COMPLIANCE PLAN October, 2014
TABLE OF CONTENTS Introduction...3 I. Code of Conduct...3 A. University of Illinois at Chicago Code of Conduct...3 B. COD Standards of Conduct...4 II. Potential Risk Areas...4 A. False Claims, False Statements...4 B. Violations of Patient Privacy...5 C. Medical/Dental Necessity- Reasonable and Necessary Services...5 D. Bad Debts...6 E. Retention of Records...6 III. Processing Allegations of Misconduct/Non-Compliance...6 A. Allegations of Student Misconduct...7 B. Allegations of Faculty Misconduct...7 C. Allegations of Staff Misconduct...7 IV. Procedural Guidelines for Investigations...8 A. Violations and Investigation...8 V. Disciplinary Procedures...9 A. Failure to Comply...9 B. Policy Review...10 C. Monitoring...10 VI. Government Investigations...10 A. Government Investigators...11 B. Speaking with Investigators...11 VII. Compliance Committee...12 A. Charge of the Committee...12 B. Membership...12 VIII. APPENDICES...13 I. Benefits of a...13 II. Elements of an Effective...14 III. Prevention of Individuals Involved in Illegal or Unethical Activities from Exercising Discretionary Authority...15 IV. Conducting Effective Training and Education Plans...16 V. Developing Corrective Action Initiatives...17 VI. COD Compliance Officer Job Description...18 2
Introduction THE UNIVERSITY OF ILLINOIS AT CHICAGO COLLEGE OF DENTISTRY (COD) has a strong and abiding commitment to ensure that its affairs are conducted in a manner that facilitates quality, efficiency, honesty, integrity, respect, and full compliance with all applicable laws and regulations. The purpose of this is to promote good COD citizenship through the education of administrators, directors, faculty, students and employees concerning the legal and ethical standards as well as the risks of non-compliant business practices. The is designed to provide information, prevent violations, and to identify and address offenses. I. Code of Conduct The Code of Conduct for the University of Illinois at Chicago provides the guiding standards for our decisions and actions as members of the COD community and will be integral to the operation of the COD and the activities in the community. This Code of Conduct establishes guidelines for professional conduct by those acting on behalf of the University executive officers, faculty, staff, and other individuals employed by the University using University resources or facilities, and volunteers and representatives acting as agents of the University. The Code of Conduct communicates the University's expectations of proper conduct and the professional conduct the University values. A. University of Illinois at Chicago Code of Conduct* http://www.uic.edu/depts/oaa/fachandbook/sections/faculty_handbook_section_iii.pdf Those acting on behalf of the University have a general duty to conduct themselves in a manner that will maintain and strengthen the public's trust and confidence in the integrity of the University and take no actions incompatible with their obligations to the University. With regard to professional conduct, those acting on behalf of the University shall practice: Integrity by maintaining an ongoing dedication to honesty and responsibility; Trustworthiness by acting in a reliable and dependable manner; Evenhandedness by treating others with impartiality; Respect by treating others with civility and decency; Stewardship by exercising custodial responsibility for University property and resources; Compliance by following State and Federal laws and regulations and University policies related to their duties and responsibilities; Confidentiality by protecting the integrity and security of university information such as student records, employee files, patient records, and contract negotiation documents. *(Approved January 22, 2002 by the University Senates Conference) 3
B. COD Standards of Conduct The COD Compliance Office has established standards of professional conduct in recognition of the institution s responsibility to COD patients, faculty, staff, and the community it serves. It is the responsibility of every member of the COD to act in a manner that is consistent with the organizational statement and its supporting policies. *Please reference the following documents for details COD Academic Professionalism for Students, The Ethical Mission of the COD Faculty and College of Dentistry Employee Handbook. Faculty, Staff and Students of UIC College of Dentistry will comply with all applicable laws; will conduct their affairs in accordance with the highest ethical standards; will avoid conflicts of interest; will protect patient privacy and ensure compliance with HIPAA regulations; will maintain proper and accurate records and a relationship of integrity with all payer sources; will conduct all business practices with honesty and integrity; will have proper regard for safety within COD and for safety measures that may affect the community; will strive to attain the highest standards for all aspects of patient care; will provide patient care and consultations in a timely manner; will maintain contact with the patient in all care settings in an appropriate manner; will conduct all patient care activities within COD, affiliated settings, or college approved settings; will appropriately supervise assigned individuals; and will provide equal opportunity and respect the dignity of each employee, student and patient. II. Potential Risk Areas While it is important to recognize the overall positive effects of a and the need to orient all personnel, there are many areas that are susceptible to potential compliance risk. These areas include improper patient care, false claims and statements, and Stark Law infringements regarding potential kickback issues with providers. Leadership at both the administrative and provider level must understand and remain compliant in these areas. A. False Claims, False Statements False Claims and False Statements include but are not limited to: billing for items or services not actually rendered (services must be documented); billing for dentally unnecessary services; upcoding; duplicate billing; false cost reports; 4
lack of integrity when using computer systems relative to electronic health records, billing services, and communication modalities; failure to maintain patient records' confidentiality HIPAA violations; failure to maintain student records' confidentiality FERPA violations; incentives violating anti-kickback statute; Stark Law; tax-exemption laws, as applicable. B. Violations of Patient Privacy The College of Dentistry administration, faculty, staff and students will maintain industry recognized standards and appropriate administrative, technical, and physical safeguards to ensure the integrity and confidentially of healthcare information, to protect against reasonably foreseeable threats or vulnerabilities to the security or integrity of the information, and to protect against unauthorized uses or disclosure of the information. The College of Dentistry administration, faculty, staff and students will be in compliance with the following: Health Insurance Portability and Accountability Act (HIPAA); HIPAA Privacy Rule and HIPAA Security Rule; HITECH Act; Final Omnibus Rule; Interim Final Rule; and The University of Illinois College of Dentistry HIPAA Management Policies and Procedures which is located on the COD intranet site, listed under HIPAA. C. Medical/Dental Necessity-Reasonable and Necessary Services Claims are only submitted for services that COD has reason to believe are dentally necessary and that were ordered by a dentist or other appropriately licensed individuals. (For Medicare reimbursement purposes, a physician is defined as a doctor of medicine or osteopathy; a doctor of dental surgery or of dental medicine; a podiatrist; an optometrist; or a chiropractor, all of whom must be licensed by the state). Licensed Health Care Professionals are authorized to order or provide any services that are appropriate and recognized to be in their scope of practice for the treatment of their patient; however, Medicare and other governmental and private health care plans will only pay for those services that meet appropriate medical necessity standards (i.e., in the case of Medicare, reasonable and necessary services). Documentation in the patient's dental record will be accurate, complete and timely, within the recognized standards of professional practice. 5
D. Bad Debts COD has developed a mechanism to ensure that COD's policies and procedures for billing and collections are in accordance with applicable federal and state statutes, regulations and guidelines. *Please reference - COD Billing and Collections Policy Document, available on the COD intranet site for details. E. Retention of Records Written policies and procedures are in place regarding the creation, distribution, retention, storage, retrieval and destruction of documents. Please reference the Clinic Manual, Section seven (7) [Patient Care], pages 27-34. III. Processing Allegations of Misconduct/Non-Compliance The UIC College of Dentistry Compliance Officer investigates all reported allegations of noncompliance relative to violations of the UIC Compliance Policy. Members of the college community should report possible infractions to his or her direct supervisor, faculty member, department chair or directly to the Compliance Officer. All members of the of COD community have an obligation to report a violation of the. All reported information is confidential and may be reported anonymously. It is a violation of the Code of Conduct to commit or allow reprisals against anyone making a good faith report of potential violations of the Code. 6
Compliance Officer must perform an investigation on all reported allegations: Compliance Officer processes the allegation. If the allegation is determined to have merit, a formal investigation is required. The Compliance Officer will refer and participate in the process. Allegation of Student Misconduct Allegation of Faculty Misconduct Allegation of Staff Misconduct Compliance Officer refers the issue to the Office of Student and Diversity Affairs and/or the Office of Academic Affairs, and/or the Office of Access and Equity. Compliance Officer refers issue to the College of Dentistry Office of Faculty Affairs and the Department Chair, and/or the Office of Access and Equity. Compliance Officer refers issue to the College of Dentistry Human Resource Department, Department Chair, and/or the Office of Access and Equity. 7
IV. Procedural Guidelines for Addressing Alleged Violations A. Violations and Investigation When there is reasonable cause to believe that a violation of the COD, failure to comply with applicable federal or state law, or any other type of misconduct that may threaten the College s status as a reliable, honest and trustworthy provider capable of participating in the federal and state health care programs has occurred, a prompt and confidential investigation will be initiated. Such investigation will also be reported to the Dean of the College, Chief Compliance Officer of the Medical Center and to the Associate University Counsel for Health Affairs. A record of investigation will be initiated and will contain documentation of the alleged violation, a description of the investigative process, copies of interview notes, key documents, a log of the witnesses interviewed and the documents reviewed. The results of the investigation, any disciplinary action taken, and the corrective action that was implemented will be maintained in the office of the COD Compliance Officer. No administrator, faculty member, staff member or student will retaliate against or otherwise discipline any individual simply because he or she reports suspected misconduct or noncompliance. The COD Compliance Officer will ensure that those who report suspected misconduct or noncompliance are not the victims of retaliation, retribution or other unwarranted conduct. Allegations relative to retaliation should be reported to the Compliance Officer. In addition, the COD Compliance Officer has the authority to withhold names of all COD personnel who report information. The COD Compliance Officer does not, however, have the authority unilaterally to extend any protection or immunity from disciplinary action or prosecution to COD personnel who may have engaged in misconduct or noncompliance. Investigation procedures include the following: COD will ensure the privacy of the individual making the report; the COD Compliance Officer, in consultation with University legal counsel, will promptly coordinate an investigation of all reports of suspected misconduct or noncompliance and may involve the engagement of outside counsel or consultants; the COD Compliance Officer has the authority to directly communicate, consult with and request audits; the COD Compliance Officer will obtain all documents or records that may be related to the disclosure or its investigation; COD personnel will cooperate fully with any compliance investigation undertaken pursuant to the Plan and may be subject to legal action for failure to participate or for giving false or misleading information in connection with an investigation; COD will make every effort to preserve and maintain confidentiality in connection with an investigation; COD will ensure that reports by innocent COD personnel do not subject those individuals to retaliation or retribution; the COD Compliance Officer will document and maintain a written record of all compliance investigations; 8
COD will ensure that the existence and process of the disclosure program is adequately communicated to all COD personnel on a regular basis; the report of the process and procedural response will be reviewed and evaluated by the Compliance Committee; and after the investigation, a written report of the investigation will be sent to the Dean of COD and University legal counsel. V. Disciplinary Procedures A. Failure to Comply Failure to comply with the Plan or any applicable law, rule or regulation may result in disciplinary action. COD employees involved in verified misconduct or noncompliance are subject to the disciplinary procedures set forth in COD policies and procedures. If it is determined, after investigation, that misconduct or noncompliance occurred as a result of negligence or inadvertence, the matter will be referred to the Department Head, or other person who is administratively responsible. If it is determined, after investigation, that misconduct or noncompliance occurred as a result of willful and knowing conduct or gross negligence, the matter will be referred to the appropriate authoritative bodies (refer to Section III : Procedural Guidelines for Addressing Alleged Violations). Disciplinary measures are determined on a case-by-case basis, and may include, without limitation: o Employees (paid and unpaid) Verbal Warnings; Written Warnings; Temporary Suspension of Clinical Privileges and Written Reprimand; Unpaid Suspension; Reassignment; Termination of employment; and Reporting the responsible individuals to the appropriate governmental authorities. o Student Warning; Temporary Suspension of Clinical Privileges and Written Reprimand; Developmental Sanction; Recommended Counseling; Restitution and Fines; Failure or Grade Modification; Probation; Suspension; Dismissal; Expulsion; and Reporting the responsible individuals to the appropriate governmental authorities. 9
B. Policy Review COD will review and respond to confirmed misconduct by re-evaluating the current policies, using methods including: Revising the Plan to prevent the occurrence of future similar misconduct or noncompliance. Increasing auditing and monitoring procedures. Amending policies and procedures. Engaging in measures necessary to reduce error rates. Reporting the problem to governmental authorities. Making restitution to the appropriate injured party. C. Monitoring Following the detection of any misconduct or noncompliance, COD will monitor the corrective action efforts to ensure that future conduct is corrected. Specifically: When an offense has been committed and detected or a potential issue identified and reported through the Plan, the COD Compliance Officer will monitor compliance with the implementation of corrective action and will provide a report for each offense or issue. The COD Compliance Officer will provide regular reports to the Dean and to the Compliance Committee. Such reports will contain information regarding the status of all corrective action and recommendations regarding the corrective action process. The COD Compliance Officer will ensure that appropriate follow-up audits will be performed to monitor compliance with the corrective actions. COD Compliance Committee will implement action steps for modifying the Plan and its policies and procedures in the event the Plan fails to detect or prevent misconduct. The Plan will also be modified as appropriate to comply with any changes in federal or state laws, rules or regulations. VI. Government Investigations The COD is committed to full compliance with all state and federal laws, rules and regulations, and will cooperate with all legitimate requests made in any government investigation of COD personnel. In doing so, COD considers it essential that the legal rights of the COD and COD personnel are protected. When interacting with government investigators, COD employees and students should follow the procedures set forth below, to ensure consistency and appropriate communications with government investigators (e.g., the OIG, the Federal Bureau of Investigation, the United States Attorney, Illinois Department of Health and Hospitals, etc.) The COD Compliance Officer will coordinate all responses to requests for information about COD operations, policies, procedures, patients, and employees, including requests for documents. All COD employees who are requested by a government investigator or other person not employed by COD to provide information about COD patients, operations, policies, procedures, and employees, including any request for documents, must immediately notify the COD Compliance Officer. The COD Compliance Officer will contact UIC s Associate University Counsel for Health Affairs and the Chief Compliance Officer of the Medical Center. 10
A. Government Investigators The COD Compliance Officer is the COD designated liaison with government investigators. Whenever a government investigator makes a request for information about the operations, policies, procedures, patients, and/ or COD employees or for documents pertaining to any of these subjects, the COD Compliance Officer will assure that the COD employee or student to whom such a request is made will request formal identification from the investigator or will make the request on behalf of the involved employee or student. Acceptable formal identification includes a badge and/or a picture identification card. Legitimate government investigators will always be prepared to show proper identification. Business cards do not constitute formal identification. Once notified, the COD Compliance Officer will introduce himself/herself to the investigator and escort the investigator to a conference room. The COD Compliance Officer will make a point to identify to the investigator his or her position as the designated liaison, as well as an alternate person available to assist the investigator in the designated liaison s absence. The COD Compliance Officer will inform the Dean as to the exact title of the government investigator who is present at the COD and what the government investigator s stated purpose is. The COD Compliance Officer will determine what other requests the government investigator may have. The COD Compliance Officer will determine the need for legal consultation and, if appropriate, will contact legal counsel. The appropriate COD employees will be alerted and/or assigned to gather needed information, but not informed of the reason for gathering the information. All government investigators are to be accompanied at all times while on COD premises. Visitors are not to have unlimited access to COD facilities and/or to COD employees. B. Speaking With Investigators Unless specifically permitted by the COD Compliance Officer, individual COD employees and students are not authorized to speak to government investigators about the patients, operations, policies or procedures of the COD or to provide documents about these matters to government investigators. An exception to this rule is an investigation under the auspices of the Office of Executive Inspector General of the State of Illinois (OEIG). The OEIG has broad discretionary powers under which they may prohibit an employee from contacting their supervisor. A COD employee or students confronted with any other such request should immediately notify his/her immediate supervisor and/or the COD Compliance Officer, who will be responsible for obtaining answers for any questions the investigator may have, for ensuring that COD employee or student is properly advised of his or her rights in the matter, and for ensuring that COD s rights and those of its patients are properly protected. All COD employees and students will be made aware that they have a right to consult with legal counsel and to request the opportunity to do so before deciding to be interviewed by any investigator. No COD employee or student will provide inaccurate or false information to any government investigator. 11
Patient and employee information is confidential and should be protected. The Disclosure of Medical/Dental Information Policy should be strictly followed. Documents pertaining to patients will not be provided to any government investigator without the express knowledge and permission of the COD Compliance Officer. Employees and students should always be cordial and courteous to government investigators. VII. Compliance Committee A. Charge of the Committee Serve an advisory role to the COD Compliance Officer in the implementation and operation of COD compliance plan. Participate in the development of policy and guidelines to assure COD, Clinics, Faculty Dental Practice and associated Clinical Activities compliance with all appropriate business and regulatory requirements of Health Affairs enterprises. Receive reports from and recommend actions to the COD Compliance Officer with regard to corrective actions that may be necessary to maintain compliance with all established policies. The Committee will review the College annually and more often as indicated. B. Membership Members, appointed at the discretion of the COD Compliance Officer, will include, but not be limited to: COD Compliance Officer (chair) Associate Dean for Administration Associate Dean for Student and Diversity Affairs Associate Dean for Faculty Affairs Director of Clinics Department Head (1) Faculty Member Post Graduate Student Academic Professional 12
Appendix I: Benefits of a 1. Demonstrates that COD has established standards and procedures to affect compliance with applicable federal and state laws and regulations. 2. Assists the COD to fulfill its fundamental care-giving mission to patients and the community, and to identify weaknesses in internal systems and management. 3. Concretely demonstrates to employees and the community at large COD s strong commitment to ethical, professional and responsible provider conduct. 4. Provides a more accurate standard of employee and student behavior relating to fraud and abuse. 5. Identifies and seeks to prevent criminal and unethical conduct. 6. Creates a centralized source for distributing information on health care statutes, regulations, and other Plan directives related to fraud and abuse and related issues. 7. Develops a methodology that encourages employees to report potential problems. 8. Develops procedures that allow for prompt and thorough investigation of alleged misconduct by administrators, directors, supervisors, employees, independent contractors, dentists, and other health care professionals and consultants. 9. Initiates immediate and appropriate corrective action. 10. Improves the timeliness and quality of responses to legal inquiries, investigations, and other emergencies that often occur with little or no advance notice. 11. Provides protection for the COD against fines, mandatory probation, and prosecution under the Federal Sentencing Guidelines. 12. Provides the COD with a more definitive expectation of employee and student behavior, identifies criminal and unethical conduct, and seeks to prevent and detects costly misconduct. 13. Provides efficient methods of disseminating information relating to changes in regulations and requirements. 14. Establishes a structure in which employees can report concerns internally rather than externally which may enhance college management of the concerns. 13
Appendix II: Elements of an Effective 1. Development, dissemination, and training of written standards of conduct, policies and procedures that promote COD s commitment to compliance, and reduce the likelihood of criminal conduct. 2. Establishment of reasonable steps to respond to detected offenses and prevent similar offenses. 3. Development and implementation of a formal education and training Plan for all appropriate employees and agents. 4. Establishment of reasonable steps to achieve compliance with Standards of Conduct. 5. Use of audits and/or other evaluation techniques to monitor compliance and assist in the reduction of identified problem areas. 6. Development and maintenance of a process for employees to report possible compliance violations. 7. Development of a system to respond to allegations of improper/illegal activities and the enforcement of appropriate disciplinary actions against employees who have violated internal compliance policies, applicable statutes, regulations or federal health care Plan requirements. 8. Consistent enforcement of standards through appropriate and well-publicized disciplinary mechanisms. 14
Appendix III: Prevention of Individuals Involved in Illegal or Unethical Activities from Exercising Discretionary Authority 1. The COD will not permit individuals previously involved in certain illegal or unethical activities to exercise discretionary authority. Ongoing and recurring reviews of federal databases for all persons excluded from Medicare or other federal Plans will occur. 2. The COD requires background checks for all potential employees and students and a review of federal databases on persons excluded from Medicare or other federal health care plans for all prospective officers, directors, employees, independent contractors, students and dental staff members. 3. No individual who has been convicted of illegal or unethical behavior and/or who has been convicted of crimes related to the provision of health care services or products (including billing services) will occupy a position within the COD that involves the exercise of discretionary authority. 4. All prospective COD employees and students (and all non-employed COD personnel) must disclose whether they have changed their names and whether they have ever been convicted of a crime, including, without limitation, a crime related to the provision of health care services or products. 5. The COD will remove any employee or student in a position of authority where there is clear evidence that the person is not willing to comply with the Plan. The COD will implement procedures to terminate any COD employee, dismiss any student, or to terminate its relationship with any non-employed COD personnel, who is convicted of a crime related to the provision of healthcare services or products or is currently excluded from participation in a federal health care plan, including immediate removal from direct responsibility for or involvement in any federal health care plan. Pending final disposition, the COD will remove or otherwise insulate from direct responsibility for, or involvement in, any federal health care Plan all COD personnel with pending criminal charges relating to the provision of health care services or products or proposed exclusion from participation in any federal health care plan. 15
Appendix IV: Conducting Effective Training and Education Plans 1. Education and training of administrators, directors, supervisors, employees, dentists, students, and other health care professionals and the continual retraining of current personnel at all levels, are significant elements of an effective compliance Plan. The COD Compliance Officer will work with representatives of each Department to ensure that there is a systematic and ongoing training plan that enhances and maintains awareness of new and/or changes in policies, rules, and regulations among existing staff and that introduces new personnel to the same. 2. Education and training plans will be provided for all employees and supervisory staff to whom the plan is applicable, as well as for clinical department dentists. The Compliance Plan will be presented to all new employees during new employee orientation. Ongoing educational sessions will be offered on a departmental basis as needed. Attendance is mandatory and will be documented. Those employees and students who do not attend the original sessions and/or the make-up sessions will be subject to disciplinary action. 3. A person in each designated service or department will be responsible for developing the content of each education and training session. A copy of the content of each plan that was presented and the attendance documentation is to be retained in each department. 16
Appendix V: Developing Corrective Action Initiatives One of the critical predicates upon which this compliance Plan is built is that it will continue to adjust to new regulatory and legal developments, as well as to implement corrective action in response to demonstrated misconduct. It is the responsibility of the COD Compliance Officer to be continually aware of these regulatory and legal developments and to disseminate this information to the appropriate departmental personnel for their action. 17
Appendix VI: COD Compliance Officer Job Description Responsibility for development, implementation and oversight of a comprehensive Compliance Plan that will assure compliance with 1) third-party/billing requirements for professional and institutional fees, and 2) federal and state laws regarding Health Affairs business practices. The COD Compliance Officer will perform the following duties: 1. Develop and formulate policies and procedures that establish standard compliance, giving specific guidance to management, dental staff, individual departments or employees and students as appropriate. 2. Assist line management with implementation of Plans, policies and procedures to ensure compliance with applicable federal and state laws and regulations for Medicare, Medicaid, and other third party payers. 3. Commission and participate in audits established to investigate and monitor compliance with standards and procedures required by state and federal law. 4. Serve on the Compliance Committee to keep members informed on current issues regarding compliance; present written materials for discussion and action. 5. Maintain an awareness of laws and regulations through personal research, seminars, training plans, and peer contact. 6. Maintain a system of management reporting that provides the system with timely and relevant information on all aspects of compliance issues. 7. Direct efforts to communicate and promote understanding of the components of the, laws and regulations, and consequences of non-compliant behavior through written materials and training plans. 8. Review complaints, concerns or questions relative to compliance issues, and provide consultative leadership and support to management as appropriate. 9. Develop and maintain a confidential line of communication to ensure highest commitment to organization values, and trust in the ethics and compliance process. 10. Ensure mandatory and ongoing education and training plans for faculty, residents, billing staff, and other departmental staff as appropriate. Personally provide plans and/or attend educational plans as requested. 11. Develop policies and procedures for investigating reported violations and noncompliance. 12. Organize and maintain all documentation regarding the Plan. 13. Periodically recommend revisions to the Plan in response to new or amended governmental laws, rules or regulations, new or revised third party payer policies and/or changed needs of COD. 14. Consult with legal counsel, as necessary, with regard to misconduct or noncompliance. In addition to making performance of these duties an element in evaluations, the COD Compliance Officer should include in the COD a policy that Department Heads and supervisors will be sanctioned for failure to adequately instruct their subordinates or for failing to detect noncompliance with applicable policies and legal requirements, where reasonable diligence on the part of the Department Head or supervisor would have led to the discovery of any problems or violations and given the COD the opportunity to correct them earlier. 18