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Compliance Policy


Applicable to:  Shawnee Organization
Subject:  Corporate Compliance
Category:  Corporate ComplianceExecutive Director:  Signature on file
Distribute to:  Management ManualBoard President:  Signature on file
Effective Date:  08/19/04Review Dates:  09/14/06; 12/09
Policy Revised Date(s):Procedure Revised Date(s):  12/09
Reference Policies:  Code of Ethics – Management Manual
Disciplinary Procedures – Personnel Manual


The development of the corporate compliance program is part of the continuing effort of Shawnee Health Service to improve the quality of services and to further the Shawnee mission.  Shawnee Health Service is committed to providing high quality, cost-effective health care in compliance with the law.  Shawnee Health Service programs and health centers can meet its commitment through the efforts of providers and support staff.  Each must earn the trust and respect of Shawnee clients and of the individuals and organizations with whom and with which Shawnee does business by conducting himself or herself with honesty and integrity and by adhering to the laws that are applicable to the health centers and programs.
In this regard, Shawnee Health Service recognizes that the Department of Health and Human Services, Office of Inspector General (OIG), the federal agency charged with enforcing the Medicaid and Medicare laws, has published a series of compliance program guidance for members of the health care industry. These guidance set forth the components of an effective compliance program and encourage health care providers, including health centers, to develop and implement these components as part of their efforts to monitor compliance with applicable statutes, regulations and program requirements.
Shawnee Health Service’s compliance program has utilized the seven elements of the U.S. Sentencing Commission Guidelines, recommended by the Office of Inspector General (OIG), in developing a comprehensive value-based Corporate Compliance Program that will establish internal controls and monitoring to correct and prevent fraudulent activities. The SHS Corporate Compliance Program will satisfy, at a minimum, the following elements:

  1. Develop and distribute a written code of ethics which provide standards of conduct, as well as written policies and procedures that promote the commitment to compliance;
  2. Designate a corporate compliance officer and other appropriate bodies responsible for operating and monitoring compliance program;
  3. Develop and implement appropriate and effective education and training programs;
  4. Maintain a process to receive complaints and procedures to protect anonymity and prevent retaliatory measures;
  5. Enforce standards through well-publicized disciplinary guidelines;
  6. Conduct audits or other evaluation techniques to monitor compliance and address identified problem areas;
  7. Respond to detected offenses and develop corrective action initiatives.

Success of the SHS Corporate Compliance Program (the “Program”) depends upon the development and integration of ethical and legal requirements of the organization. These requirements are delineated as follows:

  • The Code of Ethics is an SHS organizational policy delineating the moral principles guiding the
    mission and values of SHS and its members. This policy is located in SHS Management Manual.
  • Compliance Policies and Procedures, located in this policy, are developed to meet the legal and
    regulatory requirements of the organization.

Although the implementation and management of the Program is centralized, compliance is the direct responsibility of each employee.  The Program will communicate to every employee and independent practitioner their responsibility to comply with ethical and legal standards and the duty to report suspected violations to Management and the Corporation Compliance Officer.  The Program will be communicated to every employee through compliance training programs.  Employees will receive the level of compliance training relevant to their function and position of authority.  Human Resources will maintain current compliance training records to be used as a standard for employee performance evaluations.  Committees will periodically perform audits to monitor compliance training effectiveness.
It is the intent of the organization to integrate corporate compliance throughout the corporation’s policies and procedures, thus this policy merely provides an overview of Shawnee Health Service’s Corporate Compliance Program.  For example, policies in the Business Office Manual outline specific procedures to ensure compliance to coding and billing practices; and the Personnel Policy and Procedure Manual outlines policies that related to nondiscrimination and equal employment opportunity.


  1. Responsibilities of Corporate Compliance
    For the Corporate Compliance Program to be effective, all employees must participate and understand their roles and responsibilities.  Roles and responsibilities are as indicated:
  1. Board of Directors:
    The Board of Directors has the responsibility to ensure that the Program’s objectives are consistent with Shawnee’s mission.  Objectives of the Program will be reflected in all governance, risk management, information management, financial and operational activities, and that those activities are in compliance with all applicable laws.  The effectiveness of the Program will be monitored through reports from the Corporate Compliance Officer.The Board of Directors has the authority and responsibility to make final decisions concerning compliance issues.  Any policy change must be approved by the Board of Directors.
  2. Senior Leadership Committee
    The Senior Leadership Committee will advise the Corporate Compliance Officer and will assist in the implementation and management of the Corporate Compliance Program. The Senior Leadership Committee will collaborate with the Corporate Compliance Officer to perform the following responsibilities:
  • analyze the organization’s business environment, the legal requirements with which it must comply, and the identification and prioritization of specific risk areas;
  • assess existing policies and procedures that address specific risk areas for possible incorporation into the Compliance Program;
  • work with appropriate committees to develop new policies and procedures;
  • determine the need for internal or external audits, assist in the selection of external auditors or internal audit teams;
  • participate on, or appoint, interdisciplinary teams to improve process and/or performance concerning compliance related issues pertinent to different programs;
  • monitor the Corporate Compliance Program’s effectiveness within Shawnee programs and health centers and assist in preparing an annual report for the Board of Directors including goals for performance improvement;
  • exercise vigilance in detecting areas of risk or possible violation of state or federal laws, policies or procedures; and,
  • act as a source of information or liaison for employees and the Corporate Compliance Officer.
  • Executive Director
    The Executive Director will supervise the daily activities of the Corporate Compliance Officer. The Executive Director will work with the Corporate Compliance Officer in identifying legal requirements that apply to the organization’s business to minimize risk of non-compliance. Executive Director will assist the Corporate Compliance Officer in planning special external investigations and will address audit findings.
    Executive Director will review the work of the Corporate Compliance Officer to confirm appropriate investigations of potential fraud and abuse violations are conducted, that proper procedures in identifying potential liabilities are followed, and that policies and procedures are reviewed as necessary. Executive Director is authorized to retain external experts for consultation, assistance or audits. Executive Director will consult with the Corporate Compliance Officer to determine if voluntary disclosure and repayment is warranted.
    If SHS is investigated Executive Director will discuss the scope of the investigation with the investigators and will be responsible for coordinating the organization’s response to the investigation. Executive Director will negotiate any organization settlement deemed necessary or prudent.
  • Corporate Compliance Officer:
    The Corporate Compliance Officer responsibilities will be conducted by the Assistant Director and Operating Officer.
    All reports received, inquiries conducted, recommendations for action, and all related matters shall be reported in writing to the Executive Director and to the Senior Leadership Committee on a formal basis quarterly.
    The Corporate Compliance Officer is responsible for the development, implementation and management of the Corporate Compliance Program for SHS programs and health centers. To assure the effectiveness and integrity of the Program, the Corporate Compliance Officer shall have the cooperation of the Board of Directors, Executive Director, management staff, as well as professional staff and employees. Investigations of complaints may be undertaken by the Corporate Compliance Officer after consultations with the Executive Director.
    The Corporate Compliance Officer will develop and implement a multifaceted education and training program that focuses on SHS Codes of Ethics and Corporate Compliance Program. SHS Board of Directors and employees will receive appropriate compliance training that is pertinent to their responsibilities.
    The Corporate Compliance Officer will establish and manage a confidential communication system for employees and others to report suspected non-compliant activities or seek guidance concerning compliance issues without fear of retaliation.
    The Corporate Compliance Officer may investigate any issues of non-compliance after consultation with the Executive Director.  Corrective action plans will be developed in consultation with the Executive Director to address noncompliance for various department and service areas, including providers and independent contractors.
    The Corporate Compliance Officer will monitor compliance through periodic internal and/or external audit systems.  All audit systems shall be approved in advance by the Executive Director.
    The Corporate Compliance Officer will require that independent contractors and agents who furnish medical services to the facility receive education on the Corporate Compliance Program and agree to comply with pertinent policies and procedures concerning coding, billing, marketing, and any other area specific to their functions.
    The Corporate Compliance Officer will submit a quarterly compliance activity report to the Senior Leadership Committee and the Board of Directors on all reports received, investigations conducted, recommendations made and all other compliance related issues.  The report will include any prosecutions or administrative actions commenced against SHS, professional staff, or employees, which involve or are alleged to involve any of the following:
  • Any criminal action involving a felony, any material crime against SHS, embezzlement or larceny, violation of any law relating to performance in a governmental program, or regulation by a public body.
  • Any material administrative action by a regulatory body relating to a finding of illegal or improper conduct by professional staff or employees.
  • Program Directors and Clinic Managers
    Program or clinic managers are responsible for contributions to the development and implementation of the Corporate Compliance Program.  Their responsibilities are to:

    • Assist the Corporate Compliance Officer in performing a program or clinic risk assessment:
    • Develop, or participate in the development of compliance policies and procedures in their areas of expertise;
    • Ensure that implementation guidance and education is provided to their program/clinic and its employees;
    • Establish monitoring processes for their area of compliance risk;
    • Review audit reports to determine if additional education or policy revision or development is needed;
    • Network with colleagues, subscribe to informative publications relating to new developments in their areas of compliance responsibility, and appropriate dissemination and management of that information;
    • Provide advise or interpretation of policies and procedures concerning area of expertise;
    • Communicate policy changes to their program/clinic and its employees; and,
    • Communicate questions or concerns regarding compliance issues to the Corporate Compliance Officer.
  • Internal Audit Teams
    Internal audit teams will be selected by the Corporate Compliance Officer and/or the Senior Leadership Committee when appropriate.  An internal audit team will meet before an audit to prepare an action plan and receive any additional information and training as needed.  Responsibilities of the internal audit teams are to assist the Corporate Compliance Officer in performing risk analysis to determine fraud and abuse risk factors, perform audits to detect illegal acts, identify and report any significant deficiencies in the system of internal control, and make recommendations for improvement of internals systems.
  • Employees
    The effectiveness of the Corporate Compliance Program depends upon the complete participation of all employees.
    All employees are required to comply with all the standards, policies and procedures of the Corporate Compliance Program. Employees are required to attend all mandated ethics and compliance education and training sessions; perform job responsibilities in an ethical, effective, and professional manner; understand and abide by SHS Code of Ethics; comply with all state and federal laws, standards, policies and procedures; report potential fraud and abuse violations to Program Director, Clinic Manager or Corporate Compliance Officer.
  • Corporate Compliance Education and Training Programs
    1. Ethics Training
      Training on SHS Code of Ethics is an integral part of the Corporate Compliance Program. Training will be completed at new employee orientation; existing employees will receive initial training. The training will integrate the SHS code of Ethics with its mission.
    2. Compliance Training
      SHS requires employees to attend compliance training specific to their job duties and responsibilities on an as needed basis, including training in federal and state laws, policies of private payors, SHS policies and procedures, and corporate ethics.  SHS training programs consist of three levels of training: orientation, advanced and specific.
      The Orientation level includes a review of SHS’ mission and code of ethics, compliance background, program purpose and an overview of the SHS Corporate Compliance Program.  All existing employees will receive compliance orientation within six (6) months of Board approval of the Corporate Compliance Program. All new employees must receive compliance training orientation within 60 days of their hire date.
      The Advanced level will include appropriate training in federal and state statutes, regulations, guidelines and policies of private payors pertaining to fraud and abuse laws and violations.  This level will also include training in the identification of areas of high risk and vulnerability.  This level will concentrate on healthcare law and devote more attention to business practices.
      The Specific level will provide specialized training for specific areas.  This training will focus on compliance with specific policies and procedures in particular environments including, but not limited to, coding, billing, cost reporting and marketing processes.
      All employees will participate in various compliance training programs.  Their attendance and participation in training programs are a condition of continued employment and failure to comply with these requirements will result in disciplinary action, including possible termination, when such failure is serious.  Adherence to the Corporate Compliance Program, including training requirements, is a factor in the annual evaluation of each employee.  Records of training of employees will be retained by the Human Resources Department, including attendance logs and material distributed at training sessions.
      Listed below are employee groups and the level(s) of compliance training they will receive:
      Orientation Advanced Specific
      Board of Trustees x x As needed
      Senior Leadership Committee x x As needed
      Program Directors and Clinic Managers x x As needed
      Employees x As needed
      The Corporate Compliance Officer will audit and review, on an annual basis, the training programs to determine if they are effective and their content is applicable to current policies and laws; recommendations for improvement will be made to the Senior Leadership Committee.
      The Corporate Compliance Officer shall disseminate updates of state and federal regulations, SHS policies and procedures, and any other information pertaining to compliance issues through newsletters, memos, e-mail or other appropriate means.  This information will be shared with all appropriate employees by the Program Directors or Clinic Managers at staff meetings, special meetings, or on an individual basis.
      Program Directors or Clinic Managers will assist in identifying areas that require specific training and will assist in implementing training.  The Corporate Compliance officer will utilize internal and external trainers to deliver specific training program.  Any formal training as part of the Compliance Program will be documented and maintained in the Human Resources file.
  • Communication Systems
    1. Mechanisms for Communications to Employees:
      The Corporate Compliance Officer will disseminate all pertinent compliance program information through employee orientation, Program Director and Clinic Manager training, publications, memos, updates and e-mail.  Program Directors and Clinic Managers will disseminate this information through staff meetings and special meetings on an asneeded basis.  Information concerning new regulations or policies will be addressed in a timely manner in order to implement new procedures.
    2.  Mechanisms for Communications from Employees:
      Employees are encouraged to discuss questions concerning interpretation of laws, policies and procedures, concerns about ethical or legal acts of wrongdoing or any other compliance issues with their immediate supervisor.  When, due to the nature of the concern, this is not possible, or the employee is not satisfied with the response, he/she may continue with the line of authority or call the Corporate Compliance Officer at the “employee helpline” number.
      It is the responsibility of the Corporate Compliance Officer to provide all employees with a means of reporting noncompliant activity at any time and without fear of repercussions or retaliation.  SHS has established a helpline number, 618-956-9506.  This number is available at any time for employees to ask compliance related questions or report actual or potential non-compliant activities, including those involving billing and claim submission, fraud and abuse laws and regulations, violation of SHS Code of Ethics, policies and procedures.  Helpline reports can only be accessed by the Corporate Compliance Officer or an authorized designee.  All reports made to the helpline will be investigated in a prompt and reasonable manner by the Corporate Compliance Officer or Senior Leadership Committee.  Individuals shall not be subject to retaliation on the part of any person affiliated with SHS based on reports that are submitted in good faith.  Any such retaliation is a violation of the Corporate Compliance Program and should be reported immediately to the Corporate Compliance Officer.
      It is the responsibility of the Corporate Compliance Officer to ensure the integrity and confidentiality of all reports received through the helpline.  The Corporate Compliance Officer shall also maintain a record of all reports and inquiries.
  • Enforcement
    As noted in SHS Personnel Policies and Procedures, employees are responsible for conducting themselves in an ethical and professional manner at all times while acting in an official capacity with SHS. Failure to comply with any of the Shawnee’s policies, including the Corporate Compliance policies, subjects the employee to disciplinary action, including discharge.  SHS’ commitment to compliance applies to all personnel levels within the organization.  The consequences of non-compliance will be consistently applied and enforced.  All employees, independent practitioners and independent contractors will be subject to the same disciplinary action for the commission of similar offenses.
    All compliance training programs will stress that all employees have a responsibility and obligation to report any noncompliant activities committed by others, including supervisors.  Violation of the Corporate Compliance Program, applicable statues and regulations is considered very serious and those failing to comply or neglecting to report others failing to comply will be disciplined.
  • Auditing and Monitoring
    1. Audits
      The Corporate Compliance Officer, in consultation with the Executive Director and Senior Leadership Committee, will construct a corporate annual audit plan, determine who shall comprise the internal audit teams based upon the particular expertise requirements and the situation, and determine the priority and frequency of audits.  Audits will focus on the corporation’s compliance with specific rules and policies that have been the focus of particular attention on the part of the Medicare fiscal intermediaries or carriers, as evidenced by the OIG Special Fraud Alerts, OIG audits and evaluations grant funding agencies and law enforcement initiatives. In addition, audits will focus on any area of
      concern that has been identified by any employee.
      Audits may be performed by the Corporate Compliance Officer or by internal audit teams consisting of SHS employees or external auditors, depending upon the specific area being audited and the situation.  Attachment A notes the audit process to be employed.
      Audits will establish baseline for future monitoring and benchmarking analyses to determine the facility’s progress in reducing or eliminating the risks.  The Corporate Compliance Officer will review audit findings and provide recommendations for corrective action to the Senior Leadership Committee.  If it is determined that an audit revealed improper procedures, misinterpretation of rules, including fraud and systemic problems, the Corporate Compliance Officer in consultation with the Executive Director will take prompt steps to correct the problem.  The Corporate Compliance Officer will report any overpayments discovered to the Executive Director to determine appropriate
      reporting and reimbursement to the affected payor.  Any overpayments will be paid promptly, regardless of whether demand has been made for such payment. Any such payment must be approved by the Executive Director.
    2. Validation
      Any time a corrective or improvement plan is a result of an audit, it is vital to monitor that change to validate its success.  To accomplish this, the Corporate Compliance Officer will perform a status review audit within eight (8) months after implementation of the action plan.  This audit will serve as a “spot check” to determine if the changes made are resulting in the desired outcomes.  Validations and audits will be monitored and scheduled by the Corporate Compliance Office.  Any need for major change will be reported to the Executive Director for authorization.
  • Response to Detected Systemic Non-Compliance and Initiating Corrective Action
    Non-compliance of the Corporate Compliance Program and the failure to comply with SHS Code of Ethics, federal or state law or regulations threaten SHS’s status as a reliable, honest and trustworthy provider.  Detected but uncorrected non-compliant activities can seriously endanger the mission, reputation and legal status of SHS.  Consequently, upon the receipt of reports or reasonable indications of suspected non-compliance, the Corporate Compliance Officer will initiate prompt steps to investigate the conduct in question to determine if a material violation of applicable law or the
    requirements of the Corporate Compliance Program has occurred, and if so, take steps to correct the problem.

    1. Response
      Upon Receipt of an allegation of a violation of Shawnee’s Code of Ethics, policies or procedures, state or federal law or regulation, the Corporate Compliance Officer shall review all the facts to ensure comprehension of the issue.  Upon receipt of reports, the Report of Non-compliance protocol (attachment B) will be utilized, and the Corporate Compliance Officer will notify the Executive Director.
      The Corporate Compliance Officer and the Executive Director will identify any investigational support needed for the investigation and prioritize as follows:
      Priority One Initiate within 24 hours
      Priority Two Initiate within 7 working days
      Priority Three Initiate within 24 working days
      The Corporate Compliance Officer shall then submit a summary report of the investigation to the Executive Director.
    2. Corrective Action
      The results of an investigation may be serious enough to warrant immediate corrective action or to require interdisciplinary efforts to address and to correct.  The Executive Director shall have the authority and the responsibility to terminate the operation of any department or function that is in regulatory violation.  The “Follow-up Protocol” (attachment C) will be utilized to terminate any inappropriate billing or non-compliant activity and identify any employee who may be engaging in illegal or non-compliant activity.
      The Executive Director and Corporate Compliance Officer will determine if credible evidence of non-compliant activity involving criminal, civil or administrative law which warrants reporting to the appropriate governmental authority.  If it is determined there is credible evidence of non-compliant activity, it must be reported within a reasonable period of time and SHS will take appropriate corrective action, including prompt restitution of any overpayment to the affect payor and
      the imposition of proper disciplinary action.  The Corporate Compliance Officer will see that employees receive appropriate training to prevent reoccurrence.  Ongoing monitoring will be established to ensure continued compliance, and the case will be closed.  All compliance documentation will be maintained in a confidential file by the Corporate Compliance Officer.
  • Recordkeeping Requirements:
    The Corporate Compliance Officer will document efforts to comply with applicable statutes, regulations and federal health care program requirements.  Reports will be maintained by the Corporate Compliance Officer in accordancewith this Program and shall be maintained for a period of seven (7) years.  At the end of seven (7) years, all pertinent documentation relating to reporting of compliance activities may be destroyed in accordance with procedures established by SHS for destruction of confidential records. Compliance documents to be destroyed will include, but are not limited to:

    • Helpline Reports
    • Helpline Logs
    • Reports to the EXECUTIVE DIRECTOR, Senior Leadership Committee or Board of Directors
    • Audit Reports
    • Audit Worksheets
    • Corporate Compliance training records.
  • Attachments:
    1. Compliance Audit Process
    2. Report of Non-Compliance Protocol
    3. Follow-Up Protocol
    4. Compliance Activity Report

Corporate Compliance Policy Attachment A

Corporate Compliance Policy Attachment BCorporate Compliance Policy Attachment C


  1. Education and Training Update
  2. Audit Activities
    1. Scheduled
    2. Investigative
    3. Future Audits
  3. Helpline Report Summary
    1. Type of Call
    2. Subject
    3. Status
  4. Policy Changes
  5. Compliance Updates


data/Mangmt P&P/Corporate Compliance 1209 1

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