All CANM personnel are required to take all reasonable steps to act in conformity with relevant laws and regulations governing the health care industry.

As an integral part of our mission, this Plan reflects standards set by CANM for ethical business conduct. The Plan incorporates systems and procedures to ensure that regulatory requirements are observed. The Plan demonstrates our strong commitment to honest and responsible conduct; to identify and prevent unethical conduct through early detection; to encourage employees to report potential problems; and to investigate alleged misconduct with initiation of appropriate corrective action.

These standards can only be achieved through the action and professional conduct of all CANM personnel. Each employee is obligated to conduct himself/herself in such a manner to ensure maintenance of these standards.

This Compliance Plan incorporates policies and procedures that can be found on the CANM team Web Site (https://canm.com/canmteam), to serve as a reference tool for all personnel and to serve as a guide in their efforts to comply. 

A. Quality Care
CANM providers and other personnel will take all reasonable steps to provide treatment in accordance with pertinent federal and state laws. CANM will always strive to provide quality care. We will treat patients with respect and dignity and will provide care that is appropriate and necessary. Clinical care is based on identified patient needs. We assure patient’s involvement in their care and obtain informed consent for treatment. Each patient is provided with a clear explanation of care including, but not limited to, diagnosis, treatment plan, and an explanation of risks and benefits associated with the treatment options. Compassion and care are our commitment to the patients we serve.

B. Billing
CANM will take all reasonable steps to bill patients and payers accurately and in compliance with laws and regulations. CANM is committed to accurate billing and correct representation of charges. Every effort is made to submit claims only for services actually provided, emphasizing complete and accurate documentation of those services.

CANM intends to follow government sponsored health care programs’ rules on assignment and reassignment of billing rights. 

CANM’s policies and procedures are designed to reflect and reinforce current federal and state statutes and regulations regarding the submission of claims.

CANM’s policy requires that:

• Each provider documents all services in an appropriate and timely manner to ensure that only documented services are billed.  Providers will affix an electronic signature to the documentation in the electronic medical record.   Coding and billing personnel will seek provider clarification of any questions or issues. 

• Documentation is maintained and available for audit and review.

• Compensation for billing department coders and billing consultants will not provide any financial incentive to improperly code claims.

Furthermore, to prevent violations of any federal or state laws and regulations, CANM will make every effort to:

• Bill only for items or services actually provided.  There should be adequate information to indicate that a service or item was provided before any claim for reimbursement is submitted. Information necessary for submitting such a claim includes the site of the service, date the item or service was provided, a description of the item or service, the person for whom the service or item was provided, and the person who provided the service for which reimbursement is being sought.

• Review all rejected claims pertaining to diagnosis codes.  Claims that are rejected based on the diagnosis and procedure codes used will be reviewed by the claim review specialist and/or coder who did the coding.  This policy is meant to facilitate a reduction in similar errors. 

• Educate on the proper documentation guidelines for Evaluation and Management Services.

• Document patient encounters properly.  Documentation may include the reason for the encounter, any relevant history, physical examination findings, prior diagnostic test results, assessments, clinical impressions, or diagnoses, plan of care, and the date and identity of the observer (electronic signature in the electronic medical record).  Appropriate health risk factors and the patient’s progress, his or her response to, and any change in, treatment and diagnosis will also be documented.

• Bill only for services that are “reasonable and necessary” for the diagnosis and treatment of the patient.  Claims should be submitted only for services that CANM has reason to believe are warranted by the patient’s current and documented medical condition.  Claims should only be submitted for services ordered by a licensed medical provider and should be medically necessary.  Published Clinical Practice Guidelines may be useful tools.   CANM recognizes that Medicare will only pay for services that meet the Medicare definition of “reasonable and necessary” and staff will seek to comply with all Medicare guidelines, including staying current on National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and local coverage articles.

• Use the correct billing codes and modifiers.  Claims should reflect the correct billing code, and, if applicable, modifier, for a particular service or item.  Particular attention should be paid to ensuring that the billing code used does not include extra services not provided.  The OIG has special concerns related to upcoding.  CANM personnel should take special care to strive for accurate billing and if any questions regarding the proper code to use arise, advice from management personnel, the carrier, or the payer should be sought prior to submitting any claim. 

• Bill for claims only once.  Care should be taken to ensure that no duplicate billing occurs.  Duplicate billing can occur when more than one claim for the same service or item is submitted or if the bill is submitted to more than one primary payer at the same time.    

• Ensure that all claims are bundled in the appropriate manner.  Claims should be bundled appropriately and global billing codes need to be properly assigned prior to submitting claims for services or items.    

• Refund credit balances.   All reasonable efforts are made to return credit balances in a timely fashion.  A good faith investigation of credible information will be conducted to support the belief that an overpayment may have been received. 

• Ensure that copayments or deductibles are not waived improperly.  The patient is responsible for the appropriate copayment or deductible.  If in accordance with practice procedures, the patient to whom the item or service was provided is determined to be indigent, the copayment or deductible may be waived. 

• Ensure that no claims for improperly referred patients are made.  Care should be taken to ensure that CANM is not involved in any contracts or arrangements that violate the Anti-Kickback statute, the Stark laws, or any other anti-referral laws.  If CANM becomes aware of any arrangements that might violate any of the aforementioned laws, the Billing Department should be notified immediately so that it can identify any patients who may have received services due to an improper arrangement and prevent any claims for reimbursement from being made.  (Refer to Section II-Y – Overview of Laws.)

• Be mindful of “clustering.”  Clustering is the practice of coding or charging one or two middle levels of service codes exclusively under the philosophy that some will be higher, some lower, and the charges will average out over an extended period.  This practice results in the overcharging of some patients and the undercharging of others.

• Ensure that the correct provider numbers are used when billing.

• Ensure that it does not bill for non-covered services as though they are covered.

• Ensure that claims for diagnostic testing services are accurate and correctly identified.  Claims should properly identify the services ordered by the licensed provider and performed by CANM for diagnostic testing services.  

The Research Department of CANM is leased to Cardiology Associates Research, LLC, (CARe).  CANM and CARe will make every effort to ensure protocol compliance as well as compliance with state and federal regulations in the conduct of clinical research.  Each study protocol will be reviewed prior to research project initiation.  Documentation will be maintained to support our involvement in clinical trials. Services specifically required for the research study outside the standard of care should not be billed.  

Any suspect billing should be immediately reported to the Compliance Committee.  The Compliance Committee will take steps to investigate and prevent the reoccurrence of the error, as well as ensure that any overpayment received is promptly repaid to the appropriate party.

C. Billing for Non-Physician Practitioners/Auxiliary Personnel
Incident-to:

CANM’s policy is to ensure billing and documentation compliance of rules pertaining to “incident to” services provided by non-physician practitioners and/or auxiliary personnel. These are services rendered in the office setting which are an integral, although incidental, part of the physician’s personal professional service to the patient.  There must be an attending physician relationship established before ancillary personnel may see patients without physician involvement in the care.   A physician member of the practice must be on the premises in the office suite, and immediately available to assist at all times.   

Direct Billing (Non-Physician Practitioner):

Some insurance companies, including Medicare, allow certain non-physician practitioners to obtain their own provider identification numbers.  This allows the non-physician practitioners to submit charges under their own names / provider identification numbers for services provided within their scope of practice.

Split/Shared Services (Non-Physician Practitioner):

There are no “incident to” services in the hospital setting.  When a physician and non-physician practitioner in the same group practice share an evaluation and management service in the hospital setting, this constitutes a “split/shared service”.  Split/shared services may be reported for new as well as established patients, and initial and subsequent visits.  Documentation in the medical record should identify which provider performed the substantive portion of the visit.    

Diagnostic Testing:

Diagnostic testing has its own Medicare benefit category that defines the conditions for payment.   CMS publishes the level of supervision for the CPT code specific to each diagnostic test.   Nurse practitioners, clinical nurse specialists, and physician assistants are subject to requirements of state law and publicized guidelines regarding supervision, and they may perform diagnostic tests pursuant to state scope of practice laws.

D. Medical Record Documentation
It is imperative that there be timely, accurate, and complete documentation of diagnoses and treatments.  Provider documentation is necessary to determine the appropriate medical treatment for the patient and is the basis for coding and billing determinations.  In addition to the serious problems that can result from inadequate or inappropriate documentation, the failure to document information properly can compromise good patient care. 

Our electronic medical record has functionality (e.g. templates and macros) to assist with documentation. Providers are ultimately responsible for reviewing the accuracy of all documentation.   

The Medical Record may be used to validate: (a) the site of service; (b) the appropriateness of the services provided; (c) the accuracy of the billing; and (d) the identity of the provider and/or staff.  As a result, medical records must comply with the following principles:

• The medical record must be complete and include electronic signature of provider.

• The documentation of each patient encounter may include the reason for the encounter; any relevant history; physical examination findings; prior diagnostic test results; assessment, clinical impression, or diagnostic plan; plan of care; and date and identity of the provider and/or staff.

• The rationale for ordering diagnostic and other ancillary services should be documented.  If it is not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred by an independent reviewer or third party.  Past and present diagnoses should be accessible to the treating and/or consulting provider.

• Appropriate health risk factors should be identified.  The patient’s progress, his or her response to, and any changes in, treatment, and any revision in diagnosis should be documented.

• Any amendments to a record should be clearly marked as such. 

• The CPT (procedure) and ICD (diagnosis) codes reported on the health insurance claim form should be supported by documentation in the medical record and the medical chart should contain all required information.  Additionally, CMS and other payers should be able to determine who provided the services.

• The CMS-1500 Form should be properly completed; claims sent electronically must abide by the standards adopted under the Health Insurance Portability and Accountability Act of 1996.  CANM plans to follow these practices to ensure that the form has been properly completed:

• Link the diagnosis code with the reason for the visit or service.
• Use modifiers appropriately.   
• Provide Medicare with all information about a patient’s other insurance coverage.

A medical record is maintained for every person treated at a CANM facility.  No one may falsify information on any record or document.

E. Usage of Advance Beneficiary Notice (ABN)
An Advance Beneficiary Notice (ABN) is how the practice tells the patient in advance that certain care will likely not be covered by Medicare.  

A properly executed ABN acknowledges that coverage is uncertain or yet to be determined, and stipulates that the patient promises to pay the bill if Medicare does not.  Patients who are not notified before they receive such services are not responsible for the payment.  The ABN must be sufficient to put the patient on notice of the reasons why the provider believes that the payment may be denied.  The objective is to give the patient sufficient information to allow an informed choice as to whether to pay for the service.  Accordingly, each ABN should:

• be in writing;
• identify the specific service that may be denied (procedure name and CPT/HCPCS code is recommended);
• state the specific reason why the provider believes that the service may be denied (e.g. not covered under national or local coverage rules); and
• be signed by the patient, who thereby acknowledges that the required information was provided and that the patient assumes responsibility to pay for the service. 

Patients may not be asked to sign blank ABN forms.  ABNs are not to be used routinely without regard to a particularized need.

F. Certifications for Medical Equipment, Supplies, and Home Health Services
The OIG is particularly concerned about providers signing Certificates of Medical Necessity (“CMNs”) when they know that the information provided is false or when they have a reckless disregard for the truth of the information.  CANM intends to abide by Medicare rules concerning the use of CMNs.  As a result, providers will sign CMNs only when they can truthfully represent that:

• they are the patient’s treating provider and the information regarding the provider’s address and provider identification number is correct;

• the entire CMN, including the sections filled out by the supplier, was completed prior to their signing; and

• that the information relating to whether the item or service is reasonable and necessary is true, accurate, and complete to the best of the provider’s knowledge. 

Providers who sign blank CMNs, sign them without seeing the patient to verify that the item or service is reasonable and necessary, or who sign CMNs knowing that the items or services are not reasonable and necessary may face not only discipline, including termination, by CANM; their actions can also lead to substantial criminal, civil, and administrative penalties.

G. Integrity of Data Systems
The medical industry is relying on capabilities of computers to conduct business more quickly and efficiently. CANM utilizes a sophisticated computer system, which requires a sign‑on code in order to access each individual’s authorized area. Employees will never use another person’s password, and will not share passwords with others. Confidentiality rules apply to electronic medical records; the records should not be accessed unless there is a “need to know” in order to perform job duties. 

Personnel should be aware that usage of the computer system to access computerized medical records will be monitored and tracked.

Passwords will be given to employees for authorized access to those areas needed for the particular job function.  North Mississippi Health Services Information Technology staff is responsible for “back-up” of data in the computer system and will maintain the network.   

H. Confidentiality
CANM collects information about patients’ medical conditions to provide the best possible care. We realize the sensitive‑nature of this information and are committed to maintaining confidentiality.

Patient information must be kept confidential.  We are committed to honoring our patients’ expectations of privacy as well as all applicable laws and regulations concerning patient privacy.  CANM will maintain the privacy and confidentiality of patient information, including patient records, in accordance with state and federal law, specifically including, but not limited to, the Health Insurance Portability and Accountability Act of 1996, and any regulations promulgated thereunder (collectively, “HIPAA”).  More specific HIPAA privacy and security policies are maintained on the CANMteam Web site, in designated areas titled HIPAA Privacy and HIPAA Security.  

Personnel should not discuss a patient’s medical condition with others when the discussion is not in the line of assigned duties.  No CANM personnel should access any record without a legitimate reason.

Proprietary information must be kept confidential.  Personnel shall not discuss, disclose or permit the disclosure of proprietary information, data, systems, pricing, finances, plans or policies to any competitor or to anyone who might be in a position to disclose such matters to competitors. 

Personnel will sign confidentiality statements with an understanding of what they are signing.  The Confidentiality policy and procedure as well as the confidentiality agreement are located on the CANMteam Web site. Violation of confidentiality can result in disciplinary action up to and including termination.   

I. Retention of Records
CANM is committed to accurate record keeping. Records are kept to confirm the effectiveness of the compliance efforts (i.e., training records, comments reported, any investigation results, any program modifications).   

There are two types of documents that CANM shall retain:

1. All records and documentation already required by either federal or state law for participation in federal health care programs; and
2. All records necessary to protect the integrity of CANM’s compliance process and confirm the effectiveness of the Plan.

Privileged files with legal opinions regarding provider agreements, records of requests for legal opinions or assistance with the handling of reports of suspect behavior, and responses from legal counsel regarding such issues shall be marked confidential, protected by privilege and kept in a secure location. 

All documentation related to the Compliance Plan shall be retained by CANM for no less than six (6) years, though efforts will be made to keep such records for ten years.

All patient records shall be retained by CANM in accordance with the law and its records retention policy.  Privileged documents shall be retained until the issue raised in the documentation has been resolved.

J. Business Conduct
Employees shall perform their duties in good faith and to the best of their abilities.  All business affairs must be conducted with honesty, fairness and integrity.

K. Fair Treatment / Equal Employment Opportunity
We are dedicated to the fair treatment of all individuals and maintaining a work environment that provides for dealing with employees, providers, contractors and other providers of services in a fair and respectful manner.

CANM employees provide a wide complement of talents, which contribute to our success. We are committed to providing an equal opportunity work environment. CANM will not discriminate with regard to race, color, sex (sexual orientation, gender identity), national origin, religion, age, equal pay, disability or genetic information, or any other classification protected by federal or state laws, provided the employees meet the qualifications and can perform the essential job functions.  The Labor Law poster is posted in the workplace and on the CANMteam Web site for reference.     

CANM employees must have a working environment free from harassment and intimidation. Conduct, which creates an intimidating, hostile, or offensive work environment is prohibited. Sexual harassment is strictly prohibited. Also, offensive behavior and/or harassment via e‑mail are not acceptable. Any conduct believed by you to be discriminatory or harassing should be reported immediately to the Compliance Committee.

As part of our commitment to a safe workplace, possession of firearms of any kind on CANM premises is prohibited, with the exception of authorized individuals. CANM has no tolerance for violence of any kind. Any act of violence, including verbal threats, is grounds for disciplinary action. Employees should report any violence, or threat of violence, to the Compliance Committee.  In cases of emergencies, which require immediate assistance, notify the appropriate law enforcement or facility security officer (hospital setting).

We have an obligation to create a work environment in which ethical concerns can be raised and openly discussed without fear of retribution or retaliation and we intend to meet that obligation.

L. Nondiscrimination
CANM does not exclude, deny benefits to, or otherwise discriminate against any person on the grounds of race, color, national origin, age, disability, sex (sexual orientation, gender identity), or any other classification protected by federal or state laws, in admission to, participation in, or receipt of the services and benefits of any of its programs and activities.    

The clinic notice regarding this policy is posted in the waiting areas for all patients and employees to review.  In case of questions concerning the notice, or in the event of a desire to file a complaint alleging violations of the above, the Compliance Committee should be contacted. 

M. Work Environment

CANM is committed to an alcohol, tobacco and drug‑free work environment. Employees must report for work free of influence of alcohol and/or illegal drugs. Failure to abide by this rule may result in disciplinary action up to and including termination.
 
Employees taking prescription medication should ask their health care provider whether the medication might have any side effects that could impact them negatively while performing their duties.

CANM is committed to providing each of its employees with a safe and healthy work environment.  The clinic will maintain a safety program and will provide all employees with the information and training to minimize injury.  An informed employee is more likely to be a careful employee.  Each employee is responsible for complying with all applicable environmental, health and safety laws, rules and regulations.  The safety manual and Material Safety Data Sheets contain more detailed information on safety topics. 

N. Policy to Screen Employees
CANM will not knowingly employ any individual, or contract with any entity, who has been convicted of a criminal offense related to health care.

Individuals who have been convicted of a criminal offense related to health care or who are listed as debarred, excluded, or otherwise ineligible for participation in Federal health care programs will not be considered for employment or will be terminated from employment. 

CANM will perform the necessary screening to adhere to the requirements outlined below.

Personnel:

It is the policy of CANM to screen the background of prospective personnel, independent contractors, and vendors whose job function or activities may involve compliance with the law or compliance oversight, or that may materially impact the Medicare/Medicaid claim development and submission process, the organization’s relationship with providers, or referral patterns between providers.

In order to screen new personnel CANM will require them to fill out a pre-employment application and respond to all the questions on the application, including whether or not they have ever been sanctioned by Medicare or any other federally-funded healthcare program.  CANM will conduct a reference check as part of every such employment application.

In addition, CANM will periodically re-screen employees. 

Vendors and Contractors:

CANM will not knowingly contract with or retain on its behalf any person or entity which has been: (a) convicted of a criminal offense related to health care (unless such person or entity has implemented a compliance program as part of an agreement with the federal government); or (b) listed by a federal agency as debarred, excluded, suspended or otherwise ineligible for federal program participation. 
 
Inquiry:
In attempting to ascertain whether an individual or entity is ineligible, CANM shall review HHS/OIG List of Excluded Individuals/Entities.  To search for excluded individuals or entities, the HHS/OIG database may be accessed at  https://oig.hhs.gov/. 

Investigation of Current Employees/Independent Contractors/Vendors:
CANM’s Compliance Committee must be notified by all current employees, independent contractors, and vendors immediately upon their receipt of any information indicating that they have been charged with a crime related to health care or that they are facing a proposed debarment, exclusion or other ineligibility for participation in any federal health care program.  Failure to provide such information shall result in disciplinary action, up to and including termination.

Until a decision is made regarding any proposed debarment, exclusion, or other ineligibility for federal health care programs, or until the resolution of any criminal charges related to health care, the employee, independent contractor or vendor shall be removed from direct responsibility for or involvement in any activities paid for by federal health care programs that affect CANM.

Should a resolution to one of the aforementioned situations result in conviction, debarment, or exclusion, CANM shall immediately terminate the employment or contractual arrangement with the individual or entity involved.

O. Element of Performance Evaluation
In employees’ evaluations / performance appraisals performed periodically, employees will be rated on compliance as well as job performance.

The promotion of, and adherence to, the elements of the Compliance Plan is a factor in evaluating the performance of all employees. Employees will receive mandatory training on the Compliance Plan. Strict compliance with this Plan is a condition of employment. Violation of the Plan will result in disciplinary action up to and including termination.

This Plan is not an employment contract. It is not intended to alter the at‑will relationship that gives CANM and any employee the right to discontinue an employment relationship for any reason at any time. 

Exit interviews, or other end of employment discussions, will be offered to give employees an opportunity to speak about any potential problems or questionable practices.

P. Conflict of Interest
Employees must avoid any actions that may involve, or may appear to involve, a conflict of interest with their obligations to CANM.  Employees should disclose possible conflicts of interest involving themselves or their immediate families to their supervisor or the Compliance Committee.

A conflict of interest occurs if your activities or personal interests appear to or might influence business decisions required by your responsibilities.

Q. Gifts
Employees shall not solicit or receive from any person or entity, nor offer or give to any person or entity, anything of value in order to induce referrals of individuals to our providers.  No employee shall receive gifts (including kickbacks, bribes or rebates) in return for the purchase of goods or services.

R. Personal Activity
Employees may not realize any profit or gain as a result of their position with CANM apart from CANM’s compensation/benefit programs.  They must not become involved in non-CANM related interests to the extent that they spend a substantial portion of CANM’s normal business hours on such other interests.

S. Competitors
Employees should not hold a significant financial interest in, serve as a member or officer of, receive compensation from, or provide consultation or other services to suppliers of CANM or competitors of CANM, in the health care industry without the consent of their supervisor.

T. Suppliers / Purchasing / Industry Representatives
CANM employees who deal with suppliers must do so in a reputable, professional and legal manner.  To avoid the appearance of impropriety, CANM employees should decline any gifts from suppliers, including discounts, the acceptance of which would raise suspicion of improper influences.  Any purchasing done for or on behalf of CANM must be free from conflicts of interest and done in accordance with all applicable laws and regulations.   CANM is determined to maintain a fair and objective procurement program that results in CANM acquiring quality services and goods at a fair price.  If an employee has any reservations about the legality of a proposed purchase, including knowledge or suspicion of inducements offered by a vendor, they should make such concerns known to CANM’s Compliance Committee.

Provider interactions with industry representatives (e.g. pharmaceutical representatives and device manufacturers) should follow industry guidelines. 

U. Physician Recruitment  / Physician Practice Acquisition
Physician recruitment practices and physician practice acquisitions will comply with applicable laws and regulations, including Stark and Anti-Kickback laws.

V. Financial Records
Financial records are to be kept in accordance with generally accepted accounting principles and must not contain any false or misleading information.  Improper or fraudulent accounting, documentation or financial reporting is contrary to the standards we have always demanded of our organization.

W. Antitrust
All employees must comply with applicable antitrust laws that regulate competition.  Examples of conduct prohibited include price fixing, collusion with competitors, bribery, and misappropriation of trade secrets.  If you are confronted with business decisions that might involve a risk of violation of these laws, advice should be obtained from our legal counsel.

An exception can be found in the protection offered by clinical integration.  The Compliance Committee (or designees) will have the authority to engage in discussions with other entities about clinical integration.

X. Advertising
CANM will not advertise its services using the names, abbreviations, symbols, or emblems of the Social Security Administration, Department of Health and Human Services, Medicare, Medicaid, or any combination or variation of such words, abbreviations, symbols, or emblems in a manner that conveys the false impression that the advertised item is endorsed by the named entities.

For instance, no ads will be placed in newspapers suggesting that a provider has been “approved by both the Medicare and Medicaid programs.” 

Violations of the law making such advertising unlawful (42 U.S.C.1320b-10) may result in a penalty as established by law. 

Y. Overview of Laws
Listed below are some of the statutes of primary concern for providers.  For questions on any of these, contact the Compliance Committee who will defer to General Counsel if needed.  

• False Claims Act: This statue prohibits a person from presenting a claim for payment to the Federal Government that the person knows or should know is false or fraudulent.  CANM prohibits anyone from knowingly presenting claims for payment that are false.    

False claims may take a number of forms, but any false statement to the federal government, including one on Medicare and Medicaid forms, is illegal.  The federal False Claims Act (“FCA”) makes any person who

(1) knowingly presents, or causes to be presented . . . a false or fraudulent claim for payment or approval; (2) knowingly makes, uses, or causes to be made or  used, a false record or statement;  (3) conspires to defraud the Government by getting a false or fraudulent claim allowed or paid; . . . or (7) knowingly makes, uses, or causes to be made or used, a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money or property to the Government,

liable to the government for a penalty as established by law.

“Knowing” and “knowingly” are defined to mean that “a person, with respect to information, (1) has actual knowledge of the information; (2) acts in deliberate ignorance of the truth or falsity of the information; or (3) acts in reckless disregard of the truth or falsity of the information, and no proof of specific intent to defraud is required.”

• Anti‑Kickback Statute: This statute prohibits the knowing and willful solicitation, offer or payment of any remuneration (including any bribe or kickback) in return for referring individuals for services that may be paid by any federal healthcare program. This prohibits receiving of money and/or paying money for referrals of federal healthcare programs’ patients.  CANM will adhere to two primary rules regarding referrals. We do not pay for referrals, and we do not accept payment for referrals that we make. We accept patients based on their clinical needs and our ability to render the needed services.  When sending patients to other providers, we do not take into account the volume of referrals that that provider has made to us.

• Stark Self‑Referral Statute: Stark I and II prohibit physicians from referring Medicare patients to other designated health services (e.g., clinical laboratories, radiology services, imaging services including CT, PET, and nuclear imaging, radiation therapy, physical therapy, occupational therapy, home health services, inpatient and outpatient hospital services, durable medical equipment, outpatient prescription drugs, and parenteral and enteral nutrition) if the referring physician or a member of the physician’s immediate family has a financial relationship with the entity providing the designated health service.   CANM makes every effort to abide by the Stark Statute.

There are some “safe harbors” in the anti-kickback laws and “exceptions” under the Stark law that allow legitimate payment practices while protecting against abusive ones.  The availability of safe harbors or exceptions to existing laws for certain practices turns on specific facts so employees should not unilaterally decide that a practice falls within a safe harbor or exception. 

Before contracts are entered into for the rental of space and equipment or agreements for professional, management, or consulting services are entered into, the Compliance Committee will be consulted to ensure that they are reviewed for compliance with applicable laws.
Violations of the Stark or anti-kickback laws can result in substantial penalties, including fines and/or imprisonment. 

• EMTALA:  The statute is intended to ensure that all patients who come to the emergency department of a hospital receive care, regardless of their insurance or ability to pay.  Both hospitals and providers must work together to ensure compliance with the provisions of this law. 

Providers who may provide call coverage for an emergency department should make sure that they are familiar with the hospital’s policies regarding their responsibilities to respond to, examine, and treat patients with an emergency medical condition. 

In general, the requirements of the EMTALA statute are that once a person comes to an emergency department requesting emergency care, an appropriate medical screening examination must be conducted to determine if an emergency medical condition exists.  If an emergency medical condition does exist, either the treatment necessary to stabilize the emergency medical condition will be provided within the capacity and capability of the hospital and its medical staff, or a transfer to another facility will be arranged. 

Hospitals and providers, including on-call providers, who violate this statute face stiff penalties as established by law. 

Z.  Provider Enrollment / Credentialing

CANM will ensure all providers and other licensed health care professionals maintain a current license and / or appropriate certification.  The provider enrollment and credentialing process is performed for all providers when required.  This includes initial enrollment as well as periodic reviews of enrollment information to ensure that all remains complete and up-to-date.   

Medicare enrollment information is submitted through Centers for Medicare and Medicaid Services’ (CMS’) online Provider Enrollment Chain and Ownership System (PECOS).