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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority (UWHCA) as integrated effective July 1, 2015, including the legacy operations and
staff of University of Wisconsin Hospital and Clinics (UWHC) and University of Wisconsin Medical
Policy Title: UW Health Professional Services Business Conduct/Compliance Standards
Policy Number: 1.60
Effective Date: August 1, 2016
UW Health providers have a tradition of providing the highest quality medical care in a manner compliant
with all governing laws and regulations. The identification of UW Health with the image and mission of
the University of Wisconsin has led to a unique relationship and rapport with the citizens and referring
physicians of Wisconsin and the surrounding areas. Maintaining the benefits of this relationship and
rapport in a time of increasing regulation and scrutiny of health care and reimbursement requires constant
attention by the entire organization.
The UWMF Board created the UW Health Professional Services Compliance Program to monitor and
report on internal adherence to the applicable laws and regulations. This policy defines the business
conduct/compliance standards for all UW Health providers of medical care.
UW Health Provider for purposes of this policy means all providers who bill professional services using
their own NPI.
III. POLICY ELEMENTS
A. All UW Health providers must:
1. Furnish appropriate (medically necessary) medical care with sensitivity, respect and
2. Seek new approaches to increase the quality of medical care in the most cost-effective
manner for the patient.
3. Conduct practice with honesty, fairness and integrity as demonstrated through respect for
the laws and regulations applicable to our profession.
4. Participate in all UW Health required compliance program educational sessions, make an
effort to understand the information presented, and seek clarification if the information is
not understood so that they may incorporate the information into their activities as a UW
5. Understand and accept responsibility for ensuring that all bills submitted in their name
are true, accurate and complete and provide substantiating documentation for all services
rendered. This is necessary to ensure proper patient billing and to preserve the integrity of
the medical database.
6. Ensure the compliant use of templates and other automated documentation by deleting,
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editing, adding data to create a true reflection of the service provided to the patient on
7. Provide documentation in a timely manner so that it is available to other providers
treating that patient as well as to support the billing of the service. See UW Health
Administrative Policy 6.15-UW Health Medical Record Documentation.
8. Cooperate fully with compliance reviews or investigations. This includes (but is not
limited to) being available for individual education regarding documentation and billing,
promptly responding to requests for information, providing all requested documents such
as copies of medical records and schedules, and arranging for timely interviews.
9. Promptly report knowledge of all suspected unethical or illegal business practices directly
to a compliance program representative, or to the UW Health compliance program via
email, online reporting form, or telephone hotline. UW Health has an “open door,” non-
retribution policy with regard to reports of potential compliance violations. All reports or
inquiries are held in strict confidence and reporters are offered complete anonymity.
10. Understand that they are ultimately accountable by law and that non-compliance with the
above provisions could result in disciplinary actions including termination of
UW Health Administrative Policy 6.15-Medical Record Documentation
Sr. Management Sponsor: VP & Deputy Chief Legal Officer
Author: UW Health Compliance Officer – Professional Services
Approval committee(s): UW Health Professional Services Compliance Support Committee; UW Health
Administrative Policy and Procedure Committee
UW Health Chief Administrative Officer
Previous revision: 112011
Next revision: 082019