2023 Board Resources

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Title Page and TOC 2021 BOD Handbook	3
BANNER BOARD OF DIRECTORS COMPLIANCE PROGRAM HANDBOOK	3
1.a.COI Scenarios	13
4. INTRO to PRACTICAL GUIDANCE FOR HEALTH CARE GOVERNING BOARDS ON COMPLIANCE OVERSIGHT	45
4a (2019) 2015 Practical-Guidance-for-Health-Care-Boards-on-Compliance-Oversight	46
About the Organizations	48
Table of Contents	49
Expectations for Board Oversight of Compliance Program Functions	51
Although compliance	52
Roles and Relationships	55
Reporting to the Board	58
The Board should receive regular reports regarding the organization’s risk mitigation and compliance efforts....	58
Identifying and Auditing Potential Risk Areas	60
Encouraging Accountability	62
Compliance is an enterprise-wide responsiblity.	62
Conclusion	64
Bibliography	65
5. US Ex Rel Guardiola CIA etc	121
EXECUTIVE SUMMARY OF	121
Ms. Cecilia Guardiola, Relator	122
EXECUTIVE SUMMARY OF	123
Term of the CIA	123
Scope of the CIA	123
Operational Requirements of the CIA	123
II. Compliance Documents	124
III. Compliance Training and Education	125
IV. Independent Review Procedures	125
V. Risk Assessment and Internal Review Process	125
VI. Disclosure Program	126
VII. Ineligible Person Screening	126
VIII. Overpayment Policies and Procedures	126
Reporting Requirements of the CIA	126
II. Scheduled Reporting	127
Penalties for Noncompliance	127
II. Exclusion	127
AUDIT COMMITTEE’S CIA RESPONSIBILITIES	128
7. DOJ evaluation-of-corporate-compliance-programs-june-2020-revision	69
Introduction	69
I. Is the Corporation’s Compliance Program Well Designed?	70
A. Risk Assessment	70
B. Policies and Procedures	72
C. Training and Communications	73
D. Confidential Reporting Structure and Investigation Process	74
E. Third Party Management	75
F. Mergers and Acquisitions (M&A)	77
II. Is the Corporation’s Compliance Program Adequately Resourced and Empowered to Function Effectively?	77
A. Commitment by Senior and Middle Management	78
B. Autonomy and Resources	79
C. Incentives and Disciplinary Measures	81
III. Does the Corporation’s Compliance Program Work in Practice?	82
A. Continuous Improvement, Periodic Testing, and Review	83
B. Investigation of Misconduct	84
C. Analysis and Remediation of Any Underlying Misconduct	85
8. 2019 OIG Comparison Chart of the AKS and Stark Law	91
9. 2019 Maida FA Paper (2019)	95
COMMON FRAUD AND ABUSE AND OTHER LEGAL ISSUES	95
Page	96
ARTICLE 2 THE STARK LAW	100
2.3 Statutory and Regulatory Exceptions.	103
ARTICLE 3 FALSE CLAIMS ACT	104
ARTICLE 4	106
ARTICLE 5 EXCLUSION	109
5.2 Mandatory Exclusions.	109
ARTICLE 6	111
ARTICLE 7 SUSPENSION AND REVOCATION	112
ARTICLE 8	116
8.2 Corporate Form.	116
ARTICLE 9	117
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ADP3750.tmp	25
CORPORATE RESPONSIBILITY AND CORPORATE COMPLIANCE: A RESOURCE FOR HEALTH CARE BOARDS OF DIRECTORS	25
CORPORATE RESPONSIBILITY AND CORPORATE COMPLIANCE:	26
THE OFFICE OF INSPECTOR GENERAL OF THE	26
AND	26
I. INTRODUCTION	28
Fiduciary Responsibilites	28
Purpose of this Document	28
II. DUTY OF CARE	29
III. THE UNIQUE CHALLENGES OF HEALTH CARE ORGANIZATION DIRECTORS	30
V. SUGGESTED QUESTIONS FOR DIRECTORS	31
1. How is the compliance program structured and who are the key employees responsible for its implementation and operation? How is the Board structured to oversee compliance issues?	31
2. How does the organization’s compliance report ing system work? How frequently does the Board receive reports about compliance issues?	31
3. What are the goals of the organization’s compli ance program? What are the inherent limita tions in the compliance program? How does the organization address these limitations?	31
4. Does the compliance program address the significant risks of the organization? How were those risks determined and how are new compliance risks identified and incorporated into the program?	32
5. What will be the level of resources necessary to implement the compliance program as	32
OPERATIONAL QUESTIONS	32
A. Code of Conduct	32
B. Policies and Procedures	32
C. Compliance Infrastructure	33
2. Have compliance-related responsibilities been assigned across the appropriate levels of the organization? Are employees held accountable for meeting these compliance-related objectives during performance reviews?	33
D. Measures to Prevent Violations	33
2. How is the Board kept apprised of significant regulatory and industry developments affecting the organization’s risk? How is the compliance program structured to address such risks?	33
3. How are “at risk” operations assessed from a compliance perspective? Is conformance with the organization’s compliance program periodically evaluated? Does the organization periodically evalu ate the effectiveness of the compliance program?	33
4. What processes are in place to ensure that appropriate remedial measures are taken in response to identified weaknesses?	33
E. Measures to Respond to Violations	34
2. Does the organization have policies that address the appropriate protection of “whistleblowers” and those accused of misconduct?	34
3. What is the process by which the organization evaluates and responds to suspected compliance violations? What policies address the protection of employees and the preservation of relevant documents and information?	34
4. What guidelines have been established for reporting compliance violations to the Board?	34
5. What policies govern the reporting to government authorities of probable violations of law?	34
VI. Conclusion	34
BANNER HEALTH	35
How is the Board kept apprised of significant regulatory and industry developments affecting the organization’s risk? How is the compliance program structured to address such risks?	39
How are “at risk” operations assessed from a compliance perspective? Is conformance with the organization’s compliance program periodically evaluated? Does the organization periodically evaluate the effectiveness of the compliance program?	39
What processes are in place to ensure that appropriate remedial measures are taken in response to identified weaknesses?	39
What is the process by which the organization evaluates and responds to suspected compliance violations? How are reporting systems, such as the compliance hotline, monitored to verify appropriate resolution of reported matters?	40
Does the organization have policies that address the appropriate protection of “whistleblowers” and those accused of misconduct?	40
What is the process by which the organization evaluates and responds to suspected compliance violations? What policies address the protection of employees and the preservation of relevant documents and information?	40
What guidelines have been established for reporting compliance violations to the Board?	40
What policies govern the reporting to government authorities of probable violations of the law?	41

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