A variety of employees who fall under the category of “Certifying
Employees” must sign an annual statement that they have received
training in compliance and have promoted compliance for their
The entity must adopt policies and procedures associated with the
Anti-Kickback Statute56 and the Stark Law57 within 90 days of the
effective date of the CIA.
A comprehensive training plan must be developed for the workforce
members that covers a variety of compliance policies and procedures
sources meet compliance with federal law, including tracking all
monies paid to and from the parties, logging and tracking services
performed under the arrangements, and a host of other monitoring
obligations associated with the arrangements.
When entering into a service arrangement with a referral source, the
other party must agree to have certain workforce members receive at
least one hour of compliance training under the WCH CIA.
The entity must hire an “Independent Review Organization” to
conduct extensive reviews of the compliance program and the
organization’s compliance with federal laws governing financial
relationships with referral sources.
The entity must conduct an annual risk assessment associated with its
activities related to participated in federal health care programs.
Access to the compliance program must be established for any
individual to disclose suspected non-compliance to the organization
that offers anonymous correspondence.
All employees and independent contractors must be screened against
the HHS-OIG List of Excluded Individuals/Entities.
The entity must disclose certain “reportable events” (e.g., substantial
overpayments from federal health care programs) to HHS-OIG
within 30 days of identifying that a matter meets the definition of a
Compliance Committee. Based on its inquiry and review, the Board has concluded that, to the
best of its knowledge, WCGH has implemented an effective Compliance Program to meet
Federal health care program requirements and the obligations of the CIA.” Id.
55. The certification ends with following ominous statement: “To the best of my
knowledge, the [insert name of department] of which WCH is in compliance with all
applicable Federal health care program requirements and the obligations of the Corporate
Integrity Agreement. I understand that that this certification is being provided to and relied
upon by the United States.” Id. at 6.
56. 42 U.S. C. § 1320a-7b(b).
57. 42 U.S. C. § 1395nn.