Compliance Program Guidance for Hospitals from the OIG


Audio Conferences
		Disruptive Behavior and the Joint Commission's Sentinel Event Alert Effective Performance Improvement Plans
Audio CDs/MP3s
	AHP Potpourri Board Conflicts of Interest The "Borderline" Physician: Managing Performance Improvement for Those Who Can Improve (and Building the Legal Record for Those Who Can't) Charity Care Class Action Lawsuits Clinical Privileges: Tough Issues and Solutions CMS Clarification on Hospital Privileging CMS Issues Final Rule on 4 CoPs CMS: The New Guidelines for Informed Consent - Process, Policies and Forms Community Need for Physicians: How to Analyze, Prove and Document It Conduct Outside the Hospital: Are You Your Brother's Keeper? Conflicts of Interest on the Medical Staff Contracting and Credentialing: Bridge the Gap or Pay the Piper Corporate Bylaws: When Was the Last Time You Looked Yours Over? Credentialing and Medical Staff Records - Access, Control and Confidentiality Credentialing and Privileging Teleradiologists The Credentialing Process: Who is Slipping Through the Cracks? Credentialing the Aging Physician Credentialing Verification in the Trenches Criminal Background Checks for Physicians Deferred Compensation for ER Call Employing Physicians Series EMTALA and On-Call: Important New Changes EMTALA: The Final Rule and Regulations EMTALA Guidelines EMTALA Investigations: How to Survive Excess Benefit Transactions Exclusive Contracts - Strategies to Deal with the Shortage of Doctors Executive Compensation in IRS Crosshairs Fair Market Value The Feds Are Coming – Do You Know Where Your Physician Contracts Are? Forgoing Life Sustaining Treatment Fraud, Abuse & the OIG: A Look Back — A Look Ahead Free Speech or Disruptive Behavior? The FTC's Evanston Decision - Are Mergers Still OK? HIPAA and Credentialing HIPAA - Everything You Ever Wanted To Know — And Weren't Afraid to Ask HIPAA Investigations and Enforcement HIPAA Security Regulations Hospitalists: The Who, What and How The "Independent" Medical Staff – What Would It Really Mean? Investigations and Hearings — Should You Follow Your Bylaws? Maybe Not! IRS Final Form 990 The IRS is Watching YOU – Part I: Good Governance Practices for 501(c)(3) Organizations The IRS is Watching YOU – Part II: Exempt Organizations Executive Compensation Compliance Project Report It's Never Too Late for an Amicable Resolution — Alternatives that Can Protect Patients and Save a Career Joint Venture Series The Kadlec Appeal – Decision Against Hospital Reversed! The Limited English Proficiency Rules Low and No Volume Practitioners Malpractice Claims and Your Credentialing Process Malpractice Insurance Premiums: Helping Your Doctors Pay Managing the Disruptive or Difficult Patient Medical Ethical Issues - Right Choices, Legal Answers Medical Record Deficiencies: Practical Solutions to a Persistent Problem Medical Staff Integration Models for a Sustainable Future Medicare Physician Supervision and "Incident-to" Billing: What are the Rules? New MS.1.20: Stay the Course or Jump Ship? Must Hospitals Train Their Staffs to Bite the Hand that Feeds Them? Nonprofit Governance Audio Series: Legal Compliance and Public Disclosure Effective Governance Practices Financial Management and Fundraising On-Call Audit & EMTALA Update On-Call Problems and Solutions The Organized Medical Staff & Joint Commission Compliance:: Real Life Issues, Practical Solutions Panel on Nonprofit Sector Announces Principles for Good Governance and Ethical Practice Patient Complaints and Grievances – Time to Take Them Seriously Patient Safety and Quality Improvement Act: Proposed Regulations Paying for On-Call Services - the OIG Speaks Physician Behavior Physician Recruitment and Retention After Stark III Poliner: Court Upholds Jury's Findings Practical Solutions to Your Toughest On-Call Problems Practical Tips for Developing Medical Staff Leaders Precautionary Suspensions are to Protect Patients A Primer on Preemption: Incorporating State Privacy Laws into Your HIPAA Compliance Plan Protecting Peer Review Information Quality/Performance Improvement & Peer Review Best Practices Reconciling Conflicting Financial Interests of Physicians & Hospitals Recruitment Before Credentialing: What Were You Thinking? Resignation of Privileges to Avoid On Call Responsibilities Self-Disclosure & Government Investigation Sexual Harassment - It's Not Going Away! Does "Sham" Peer Review Really Happen? Sizzlin' Hot Credentialing Issues Specialty Hospitals and Gainsharing Alert! Stark 3.5? Proposed Changes in Inpatient Prospective Payment Rules Stark 2.5 - the Party's Over Stark Phase III Regulations ... They're he-e-e-e-e-e-re! Stark: Software/New Stark and Antikickback Rules Stark Violations in Your Medical Staff Office? Strategies to Address Medical Records Violations Take Control of Your Medical Staff Hearing Process Tax-Exempt Hospitals and Politics: Survival Guide for the Election Year Teleradiologists: Credentialing and Privileging Temporary & Locum Tenens Privileges Unanticipated Outcomes Disclosure and Medical Error Reporting

Corporate Bylaws: When Was the Last Time You Looked Yours Over? Audio CD
Recorded July 6, 2004

Faculty: Dan Mulholland & Susan Lapenta

The corporate fraud disasters of late have changed the way the public views corporate responsibility. Some states have moved to extend the Sarbanes-Oxley law to non-profit corporations. The IRS has announced that it will embark on a sweeping review of executive compensation practices in tax- exempt organizations. And the OIG has once again reiterated that the Board is ultimately going to be held responsible for the organization's corporate compliance program.

At the same time as legal and public scrutiny has been ratcheted up, hospital and health system Boards are faced with unique and daunting challenges, such as what to do about competition from physician-owned entities, how to recruit and hold on to top level talent, not only in the medical staff and management ranks, but also on the Board, and how to account for the way that the Board carries out its fiduciary duties relative to finances, quality and overall governance. These issues cannot be dealt with unless the Board has a sound framework for its actions.

That framework starts with a good set of corporate bylaws. The bylaws should provide a platform from which the Board can make decisions, exercise its oversight responsibilities, and deal with tough issues like conflicts of interest with confidence. Unfortunately, corporate bylaws have often been ignored until they cause trouble, usually by tripping the Board up with antiquated or constrictive language in a lawsuit or medical staff privileging dispute. It's time for hospitals to take their corporate bylaws out of the drawer of the CEO's executive assistant, shake the dust and cobwebs off of them, and bring them up to date for use in the 21st Century.

Dan Mulholland and Susan Lapenta can help you get started with a special audio CD where they discuss the following issues:

The basics of bylaws: what they are and why you have them
What corporate bylaws need to say about the medical staff
The application of Sarbanes-Oxley to non-profits and how it could affect your bylaws
Nomination of and qualifications for Board members
Conflicts of interest: the next generation
Exclusive contracts with physicians
Redefining the Board's role in credentialing, peer review, patient safety and quality matters
Selection of medical staff and Board leadership
When corporate bylaws and medical staff bylaws collide

Audio CD: $225

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supplementary materials.

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