ALEGENT CREIGHTON HEALTH CORPORATE INTEGRITY PROGRAM PURPOSE

Alegent Creighton Health continually strives to provide the highest level of care and services. We are committed to providing health care services in accordance with the highest standards of business and community ethics and in compliance with applicable laws. The Corporate Integrity Program is integral to the achievement of these goals.

The Corporate Integrity Program was developed in accordance with Alegent Creighton Health's high standard of business and health care ethics, as well as applicable state and federal law. The Corporate Integrity Program is intended to be applicable to every Alegent Creighton Health employee, agent, officer and all corporate entities in which Alegent Creighton Health has a majority ownership, interest or operational control. The procedures and Standards of Conduct contained in the Corporate Integrity Program are intended to generally define the scope of conduct, which the Corporate Integrity Program is intended to cover, and are not to be considered as all-inclusive.

The common Mission of all Alegent Creighton Health entities is a pledge to offer high quality, cost effective healthcare to the communities we serve. Alegent Creighton Health has a reputation, achieved and maintained through the integrity and ethical standards of our officers and employees, in conducting itself in accord with the highest levels of business ethics and in compliance with applicable laws.

Because the healthcare environment continues to experience dramatic changes in a heavily regulated environment, Alegent Creighton Health has committed itself to maintaining its reputation by enforcing system-wide standards of business ethics, integrity and corporate conduct. Alegent Creighton Health's Corporate Integrity Program is meant to consolidate the ethical and professional standards already required by the Policies and Procedures of Alegent Creighton Health, to supplement them as appropriate, and to provide a clear mandate for all employees and officers to follow.

As a role model for other healthcare systems and as a respected corporation in our community, Alegent Creighton Health is committed to creating an atmosphere of integrity to encourage all employees and officers to actively participate in accomplishing effective system-wide compliance. Alegent Creighton Health is proud to set this standard to benefit its employees and officers and the communities we serve.

"The adoption and implementation of voluntary compliance programs significantly advances the prevention of fraud, abuse and waste in these healthcare plans while at the same time furthering the fundamental mission of all hospitals, which is to provide quality care to patients."

Federal Register

Alegent Creighton Health CORPORATE INTEGRITY STATEMENT
Alegent Creighton Health's Corporate Integrity Program assists us in accomplishing the following goals:

  • Fulfill our fundamental care giving mission to our patients and our communities;
  • Improve quality of patient care;
  • Assist in identifying weaknesses in internal systems and management;
  • Demonstrate our strong commitment to honest and responsible providers and corporate conduct;
  • Create a centralized source for distributing information on healthcare regulations and program directives related to fraud and abuse;
  • Develop a methodology that encourages employees to report potential problems;
  • Develop procedures and processes that allow prompt, thorough investigation of alleged misconduct;
  • Initiate immediate and appropriate corrective action; and
  • Minimize financial loss to government and taxpayers as well as any corresponding financial loss to Alegent Creighton Health
The Seven Fundamental Compliance Program Elements

Compliance efforts help establish a culture within Alegent Creighton Health that promotes prevention, detection and early and prompt resolution of issues that may not be in compliance with Federal and State laws, Federal, State and private payor healthcare program requirements, as well as Alegent Creighton Health's ethical and business practices.

Our Corporate Integrity Program also assists us in accomplishing the following goals:

  • Fulfill our fundamental care-giving mission to our patients and our communities;
  • Improve quality of patient care;
  • Assist in identifying weaknesses in internal systems and management;
  • Demonstrate our strong commitment to honest and responsible providers and corporate conduct;
  • Creates a centralized source for distributing information on healthcare regulations and program directives related to fraud and abuse;
  • Develop a methodology that encourages employees to report potential problems;
  • Develop procedures and process that allow prompt, thorough investigation of alleged misconduct;
  • Initiate immediate and appropriate corrective action; and• Minimize financial loss to government and taxpayers as well as any corresponding financial loss to Alegent Creighton Health. 

The first step to an effective compliance program begins with the formal commitment of the healthcare organization's governing body. The Alegent Creighton Health Board of Directors approved the Corporate Integrity Program on December 4, 1998 and has approved its updates and revisions annually thereafter.

The Seven Fundamental Compliance Program Elements

1. Written Policies and Procedures

A. Standards of Conduct
The Alegent Creighton Health Standards of Conduct Policy and Procedure (300.004) is Alegent Creighton Health's guide for ethical and professional business conduct. It is each individual's responsibility to adhere to the Standards of Conduct and to actively participate in and promote compliance and integrity.

B. Risk Areas
The Alegent Creighton Health Corporate Integrity Program Document and Standards of Conduct address but a few of the rules and regulations that a healthcare provider must adhere to on a daily basis. Alegent Creighton Health identifies areas where the organization may be at risk for noncompliance and addresses and corrects these areas.

2. Designation of a Compliance Officer and a Compliance Committee

A. Compliance Officer
Leigh Bertholf - Vice President, CRP NE/SW Iowa Division CRO & ACO CRO

B. Compliance Committee
Alegent Creighton Health's CEO and General Counsel, an internal audit representative, and other representatives from senior leadership, appointed by the CEO, all serve on the Alegent Creighton Health Corporate Integrity Committee.

3. Conducting Effective Training and Education

Since 1999, Corporate Integrity annual education has been provided to all employees on a wide variety of topics. Such topics as fraud and abuse, gifts and gratuities, Stark and Anti-kickback statutes, HIPAA, Limited English Proficiency and much more have been presented. In addition to the annual education requirement, specialty training is prepared and presented to appropriate staff as the need arises.

In addition to the one hour of required employee training, managers receive an additional hour of specialized training.

4. Developing Effective Lines of Communication

The Compliance Officer is available through many communication methods - phone, in-person, fax, e-mail, pager, on-line through www.ethicspoint.com and Corporate Integrity Hotline (1-800-261-5607).

5. Enforcing Standards Through Well-Established Disciplinary Guidelines

Not reporting an issue of suspected non-compliance could have serious consequences. Suspected issues of noncompliance should be reported to a manager or the Compliance Officer. Alegent Creighton Health does not allow any retaliation against an individual who reports an issue that the individual suspects is wrong. An individual cannot be terminated when the individual, in good faith, reports an issue they thought was non-compliant.

6. Auditing and Monitoring

The payor billing rules are complicated and rapidly changing. Many times we really believe that we are doing something correctly but may, in fact, not be. Have we committed an act of fraud? Probably not, as we did not intentionally bill something incorrectly.

That is why we audit and monitor and audit and monitor. To make sure we are doing things correctly, to fix the situation if not correct, and to make sure that is stays corrected.

7. Responding to Detected Offenses and Developing Corrective Action Plans

If during an audit, internal or external, an issue is identified and no action is taken to correct the issue and we continue to do the incorrect thing, this may be considered fraud. The Office of Inspector General (OIG) favorably looks upon internal action, correction and reporting.

However, there is nothing worse than developing a corrective action plan, believing that we are correcting an issue, but then not actually correcting it. Payor representatives retain copies of our corrective action plans and use them during other medical reviews. If we say we are going to correct something, we need to do it and then make sure the corrections stay in place.

That is why Alegent Creighton Health has a Corporate Integrity Program. We are committed to act with integrity in everything we do and providing our patients with quality care. Our Corporate Integrity Program gives us an additional tool to meet and exceed our commitment to our patients.