Compliance is understanding your job responsibilities and following the laws, regulations, and internal policies that apply. The DUHS Compliance Program creates the framework to ensure that our workforce is properly trained to follow all the laws, regulations, and policies that relate to our operations and provide a way for the workforce to raise compliance concerns and ask questions.

The Compliance Offices oversees the program and addresses such activities as:

• Honoring patients' rights
• Maintaining and retaining records
• Billing and coding for services
• Protecting the health and safety of human and animal subjects in research
• Reviewing Conflict of Interest
• Providing a safe working environment free from disruptive and inappropriate behavior
• Protecting the confidentiality of patient, business, and personal information
• Complying with all the laws governing federal- and state-funded health care programs and the requirements of insurance companies

All DUHS staff, medical staff, volunteers, contractors, vendors and others with whom we do business are required to comply with federal, state and local laws and regulations, the DUHS Compliance Program, the Duke Medicine Code of Conduct and other Duke policies or procedures

Anyone who violates applicable policies, laws, regulations such as the False Claims Act, or the Code of Conduct may be disciplined. People may also be disciplined if they do not report a compliance violation. Disciplinary action may include being terminated or having a contract revoked.

It is a violation of the Federal False Claims Act for anyone to knowingly submit, or cause another person or entity to submit, false claims for payment of government funds. Examples of actions that could violate the False Claims Act include:

• Filing a claim for services that were not provided.
• Filing a claim for services that were provided but were not medically necessary.
• Submitting a claim containing information known to be false.

Penalties for such action(s) may be three times the government's damages plus civil penalties of $5,500 to $11,000 per false claim and in criminal cases may include imprisonment. Healthcare organizations also can be excluded from participation in federal health care programs.

The False Claims Act contains provisions that allow employees with actual knowledge of alleged false claims to sue on behalf of the government. These individuals will be protected from retaliation, e.g., harassment, demotion, and wrongful termination, as a result of the employee's lawful acts in furtherance of a false claims action.

Anyone who has a question or suspects a violation of the False Claims Act or any other federal or state law, the DUHS Compliance Program, the DUHS Code of Conduct, or other policies or procedures has a duty to report the issue. The following reporting channels may be used to inform Duke management officials of questionable activities:

• Report directly to your supervisor, a department head or chair, your Facility Compliance Officer or to the DUHS Chief Compliance Officer (668-2573). See http://staff.dukehealth.org/compliance for a list of compliance contacts.
• Call the toll-free Compliance Program Integrity Line (1-800-826-8109). Reports may be made anonymously and all calls are not recorded or traced.

No one who in good faith reports an actual or suspected violation of law or DUHS policy will experience any retaliation or retribution as a result of such reporting, regardless of whether or not, after investigation, a violation is found to have occurred.