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Broward Health is committed to complying with all of the Federal and State laws and regulations surrounding health care. In 1999, to support this commitment, we established a Corporate Compliance Program.
Our program is focused on preventing, detecting and correcting any fraud, waste or abuse within our hospitals and facilities in connection with Federal health care programs as well as other payors. The Corporate Compliance Program is modeled after the United States Sentencing Commission Guidelines which contain seven elements of an effective program. The seven major components of our Corporate Compliance program include:
- High-level oversight provided by our Corporate Compliance Officer
- Written standards and policies;
- Training and Education;
- Auditing and monitoring;
- Open lines of communication through our Compliance Hotline;
- Response to detected deficiencies; and
- Disciplinary action as warranted.
The summary below provides an overview of our structure. For a copy of the Compliance Plan, please click here.
Corporate Compliance Officer
Broward Health has a Vice President Chief Compliance Officer/Privacy Officer, Donna L. Lewis, who is responsible for developing and implementing policies, procedures and practices designed to ensure compliance with Federal health care program requirements. In addition, she is responsible for monitoring the day to day compliance activities engaged in by Broward Health as well as reporting any Federal Health Care Program obligations. The Vice President Chief Compliance Officer/Privacy Officer is a member of senior management and reports directly to Broward Health’s President and Chief Executive Officer, Frank Nask. In addition the Vice President Chief Compliance Officer/Privacy Officer makes periodic reports regarding compliance matters directly to the Board of Commissioners and has the authority to report such compliance matters to the Board at any time.
Broward Health has a Corporate Compliance Steering Committee which is chaired by the Vice President Chief Compliance Officer/Privacy Officer. The Committee supports the Vice President Chief Compliance Officer/Privacy Officer in fulfilling her responsibilities such as analyzing Broward Health’s risk areas and overseeing monitoring of internal and external audits and investigations. The Committee meets at least quarterly. The Corporate Compliance Steering Committee has a Privacy and Security Subcommittee which meets at least quarterly to review Privacy/Security audits, trends as well as policies and procedures.
In addition, the Vice President Chief Compliance Officer/Privacy Officer makes quarterly reports to the Audit and Compliance Committee of the Board and provides an update on compliance activities.
Code of Conduct
Broward Health has developed, implemented and distributed a written Code of Conduct to employees.
Policies and Procedures
Broward Health has implemented policies and procedures regarding its Compliance with Federal Health Care Program requirements. The policies address specific areas including the False Claims Act, the Stark Law and the Anti-kickback Statute. Policies and Procedures are posted on the Intranet and made available to all employees.
Training and Education
All employees receive Compliance Training upon hire and annual training during the time of their annual performance appraisal. In addition, employees may receive specific training based on their job role and responsibility. Vendor training is also available.
Auditing and Monitoring
Broward Health audits and monitors its Compliance activities by conducting an annual risk assessment and developing an annual Work Plan based on identified risks and conducting audits. These audits include reviews of arrangements with physicians, coding compliance audits, and privacy/security reviews as well as audits of the hospitals and specialty units.
Responding to Detected Offenses/Corrective Actions
All reported/identified issues are investigated and the appropriate corrective actions are taken which may include external reporting to regulatory agencies, returning/recouping identified overpayments and developing additional internal controls. In addition the following elements may be included in each corrective action plan:
- Identification of the issue;
- Revisions to policies and procedures, if necessary;
- Training on those policies and procedures, or retraining on established policies and procedures;
- Monitoring to ensure compliance; and
- Appropriate disciplinary action in the event of non-compliance.