and administrative services consistent with federal, state and local laws and regulations that apply to our organization.
We provide Martin’s Point employees and agents with information about the governing rules and regulations and relevant changes related to the organization’s business practices and delivery of care to our patients.
We do not engage in inappropriate discussions with competitors regarding business issues.
All employees are bound by laws and regulations that govern our company which include but are not limited to:
False Claims Act
Health Insurance Portability and Accountability Act (HIPAA)
Medicare Advantage (MA) Regulations
Regulatory guidance produced by CMS for MA and Part D
Applicable state laws
We maintain the privacy and confidentiality of information entrusted to us in accordance with legal and ethical standards. We maintain this privacy even after our association with Martin’s Point has ended.
We respect the privacy of our patients, members, and co-workers through policies and procedures that safeguard patient, member, and customer information. We protect the privacy of health records according to state and federal laws and accreditation requirements.
We maintain medical and business documents and follow our record retention policy in accordance with HIPAA, state privacy laws and other applicable guidelines.
We only disclose minimum necessary information regarding medical, clinical, or business information when such information is related to treatment, payment or operations. We provide specialized training to employees pertaining to personal health information (PHI) as it pertains to their particular job function.
We do not discuss patient, member, or employee information in any public area where conversations may be overheard.
We use secure email to transmit protected health information both internally and externally.
We safeguard employee and corporate proprietary information by maintaining protected and access-restricted systems.
We welcome customer feedback as it helps us learn better ways to do things and we do not tolerate any act of retaliation or reprisal against any customer, who, in good faith, reports suspected violations of law, regulation, Martin’s Point policy or our Code of Ethics.
We understand that Martin’s Point business and proprietary information, such as business plans, strategy, innovations and financial data is confidential information that has significant value to Martin’s Point and that we are legally bound to keep this information confidential.
We understand that we do not share confidential information outside of Martin’s Point unless there is a legitimate business reason to do so and we have entered into a non-disclosure agreement with the intended recipient of the confidential information.
We safeguard confidential information by maintaining protected and access-restricted systems.
SOCIAL MEDIA Martin’s Point recognizes that social media is a powerful tool for the reinforcement of our brand, our mission, our values and our passion for caring for people. Social media is also a communication tool for providing timely information to the people we serve, therefore, the integrity of the content is critical to maintain the trust of users. To this end, we support and maintain several social media sites available to the public that discuss happenings at Martin’s Point, as well as, health related topics and other information of interest to our readers. Additionally, many Martin’s Point employees maintain his\her own blogs, Facebook, Twitter and other social media accounts. Martin’s Point has no control over these sites or what is published on them. The purpose of this section of our Code of Ethics is to provide Martin’s Point employees with guidelines for participation in social media that is and is not hosted by Martin’s Point.
This section of the Code of Ethics applies to employees using social media while at work, away from work and when the employees’ Martin’s Point affiliation is identified, known or may be presumed. It does not apply to content that is unrelated to Martin’s Point. This section also applies to employees working for or acting on behalf of Martin’s Point, vendors and contractors.
Posting on Martin’s Point Hosted Sites
We understand that all employees are expected to adhere to the Martin’s Point Compliance Program and Code of Ethics requirements when using or participating in social media. All of the expectations of Martin’s Point employees that apply to other types of communication also apply to communication via social media, including respecting members, patients, customers and one another; protecting confidentiality, privacy and security; and safeguarding improper use of Martin’s Point assets.
We understand that we, as employees, may not pose any material that is proprietary, obscene, defamatory, profane, libelous, threatening, harassing, abusive, hateful or embarrassing to another person or entity when posting Martin’s Point hosted sites.
We understand that Martin’s Point hosted social media must focus on subjects related to the organization. Employees may not post content or conduct any activity that fails to conform to any applicable state and federal laws. For the protection of our company and our employees, it is critical that everyone abide by the copyright laws by ensuring they have permission to use or reproduce any copyrighted text, photos, graphics, video, or other material before publishing this material.
Posting on Non-Martin’s Point Hosted Sites
We understand that we may not disclose any confidential or proprietary information that is the property of Martin’s Point, its affiliates, vendors, or suppliers, including, but not limited to, business and financial information.
We understand that we may not represent that we are communicating the views of Martin’s Point; say or suggest that the views and opinions being expressed represent the official views of Martin’s Point or do anything that might reasonably create the impression that we are communicating on behalf of or as representative of the organization.
We understand that we may not use or disclose any member/patient identifiable or private health information anytime on any social media without the express written permission of the member or patient. Even if an individual is not identified by name, if there is a reasonable basis to believe that the person could still be identified from that information, its use or disclosure could constitute a violation of HIPAA and Martin’s Point policy and is, therefore, prohibited. If you have any questions pertaining to the disclosure of information, contact Compliance & Legal Affairs or your Compliance Business Partner.
FEDERAL CONTRACTS & FEDERAL PROCUREMENT We follow all requirements of the Federal Procurement Act when bidding on federal contracts.
Martin’s Point Generations Advantage, a Medicare Part C and Part D plan, is subject to the Federal Procurement Integrity Act when bidding on federal contracts. This law prohibits certain business conduct for companies seeking to obtain work from the federal government. During the bidding process, MPGA employees and agents may not:
Offer or discuss employment or business opportunities at MPGA with agency procurement officials.
Offer or give gratuities or anything of value to any agency procurement official.
Seek or obtain any confidential information about the selection criteria before the contract is awarded.
In addition, other federal provisions prohibit federal officials from accepting anything of value, subject to reasonable exceptions such as modest items of food and refreshments. Because of these restrictions, no employee or agent shall either offer or make a gift to a federal employee.
WORKPLACE CONDUCT & EMPLOYMENT PRACTICES
We recognize that the greatest strength of our organization lies in the efforts and talents of our employees. We treat each other with respect, dignity and courtesy. We care passionately for the well-being of the people we serve, each other, our families and our communities by living our values.
We provide equal employment opportunities to prospective and current employees, based solely on merit, qualifications, and abilities. Martin’s Point does not discriminate in employment opportunities or practices on the basis of race, color, religion, gender, national origin, ancestry, age, physical or mental disability, sexual orientation, veteran status or any other status protected by law.
We support and observe a workplace free of alcohol, drugs, and smoking.
We do not tolerate any act of retaliation or reprisal against any employee who in good faith reports suspected violations of law, regulation, Martin’s Point policy, or our Code of Ethics. Our Management Team has an open-door policy and fosters a work environment in which concerns are addressed.
All Martin’s Point employees receive appropriate training and orientation and have the opportunity to gain experience and expertise to perform their duties and meet the needs of our customers.
We support a working environment that recognizes and values diversity.
We expect every employee to abide by our Compliance Program and Code of Ethics and Policies & Procedures. Behavior outside our conduct expectations will be dealt with through disciplinary action.
EXCLUDED/SANCTIONED INDIVIDUALS We seek employees, vendors and business partners of the highest integrity.
We only seek employees, vendors and business partners who have not been sanctioned by any regulatory agency and are able to competently perform their designated responsibilities.
All new and existing employees, providers, vendors and any first tier, downstream and related entities are regularly checked against the Office of Inspector General Sanctions List and the General Services Administration Excluded Parties List Systems. Anyone who appears on either list is excluded from doing business with or representing Martin’s Point.
We safeguard Martin’s Point’s information technology and proprietary electronic information from improper use and access.
We follow the laws regarding intellectual property including patents, trademarks, marketing, copyrights, and software and do not copy Martin’s Point computer software unless it is specifically allowed in the license agreement.
We follow the HIPAA Security Rule statutes (45 CFR Part 160 and 164).
We provide our staff with the appropriate training to electronically secure and safeguard PHI in accordance with HIPAA, 45 CFR Part 160 and subparts A and C of Part 164.
We maintain and monitor computer security systems to ensure that information is secure and protected.
We only allow authorized persons to have access to computer systems and software.
We have a disaster recovery plan.
CODING, BILLING & COLLECTION We maintain coding, billing and collection procedures in accordance with HIPAA, nationally recognized standards and federal and state laws.
We submit accurate and complete insurance claims.
We perform regular internal and external coding audits.
We support continuous training of all coding, billing and collection staff.
We maintain complete financial records to fulfill requirements set forth by Martin’s Point policies and procedures, as well as applicable federal and state laws and regulations.
We will not knowingly employ or contract with providers under state or federal sanctions.
FINANCIAL RELATIONSHIPS WITH VENDORS & REFERRAL SOURCES
We ensure that all of our relationships and financial arrangements with vendors, suppliers and referral sources comply with all federal and state laws and regulations.
We do not give or receive any form of payment, kickback or bribe to induce the referral or the purchase of any service.
We do not offer any improper inducements or favors to patients, providers or others to encourage the referral of patients to our facilities or to use a particular product or service.
All discounting arrangements with vendors will be in accordance with all applicable state and federal laws.
GIFTS & GRATUTITIES We adhere to the highest ethical standards and laws in our industry with respect to giving and receiving gifts and gratuities.
We may not accept or encourage gifts of money under any circumstances, or solicit non-monetary gifts, gratuities or any other personal benefit or favor of any kind from suppliers or customers.
We and our immediate families may accept unsolicited, non-monetary gifts from a business firm or individual doing or seeking to do business with Martin’s Point only if the gift is primarily of an advertising or promotional nature. Acceptable gifts may include those that a vendor provides to a wide spectrum of existing and potential customers, if they are of a modest value. Martin’s Point employees or agents should contact their supervisor or the CCO if they are unsure if accepting a gift or gratuity is permitted.
We understand that federal law makes it a crime to give, offer, or promise anything of value to any public official for or because of any official act performed or to be performed by such official. It is also a federal crime to make any payments to government employees, representatives or officials, made on account of or as compensation for public duties.
We will not give gifts or gratuities exceeding the value of $10 per gift or $50 per calendar year to vendors, contracts, and outside entities.
ENVIRONMENTAL & SAFETY CONSIDERATIONS
We provide a safe and secure environment for patients, members, employees, visitors and customers.
We comply with established safety and infection control policies and procedures which are intended to prevent job-related hazards.
We comply with all laws and regulations governing the handling, storage, use and disposal of hazardous materials, other pollutants and infectious wastes.
We procure, maintain, dispense, and transport drugs or other controlled substances used in the treatment of patients, according to applicable laws and regulations.
We review organizational safety issues as they arise and at a minimum, on a monthly basis, ensure that building security and safety issues are identified and resolved in a timely manner.
We perform annual ergonomic evaluations to ensure employees have safe working environments.
We encourage any concerns regarding safety of an employees work area be reported to the Support Services Hotline at 207-791-3777 or extension 3777. Non-emergency related reports may be submitted through the “Work Order Portal” on Compass.
CONFLICT OF INTEREST
We avoid engaging in any activity, practice, or act that creates an actual, apparent, or potential conflict with the best interests of Martin’s Point.
While in the service of our employment, we act in the best interest of Martin’s Point in our dealings with suppliers, customers or government agencies.
No employee or member of his or her immediate family shall directly or indirectly participate in, or have a significant interest in, any business that competes with or is a supplier to Martin’s Point, unless that participation is disclosed to Martin’s Point in advance and agreed to in writing by the Martin’s Point CCO.
PROTECTING MARTIN’S POINT ASSETS
We protect our assets and the assets of others entrusted to Martin’s Point, including physical and intellectual property and protect information against loss, theft or misuse.
We establish policies, practices and educational mechanisms within our areas of responsibility to ensure the safeguarding of Martin’s Point’s assets.
We use Martin’s Point property appropriately, with approval and take measures to prevent any unexpected loss of equipment, support materials or services and adhere to established policies regarding approval for disposal of property.
We report time and attendance accurately.
Expenses are consistent with and justified by our job responsibilities and the organization’s policies, procedures and required needs.
We adhere to established policies and procedures governing record management and comply with the record retention and destruction policies/schedules.
If you are considering working or consulting for another organization while at Martin’s Point, you must discuss this with your supervisor.
POLITICAL ACTIVITIES & CONTRIBUTIONS As a tax exempt organization, we do not contribute company funds to federal or state elections.
Federal law restricts the use of corporate funds in connection with federal elections. Similarly, state laws restrict the use of such funds in connection with state and local elections.
Employees and agents may not include any political contribution on expense accounts or in any way that causes the Martin’s Point to reimburse them for that expense.
B. POLICIES & PROCEDURES Martin’s Point has written policies, procedures and a Code of Ethics containing standards of conduct that apply to all employees, members of the Martin’s Point Board of Directors and employees of first tier/downstream/related entities.
Our policies and procedures articulate Martin’s Point’s commitment to comply with our contractual obligations, as well as applicable statutory, regulatory and other requirements, such as federal and state laws including, but not limited to, the False Claims Act, the Anti-Kickback Statute, HIPAA, the Code of Federal Regulations, the Federal Sentencing Guidelines and state privacy laws. These Policies and Procedures are a critical component of Martin’s Point’s program to detect, prevent, and control fraud, waste and abuse. Martin’s Point Policies & Procedures also address non-retaliation, non-intimidation, the Excluded/Sanctioned parties’ process, the process for reporting violations to appropriate oversight agencies, expectations of employees and the role of senior management in creating and maintaining a culture of compliance in the organization. Martin’s Point’s policies and procedures are reviewed regularly to incorporate any changes in applicable law, regulations and other requirements.
Board of Directors, Chief Compliance Officer, Medicare Compliance Officer and Committees
Martin’s Point has established a Compliance & Legal Affairs (C&LA) Department, led by the Chief Compliance Officer (CCO) and a Medicare Compliance Officer (MCO), as well as an Audit and Compliance Committee (ACC) of the Board. The CCO, MCO and the ACC are accountable to the Board of Directors. See Board of Director’s Committee Organization Structure - Exhibit A.
The Board of Directors is responsible for ensuring that Martin’s Point adheres to applicable regulations, laws, and contractual obligations, ethical and conduct standards and ensures the effectiveness of the compliance and ethics program.
The CCO is selected based on the individual’s record of achievement, high level of integrity and educational accomplishments. The CCO has an enterprise-wide responsibility for all lines of business. The CCO has direct access to the Board and has the responsibility to report directly to the Board at least twice per year, or as needed. The CCO is responsible for developing, operating, and monitoring the Compliance Program. The CCO reporting relationships and other responsibilities pose no self-policing of CCO activities. The CCO has the authority to report directly to the Board of Directors, interview employees and other relevant individuals, review and retain company contracts, review the submission of data to CMS, seek advice from legal counsel, report misconduct to CMS, MEDIC and/or law enforcement and conduct and direct internal audits and investigations of any first tier entities, downstream entities or related entities. See Reporting Relationships and Committee Structure Chart Exhibit A. The Medicare Compliance Officer (MCO) and Director supports all Medicare product lines and chairs the Medicare Compliance Committee. The MCO reports to the CCO and has direct access to the Board as needed, and makes reports directly to the Board.
The Medicare Compliance Committee meets regularly, reports to the Audit and Compliance Committee of the Board, is chaired by the MCO, and includes directors and leaders from all operational areas. The Medicare Compliance Committee agendas include updates on training and education, review of regulatory changes to Martin’s Point products and physician offices, discussions of current trends and specific cases of fraud, waste, abuse and other forms of misconduct, and review of the audit work plan and feedback on completed audits. The Medicare Compliance Committee provides a forum for operational department leaders to discuss issues in their areas.
Training and Education
Martin’s Point provides compliance training and education to all employees, managers, senior management, student interns and externs, contractors, agents, temporary and per diem employees and members of the Board of Directors upon hire and annually. Martin’s Point also provides compliance training to vendors who are provided contractual access to our Electronic Health Record (EHR) to perform services on behalf of Martin’s Point. The C&LA Department works with operational departments to construct appropriate specialized training that includes relevant examples that are applicable to each specific department. C&LA provides continuing education through media such as the Martin’s Point internal website and compliance tips and reminders through organization-wide intranet postings. Martin’s Point’s Compliance training program is designed to explain our company’s commitment to compliance, monitor the effectiveness of compliance training and maintain training documentation.
New Employee Training On “Day One” of every employee’s employment at Martin’s Point or shortly thereafter, the C&LA Department provides an overview of the Compliance Department, the Compliance Program, the Code of Ethics, the HIPAA/PHI Policy, the IT Acceptable Use, the Conflict of Interest Policy and the FWA Policy. This is an open forum for questions. The new employee training also specifically emphasizes the employees’ duty to report real or potential violations through online incident reporting or the Compliance Hotline, while highlighting the company’s policy on non-retaliation. The online incident reporting form and the hotline both provide the opportunity for employees to remain anonymous when reporting potential violations of policies or laws. New employees are encouraged to complete their training within the first thirty days of employment, and by no later than ninety days. This training includes the completion of a conflict of interest attestation. The C&LA Department maintains documentation of completion of “Day One” training and completion of online compliance training by all new employees.
Annual Compliance Training Annual Compliance Training (ACT) provided to employees is web-based and interactive. It is a requirement and a condition of employment for all employees. ACT includes topics such as FWA, HIPAA Privacy and Security, Incident Reporting (including non-retaliatory language), Code of Ethics, Compliance Hotline, Conflict of Interest Statement and Attestation, Sexual Harassment, Ergonomics, and Safety as well as more specialized training modules for members of the Delivery System based on individual roles. The training references regulatory citations and examples, and concludes with a test for each module and the pass rate for each test is 80%. Employees are required to pass all modules in the training and attest that they understand the material. Employees who do not review each module and do not pass all required tests before the internal deadline are subject to disciplinary actions up to and including termination of employment. The timeframe for completion of the annual training is ninety (90) days. The C&LA Department monitors the completion rate and reminds employees who have not completed the training of the upcoming deadline. The C&LA Department also maintains documentation of completion of ACT by all employees.
Specialized Training Martin’s Point provides specialized training and education related to employees’ specific responsibilities in their job and the compliance challenges that they may be faced with in their role. For example, pharmacy claims for narcotics are a known industry-wide risk area for fraud. In response to this risk, the Claims Department needs to have specialized procedures to validate these claims and monitor for trends to identify potential fraud before passing them through for payment. Specialized training is provided annually, whenever requirements change, upon hire, or when an area has shown vulnerability to risk. Martin’s Point contractually requires FDR’s to provide their own specialized training to their employees.
Additionally, memoranda from oversight entities (CMS, Department of Defense, Office of the Inspector General, Maine Board of Insurance, etc.) that govern Martin’s Point products and services are reviewed and disseminated by the C&LA Department. The Compliance Business Partners are available to discuss, educate and provide regulatory interpretation for the operational areas.
C&LA department employees attend specialized training throughout the year that pertains to healthcare compliance and regulatory changes that affect Martin’s Point. For example, C&LA employees regularly attend webinars, conferences, compliance study groups, trade group meetings and are encouraged to obtain certifications in compliance from nationally recognized organizations.
The Martin’s Point Chief Compliance Officer is responsible for ensuring open and effective communication with all employees of the organization. The CCO is visible in the organization, routinely attends staff meetings, corporate events and other functions that encourage open communication between the CCO and the employees. Martin’s Point supports an open door policy through regular communication between the operational department staff and management and the Compliance Business Partners to discuss trends in operations, new guidelines, regulatory changes, monitoring reports and regulatory focus. The CCO and the MCO regularly attend management meetings and participate in discussions regarding compliance-related questions from operational leaders. Martin’s Point also supports and enforces a non-retaliation policy for incidents reported in good faith. Employees involved in incidents of retaliation are subject to disciplinary action up to and including termination of employment.
Martin’s Point employees who suspect potential or actual fraud, waste, abuse or other instances of non-compliance, have a duty to report these instances. The employee has the option of bringing this to the attention of their supervisor, the C&LA or the Human Resources Department. Board of Directors members can report these instances directly to the CEO or the CCO.
Martin’s Point contracts with a vendor to maintain an anonymous hotline for employees and members/patients to report suspected or actual instances of fraud, waste, abuse, or non-compliance. If an employee wishes to report an instance of suspected or actual non-compliance, but wishes to remain anonymous, they can call the Martin’s Point compliance hotline. The Martin’s Point Compliance Hotline number is 800-297-8616. The number is displayed on posters throughout Martin’s Point, and on Martin’s Point’s internal and external websites. All reports of suspected or actual non-compliance are investigated thoroughly by C&LA. The CCO is responsible for reporting all substantiated instances of fraud, abuse, HIPAA Privacy breaches or other misconduct to the appropriate oversight agencies based on the severity of the issue.
Enforcement of Standards/Disciplinary Guidelines
The Martin’s Point culture reflects a commitment to the success of Martin’s Point through the pursuit of excellence in customer service, creating a great place to work and being accountable for doing the right thing.
Martin’s Point employees each have a duty to report any and all real or suspected instances of fraud, waste, abuse, privacy violations or other instances of non-compliance. If an employee suspects or experiences a situation which they believe is in violation of the regulations and other laws and rules governing Martin’s Point, that employee is required to report this instance to their supervisor, the C&LA department or the Human Resources Department without delay. If the employee does not report the incident or potential violation, they may be subject to disciplinary action per Martin’s Point policies.
Martin’s Point is committed to providing a safe environment in which employees can report these instances without fear of reprisal. Retaliation in response to an employee who reports an instance of potential or actual non-compliance is not tolerated. Employees who take retaliatory measures against employees who report these instances are subject to disciplinary action up to and including termination of employment.
Martin’s Point maintains a structure that links employee behavior to specific disciplinary actions. Depending on the severity of the issue and the actions of the employee, Martin’s Point reserves the right to bypass all intermediate disciplinary actions and go directly to termination of employment.
Intermediate actions that may be applied include but are not limited to employee education, employee re-training, suspension of employment without pay, demotion, etc.
Monitoring and Auditing
The C&LA Department utilizes Compliance Business Partners to establish and maintain relationships with the operational staff and management in order to provide guidance in the implementation of monitors, conduct risk assessments, and internal reviews/audits. In addition, C&LA Department regularly reviews updated policies and procedures regarding FWA and HIPAA Privacy. An audit summary status is reported to the on a regular basis. Each audit includes findings, trends, process improvement/best practices recommendations and corrective action planning. The Compliance Business Partners work with the C&LA leadership to create and execute an audit calendar on a quarterly basis, and to identify areas to be audited based on risk assessments, reported incidents, past findings and new guidelines. C&LA leadership uses the following factors to construct an effective audit schedule –
Risk areas are identified by previous audits and through the oversight and monitoring process.
Industry-wide known risk areas are included.
Risks identified by governing entities (CMS, OIG etc.) are considered.
The CCO and MCO report audit results for all Martin’s Point products, including Medicare Advantage, to the Audit & Compliance Committee of the Board. Issues of high risk identified through the audit process are reported by the CCO and/or the CEO to the Board of Directors. Compliance staff are independent and have the level of system access needed to adequately perform the audits and monitor the plan and its functions.
From time to time, the C&LA Department may employ an outside auditor or consultant to oversee and report on operational areas in the following circumstances:
To ensure that the Compliance Business Partners’ audit results and methodologies are accurate and effective, and/or
To provide immediate feedback to the CCO and the MCO on a large-scale risk area. An example of this would be the hiring of a vendor to conduct a full audit of our Pharmacy Benefit Manager for our Medicare Advantage product.
When conducting audits of Martin’s Point Generations Advantage, Compliance Business Partners will avail themselves of appropriate resources, including the Medicare Managed Care and Prescription Drug Benefit manuals, as well as relevant memoranda and regulatory communications from federal and state governing entities.
Reponses to Detected Offenses and Corrective Action Plans
In the event of misconduct or non-compliance, timely and reasonable inquiry will be made by C&LA staff. Inquiries may include interviews with employees, beneficiaries, first tier entities, downstream entities, related entities, document review, auditing and other investigative activities.
The C&LA Department maintains an investigation file for each investigated instance. The file could include risk assessments, interview notes, a notification of appropriate internal personnel, root cause determinations, affected parties, applicable guidelines, regulatory impact, financial impact, a complete list of findings, recommendations/requirements for changes to business practices, system changes, and training/education and personnel actions. All investigations are documented and tracked by C&LA and stored in a secure and centralized location.
Investigations into potential non-compliant activities, including fraud, waste, abuse, HIPAA Privacy and/or misconduct are initiated and conducted in a timely fashion by C&LA staff. For the Martin’s Point Medicare Advantage product, if the C&LA Department does not have the expertise, resources or time to appropriately investigate a potential fraudulent activity, the CCO or MCO report the issue to the MEDIC within two (2) weeks from the date the activity was discovered.
If a reasonable inquiry indicates fraud or misconduct has occurred, the CCO or the MCO will report the conduct to CMS, MEDIC, Office of Civil Rights, Office of the Inspector General, Maine Bureau of Insurance and other appropriate regulatory agencies within the timeframes required under regulations. In the event fraud or misconduct has occurred at first tier/downstream/related entities, the case referred as soon as possible to the appropriate oversight agency.
Corrective action plans are developed by the leadership who oversee the personnel involved in the incident to address and correct the underlying operational problem that resulted in a violation and is geared toward the prevention of future instances of non-compliance.
Investigation reports are created quarterly for review and discussion at the Medicare Compliance Committee and the Audit & Compliance Committee of the Board. Issues of high risk, as determined by the CCO and the CEO, are reported to the Board of Directors quarterly.
The Martin’s Point Compliance Program is approved by the Board of Directors periodically. Because the Compliance Program is a living document, it must reflect current regulatory requirements and compliance strategic thinking. In order to ensure that the program meets these requirements, it is amendable as appropriate by the CCO with the approval of the CEO at any time during the year. The CCO is responsible for disseminating any changes to Martin’s Point staff. The CCO or the CEO is responsible for notifying the Chair and Vice-Chair of the Board of Directors of significant changes to the Compliance Program throughout the year.
Implementation Date December 2006
Revised by the CCO and the MCO December 2011
Reviewed by the Audit and Compliance Committee of the Board January 2012
Approved by the Board of Directors January 2012
Revised by the CCO October 2015
Approved by the Board of Directors December 2015
Reviewed by the CCO and the MCO December 2016
The Martin’s Point Compliance Program and Code of Ethics are integrated processes that reflect an underlying set of beliefs, standards and rules that are detailed in the Martin’s Point policies and procedures and are in accordance with federal and state laws and regulations. The Compliance Program discusses training, monitoring and auditing of operational processes to ensure that the company is following all applicable laws and regulations, as well as Martin’s Point values and mission.
Ann R. Connelly, Vice President Compliance and Legal Affairs
CCO – Chief Compliance Officer. The CCO of a company is the officer primarily responsible for overseeing and managing compliance issues within an organization.
CEO – Chief Executive Officer. The CEO has ultimate accountability for and authority over the operations, ethics and compliance of Martin’s Point.
CMS – The Centers for Medicare and Medicaid Services. CMS is a federal agency within the Department of Health and Human Services (DHHS) that administers the Medicare program and works in partnership with state governments to administer Medicaid, the State Children's Health Insurance Program (SCHIP), and health insurance portability standards.
Confidential Information – Information relating to Martin’s Point’s operations which is valuable due to its highly sensitive, confidential and proprietary nature. Confidential information includes, but is not limited to, technical information and data, customer lists, trade secrets, business and strategic plans and financial information to which access is limited to only those with a business need to know.
FDR – First Tier, Downstream and Related Entities. Any vendor or entity that Martin’s Point has a contractual relationship with to perform a service for our members.
FWA – Fraud, Waste and Abuse.
Fraud – An intentional act of deception, misrepresentation or concealment in order to gain something of value.
Waste – Over-utilization of services and misuse of resources.
Abuse – Excessive or improper use of services or actions that are inconsistent with acceptable business or medical practice.
HIPAA – Health Insurance Portability and Accountability Act. A 1996 federal law that restricts access to individuals' private medical information.
Martin’s Point – Martin’s Point Health Care, Inc. Martin’s Point includes insurance and health center operational departments, as well as Martin’s Point product management.
Martin’s Point Employees – All persons employed by Martin’s Point to conduct business on behalf of Martin’s Point, including but not limited to physicians and other providers, clinical support staff, insurance company personnel, senior management, temporary employees, student interns and per diem employees.
MCO – Medicare Compliance Officer. The MCO supports the implementation of the compliance program and is the direct liaison with CMS for any compliance related issues, including but not limited to, external audits. The MCO is responsible for ensuring that all Medicare regulations are satisfied as they relate to the Martin’s Point Generations Advantage program.
MEDIC – Medicare Drug Integrity Contractor. An organization that the CMS has contracted with to perform specific program integrity functions for Part D under the Medicare Integrity Program. The MEDIC is the CMS designee to manage CMS audits, oversight, and anti-fraud and abuse efforts in the Part D benefit.
P&P – Policy & Procedures. A P&P describes the rationale behind activities, assigns responsibility and accountability, a description of how an activity is performed and a quality control process as applicable.