Corporate Compliance Department

Corporate Compliance Program

Hackensack University Medical Center has a long standing commitment to good corporate citizenship and best-practice governance.  To that end, we have established a Corporate Compliance program that requires participation by every member of the Medical Center, regardless of his or her position in the organization.  The program assures that all actions conform to the highest ethical standards and comply with all applicable laws, rules and regulations.

Hackensack University Medical Center's Corporate Compliance Department is charged with implementing the organizational Compliance Plan and with assuring that the Medical Center, its employees and staff comply with applicable laws and regulations, with particular focus on the Federal and NJ False Claims Acts, the Anti-Kickback Statute and Stark Laws.

The foundation for the Compliance Program was adopted from the Department of Health and Human Services, Office of the Inspector General (OIG)  Model Compliance Program Guidance for Hospitals (February 1998) as well as the additional supplemental guidance (January 2005).   Hackensack University Medical Center has set policy, adopted by the Board of Governors that clearly articulates the desire to comply with all federal and state laws.  To that end we have implemented and will enforce procedures to detect and prevent fraud, waste and abuse regarding payments to the Medical Center from federal or state healthcare programs and private payers.  HackensackUMC is committed to providing protections for those who report actual or suspected wrongdoing.

 The Medical Center has adopted and implemented the following as part of the Compliance Plan:

  •  A Code of Conduct and policy reflecting the organizational commitment to compliance.
  •  A Compliance Officer and a Compliance Executive Committee charged with the responsibility for developing, operating, and monitoring the compliance program and with the authority to report directly to the head of the organization and the Board of Governors.  Thomas Flynn, MBA, FACHE, CHC has served as the Medical Center’s Chief Compliance Officer since 2001  and in that capacity reports directly to the Board of Governors and the Chief Executive Officer.
  • Policy and procedure designed to address state and federal requirements regarding fraud and abuse.
  • Routine training to include an initial employee orientation to the Medical Center’s Compliance program followed by annual training to reinforce the requirements of applicable laws, rules and regulations and each employee’s rights and responsibilities pursuant to those laws. 
  •  A Hotline  to provide employees and vendors doing business with the Medical Center with a confidential and anonymous means of reporting on compliance related issues when normal reporting mechanisms are not appropriate.
  • An initial and ongoing process to screen employees and physicians to assure that they have not been debarred or excluded and are eligible to participate in state and federal programs. Vendors complete a similar screening as part of the Vendor Qualification process (vendor qualification long form, vendor qualification short form,  DEHP/PVC Free letter, Sanction Form, W9, Defecit Reduction Act).  Each vendor to the Medical Center also acknowledges their acceptance of the compliance policies and their agreement to provide their staff with access.  
  • A Conflict of Interest policy that explains how interactions with industry within the medical center must conform to guidelines intended to avoid potential conflicts of interest.  Included in the policy is the requirement for covered individuals to disclose potential conflicts to their patients and the need to periodically disclose potential conflicts as a condition of appointment and reappointment to the medical staff.
  • An annual risk assessment and development of an audit plan based on identified risks.  This process is monitored and results are reported to the Audit and Compliance Committee of the Board of Governors.

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