Corporate Compliance Program
The Corporate Compliance Program is part of the Audit & Compliance Services Department. We provide oversight and education related to the following areas:
- Physician and Business Contracts Oversight & Monitoring Program
This program was established to ensure departments have appropriate monitoring and oversight of their contracts in order to ensure adherence to contract terms, services and regulatory requirements. Our office conducts outreach and education to Medical Center leadership and physicians to provide information on the regulatory requirements that mandate oversight (Stark and Anti-kickback statutes), as well as how to best establish an effective monitoring program. Our program includes oversight of the following types of contracts: Part-time physician agreements, business/consulting/administrative contracts (non-clinical), professional services (entity contracts), lease and space contracts.
- Conflict of Interest - Staff (non-faculty) and Select Persons/Departments
Mount Sinai Health System has an obligation to ensure that its trustees, faculty, employees and other staff adhere to the highest standards of ethical conduct free from any improper external influence or any appearance of impropriety. In order to safeguard the integrity of both Mount Sinai and its constituents, Mount Sinai has adopted a rigorous conflicts policy predicated on full disclosure and appropriate management of any possible conflict of interest. Our office is responsible for the dissemination, collection and review of annual disclosures from staff (non-faculty), and other key persons that perform certain critical functions for the institution. We review specific disclosures and develop management plans, as necessary, to avoid any potential conflict of interest for the institution.
- Conflict of Interest/990 Annual Reporting for the Board of Trustees, Corporate Officers and Key Employees
Our office is responsible for the annual dissemination, collection and review of disclosures from the Board of Trustees for our three main entities - MSMC, MSH, and MSSM, in order to satisfy our institutional conflicts of interest policy as well as our annual IRS reporting requirements. We are also responsible for the collection of information from the corporate officers and key employees for each of the three main entities as well as other MSMC-related entities that require separate filings.
- Stark Non-Monetary Compensation Oversight Program
In order to ensure adherence to annual IRS/Stark Law limitations to physicians who receive non-monetary compensation, Corporate Compliance is responsible for oversight of various programs and events hosted by Mount Sinai for our voluntary faculty and/or other outside physicians. The oversight program entails providing Stark Law education to physicians/employees who plan to host an event on behalf of Mount Sinai and ensure that the event plans and details are in accordance with requirements as outlined by Stark Law and IRS guidance.
- The Office of Corporate Compliance also assists with employee education on the Code of Conduct and other Compliance related policies, activities related to the confidential Compliance Helpline and disclosure process, as well as confidential investigations and exit interviews.