General Compliance Updates
Periodically, as necessary, appropriate employees will be retrained (i) in the Medical Center’s Compliance Program; (ii) the fraud and abuse laws as they relate to the claim development and submission process and Medical Center business relationships; (iii) relevant Medicare and other federal and state requirements; and (iv) the consequences both to the Medical Center and to individuals of failing to comply with applicable laws and regulations. Such training must emphasize the importance of the Compliance Program and the Medical Center’s commitment to honesty and integrity in its business dealings.

Job Specific Substantive Training
Involved employees will be trained and, as necessary, retrained in the specific federal and other health care program rules (e.g. Medicare) that relate to their particular job functions. By way of example:

Patient Access personnel will receive training regarding their role in obtaining the necessary demographic, insurance and other information to support proper application of advanced beneficiary notification, Medicare as secondary payer, the 72 hour rule, research procedures vs. standard of care considerations and other claim submission requirements. Providers of Patient Care (physicians, nurses, social workers, etc.) will receive training that includes clinical documentation requirements, medical necessity considerations, confidentiality of patient information, PATH rules, discharge in lieu of transfer documentation and other training regarding their activities affecting the claim submission process.
Ancillary department personnel training will focus on their role in compliance with applicable LMRPs, bundling/unbundling of services, accuracy of procedure documentation and charge capture.
Hospital Medical Records and FGP coding personnel training will include correct coding initiatives, risks of up-coding and DRG creep, APCs, PATH requirements, discharge in lieu of transfer considerations, and confidentiality of patient information, records retention.
Patient Financial Services personnel will receive training that includes many of the subjects identified above, plus additional training regarding specific requirements such as claim composition, credit balance reporting and disposition, billing only for items and services actually rendered and avoiding duplicate billing.
Research personnel, in addition to human-subjects course requirements, will receive training applicable to the type of research they perform - government funded grants, institutionally funded projects, and/or commercially funded clinical trials. This training will include an overview of governing regulations including cost principles, administrative requirements and the audit requirements of receiving federal funds; pre-award institutional processes, including roles and responsibilities, form and content of a proposal, budgeting, and pre-acceptance review of receiving federal funds; post award financial and program management as well as reporting requirements; and Medicare and other third-party coverage rules and avoidance of double billing for clinical research procedures.
Financial and other administrative management personnel will receive training applicable to their role. For finance personnel, these areas include submission of cost reports, disposition of credit balances, charity and bad debt policies and requirements, graduate medical education requirements and tax-exempt status. Other management training will include courses related to prohibited provider relationships such as anti-kickback, hospital/physician relationships, joint ventures and antitrust laws.

Department Training and Education
Each department director or manager shall periodically identify and advise the Compliance Officer of training and education necessary or advisable for all or any employees of his or her department. The Compliance Officer and the director or manager shall promptly arrange for such training and education.

Physician Compliance Training
The Medical Center shall provide training and education to its employed physicians and to such physicians’ office personnel in the claim development and submission process, including ordering Medical Center services, medical necessity, coding, DRG documentation, and such other information as might be reasonable or useful to enable Medical Center to comply with applicable laws and regulations and to assist physicians in complying with such laws and regulations.

Type, Amount, Documentation and Evaluations
Training and education may occur in sessions with individual employees, in mandatory in-service meetings or incorporated into special or regular departmental meetings or in some other effective manner. Training may consist of live presentations, videos, question and answer sessions and written material and may occur in-house or through attendance at external workshops and seminars.

All employees need not have the identical amount of training and education, nor will the focus of training and educational efforts be the same for all employees. Targeted training and education will be provided to employees whose actions may affect the accuracy of claims submitted to the government. The actual amount of training should reflect necessity, an analysis of risk areas or areas of concern identified by the Medical Center or the Office of the Inspector General, the Medical Center’s compliance experience and the results of periodic audits or monitoring.

The training provided to each employee shall be documented. The documentation shall include the date and a brief description of the subject matter of the training activity or program. Documentation is important and will be retained on file for a minimum of seven (7) years.

There should be periodic evaluations of training and education programs to determine, and if necessary improve, the value, effectiveness and appropriateness of any such program.

Failure to Attend
Failure to comply with training requirements or to attend scheduled training sessions of the Medical Center or of each department may result in job transfer and/or disciplinary action.