Compliance Program

The mission/purpose of the Harris Health System's Compliance Program is to ensure Harris Health System operates in accordance with laws and regulations. Specifically, the program is designed to:

  • prevent any accidental and intentional violations of law,
  • detect violations if they occur,
  • and correct activities that may lead to future non-compliance.

The program structure consists of the following four parts, each of which has certain responsibilities:

  • The Board of Managers Corporate Compliance Committee provides oversight of the program;
  • The Executive Corporate Compliance Committee advises and assists with the operation of the program and supports the Corporate Compliance Officer;
  • The Corporate Compliance Officer directs the daily operations of the program; and
  • The Corporate Compliance Department staff carries out the plans, policies and assignments that make the program effective in its compliance functions.

All hospital compliance programs consist of seven elements as defined by the Office of Inspector General of the U.S. Department of Health and Human Services in 1998. The seven elements include:

Code of Conduct: The foundation document for the Harris Health Compliance Program. Everyone doing business with Harris Health is subject to the Code and must abide by it. The Harris Health Code of Conduct can be viewed by clicking on the link at the end of this page.

Corporate Compliance Officer: The Corporate Compliance Officer can be reached at 713-566-2332 for direct contact/reporting.

Policies and Procedures: Written documents describing operational compliance requirements and instructions.

Hotline and Communication: Provides the ability to report suspected wrongdoing without fear of retaliation.

Auditing and Monitoring: Involves on-going review of the Corporate Compliance Program and other risk areas.

Enforcement: Ensures disciplinary standards imposed for non-compliance.

Education and Training: Ensures all employees can perform job functions in compliance with rules and regulations.

Below is a summary of important laws and regulations that govern the Compliance Program.

Deficit Reduction Act of 2005
Requires entities that receive or make annual payments of at least $5 million under a state Medicaid program to establish written policies for employees and contractors that provide detailed information about the Federal False Claims Act (FCA), administrative remedies, any state laws pertaining to civil or criminal penalties for false claims and statements, and whistleblower protections under such laws to prevent and detect fraud, waste and abuse in Federal Health Care Programs.

Federal and State False Claims Acts
It is a violation of Federal and Texas laws to knowingly submit claims for payment with false and untrue information. Both Federal and Texas False Claims Act contain Qui Tam provisions to protect whistleblowers.

Any person who reports an allegedly false claim to the federal or state government or participates in their investigation is protected by these acts; includes a prohibition on termination, demotion, suspension, threats, harassment and discrimination; and retaliation is also not permitted.

Anti-Kickback Statute
It is a criminal offense to offer, pay, solicit or receive any remuneration to induce or reward referrals of items or services reimbursable by a Federal Health Care Program.

Stark Law
The Stark Law prohibits a physician (or an immediate family member of such physician) who has a financial relationship (including compensation and investment/ownership interests) with an entity from referring patients to the entity for certain health services covered by the Medicare program, unless an exception is available.

Health Insurance Portability and Accountability Act (HIPAA)
Provided for portability of health insurance and establishes standards for privacy and security of patient information.

Fraud and Enforcement Recovery Act of 2009 (FERA)
Expands exposure under the False Claims Act (FCA) by imposing liability for:

- Making statements to a private entity such as a subcontractor that results in payments of federal funds.

- Retaining money owed to the government such as an obligation to refund overpayments.

FERA also expands protection to whistleblowers, permits sharing and use of information between the government, state and local law enforcement agencies and the whistleblowers, and expands the statute of limitations for FCA actions.

American Recovery and Reinvestment Act of 2009 (ARRA) including the HITECH Act
The American Recovery and Reinvestment Act of 2009 (ARRA) and the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 make HIPAA's privacy and security standards more stringent and important for health care providers and their employees.

It is everyone's affirmative duty to report any violations of the law or Harris Health System Code of Conduct. To report violations of laws, regulations or policies, use the following mechanisms:

Contact the Corporate Compliance Officer at 713-566-6461, or call the confidential Compliance Hotline at 1-800-500-0333. The hotline is the only method that ensures your anonymity.

It is the policy of Harris Health System that no disciplinary action or retaliation will be taken against anyone for reporting a perceived issue, problem, concern or violation to Management, Human Resources, Corporate Compliance, DNV, or the Compliance Hotline in good faith pursuant to the Federal False Claims Act, State False Claims Act or other law.

For more information about the Harris Health System Compliance Program, please refer to the following:

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