The Quality Alliance (QA) is committed to programs and policies to ensure its members, trustees, officers, employees, independent contractors and agents conduct activities in full compliance with applicable federal, state and local laws and ethical standards. In furtherance of this obligation and commitment, our Board of Trustees unanimously accepted a resolution to develop and adopt The Cleveland Clinic Health System (CCHS) Compliance Program on July 8, 1999. The Program is intended to prevent and to detect any violations of federal, state, or local laws by QA. By acting in accordance with the Program, QA is best able to fulfill its central mission, which is to provide high quality, cost effective, comprehensive healthcare services and to measure and report on quality, outcomes and satisfaction of the care delivered to its members and enrollees.
For questions or more information, contact the Privacy Office at 216.444.1709 or Corporate Compliance
. Report privacy and other compliance issues at the Anonymous Reporting Hotline, 800.826.9294 or 216.444.4722; or Anonymous Email
on the Cleveland Clinic website.
Policy Statement of Compliance
Each member, trustee, officer, employee, contractor and agent of QA is to carry out his or her duties in full compliance with the Program. The Program is designed to prevent and to detect violations of federal, state, or local laws by QA. Any member, trustee, officer, employee, contractor or agent of QA that suspects or knows of a violation should promptly report such suspected violation in accordance with the Program procedures.
Procedure for Reporting
Employees of QA who are aware of a violation of any rules, regulations or laws are required to make the violation known to their supervisor. All other persons who suspect or are aware of a violation, or if an employee does not want to contact their supervisor, may contact the Office of Corporate Compliance at The Cleveland Clinic Foundation at (216) 444-1709 or the Law Department at (216) 448-0200. In addition, a confidential Reporting Line has been established for CCHS which is not equipped with caller identification. The confidential Reporting Line number is: (216) 791-4710 or 800-826-9294. All reported violations will be investigated.
Overview of the Program
The Program outlines various federal, state, and local laws that apply to QA, its members, trustees, officers, employees, contractors and agents. The following guidelines provide general standards of conduct applicable to participants in QA. In addition, more detailed plans and standards that focus on specific areas of compliance will be developed and distributed to members, if applicable, and to administrators and other persons who are responsible for such specific areas or issues. A full copy of the Program can be obtained from the Law Department for The Cleveland Clinic Foundation.
General Standards of Conduct
QA is committed to delivering high quality of medical care to its patients. The essential components of quality care include efficiency, effectiveness, and patient satisfaction in the delivery of health care. All members must integrate these components into their practice. In addition, all members are committed to measuring, reviewing and improving their ability to provide quality care.
The public has a right to expect that QA’s business will be conducted ethically and competently by all QA members, employees, contractors and agents. Each participant in QA should adhere to the spirit and language of the Program and strive for excellence in performing their duties. Each participant must maintain a high level of integrity in business conduct and avoid any conduct that could reasonably be expected to reflect adversely upon the integrity of QA, its members, trustees, officers, employees, contractors or other agents.
Government And Third Party Payer Requirements
QA is committed to maintaining full compliance with Medicare, Medicaid and other government health program requirements, as well as with similar requirements imposed by other third-party payors. Participants in QA are required to adhere strictly to all applicable billing requirements, and to report any violations of law or other requirements to the appropriate authority.
Fraud And Abuse
QA’s policy is that its participants fully comply with all Medicare, Medicaid and other health-related fraud and abuse requirements. In order to ensure compliance with the law and to promote an atmosphere that is free from improper dealing, QA’s policy is to follow the fraud and abuse standards in all circumstances, regardless of the identity of the payor. Government health care fraud and abuse requirements prohibit, among other things, any person from offering or paying remuneration to a Medicare, a Medicaid or any other government-funded patients referral source for making or recommending patient referrals and from making false claims for reimbursement. While not comprehensive, following is an illustrative list of the types of practices which may be in violation of fraud and abuse requirements:
- A pattern of up-coding;
- A practice of claiming for unnecessary services;
- Offering remuneration to an individual to influence selection of a provider (Remuneration in this instance can include the waiver of co-insurance or deductible; but, there is an exception for financial need); and false certification for home care.
The purpose of antitrust laws is to foster competition and ensure that business arrangements are not subject to unreasonable restraints on trade. QA is committed to conducting its business in full compliance with such requirements. Certain agreements with competitors are unlawful “per se” (e.g., the commercial justification for the arrangement is irrelevant). Per se unlawful agreements generally include those that affect prices. Because QA is comprised of non-employed physicians that may be considered to be competitors for non-QA business, QA utilizes the “messenger model” in negotiation of prices. Participants in QA should not share or disclose price or rate information among themselves or to any person or entity that is not a participant in QA.
Annual Compliance Statement on Billing Fraud, Waste and Abuse
Medicare Fraud, Waste and Abuse
The Centers for Medicare and Medicaid Services (CMS) requires health plans servicing Medicare beneficiaries to provide training in fraud, waste and abuse to health care providers with whom they contract. In an effort to assist the health plans in educating health care providers, including the employees and medical staff members of the Quality Alliance, we have provided the information below regarding our Corporate Compliance program. This information along with our policies addressing fraud, waste and abuse can be found at https://www.cms.gov/
Prevention of Fraud, Waste and Abuse
Cleveland Clinic’s policies and federal and state laws prohibit fraudulent claim or reimbursement activities, such as knowingly submitting a false or fraudulent claim, or using or making a false statement to get a false or fraudulent claim paid.
How do I recognize fraud, waste and abuse in the workplace? Depending on the facts and circumstances, the following actions may be unlawful:
- Billing for services and/or supplies not provided
- Billing for medically unnecessary services
- Billing on an outpatient basis for “inpatient-only” procedures
- Unbundling (billing for each component of the service instead of using an all inclusive code)
- Intentional failure to properly use modifiers
- Intentional misrepresentation of a diagnosis to justify reimbursement rates
- Double billing resulting in duplicate payments that are not reconciled when found
- Certain misuses of provider identification numbers
Compliance with the Anti-Kickback Statute
This statute makes it a criminal offense to knowingly or willfully offer, pay, solicit, or receive any remuneration to induce to reward referral of items or services reimbursable by a Federal health care program. For purposes of the anti-kickback statute, “remuneration” includes the transfer of anything of value, directly or indirectly, overtly or covertly, in cash or in kind. Compliance with the Stark Statute The Physician Self-Referral Prohibition Statute, commonly referred to as the Stark Law, prohibits physicians from referring Medicare patients for certain designate health services to an entity with which the physician or member of the physician’s immediate family has a financial relationship – unless an exception applies. If you suspect a violation of our policies related to Fraud, Waste and Abuse, and/or the Anti-Kickback or Stark Statutes, please contact the Office of Corporate Compliance at The Cleveland Clinic Foundation at (216) 444-1709.