It is the policy of Capitol Dental Care, Inc. (“CDC”) that its business practices be conducted in compliance with applicable laws and regulations of the United States, the state of Oregon, applicable local laws and ordinances, and the ethical standards and practices of the dental industry and the organization. The Standards of Conduct are established to:
Preserve the integrity of decision making;
Promote appropriate conduct by employees, healthcare providers, committee members, contractors, agents, consultants, volunteers, and anyone else doing business with CDC (“Individuals Affiliated with CDC”) acting on behalf of CDC;
Ensure that Individuals Affiliated with CDC will act in the best interest of CDC;
Support and promote delivery of quality of care to CDC’s member-patients.
The Compliance Plan is intended as a guide to building an effective Compliance Program. Laws, regulations and ethical rules that govern healthcare are too numerous and ever-changing to include in the Compliance Plan. However, standards addressed in this Plan reflect those laws, rules and regulations deemed particularly important to healthcare professionals and the organization as a whole. Individuals Affiliated with CDC are expected to meet these standards, and conduct business activities honestly, fairly and in the best interests of CDC. Each Individual Affiliated with CDC is responsible for his/her conduct in complying with the Plan’s content.
CDC’s leadership team expects that all Individuals Affiliated with CDC will behave in a professional and courteous manner, upholding the mission, vision and values of CDC.
Our Mission: To be Provider of choice for Oregon residents. Together with our clinical partners, we relentlessly strive to be the best at providing high-quality, affordable dental services to patients. To be Partner of choice, striving always to provide service excellence to our clinician partners (dentists and hygienists). To be Employer of choice, recognizing that to attract and retain the best teammates, we must each and every one of our teammates, and provide them with appropriate support and development opportunities. Our Vision: Our vision for the future is that every member we serve shall have access to high quality, preventive dental care that supports a fully integrated health care model, including medical, behavioral and pediatric care. Our Values: *Honesty *Integrity *Service to Others * Diversity *Teamwork
*Do the Right Thing * Make CDC a Great Place to Work *
Every Individual Affiliated with CDC is responsible for ensuring that his or her conduct is consistent with these Standards of Conduct, the policies and procedures that support CDC’s Compliance Program, as well as generally accepted standards of professionalism, courtesy, and respect. Furthermore, Individuals Affiliated with CDC in a supervisory role must assume, and are charged with, responsibility for ensuring that the conduct of everyone they supervise complies with these Standards of Conduct.
All Individuals Affiliated with CDC are required to abide by the Compliance Program. At the heart of the Compliance Program is the company’s Code of Conduct. All employees agree to be bound by the Code’s principles and acknowledge and attest to such in the document described as Exhibit A.
Employees are expected to:
Act in good faith, using the degree of care a customarily careful person would use in making a decision that does or could affect CDC.
Act in the best interests of CDC rather than making decisions based on one’s personal interests.
Observe and be dedicated to CDC’s mission when making decisions for the organization.
Comply with all federal health care program requirements and with CDC’s policies and procedures regarding such requirements.
Obtain all information necessary to accurately bill for dental services and never participate in any false or duplicative billing, nor participate in the preparation of any false report.
Confidentiality of Information
Individuals Affiliated with CDC may acquire confidential information by virtue of their affiliation with CDC. Confidential information may not be: (1) disclosed outside of CDC without appropriate authorization from the President; or (2) used for personal gain or for the benefit of a third party.
Information provided during meetings and in everyday work areas should be appropriately secured. Disposal of any confidential materials must be through secure means such as shredding or if maintained, stored in a secure manner by the employee in possession until such time as they intend to appropriately dispose of materials.
Confidentiality of patient information is protected by the Health Insurance Portability and Accessibility Act (HIPAA). All employers are required to gain an understanding of HIPAA laws and requirements and to follow HIPAA guidelines, as well as CDC policies and procedures for appropriate handling of protected health information. Employees will receive appropriate training on HIPAA laws upon hire, and at least annually.
C. Honesty in Dealing with Government and Community Care Organization Officials Employees will be cooperative and truthful in response to any governmental or CCO inquiries, investigations or requests, including audits, surveys, and certification reviews. However, employees who are not authorized to respond to audits or speak on behalf of CDC will not respond to any inquiries, investigations or requests, and will promptly report any such inquiries or requests to CDC’s President or Compliance Officer.
Violations of Standards of Conduct
Employees should promptly report compliance concerns regarding adherence to the Standards of Conduct. Reports of concern should be made initially through regular management channels beginning with the employee’s immediate supervisor. In the alternative, employees may also make such reports to the Compliance Officer. Such reports may be made confidentially and anonymously, as requested. While every effort will be made to ensure confidentiality and anonymity, for misconduct in the extreme that may involve law enforcement agencies or the court system, anonymity cannot always be assured. Committee members should report compliance concerns directly to the President or Compliance Officer. Raising such concerns is a service to CDC and will not jeopardize the terms and conditions of employment of the reporting individual. CDC has a strict non-retaliation policy that protects individuals reporting misconduct or potential misconduct.
Employees are expected to cooperate fully in the investigation of any alleged misconduct. Any employee who violates the Standards of Conduct or who intentionally makes false accusations regarding a compliance concern can be subject to dismissal. However, an accusation, reasonably based, even if found to be ultimately unsupported by evidence, will not subject an employee to disciplinary action.
Conflicts of Interest
CDC recognizes that conflicts of interest often arise in the course of normal business activities. However, employees should make every effort to avoid real or apparent conflicts of interest. Employees must strive to make decisions fairly and objectively with CDCs best interests in mind. As a participant in federal healthcare programs, CDC is bound by federal standards for managing conflicts of interest, as more fully described in HHS regulations. (45 C.F.R § 74.42.) CDC maintains a Conflict of Interest Disclosure procedure that describes the process in which CDC complies with these regulations. This procedure is updated periodically, and in response to changes in the regulations and CDC’s organizational policies.
In order to facilitate disclosure of interests, CDC requires its clinicians, key managers and candidates for Committee membership to annually complete a Conflict of Interest Disclosure form. Those required to complete the Disclosure form shall make disclosures in writing to the Compliance Officer and/or designee, while the President shall make disclosures to the Interdent, Inc. Chief Executive Officer Disclosures will be made at the first day of employment, and updated annually or at any time a designated employee or Committee member’s status changes, in order to facilitate CDC’s determination whether a conflict exists.
The fact that an employee or Committee member has interests that are reportable does not mean that a conflict of interest exists or that the individual cannot work or serve at or with CDC. However, CDC requires employees and Committee members to disclose interests that may be relevant so that the interest may be reviewed, and a determination made whether a conflict exists that would prohibit employment, or decision-making functions relevant to the conflict.
Legal Obligations and Compliance
As a participant in the Medicaid program and a recipient of federal funds, CDC is subject to numerous federal and state laws regulating practices and relationships within the healthcare industry. Those laws particularly relevant to CDC’s fraud and abuse compliance activities are listed below. A more extensive list of laws and information applicable to CDC’s role as a Covered Entity and healthcare provider is included in Exhibit B.
The federal and state laws and regulations that apply to CDC are often updated, and laws are added periodically. Exhibit B will be updated annually by the Compliance Officer to most accurately reflect those changes. These laws are designed to prevent fraud in Medicaid programs, prevent abuse of public funds supporting the programs, regulate patient referrals, and prohibit false statements to the government.
Exclusions and Disbarments
CDC prohibits the employment of individuals who have been listed as debarred, excluded, or otherwise ineligible for participation in federal healthcare programs (as defined in 42 U.S.C. § 1320a-7b (f)). With regard to current employees, the individual will be removed from direct responsibility for or involvement with, any federal healthcare program pending the resolution of any proposed debarment or exclusion. If resolution of the matter results in debarment or exclusion, CDC will terminate the individual’s employment or contract arrangement.
CDC will not knowingly hire employees, accept volunteer or contract with (or bill for services rendered by individuals or organizations excluded from participating in federal or state healthcare programs), also known as “Excluded Parties.” CDC will conduct initial “Excluded Parties” checks on potential employees, dental staff, vendors and volunteers, as well as periodic “Excluded Parties” checks after the commencement of an employment or panel provider relationship to ensure continued eligibility to participate in federal and state healthcare programs. Employees have a duty to immediately report any change in their eligibility status to the Compliance Officer and/or designated compliance employees.
No Individuals Affiliated with CDC may use CDC’s name, (including the name of any affiliated companies or organizational resources in connection with political campaign activities, nor shall any employee participate in any political campaign while at work during business hours.
Lobbying is generally defined as a communication (written or oral) that is an attempt to influence (for or against) specific legislation including appropriations. Any lobbying activities proposed to be undertaken by CDC or by any Individuals Affiliated with CDC on behalf of CDC shall require the prior approval of the President. Any Individuals Affiliated with CDC undertaking lobbying activities will work with the President, or his or her designee, to ensure that such activities are supported by non-Federal resources. Any Individuals Affiliated with CDC undertaking lobbying activities will work with the President, or his or her designee, to ensure that all disclosures and reporting of lobbying activities which are required by State or Federal law are submitted in a timely manner.
Anti-Kickback Statute, 42 U.S.C. § 1320a-7b(b
The federal Anti-Kickback Statute, 42 U.S.C. 1320a-7b(b) is a criminal statute that makes it improper for anyone to solicit, receive, offer or pay remuneration (monetary or otherwise) in exchange for referring patients to receive certain services that are paid for by the government.
No CDC employee will knowingly and willfully offer, pay, solicit or receive any remuneration, directly or indirectly, in return for referrals or to induce referrals, or to arrange for or recommend goods, facilities, services or items for which payment may be made under a federal healthcare program. Certain “safe harbor” exceptions to the general rule exist and can be found at 42 C.F.R. §1001.952. Any questions regarding the application of a “safe harbor” to an employee should be directed to the Compliance Officer, who may forward the information to Legal Counsel.
The Anti-Kickback Statute is interpreted narrowly. Under the “One-Purpose Rule” even if only “one purpose” of the remuneration that was given or received is to induce referrals - and other business/clinical purposes exist - the referral is still considered an act of fraud under the Anti-Kickback Statute. Where an employee believes such an arrangement may exist, he or she is to contact CDC’s Compliance Officer or Legal Counsel immediately.
Stark Law provides that if a healthcare provider (or a family member) has a “financial relationship” with an entity, then the provider is prohibited from referring patients to that entity for “designated health services” that are paid for by Medicare or Medicaid, unless an exception applies. A “financial relationship” includes direct or indirect ownership or investment interests and direct or indirect compensation arrangements between a provider (or a provider’s family member) and an entity that provides “designated health services”. In order to avoid even the appearance of impropriety, CDC’s panel provider agreements are based on fair market value and are not based on the volume or value of business referred. Suspected violations of Stark Law should be reported to the Compliance Officer or Legal Counsel at once.
Antitrust and Trade Regulation
Antitrust Law is the body of law designed to protect trade and commerce from unfair restraints, monopolies and price fixing. Federal anti-trust law is primarily governed by the Sherman Act and the Clayton Act, with states patterning their laws after federal law. CDC will not engage in activities that unfairly or illegally reduce or eliminate competition, control prices, allocate markets, or exclude competitors. Staff who suspect a violation has occurred shall disclose that information to the Compliance Officer.
60 Day Rules (42 U.S.C. § 1320a-7k(d) of the Affordable Care Act and 77 Fed. Reg. 9179 of CMS)
CDC will adhere to federal rules and regulations set forth regarding overpayment, including self-disclosure and the return of overpayments either received by CDC or paid to a provider. “Overpayments” are defined as funds received or retained that are payable under Medicaid to which CDC or its provider is not entitled. As part of its Compliance Program, CDC has developed, and will continue to develop and refine, policies and procedures, as well as educational opportunities to ensure that All Individuals Affiliated with CDC follow practices and procedures consistent with federal and state laws involving billing and processing of claims.
Federal and State False Claims Acts and Regulations
The federal False Claims Act (“FCA”) and similar state laws assist federal and state governments in combating fraud and recovering losses resulting from fraud in government programs. These laws and regulations impose liability on persons or companies that make, or cause to be made, false or fraudulent records, statements, or claims to the government for payment. These laws and regulations apply to federal and state health care programs, including funding through CCO and the Oregon Health Plan. These laws and regulations prohibit, among other things:
Billing for services or goods not provided;
Billing for undocumented services;
Making inaccurate, false, or improper entries in medical records, cost reports, and any other records used to support reimbursement;
Billing for services that are not dentally appropriate;
Characterizing non-covered services or costs in a way that secures reimbursement;
Assigning an incorrect code to a service in order to obtain a higher reimbursement;
Failing to seek payment from beneficiaries who may have other primary payment sources;
Participating in unlawful kickbacks and rebates; and
Altering, falsifying, destroying, or concealing medical records, income and expenditure reports, or any other records that support reimbursement.
Civil and Criminal Penalties for False Claims or Statements A violation of these laws may result in recovery of the overpayments by the government, completion of an educational program regarding the proper submission of claims and appropriate utilization of services, referral to the Oregon Medicaid Fraud Control Unit for further investigation and action, and/or suspension or exclusion from the Medicaid program. In addition, any person who violates these laws commits a felony punishable by imprisonment for up to ten years and/or a fine of up to $11,000.00 per violation as well as a penalty of 3x the damages incurred by the government.
Civil Lawsuits Currently, unlike the federal False Claims Act, Oregon laws allow civil lawsuits to recover monetary damages to be filed only by the state government and not by private citizens or employees. There is no provision for a private citizen to share a percentage of any monetary recoveries.
No Retaliation Allowed Oregon law prohibits employers from discharging, disciplining or retaliating against an employee who in good faith reports a violation of clearly defined state or federal statutes. CDC expects all its employees, including management, to adhere to its policy prohibiting retaliation. Any employee who engages in, or condones, any form of retaliation against another employee because that employee either (a) reported a potential violation of the Standards of Conduct or regulatory violation, or (b) refused to violate the Standards of Conduct or a government law or regulation, will be subject to disciplinary action up to and including termination of employment. If you have questions about any of the laws referenced above, you may contact CDC’s Compliance Officer at 503-587-7162.
Contracting for Services
Business relations with vendors, contractors and other third parties, including providers and other clinicians, are to be conducted at arm’s length and any compensation arrangement shall constitute fair market value for the services produced by the vendors, contractors and other third parties.
Financial Accounting Records
Financial reports, accounting records, research reports, expense accounts, time sheets, and other financial documents shall accurately represent the performance of operations. CDC’s employees shall be trained and work shall be monitored to ensure proper maintenance of information to comply with CDC’s policies, plans, procedures, accreditation standards, and other such laws, statutes, or regulations. CDC shall establish procedures to ensure a system of internal controls providing reasonable assurance that financial records are executed and retained consistent with state and federal regulatory requirements and accounting guidelines. CDC shall ensure records are prepared timely, properly supported, and appropriately retained.
CDC shall maintain honest, fair, and accurate billing practices whether submitting and/or reviewing claims. CDC shall work with its authorized third-party administrator to ensure that the third party administrator maintains honest, fair and accurate billing practices, as well. Individuals involved in billing and coding functions on behalf of CDC, including its clinical staff, shall have experience, knowledge and training to perform billing and coding functions in accordance with federal, state, and local law. CDC’s written policies, plans and procedures for billing and coding will reflect current federal and state statutes and regulations regarding the submission of claims. CDC has an Auditing and Monitoring Compliance Plan for Clinical Documentation and Coding that is reviewed and updated periodically as rules, regulations and policies change. This Plan also outlines the accuracy expectations of providers, billing, coding and auditing staff, and defines the Education plan for helping staff achieve the standard of accuracy required by law. CDC’s billing and coding procedures will emphasize the following:
Billing for “dentally appropriate” services provided, as supported by healthcare record documentation.
Billing for covered services and notifying patient-members and/or providers when coverage by Medicaid is uncertain.
Following state and federal regulations regarding claims submission as it relates to provider numbers and services.
Prohibition on unbundling of services when a bundled service is provided
Proper usage of Current Dental Terminology.
Providing submission for single entries with no duplicate claims submitted.
Proper, timely and accurate review of invoices submitted by providers.
Claims should be submitted and/or reimbursed when appropriate documentation supports the claims, with documentation available for review.
Coding should reflect current reimbursement principles set forth in the applicable regulations and be developed in tandem with private payer and organizational standards.
Dentally Appropriate Services
Providers may bill only for and CDC may only reimburse for “dentally appropriate” services. Providers may not sign a certification, order or prescription for any item or services when they know, or should know, the information in the certification, order or prescription to be false, or if they do not know it to be true.
CDC healthcare, business, and compliance records shall be maintained and protected according to HIPAA, Medicaid, federal, state and local regulatory guidelines, and internal CDC records retention procedures.
CDC is committed to ensuring that All Individuals Affiliated with CDC comply with federal and state laws and regulations that govern the healthcare industry. Violations of these laws and regulations can result in significant civil or criminal sanctions both to the organization and the individual employee. As a result, CDC has established a series of policies and procedures designed to assist all employees in:
Promoting open lines of communication so that every Individual Affiliated with CDC feels comfortable reporting instances of non-compliance; and
Responding to any instances of non-compliance that are discovered, and implementing the necessary internal controls to mitigate against future concerns.
CDC refers to this series of policies and procedures as its Compliance Program. Compliance covers the full spectrum of business and health care operations and is not limited to fraud and abuse or breaches of protected patient information and confidentiality. The elements included herein along with the Code of Conduct serve as a foundation for the Compliance Program. Policies and procedures will be added under each of these key elements and be available both on the CDC network as well as in paper format for any employees that seek additional guidance and education. From time to time, CDC will provide additional training on particular policies and procedures.
CDC’s Compliance Program is a comprehensive organizational program that:
Identifies the federal and state laws and regulations governing the organization, ensuing that it is in compliance with these mandates.
Develops and maintains written compliance policies and procedures and Standards of Conduct; and advances quality improvement programs throughout the organization.
Performs periodic self-audits to monitor its compliance with applicable laws and policies governing the organization.
Conducts ongoing, relevant and comprehensive education and training for all employees, volunteers and Committee members of CDC.
Guides implementation of corrective action plans to improve CDC’s operations and practices.
Elements of CDC’s Compliance Program The Compliance Program has been established to assist Individuals Affiliated with CDC in understanding and complying with the rules and regulations, industry and professional standards, operations and relationships that support a business model that delivers quality care to its member-patient base. The Compliance Program consists of the following elements:
Appointment of a Compliance Officer
It is CDC’s policy to have a Compliance Officer oversee the development and implementation of its Compliance Program and to ensure appropriate handling of instances of suspected or known illegal or unethical conduct. CDC’s Compliance Officer reports to the President of CDC and, therefore, has the necessary access for making reports and recommendations on compliance matters. The Compliance Officer’s duties include:
Accessing the relevant authority for standards of conduct and legal risks;
Developing policies and procedures for implementation and operation of the Compliance Program;
Overseeing the development and delivery of education sessions;
Coordinating investigation of all possible non-compliance;
Working collaboratively with the quality improvement department to develop and implement auditing, monitoring and assessment tools and overseeing evaluation processes;
Establishing a retribution-free system for reporting of non-compliance concerns;
Developing and implementing corrective action plans;
Communicating regularly with the President and serving as a member of the Compliance Committee and Quality Improvement Committee.
Providing leadership for the Compliance effort.
Ensuring that appropriate disciplinary actions or sanctions are applied.
To support the Compliance Officer in meeting his/her responsibilities, CDC has established a staff-level Compliance Committee comprised of various members of CDC’s management, clinical staff and Quality Improvement department.
Written Standards of Conduct and Policies and Procedures for Promoting Compliance
As part of its efforts to implement an effective Compliance Program, CDC has established written Standards to assist Individuals Affiliated with CDC in recognizing compliance issues and to guide them to do the ethically right thing. CDC will continue to develop and implement policies and procedures consistent with the requirements and standards established by the President, the Compliance Committee, federal and state laws and regulations and relevant reviewing and accrediting organizations. It is CDC’s policy to address identified areas of risk and to promote compliance by developing written policies and procedures that establish guiding principles or courses of action for affected personnel.
Education and Training
It is CDC’s policy to develop and offer ongoing and regular educational and training programs so that all Individuals Affiliated with CDC are familiar with its Compliance Program and Standards of Conduct, as well as other policies and procedures. Specifically, it is CDC’s policy to ensure that Individuals Affiliated with CDC are provided education regarding the fraud and abuse laws and, if applicable to their position, the coding and billing requirements imposed by Medicaid and other applicable government health care programs. CDC communicates and distributes this information, along with information regarding its standards, policies, and procedures, to all Individuals Affiliated with CDC.
Reporting Compliance Issues
CDC is committed to establishing and maintaining meaningful and open lines of communication between the Compliance Officer, the President and Committee members, as well as among and between Individuals Affiliated with CDC and the Compliance Officer.
System for Responding to Allegations of Improper and Illegal Activity
To support CDC’s commitment to establishing and maintaining meaningful and open lines of communication, CDC will take appropriate steps to respond to every report of suspected unethical or non-compliant conduct, as well as to address unreported incidents of suspected unethical or non-compliant conduct. These steps may include conducting investigations, reviewing documents, implementing or revising policies and procedures, offering training, conducting audits and imposing disciplinary action.
Audits and Evaluation
As part of its efforts to implement an effective Compliance Program, CDC strives to periodically conduct self-audits of its operations to ascertain problems and weaknesses in its operations and to measure the effectiveness of its Compliance Program.
Corrective Action and Disciplinary Standards
CDC is committed to ensuring that its Compliance Program and Standards of Conduct, and its policies and procedures are adhered to by all Individuals Affiliated with CDC. This goal can be best met through consistent enforcement, which may be accomplished by imposing appropriate disciplinary action in accordance with the disciplinary policies and procedures and sanctions that guide and support CDC’s operations. It is the organization’s goal that every Individual Affiliated with CDC understands the consequences of improper or non-compliant activities and that all violators of this Compliance Program and Standards of Conduct will be treated equally.
Your Role in the Compliance Program Individuals Affiliated with CDC are expected to comply with CDC’s Compliance Program and Standards of Conduct, and its policies and procedures, and are required to promptly report concerns regarding compliance with CDC’s Compliance Program and Standards of Conduct, and its policies and procedures or other laws, regulations or policies.
Such a report should normally be made initially through standard management channels, beginning with an immediate supervisor. As an alternative, Individuals Affiliated with CDC may make such report to the Compliance Officer. For Committee members, reports should be made directly to the Compliance Officer. All reports may be made confidentially, and even anonymously. Individuals Affiliated with CDC are expected to cooperate fully in the investigation of any potential non-compliance.
Reporting potential non-compliance and participating in CDC’s compliance activities are job performance requirements/expectations of each Individual Affiliated with CDC.
Any Individual Affiliated with CDC who reports a compliance concern in good faith is protected by law from retaliation. Any Individual Affiliated with CDC who retaliates against another Individual Affiliated with CDC for his or her reporting of potential non-compliance or his or her participation in addressing potential non-compliance is subject to discipline by CDC. Additionally, any Individual Affiliated with CDC who makes intentionally false accusations regarding a compliance concern is subject to discipline by CDC.
This Compliance Program and Standards of Conduct shall be reviewed periodically and updated to remain consistent with the requirements established by CDC’s President and Compliance Committee as well as federal and state law and regulations, and applicable accrediting and review organizations.
EXHIBIT A Certification of Commitment to COMPLY WITH
Compliance Program and code of Conduct
I hereby acknowledge and certify that I have received and reviewed a copy of the CDC Compliance Program and Standards of Conduct and I understand that they represent mandatory policies of CDC.
By signing this form below, I agree to abide by this Compliance Program and Standards of Conduct during the term of my employment, contract or agency or while otherwise authorized to serve on CDC’s behalf. In addition, I acknowledge that I have a duty to report any suspected or known violation of the Compliance Program and Standards of Conduct or any CDC policy or procedure to my supervisor or through the normal chain of command. I acknowledge that I may also report the information directly to the Compliance Officer or any other member of senior management.
Please return this completed, signed Certification of Commitment to the Compliance Officer.
The following list represents the laws and regulations that CDC incorporates into its Compliance Program. It is not an exhaustive list of all the requirements with which CDC will comply, but rather describes those laws most relevant to its fraud and abuse compliance activities. All Individuals Affiliated with CDC are encouraged to read and consider these laws. Should anyone have a question or concern regarding their application to CDC, please contact the Compliance Officer.