The definition of compliance embraces many things. It means adhering to laws, rules, regulations, policies, and procedures governing the day to day operations of VUMC. Because healthcare has become so complex in recent years, the industry is under constant scrutiny. Having an effective compliance program in place helps to avoid or minimize legal or regulatory penalties and potential civil litigations. VUMC's Compliance Program promotes ethical conduct and is designed to establish a culture within VUMC that promotes prevention, detection, and resolution of conduct that does not conform to federal and state law; federal, state, and private payor health care program requirements; and the hospitals ethical and business policies.
Vanderbilt University Medical Center (VUMC) is committed to its role in preventing health care fraud, waste, and abuse and complying with all applicable state and federal laws related to health care fraud, waste, and abuse. The Deficit Reduction Act of 2005 requires dissemination of information about both the federal False Claims Act and other laws, including state laws, dealing with fraud, waste, and abuse and whistleblower protections for reporting those issues.
Most physicians strive to work ethically, render high-quality medical care to their patients, and submit proper claims for payment. Society places enormous trust in physicians, and rightly so. Trust is at the core of the physician-patient relationship. When our health is at its most vulnerable, we rely on physicians to use their expert medical training to put us on the road to a healthy recovery.
The Federal Government also places enormous trust in physicians. Medicare, Medicaid, and other Federal health care programs rely on physicians' medical judgment to treat beneficiaries with appropriate services. When reimbursing physicians and hospitals for services provided to program beneficiaries, the Federal Government relies on physicians to submit accurate and truthful claims information.
The presence of some dishonest health care providers who exploit the health care system for illegal personal gain has created the need for laws that combat fraud and abuse and ensure appropriate quality medical care. This brochure assists physicians in understanding how to comply with these Federal laws by identifying "red flags" that could lead to potential liability in law enforcement and administrative actions. The information is organized around three types of relationships that physicians frequently encounter in their careers:
The five most important federal fraud and abuse laws that apply to physicians are the:
Government agencies, including the Department of Justice, the Department of Health & Human Services Office of Inspector General (OIG), and the Centers for Medicare & Medicaid Services (CMS), are charged with enforcing these laws. As you begin your career, it is crucial to understand these laws not only because following them is the right thing to do, but also because violating them could result in criminal penalties, civil fines, exclusion from the Federal health care programs, or loss of your medical license from your State medical board.