Cone Health Commitment to Our Communities and Integrity
A culture of Caring for Our Communities is one of the core values of Cone Health and we strive to engage our communities with integrity and transparency. As such, Cone Health is committed to conducting its business in accordance with the laws, regulations and standards to which health care organizations are held.
Cone Health has a Compliance & Integrity Program. The Compliance & Integrity Program includes the Cone Health Code of Conduct, Cone Health Compliance & Integrity Plan, policies and procedures, education and training, auditing and monitoring, and a Compliance & Privacy Helpline by which Cone Health team members can report concerns anonymously if they choose, without fear of retaliation.
Cone Health expects its team members (i.e., employees, board members, agents, independent contractors, students, medical professionals and specialists, volunteers, business partners and others associated with Cone Health) to support the Cone Health Compliance and Integrity Program and the Cone Health standards of integrity.
Pursuant to the Deficit Reduction Act of 2005, provided below is information about fraud, waste and abuse and how to report a compliance and integrity concern (anonymously if you choose) without fear of retaliation.
Deficit Reduction Act of 2005
Section 6032 of the Deficit Reduction Act (DRA) requires entities that make or receive annual Medicaid payments of $5 million or more to provide federal False Claims Act education to their team members and establish written policies with respect to the role of laws in preventing and detecting fraud, waste and abuse.
It is the policy of Cone Health to obey all federal and state laws and to develop policies and procedures to detect and prevent fraud, waste and abuse regarding payments from federal and state health care programs, and to provide protections for those who report actual or suspected wrongdoing.
False Claims Act
The False Claims Act (FCA) is a federal law that imposes civil liability on entities who knowingly defraud federal payment plans such as Medicare and Medicaid.
North Carolina False Claims Act
According to the North Carolina False Claims Act, it is unlawful to knowingly cause the state to pay claims that are false or fraudulent. Civil penalties will apply when money is obtained from the state by reason of a false or fraudulent claim.
Examples of Health Care Fraud
- Submitting claims that knowingly have been fabricated.
- Billing for medical services that were not provided to the patient.
- Upcoding and unbundling codes with the intent to increase reimbursement.
- Knowingly using a false record or statement to obtain payment on a false or fraudulent claim.
The FCA allows individuals to file a qui tam “whistleblower” lawsuit on behalf of the United States government against any person or entity that has committed fraud and potentially share in a percentage of the amount recovered.
The FCA grants protection from retaliation for filing a lawsuit or assisting in a false claims action. Cone Health is committed to encouraging and enabling good faith reports of observed or suspected misconduct or noncompliance with applicable laws and regulations without fear of retaliation or retribution.
Any Cone Health team member who has knowledge of suspected false claim violations or fraud, waste and abuse concerns, will report it using one or more of the following methods: their leader or a higher-level leader, Human Resources Department, or the Audit & Compliance Services Department 336-832-7073. A report may also be made directly to the Compliance & Privacy Helpline at 855-809-3042 or via the web at www.conehealth.ethicspoint.com
Conflict of Interest
A conflict of interest is any relationship that could compromise a team member’s ability to perform his or her responsibilities objectively and/or to act in the best interests of Cone Health.
The following examples would be considered conflicts of interest:
- Employment by a competitor or potential competitor while employed by Cone Health
- Direct or indirect ownership of, or substantial interest in, a company that is a competitor or a supplier of goods and services to Cone Health
- Acceptance of gifts, payments or services from those doing business or seeking to do business with Cone Health
- Serving as a director, officer, consultant or other key role with a company doing (or seeking to do) business with or competing with Cone Health
- Hiring or contracting with a family member or a friend to provide goods and/or services to Cone Health
- Any business or financial interest, or relationship you or a member of your family have that might appear to influence your ability to meet your obligations to Cone Health
All Cone Health team members have a duty to disclose actual or potential conflicts as a condition of employment or affiliation.
Medicare Advantage Special Needs Model of Care Training and Compliance Program Guidelines Training
Cone Health is required to provide Medicare Advantage training developed by Centers for Medicare and Medicaid Services (CMS) due to our contracts with Medicare Advantage Organizations (MAO).
The CMS Medicare Advantage training addresses the following:
- The special needs plans model of care for delivering coordinated care and care management to special needs members; and
- The key elements of effective compliance programs, the mechanisms for reporting potential noncompliance or fraud, waste and abuse, and various compliance resources.
Review the Special Needs Plan Model of Care Training
Review the Medicare Advantage Compliance Program Guidelines Training
HITRUST Policies and Procedures
Cone Health Information and Technology Services is committed to the security of ITS assets, personnel, and infrastructure. This requires policies and procedures that enable Cone Health to meet the high standards of HITRUST certification. View applicable policies.