University Healthcare Compliance Plan

Part 1: Institutional Policies Concerning Compliance

(A) Departmental and Institutional Responsibility
(B) Required Compliance Activities

(1) Appointment of a Compliance Liaison
(2) Development of a Departmental Compliance Plan

(a) Written Policies and Procedures
(b) Measures to support training
(c) Periodic internal reviews

(3) Implementation of University Healthcare Compliance Policies
(4) Enforcing appropriate corrective action and discipline

(C) Full Cooperation, Assistance, and Access to all records
(D) Authority to Promulgate Policies and Procedures in Furtherance of this plan.

Part 2: Compliance Office

(A) Compliance Office
(B) Director of University Healthcare Compliance, and Duties of Compliance Oversight Committee
(C) Compliance Office Goals and Objectives
(D) Operations of the Compliance Office

(1) Investigations and Receipt of Information
(2) Evaluation and reports of investigations
(3) Document Retention
(4) Periodic Internal Audits
(5) Employee Training
(6) Review of Pertinent Disciplinary Actions
(7) Cases Involving Claims of Retaliation, Reprisal, or Harassment
(8) Emergency Situations

Part 3: Exercising Due Diligence Over Persons with Discretionary Authority

(A) Pre-employment screening
(B) Current Employees

Part 4: Compliance Training

(A) Training Content
(B) Training Attendance and Documentation
(C) Training Completion Requirements

Part 5: Monitoring and Auditing

(A) Periodic Audits
(B) Audit Frequency
(C) Audit Documentation

Part 6: Enforcement and Discipline

(A) Duty to Report and Cooperate
(B) Imposition of Sanctions and Discipline for Violations
(C) Managerial Responsibility and Sanctions/Discipline
(D) Nature of Sanctions and Factors Affecting Sanctions

Part 7: Continued Compliance

(A) Compliance Office Relationship with General Counsel
(B) Recommendations for Institutional Corrective Actions

Part 8: Amendments

(A) Augmentation, Supplementation, or Stylistic Changes
(B) Deletion of Major Portions of the Plan
(C) New Compliance Plan
(D) Other Changes to Compliance Material and Policy

PART 1: INSTITUTIONAL POLICIES CONCERNING COMPLIANCE

(A) Departmental and Institutional Responsibility

The University of Utah and its Health Science Center (University Healthcare), including but not limited to its medical and other clinical faculty, staff, students, residents, fellows, medical group, departments, Clinics, Schools, and Hospitals shall undertake all necessary efforts and implement any necessary policies and structural changes to bring University Healthcare into full and ongoing compliance with all Federal payor standards and practices. It is the responsibility of each Department, Dean and supervisor in the Health Sciences Center (i.e. each person exercising line management authority) to undertake and implement compliance activities as directed by the Senior Vice President, Associate Vice President, and Director of the University Healthcare Compliance Office, and to use his or her own best efforts to discover, investigate, and correct compliance deficiencies within his or her area of responsibility. All compliance activities will be carried out with the coordination and involvement of the Director of the University Healthcare Compliance Office.

(B) Required Compliance Activities: The compliance activities required of each department include:

(1) Appointment of a Compliance Liaison to oversee departmental compliance activities, serve as a single-point-of-contact liaison with the Director of the University Healthcare Compliance Office, assure departmental level compliance activities are carried out, and participate in compliance meetings and committees as appointed. The Liaison must have sufficient authority to direct and require (with the support of Departmental Chairs) policy or practice changes to assure compliance.
(2) Development of a departmental compliance plan in support of, and in furtherance of, the University Healthcare Compliance Plan. The departmental plan will include:

(a) written policies and procedures for any billing related activities undertaken by departmental personnel;
(b) measures to support training and document training attendance;
(c) periodic internal review of records and bills (audits) to determine compliance and to assess any trends, training, or other needs for process improvement.

(3) Implementation of University Healthcare Compliance policies relating to compliance, including but not limited to any policies relating to documentation, charting, training, records maintenance, coding practices, billing practices, supervision of residents and house staff, disclosure of information, and organizational alignment and funding.
(4) Enforcing appropriate corrective action and discipline to ensure consistent and effective corrective actions are implemented for employees, including faculty, within the management control of each department.

(C) Full Cooperation, Assistance, and Access to All Records

In order to meet its obligations to assure full compliance with such regulations and standards, including private payor standards, the Health Sciences Center, its executives, Director of University Healthcare Compliance, Compliance Committee, and auditors shall have full and complete access to all records of episodes of patient care rendered by any provider, and all billing systems and records, in connection with services provided under the auspices of, as an employee or agent of, or on the premises (including leased premises or premises leased to others) of the Health Sciences Center, its divisions, departments, schools, subsidiaries, contractors, or affiliated organizations. The purposes for such access shall be compliance oversight, as a function of Health Care Operations. All records of any type for such episodes of care are the property of the University of Utah Health Sciences Center, the University of Utah, and the State of Utah, notwithstanding any provision of any agreement, policy, regulation, or practice to the contrary. Granting such access, and full cooperation with compliance activities, shall be considered a condition of affiliation or employment with the Health Sciences Center.

(D) Authority to Promulgate Policies and Procedures in Furtherance of this Plan

The Senior Vice President for Health Sciences, Associate Vice President for Health Sciences, and Director of University Healthcare Compliance, respectively, may develop and promulgate policies and procedures consistent with this Plan and in furtherance of its goals and objectives; such further policies may include departmental compliance plans and committees. Any such policies and procedures may be placed in University Healthcare Policies and Procedures Manuals and shall be effective for all employees of University Healthcare.

PART 2: COMPLIANCE OFFICE

(A) Compliance Office

The University Healthcare Compliance Office is a special staff office assigned to the Associate Vice President for Health Sciences. The office shall exist as a special investigatory, training, policy-making, and advisory office as detailed in this plan. The Director of the University Healthcare Compliance Office shall report to, and operate under the direction of, the Associate Vice President for Health Sciences, with additional access directly to the Senior Vice President for Health Sciences or President of the University as deemed necessary.

(B) Director of University Healthcare Compliance, and Duties of Compliance Oversight Committee.

The Director of University Healthcare Compliance will be assisted in his/her duties by the Compliance Oversight Committee, with membership as designated from time to time by the Associate Vice President for Health Sciences and Director of University Healthcare Compliance. The Director of University Healthcare Compliance shall chair the Compliance Oversight Committee. The Director of University Healthcare Compliance has primary responsibility for the creation, implementation, operation, and revision (as necessary) of the Compliance Plan and its related functions and operations. In addition to the Compliance Oversight Committee, the Director of University Healthcare Compliance may, in his/her discretion, form such other operational committees or working groups as may be necessary of appropriate to the implementation and operation of compliance activities. Such groups may be organized as standing committees or ad hoc groups.

(C) Compliance Office Goals and Objectives

Each Calendar Year, the Director of University Healthcare Compliance shall develop an annual plan of goals and objectives for the Compliance Program including an audit calendar. The Director of University Healthcare Compliance will periodically report to the Associate Vice President and Compliance Oversight Committee on progress toward these goals.

(D) Operations of the Compliance Office:

(1) Investigations and Receipt of Information:

The Director of University Healthcare Compliance shall facilitate receipt of either anonymous or attributable reports from Health Sciences Center employees (or any other person) of suspected violations of the Standard of Conduct or other compliance-related policy or regulation. The Director shall maintain and publicize a telephone system to receive reports of concerns or possible violations. To the extent possible, the Director will ensure the integrity and confidentiality of all reports of violations. The Director shall also facilitate the receipt of written reports. Reports of violations shall be retained in a secure location by the Director, together with copies of his/her written evaluations.
(2) Evaluation of reports and investigations:

Every credible report of a violation that is received by the Director, whether written or oral, will be promptly reviewed and evaluated. A documentary record shall be kept in which the Director or his/her staff assistants shall record pertinent data. For each allegation that the Director of University Healthcare Compliance concludes does not merit investigation, he/she shall record in writing that conclusion and any analysis of facts supporting the recommendation not to investigate. It shall be exclusively within the discretion of the Director to conduct an investigation of an alleged violation. The director may, in his/her discretion, also refer information received to other officials, offices, or committees within the University if the issue appears to be within their jurisdiction. In pursuing investigations, the Director of University Healthcare Compliance may enlist the support of other professionals, including non-university consultants and outside counsel. At the conclusion of any investigation, the Director of University Healthcare Compliance shall promptly inform the Associate Vice President of the findings and recommendations. The Vice President, with the advice and input of the Compliance Oversight Committee, shall make the final decision as to whether the matter shall be referred for any disciplinary action pursuant to University policy and procedures.
(3) Document Retention

The Director of University Healthcare Compliance shall retain the original allegation, his/her evaluation, and any communication from the Compliance Oversight Committee in a secure location indefinitely. Reports of audits and other corrective actions shall be maintained for a period of fifteen years. All other documents shall be destroyed in accordance with applicable federal state statutes and regulations.
(4) Periodic Internal Audits

The Director of University Healthcare Compliance shall direct and oversee periodic internal audits of selected facets of the Health Sciences Center's billing procedures and practices.
(5) Employee Training

The Director will conduct, oversee, and/or approve periodic employee training as set forth below.
(6) Review of Pertinent Disciplinary Actions

The Director will be informed by the responsible department or unit of all disciplinary or other corrective actions taken against any Health Sciences Center employee as a result of billing, coding, or documentation - related activities. Procedures for determining disciplinary actions will follow University Policies and Procedures Manual for Human Resources or Faculty. Corrective actions not amounting to formal discipline, including retraining, suspension of billing activities, limitation of privileges, and other Medical Group or Medical Staff sanctions may also be applied. The Director of University Healthcare Compliance shall receive and maintain copies of the summary of discipline or corrective action of any employee if related to issues connected with the standards of conduct, billing, or other matters within the scope of Compliance Office authority. If the Director concludes that inappropriate discipline or insufficient discipline has been imposed for any violation, he/she shall forward his/her recommendation to the Compliance Oversight Committee and Associate Vice President for consideration.
(7) Cases involving Claims of Retaliation, Reprisal, or Harassment

The Director of University Healthcare Compliance shall also review and investigate cases involving complaints or claims of harassment, retaliation, or reprisal involving employees or others who provided compliance related information or made a complaint concerning compliance related activities or issues. Such actions shall be considered a serious violation of the Standards of Conduct.
(8) Emergency Situations

Should the Director of University Healthcare Compliance conclude that any compliance-related matter is an emergency requiring immediate action, or should he/she determine that certain matters are extremely sensitive or confidential, the director shall have sole discretion to discuss the matter directly with the Vice President for Health Sciences, the President, or, if necessary, the Chair of the Board of Trustees, or counsel to the University. The Director of University Healthcare Compliance shall document in writing the reasons for any such direct contact, furnishing a copy to the Compliance Oversight Committee and counsel if requested. If, in the course of an investigation, the Director of University Healthcare Compliance, Compliance Oversight Committee, or other management official discovers credible evidence of misconduct and, after a reasonable inquiry, has reason to believe that the misconduct is of sufficient gravity or is intentionally committed, the Director, Compliance Oversight Committee, or other management official will consult immediately with the Director, counsel and the Senior Vice President. The Director of University Healthcare Compliance and Senior Vice President will consider, in consultation with counsel, whether immediate and referral to criminal or civil law enforcement authorities should be made or reported.

PART 3: EXERCISING DUE DILIGENCE OVER PERSONS WITH DISCRETIONARY AUTHORITY

The Health Sciences Center will undertake careful evaluation of prospective and current employees who have discretionary authority to make decisions that may involve billing compliance.

(A) Pre-employment screening

Pre-employment screening will be conducted in accordance with Human Resources policy and shall include, as a minimum, a reasonable and prudent background investigation. Employment applications will specifically require the applicant to disclose any criminal conviction and any exclusion action. Employment may be prohibited for any individuals convicted of a criminal offense related to health care or who are listed as debarred, excluded or otherwise ineligible for participation in federal health care programs. Such background checks shall be uniformly undertaken for all University Healthcare employees regardless of the entity within University Healthcare undertaking the employment. Pending the resolution of any criminal charges or proposed debarment or exclusion, such individuals will be removed from direct or indirect involvement in any federal health care program.
(B) Current Employees

The Health Sciences Center may also monitor closely the activities of current employees who are subject to this plan. Notwithstanding any other provision of any contract, employment agreement or otherwise, if any current employee or contractor is convicted of an offense relating to health care, or is debarred or excluded by CMS, such conviction, debarment or exclusion, may result in the termination of employment or other contract arrangement with the individual or contractor.

PART 4: COMPLIANCE TRAINING

The Health Sciences Center will provide training and periodic re-training for all employees and supervisory staff to whom the plan is applicable, as well as for contract physicians and clinicians providing on-site services, to familiarize their employees with all pertinent provisions of the Standards of Conduct and University Healthcare compliance- related policies.

(A) Training Content

The Director of University Healthcare Compliance will be responsible for developing and/or acquiring the necessary training materials to provide appropriate levels and types of training for all affected employees. Training content, frequency, and methods of delivery (i.e., lecture, presentation, video, computer - based, etc.) will be determined by the Director of University Healthcare Compliance.
(B) Training Attendance and Documentation

The Director of University Healthcare Compliance will work through departmental compliance liaisons to identify and notify all persons who are subject to the training requirements of this plan. It is the responsibility of supervisors to be aware of initial and ongoing training requirements and to make employees available for such training.
(C) Training Completion Requirements

Completion of training as required by the Director shall be mandatory. Failure to complete training will be grounds for corrective or disciplinary action, including review as part of credentialing and reappointment processes.

PART 5. MONITORING AND AUDITING

(A) Periodic Audits

The Director of University Healthcare Compliance shall direct and oversee periodic internal audits of selected facets of the Health Sciences Center's billing procedures and practices.
(B) Audit Frequency

It shall be within the discretion of the Director to determine how frequently each area will be audited, and which additional areas or subjects will require audit examination. Audits shall be conducted of a sufficient number of charts and encounters to achieve a reasonable degree of certainty that the departmental activities reviewed are properly delivered, documented, coded and billed. (This does not require each audit to be based on a sample size sufficient to provide statistically valid sampling).
(C) Audit Documentation

Documentation of each audit shall be maintained by the Director of University Healthcare Compliance. The results of each audit shall be communicated in writing to line management responsible for the audited area. In all cases, a concise statement of actions undertaken or planned in response to the recommendation, and a timetable for implementation will be required.

PART 6: ENFORCEMENT AND DISCIPLINE

(A) Duty to Report and Cooperate.

Each employee dealing with billing practices in any way is bound by the Standards of Conduct, including the obligation to make known violations committed by others, and that this duty carries appropriate discipline for violations of the Billing Standards of Conduct. Employees have an affirmative obligation to report to the Director of University Healthcare Compliance any violations committed by others, including departmental chairs and administrators, as well as other supervisors.
(B) Imposition Of Sanctions And Discipline For Violations

Substantial or intentional violations of the Standards of Conduct (including intentional failure to report the misconduct of other employees) will be viewed as a serious infraction. Corrective actions, including punitive measures, may include termination of employment.
(C) Managerial Responsibility and Sanctions/ Discipline

Managers will be subject to discipline for negligence or indifference that results in failing to detect compliance violations that occur. If the supervisor, due to negligence, indifference, inaction, complicity, or intentional misconduct, facilitates or prolongs misconduct of another, a penalty commensurate with the seriousness of the violation will be imposed.
(D) Nature of Sanctions and Factors Affecting Sanctions

Any formal discipline of employees who violate the Standards of Conduct or other University policy, or any law or regulation, will be governed by the University Policy and Procedures applicable to that person's employment status, i.e., staff employee, house staff officer, or faculty. In addition, corrective actions not amounting to formal discipline, including retraining, suspension of billing activities, limitation of privileges, and other Medical Group or Medical Staff sanctions may also be applied in accordance with the policies and bylaws applicable, including this Plan. An employee whose conduct otherwise would justify more severe punishment may have lesser discipline imposed. This decision will be based on (a) whether the employee reported his or her own violation; (b) whether the report constitutes the first awareness of the violation and the employee's involvement; and (c) whether the employee has provided full and complete cooperation during the investigation of the violation. In first cases involving unintentional wrongdoing, reeducation, corrective actions and monitoring, as well as possible warnings, reprimands, or probation are usually imposed. Subsequent cases will result in more serious forms of action, up to and including termination and referral for prosecution. Reimbursement for losses from wrongfully billed episodes of care, or other damages including attorney fees will be sought in cases involving financial loss to the institution as result of provider's intentional or negligent misconduct. Referral for criminal prosecution or civil action will occur in the most serious cases involving intentional wrongdoing, intentional failure to correct known negligent wrongdoing, or intentional indifference to the requirements of regulatory compliance.

PART 7: CONTINUED COMPLIANCE

(A) Compliance Office Relationship with General Counsel

The Director of University Healthcare Compliance will maintain contact with University General Counsel on a regular and ongoing basis to assure that the expertise of the Director is available to the Office of General Counsel. While the Director and Compliance Office do not work for, report to, or operate under the guidance of General Counsel, it is recognized that a close and cooperative relationship between the two offices is essential to effective compliance.
(B) Recommendations for Institutional Corrective Actions

The Director shall, as a part of each investigation or audit cycle, assess whether the issues involved require institutional-level structural or procedural change as a part of corrective actions. If, in the assessment of the Director, such change is required or advisable, the Director shall report to the Compliance Oversight Committee such recommendation. With the advice and input of the Compliance Oversight Committee, the Director shall make a recommendation to the Vice President for Health Sciences as to what actions should be taken to correct the procedures or practices giving rise to the violation.

PART 8: AMENDMENTS

This Plan may be amended from time to time as necessary. Should an amendment occur, each department chair and departmental compliance liaison shall receive a copy of the amended plan. Three types of amendment of this compliance plan are recognized:

(A) Augmentation, Supplementation, or Stylistic Changes

Proposed amendments which consist of augmentation or supplementation to the existing plan, changes to procedures or processes, typographical, grammatical or other stylistic corrections, or corrections to improve the readability (i.e. changes that do not alter the basic substance of the plan), the Director or Compliance Oversight Committee may propose the amendments to the Senior Vice President. If the Senior Vice President concurs in the proposed amendment, the amendment shall be considered adopted.
(B) Deletion of Major Portions of the Plan

If the proposed amendment would result in the deletion of any major substantive portion of this compliance plan, such amendment must be the joint recommendation of the Director of University Healthcare Compliance and the Compliance Oversight Committee to the President and Senior Vice President for Health Sciences. If the President and Senior Vice President concur with the recommendation, the amendment shall be deemed approved.
(C) New Compliance Plan

In the event that the Senior Vice President concludes that a new compliance plan should be implemented, he must first solicit the views of counsel as to the advisability of such action. The Senior Vice President shall propose the new Plan to the President and Board of Trustees. The approval process for the Plan shall be that determined by the President and Board.
(D) Other Changes to Compliance Material and Policy

Changes to any appendices, training materials, publicity materials, and policies promulgated under the authority delegated in this Plan, operating procedures of the Compliance Office, policies of the Compliance Oversight Committee, and similar documents are not considered to be formal amendments to the Plan and may be made by, and on the authority of, the Director of the University Healthcare Compliance Office.