Optional_2023 Board Resources

Title : Compliance: Board Compliance Program Oversight and Resolution Process Number : 4310 Version : 6

penalties or exclusion may be authorized, including, but not limited to, the False Claims Act, Stark Law, Anti-Kickback Statute, Emergency Medical Treatment and Labor Act (EMTALA), and Health Insurance Portability and Accountability Act (HIPAA); 3. The employment of or contracting with an Ineligible Person; or 4. The filing of a bankruptcy petition by Banner.

G. Reporting Period: Each one-year period of the CIA, beginning with the one-year period of April 9, 2018 to April 8, 2019.

H. Substantial Overpayment: For purposes of this Policy, Substantial Overpayment is defined as an Overpayment or series of Overpayments that (1) meets a threshold amount of $100.000 and (2) is considered substantial based on several factors, including, but not limited to, the number of affected claims, time period over which the Overpayment(s) occurred, dollar amount involved, and nature of the error that led to the Overpayment(s). A. CIA Requirements 1. Audit Committee Responsibilities and Composition a. Under the terms of the CIA, the Audit Committee is responsible for the review and oversight of matters related to Banner’s compliance with Federal Health Care Program requirements and its CIA obligations. b. The Audit Committee must include independent (i.e., non-employed) members. c. The Audit Committee (or designee) immediately notifies the Ethics & Compliance Department regarding changes of its members or its ability to perform the duties required under the CIA. i. The Ethics & Compliance Department will report to the OIG in writing any changes in the composition of the Audit Committee within 15 days after such a change. Meet at least quarterly to review and oversee Banner’s Compliance Program, including, but not limited to, the performance of the Compliance Officer and the System Compliance Committee. ii. Adopt an annual resolution, signed by each member of the Audit Committee, that summarizes its review and oversight of Banner’s compliance with Federal Health Care Program requirements and its CIA obligations. At a minimum, the resolution will include the following language: 2. Annual Obligation a. The Audit Committee must: i.

III. Policy:

The Audit Committee has made a reasonable inquiry into the operations of Banner’s Compliance Program, including the performance of the Compliance Officer and the System Compliance Committee. Based on its inquiry and review, the Audit Committee has concluded that, to the best of its knowledge, Banner has implemented an effective Compliance Program to meet Federal health care program requirements and the obligations of the CIA.

iii. Describe the documents and other materials that the Audit Committee reviewed, as well as any additional steps taken, during the Reporting Period in its oversight of the Compliance Program and in support of making the annual resolution. b. If the Audit Committee is unable to conclude that Banner’s Compliance Program is effective, the Audit Committee will provide a written explanation of the reasons why it

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