2010 Region II Conference Corporate Compliance Panel June 3, 2010

1. 2010 Region II ConferenceCorporate Compliance PanelJune 3, 2010 Tamy Skaist, Compliance Officer Ezra Medical Center, Brooklyn, NY 11218

2. My life before I became the Compliance Officer at Ezra Medical Center

3. My life after I became the Compliance Officer at Ezra Medical Center

4. Overview • Background on Ezra Medical Center • Organization of Compliance Program • Compliance Officer • Compliance Committee of the Board • Board of Directors • Compliance Policy Overview • Compliance Training • Compliance Reporting System • Compliance Auditing • Other Relevant Policies and Procedures

5. Background on Ezra Medical Center • Located in Brooklyn, NY • State-of-the-art facility built in 2008

6. EZRA MEDICAL CENTER

7. Bird’s-Eye View of EMC Facility

8. Reception Area

9. Dental Exam Room

10. Background on Ezra Medical Center • Services offered: • Primary care, adults and pediatrics • Dentistry, adults and pediatrics, Mobile Dental Van • Optometry and vision therapy • Dermatology • Podiatry

11. Background on Ezra Medical Center • Ezra Medical Center opened its doors in 2001. With minimal resources, the health center created a vital community resource of medical, dental and social service visits for its target population. • During the past 5 years, we’ve seen a growth of over 1,000%. • Currently, we see over 3,000 visits per month.

12. Organization of Compliance Program • Compliance Officer • Manages Compliance Program • Tracks new developments • Ensures compliance reviews are performed • Conducts compliance training • Responds to reports, complaints and questions • Makes reports to Compliance Committee of the Board

13. Organization of Compliance Program • Compliance Committee of the Board • Oversees Compliance Program • Receives reports from Compliance Officer • Reviews compliance activities • Addresses specific compliance-related concerns • Makes recommendations for changes

14. Organization of Compliance Program • Employees • Given periodic compliance training • Front line in detecting potential compliance issues

15. Compliance Program • Purpose • To ensure that Ezra Medical Center operates in full compliance with all relevant laws, regulations, and guidelines • Particular areas of focus include: • Accuracy of coding • Claims development and submission • Documentation of services rendered • Services are reasonable and necessary • False Claims Act issues • Fraud and abuse (kickbacks/self-referrals)

16. Compliance Policy Overview • Privacy and security: • Security Officer with responsibility for privacy and security issues • Regular HIPAA training for staff • Workstations are physically secure • Workstations in public areas are protected with privacy filters • Password protected screen savers when workstations unattended for 5 minutes or more • User accounts disabled immediately upon termination of user’s employment

17. Compliance Training • Bi-annual compliance training for all staff • Review compliance program • Review of staff responsibilities • Discussion of reporting mechanisms • Coding and billing training: • Done upon hire, and two times a year

18. Compliance Reporting System • Staff are required to report any potential issues to their supervisor, another person in management, or the Compliance Officer • Compliance hotline has been established • Toll-free number • Available 24 hours per day, 7 days per week • Reports are anonymous • Reports go to Compliance Officer and/or the Executive Director

19. Compliance Auditing • Current and prospective employees are screened against applicable databases, including: • HHS OIG’s List of Excluded Individuals and Entities • GSA’s List of Parties Debarred from Federal Programs • New York State Medicaid Office of Inspector General List of Excluded Individuals and Entities • Regular self-audits • Done on a quarterly basis • Audit of sample charts to ensure that coding and billing accurate • Review by medical records personnel

20. Responding to Violations • Investigation by Compliance Officer • Ensure that investigation is initiated as soon as reasonably possible. • Identify and review relevant documentation • Identify and interview relevant staff members • Suspension of staff member from job function to protect integrity of investigation, if necessary • Involvement of legal counsel as required • Report to Compliance Committee of the Board • Corrective action • Up to and including termination of staff member(s) involved

21. Other Relevant Policies and Procedures • Whistleblower Protection Policy • Prohibits retaliation or discrimination against any person for making a complaint, assisting in an investigation, or reporting an incident of suspected illegal or unethical conduct • Subjects anyone engaging in retaliation to appropriate disciplinary action, which may include termination • Conflict of Interest Policy • Establishes policy for handling potential conflicts of interest • Among other things, requires approval of non-conflicted Board members for any transaction involving a conflicted party • Document Retention Policy • Implemented by Compliance Officer • Establishes minimum retention periods for records • Developed in consultation with legal counsel

22. Questions?