Departments & Programs,UW Hospital and Clinics,Compliance

Summary of Compliance Program

Summary of Compliance Program - Departments & Programs, UW Hospital and Clinics, Compliance


University of Wisconsin Hospitals and Clinics Authority (UWHCA) is committed to full compliance with applicable laws, regulations, and ethical principles. In furtherance of this commitment, UWHC has in place the Compliance Program. The Program ensures system-wide compliance through:           

  1. Designation of a Compliance Director, with reporting responsibilities to multiple oversight committees
  2. Development and distribution of internal policies and procedures and written standards of conducts
  3. Implementation of regular employee compliance trainings
  4. Maintenance of an anonymous process for receiving and investigating complaints
  5. Participation in internal and external audits, and maintenance of a system to respond to identified compliance deficiencies
  6. Enforcement of disciplinary standards

1. Compliance Director and Reporting Responsibilities

The Compliance Director heads the UWHC Office of Compliance and (CD) has the authority to:

The CD presents regular reports to the Compliance Executive Oversight Committee, which is composed of the CEO, Senior Vice Presidents of UWHC, and, as appropriate, others appointed by the CEO. The CD also presents reports at quarterly meetings of the Audit Committee of the Board. 

The CD has a high degree of autonomy and may report directly to the full Board and the CEO, as appropriate. The CD may operate around the General Counsel, as appropriate. 

2. Codes of Conduct and Policies and Procedures

All policies, procedures, and codes of conduct are posted on the hospital intranet and are handed out to employees during New Employee Orientation. Under the CD’s oversight, Policy Review Committees evaluate policies and procedures no less than every thirty-six months. External auditing and consulting firms review the documents per their discretion.

  1. Codes of Conduct
    The Compliance Code of Conduct summarizes internal policies and describes staff member responsibilities.  The UWHC Code of Ethics on Conflicts of Interest lays out standards of conduct and reporting requirements, describes which actions to avoid, and details the sanctions process.  The Restatement of Commitment to Compliance outlines the structure of the Compliance Program.

  2. Internal Policies and Procedures
    UWHC maintains policies and procedures regarding the following areas of compliance:

    1. Fraud and abuse prevention
      1. False Claims Act: UWHC takes numerous measures to ensure that all employees act to prevent and detect false claims, including: employee training; use of “claims scrubbing” software; performance of internal audits and risk assessments; internal investigation and monitoring; cooperation with state and federal agencies.
      2. Research Billing: Clinical Trial managers use a standardized billing checklist to determine when and how to bill Medicare for clinical trial research.
      3. Anti-Kickback Laws: UWHC provides employees with detailed guidelines concerning whether and how to report on and participate in outside activities, how to identify and disclose potential conflicts of interest and what constitutes unlawful solicitation or acceptance of gifts.
      4. Stark Anti-Referral Law:  The CD coordinates with the General Counsels of UWHC and UW Medical Foundation to monitor compliance with anti-referral laws.
      5. Patient billing: UWHC posts charges for services to patient accounts and applies charges in a transparent, timely, and consistent manner.
    2. Privacy and confidentiality
      1. Protected health information: UWHC has strict guidelines regarding the use and protection of personal health information (PHI). Electronic access to PHI is restricted by user and is auditable. Remote access to electronic PHI and communication of PHI via e-mail is strictly controlled. Detailed policies ensure that PHI exchange, disclosure, reuse, destruction and disposal comply with HIPAA guidelines. UWHC provides patients with information regarding the security and maintenance of their PHI.
      2. Business Association Agreements: As necessary, UWHC executes Business Association Agreements with outside entities to maintain the privacy and confidentiality of PHI.
    3. EMTALA: Patients presenting with emergency medical conditions at the UWHC Emergency Department receive appropriate medical screening examinations, if required, or appraisals and referrals for emergency services. UWHC accepts transfer patients as appropriate.
    4. Government and donor contacts: UWHC conducts political activities and maintains government contacts according to the relevant laws and requirements for non-profit, tax-exempt entities.  UWHC does not permit political fund-raising or lobbying activities by individuals acting in their official UWHC roles.
    5. Caregiver misconduct: UWHC maintains a process for receiving, investigating, and (as necessary) reporting complaints of caregiver misconduct and/or injuries of an unknown source, as required by Wisconsin law.
    6. Anti-trust compliance: UWHC does not share price or wage information with competitors.
    7. Background screening: UWHC reviews the criminal records of employees, potential employees, vendors, contractors, volunteers, etc., as required by Wisconsin law.
    8. Government investigations: UWHC cooperates with state and federal inspections, surveys, and formal inquiries, as appropriate.

3. Employee training

UWHC trains all employees on compliance policies and procedures, including how to report suspected compliance violations. Recently-hired employees attend a “New Employee Orientation,” and all employees attend annual compliance trainings. At these sessions, employees learn about the Compliance Program and about pertinent UWHC policies. After annual trainings, employees must pass a compliance test, as a condition of continued employment. The CD conducts manager and director compliance trainings, which provide more detailed instruction on fraud and abuse laws and compliance standards.  

The CD evaluates, reformulates, and updates trainings based on solicited feedback, internal investigations and changes in federal health care program requirements. Training materials and videos are posted on the hospital intranet. 

4. Process for receiving and investigating complaints

UWHC maintains an anonymous process for receiving compliance-related complaints. The Office of Compliance operates a hotline through which employees can leave anonymous complaints. The hotline number is posted on the hospital intranet and is given to employees at New Employee Orientation and annual trainings. Employees may also contact the Compliance Department directly, through communication tools like Patient Safety Net. 

In conjunction with the General Counsel, the CD thoroughly investigates all complaints. Depending on the nature of the investigation, the CD may collaborate with other departments, including Human Resources, Health Information Management, Risk Management and Patient Relations. Materials posted on the hospital intranet provide templates, guidance and other investigation tools.  

5. Internal and external audits

The UWHC Internal Audit Department (IAD) uses a detailed risk assessment tool to identify compliance weaknesses and risks. The IAD updates the risk assessment as necessary, based on compliance publication recommendations, fraud alerts and new federal health care program requirements. 

Every fifteen months, the IAD relies upon the risk assessment tool and the DHHS OIG audit plan to reformulate its Internal Audit Plan, which provides guidance for department audits. Among other areas, the Plan assesses billing systems and claims accuracy and investigates whether audit personnel are qualified, certified, and independent. The IAD can also conduct unscheduled reviews as appropriate, or at the request of the CD.  

In addition, UWHC coordinates with internal experts and external consultants to audit complex revenue cycle areas. These areas include coding, medical necessity determination and documentation, clinical document improvement and accounting.  

The CD relies on the results of internal and external audits to identify and resolve areas of risk and weakness. The CD convenes intra-disciplinary response teams and ad hoc committees to promptly investigate areas of concern. The CD uses tracking tools and logs to monitor investigations and develop corrective action plans. The CD reports progress to senior leadership and, no fewer than four times a year, to the Audit Committee of the UWHC Board. 

The CD oversees audit follow-ups, as needed.  

6. Enforcement of employee discipline

The Office of Compliance collaborates with the Department of Human Resources to address misconduct through a documented disciplinary process. As appropriate, prior to disciplining an employee, his/her manager investigates the incident and meets with the employee. Discipline is progressive and includes, as appropriate, verbal and written warnings, suspension, and termination. Managers apply detailed criteria, such as length of employment and prior record, to determine the severity of discipline.