Clinical Compliance Program

Clinical Compliance Program The University at Buffalo School of Dental Medicine, Daniel Squire Diagnostic and Treatment Center (UBSDM) has always been and remains committed to conducting its business in compliance with the law while maintaining the highest standards of ethics and integrity. The UBSDM can meet this commitment through the efforts of our faculty, staff and students. We must continue to earn the trust and respect of patients and others by conducting our daily affairs with honesty, integrity, and in compliance with the letter and spirit of all applicable laws. Although honesty and integrity are individual attributes, and each individual is ultimately responsible for his or her own conduct, the UBSDM is committed to maintaining a working environment that promotes these ideals and permits our employees to demonstrate the highest professional standards in performing their daily tasks. The Clinical Compliance Program is intended to define and govern the conduct expected of faculty, staff and students and to provide guidance on how to resolve questions regarding legal and ethical issues, and to establish a mechanism for the reporting of possible violations of law or ethical practices within the UBSDM. Clinical Compliance Program Introduction The UBSDM has developed a Clinical Compliance Program as a comprehensive statement of the responsibilities and obligations of all employees, students and professionals, to understand and adhere to applicable federal and state laws, and to fulfill the program requirements of federal and state health plans. Compliance practices and procedures of the UBSDM will be developed and kept current with applicable laws and regulations. UNIVERSITY LEVEL: Additionally, The New York State Governmental Accountability, Audit and Internal Control Act (The Internal Control Act) embodies New York State s commitment to efficient and effective business practices, quality services, and ethics in the operations of State government. The Accountability Act outlines the requirements for a comprehensive system of internal controls. Internal control is defined as the integration of activities, plans, attitudes, policies, and efforts of an organization working together to provide reasonable assurance that the organization will achieve its objectives and mission. As such, internal control is people-dependent. Every member of the organization has a role, since every activity of the organization should be directed toward achieving its mission. One of the internal control requirements is to provide each university employee a clear and concise statement of the generally applicable management policies and standards with which employee is expected to comply. These include a position description and

performance program, pertinent collective bargaining agreement, and policies of the SUNY Board of Trustees Public Officers Law. Copies of these documents may be obtained by contacting Human Resource Services, 120 Crofts Hall at 645-7777. In addition, other policies and standards are issued by the President and other officers of the University. Examples include the Cash Receipts and Petty Cash Reimbursement Procedures, University Travel Policy, and General University Service Fee Policy and Guidelines. Documents such as these can be accessed on the University Business Services web site at http://ubbusiness.buffalo.edu/ubb/cfm/ubs_pages/homepage.cfm Contact - Michael F. LeVine, Associate Vice President and Controller and the University s Internal Control Officer at 645-2505 or mlevine@business.buffalo.edu Elements of an Effective Compliance Plan The Department of Health and Human Services, Office of Inspector General (OIG) and the New York State Office of Medicaid Inspector General (OMIG) believes that every effective compliance program should begin with a commitment by the institution to address all of the applicable elements listed below, which are based on the eight elements set forth in the Federal Sentencing Guidelines: 1. Establishing compliance standards through the development of a code of conduct and written policies and procedures: Members of the various Compliance Oversight Committees have developed a body of policies and procedures that constitute an ongoing commitment to the promotion of integrity and compliance. 2. Assigning compliance monitoring efforts to a designated compliance officer or contact: The UBSDM Dean has approved the appointment of two Compliance Officers to operate and monitor the compliance program for the delivery of patient care and facility (structural) based initiatives. The officers report to the Dean through the Associate Dean for Clinical Affairs and / or the Associate Dean for Advanced Education as well as the Director of Clinical Operations. 3. Conducting comprehensive training and education on ethics and policies and procedures: Educational programs covering ethics and billing compliance have been offered and will continue to be developed on a regular basis as needs allow. 4. Conducting internal monitoring and auditing focused on high-risk billing and coding issues through performance of periodic audits:

Both routine and special reviews are conducted on a regular basis to monitor compliance, identify problems, and develop corrective action plans in an effort to reduce policy violations. 5. Developing accessible lines of communication regarding fraudulent or erroneous conduct issues to keep employees updated regarding compliance activities: Employees are encouraged to report compliance violations or concerns to their immediate supervisors / managers. Additional means to report violations are addressed within this program. Existing policies protect complainants from retaliation. 6. Enforcing disciplinary standards by making clear or ensuring employees are aware that compliance is treated seriously and that violations will be dealt with consistently and uniformly: Response to allegations of improper activities are reviewed and reported to administrative authorities; if necessary additional University, state and federal authorities will be notified depending on the severity of the activity. These policies are discussed within the contents of this program. 7. Responding appropriately to detected violations through the investigation of allegations and the disclosure of incidents to appropriate government entities: Problems identified through routine auditing and monitoring processes and through issues reported by employees are investigated and remediated in a timely and appropriate manner, and may be voluntarily disclosed to appropriate governmental entities. 8. Ensure that good faith participation in the Compliance Program shall not result in retaliation: Policy shall include non-intimidation and non-retaliation for good faith participation in the compliance program, including, but not limited to, reporting potential issues, investigating issues, self-evaluations, audits and remedial actions, and reporting to appropriate officials as provided in sections 740 and 741 of the NYS Labor Law. Existing policies protect complainants from retaliation. Clinical Compliance Program Basic Principles Integrity: The UBSDM honors integrity as a fundamental value and demonstrates the highest levels of professional conduct in all its dealings. Each individual associated with School must perform his/her personal duties in accordance with these values. Compliance with Legal Standards: The UBSDM follows all applicable federal and state laws and regulations. Each person associated with the School is charged

with the responsibility to learn and understand the legal standards which relate to his/her duties and to follow them accordingly. Accurate Billing and Records: The UBSDM is committed to maintaining accurate documentation and billing records that reflect services provided. Errors will be assessed and corrected appropriately. Clinical Compliance Program Structure Participation: It is the responsibility of each faculty member, staff, student and independent contractor to abide by applicable laws and regulations and support the UBSDM s compliance efforts. Responsible Coordinators: The UBSDM has designated two Compliance Officers (Patient Care and Facilities) as the individuals within the School responsible for overall implementation and operation of the Compliance Program. Compliance Committees: Several committees within the UBSDM will serve together to oversee compliance initiatives. Education: The UBSDM will provide ongoing, effective education and training programs for all faculty, staff and students on Organizational Professionalism and Ethics. Auditing and Monitoring: The UBSDM will establish procedures for monitoring the effectiveness of the Compliance Program. Risk Assessment: The UBSDM will conduct ongoing risk assessments and take appropriate steps to reduce the risk of law violation identified through the assessment process. Enforcement and Prevention: Individuals violating the standards of this Compliance Program will be subject to progressive discipline, up to and including termination, if warranted. Sanctions will be applied in accordance with relevant staff personnel policies, School policies/procedures and/or faculty code as appropriate. Organizational Response: The UBSDM will respond to potential violations of the Compliance Program and/or applicable federal and state laws/regulations reported by staff, students, faculty members or others that have questions or concerns regarding UBSDM activity. Employee Participation and Reporting Policy: It is the responsibility of every individual to abide by applicable laws and regulations and support the UBSDM s compliance efforts. All staff, students and faculty members are required to promptly report their good faith belief of any potential violation of the Compliance Program or applicable law. The UBSDM will provide anonymity to the individuals who report concerns to the greatest extent possible under the circumstances. There will be no retaliation in the terms and conditions of employment as a result of such reporting. Any such retaliation, retribution or harassment will be met with disciplinary action.

Purpose: The purpose of this policy is to define the individual UBSDM staff, student and faculty member responsibilities for assuring ethical business practices and supporting the Compliance Program Procedures: Individuals will report their good faith belief of violations of the Compliance Program or applicable laws and regulations via one of the following methods: - written or oral report to a supervisor - contact either one of the Compliance Officers Patient Care Related - Ms. Robin L. Comeau at 829-6402 rcomeau@buffalo.edu Facilities Related - Robert Tronolone at 829-6432 rjt24@buffalo.edu Human Resource Issues Human Resources Manager 829-2836 If you suspect a fraud or other dishonest or questionable act, do not try to question anyone or otherwise investigate the matter yourself. Report your suspicions to one of the following: Your Supervisor UB's Controller Michael F. LeVine 420 Crofts Hall (716)645-2505 Email: mlevine@business.buffalo.edu UB's Director of Internal Audit (vacant) University Police Dan Jay, Inspector Bissell Hall (716)645-2228 Email: pbsdj@buffalo.edu University Police Silent Witness Reporting http://www.public-safety.buffalo.edu/silentwitness.shtml All staff, student and faculty member reports of potential violations will be reviewed at the level determined appropriate. Consequences of Reporting / Non - Retaliation No employee will be disciplined because he or she made a report in good faith. Where possible, the confidentiality of the employee making the report will be protected.

Employees who participate in the UBSDM Compliance Program in good faith, including but not limited to reporting potential issues, investigating issues, self-evaluations, audits, and remedial actions, and reporting to appropriate officials as provided in sections 740 and 741 on the New York Labor Law (new whistleblower provisions for health care fraud) shall not be subject to retaliation, retribution, or harassment for such good faith participation. Any such retaliation, retribution, or harassment will be met with disciplinary actions. [Section 740 applies to disclosures by employees of conduct that (a) violates a rule, law, or regulation, and (b) creates a danger to public health or safety.] [Section 741 applies to disclosures by employees of conduct that the employee reasonably believes constitutes improper quality of patient care, or the employee s refusal to participate in an activity that s/he believes constitutes improper quality of patient care.] Responsible Officers Policy: The UBSDM has designated two Compliance Officers (Patient Care and Facilities) as the individuals within the School responsible for overall implementation and operation of the Clinical Compliance Program. The Officers directly report to the Associate Dean for Clinical Affairs and Director of Clinical Operations respectively. Purpose: The purpose of this policy is to assign and communicate the responsibility for implementation and operation of the UBSDM s Compliance Program. Procedures: The Compliance Officers will be responsible for ensuring that: 1. Practices and procedures are reviewed and updated as necessary. 2. Staff, students and faculty are receiving adequate education and training and that such education and training is documented. 3. Internal compliance reviews and monitoring activities are conducted. 4. Staff, student and faculty complaints and other concerns regarding compliance are promptly investigated. 5. Adequate steps are taken to correct any identified problems and prevent the reoccurrence of such problems. 6. External sources of compliance issues are monitored and utilized as prompts for evaluating UBSDM s activities.

Clinical Compliance Oversight Committees Policy: The UBSDM s Compliance Oversight Committees will work in tandem to advise and assist the Compliance Officers with implementation of the Compliance Program. Purpose: The purpose of this Policy is to assign and communicate the responsibilities of the Compliance Oversight Committees for the Compliance Program at the UBSDM. Procedures: The Compliance Officers will report to the Associate Dean for Clinical Affairs and Director of Clinical Operations respectively. Reports will include the results of any recommendations from ongoing reviews, and any other information requested by any one of the Committees. UBSDM COMPLIANCE OVERSIGHT COMMITTEES Committees: Clinic Council, Clinic Management Committee, Executive Council, Quality Assurance, Advance Education, Clinic Budget. [Committee descriptions are found in Appendix I] Members: Dean, Compliance Officers, CFO and Assistant, CIO, Director of Clinical Operations, Associate Deans for Clinical Affairs and Advanced Education and Research, Department Chairs, Clinical Group Directors, Patient Advocate, Business Operations Manager and additional faculty and staff as needs require. Meetings: The committees will meet on their individual regular set schedule. Role: The primary role of the Compliance Oversight Committees is to assist the Compliance Officers by providing oversight, participating in strategy development, and assessing operational performance of the organization with respect to compliance. In performing this function, the committees will: Review concerns and assist with internal risk assessment activities Make policy decisions Participate in development of the compliance work plan Provide executive sponsorship of the work plan initiatives Allocate resources for work plan initiatives Track resolution of issues Basic Rules of Conduct Comply with All Laws and Regulatory Requirements

Every employee must strictly observe all laws and regulatory requirements that apply to UBSDM as well as the University at Buffalo. Every employee is expected to be familiar with the basic legal requirements that are relevant to his or her duties. Employees can learn the laws and regulations that apply to their work through in-service training programs, from supervisors, and by reviewing UBSDM and University policies. Employees are expected to ask supervisors when they require assistance in understanding their legal obligations. Each department is responsible for providing specialized training in their area of expertise / discipline as required for employment. Record Keeping and Retention The UBSDM is obligated under both state and federal law to maintain and retain different types of records concerning various aspects of its operations. Proper record keeping is necessary not only to comply with state and federal law but to also ensure proper dental treatment for our patients. Accurate records play a vital role in assuring the maintenance of high ethical standards. Additionally, all of UBSDM s transactions must be recorded accurately, completely and timely and retained in accordance with applicable requirements. Every employee is expected to comply with UBSDM and government requirements regarding record keeping, never make false or artificial entries in any of UBSDM s records, never understate or overstate reports of revenues or expenses, or alter any documents used to support those reports. A records retention and disposition schedule has been developed for the UBSDM with Executive Council approval March 20, 2003. Ethics Every employee is expected to adhere to high ethical standards when he or she acts on behalf of UBSDM. Additionally, licensed health care providers are expected to abide by the American Dental Association Principles of Ethics and Code of Professional Conduct. http://www.ada.org/prof/prac/law/code/ada_code.pdf Dental students are expected to abide by the policies of the Student Handbook which also contains a statement of ethics and professional conduct as well as requirements set forth by the University. http://intranet.sdm.buffalo.edu/student/handbook/studenthandbook.pdf Education / Training Policy: All employees (workforce personnel) of the UBSDM will complete HIPAA Privacy and Security training. Employee in this case refers to clinical as well as nonclinical staff, faculty, dental students and residents, including those involved in workstudy, research and observation programs. Procedure: All workforce personnel will be directed to the online training site:

http://intranet.sdm.buffalo.edu/hipaaquiz/ Successful completion of the training is retained online. All returning and new students are expected to complete annual training prior to the start of clinics. 1. HIPAA Privacy - HIPAA stands for the "Health Insurance Portability and Accountability Act of 1996, Public Law 104-191." HIPAA is a federal law. HIPAA includes three sets of rules: Administrative Simplification (Transactions and Code Sets), Privacy, and Security. The HIPAA Privacy Rule, which affects the delivery of health care services and operations, requires protection of patient information so as not to interfere with patient access to, or the quality of, health care delivery. 2. HIPAA Security - Under the Health Insurance Portability and Accountability Act of 1996, a requirement is that all covered entities, such as UBSDM, must comply with the electronic Protected Health Information (ephi) standards. Hazard Communication Training http://wings.buffalo.edu/services/fac/ehs/training/hazcom.htm Radiation Safety Training http://wings.buffalo.edu/services/fac/eh&s/radsafety/radtraining.htm Infection Control Training http://intranet.sdm.buffalo.edu/icquiz/ 3. Fraud / Integrity Training- online training utilized through the Governor s Office of Employee Relations. http://www.goer.state.ny.us/training_development/online_learning/ig/index.cfm Helps employees to recognize and report wrongdoing by others as well as adhere to high standards of professional conduct. Explains the responsibility of a New York State employee to contact the Office of Inspector General (IG) with information regarding wrongdoing by providing participants with an introduction to the IG s office, the reporting procedure when contacting the IG, the basics of Executive Law 4-A, and the right to privacy and confidentiality under New York State s whistle blower law. The UBSDM will ask participants to login for internal tracking purposes; additionally, the participant can print out certification of course completion at the end of the training. Additionally, each department is responsible for providing specialized training in their area of expertise / discipline as required for employment.

Billing and Claims When claiming payment for services, all providers in the Clinic Management System, as well as administrators in the University Business systems have an obligation to their patients, employees, vendors and the state and federal governments to exercise diligence, care and integrity. UBSDM is committed to maintaining the accuracy of every claim. Many members of our workforce have responsibility for entering charges, diagnoses and procedures codes. Each individual is expected to monitor compliance with applicable billing rules and established coding guidelines. Medicaid regulations prohibit knowingly and willfully making or causing to be made a false statement or representation of a material fact in an application for benefits or payment. Examples of false claims include, but are not limited to: - claiming reimbursement for services that have not been rendered - filing duplicate claims - upcoding to more complex procedures - Including inappropriate or inaccurate costs on cost reports - Falsely indicating that a particular health care provider attended a procedure - Billing for services or items that are not medically necessary - Failing to provide medically necessary services or items - Billing excessive charges Each employee and health care provider who is involved in submitting charges, preparing claims, billing, and documenting services is expected to maintain the highest standards of personal, professional and institutional responsibility. Business policies and procedures are communicated to health care providers through orientation, seminars, intranet and/or newsletters. University business manuals as well as policies and procedures can be located online: http://ubbusiness.buffalo.edu/ubb/cfm/policies/ and are available to all personnel. Auditing and Monitoring The focus of this effort is on accuracy as it relates to documentation and coding. The objective of accuracy monitoring is to ensure complete documentation of dental services rendered and accurate coding. Routine chart review is required to access compliance with the established standards of billing guidelines. Charts will be audited without regard to payor type. Several different types of audits / chart review may be performed such as: 1. Periodic chart audits designed to identify deficiencies in the documentation process are performed as part of the UBSDM s continuous quality improvement program. Remediation is expected by the health care provider if deficiencies are discovered. Results of this audit are reviewed by the Quality Assurance Committee. 2. Investigational audits will be conducted in response to an issue or concern that has been raised within one of the Compliance Oversight Committee members, or as a result of an audit conducted by an outside agency such as the Department of Health.

3. Financial audits are conducted by members of the Clinic Budget Committee and / or by outside financial agencies. Routine and investigational audits of the finance and business departments can and will be conducted as part of our self-assessment. Prepared by: Robin L. Comeau Compliance Officer Patient Care October 24, 2008 Revised October 2009 Revised January 20, 2010 Revised January 11, 2011

APPENDIX I CLINICAL COUNCIL The Clinical Council may consider all matters referred to it by the Dean, the Chair or the faculty. The council will hear all clinical matters dealing with policy or long-term planning. The council shall, after consideration, make recommendations in written form to the Dean. The council is responsible for general policies affecting all clinics. EXECUTIVE COUNCIL The Executive Council shall have the following duties to: - Receive and take action on all recommendations and resolutions of the Voting Faculty. - Determine the requirements for all DDS degrees conferred upon its recommendations and to recommend to the Dean all candidates for that degree. - Approve the predoctoral curriculum of the School of Dental Medicine and to make such changes in it as seem appropriate. - Review and recommend to the Dean appropriate action on appointments, promotions and changes of status. - Review the recommendations of the Student Progress and Promotions Committee and make final recommendation to the Dean. - Report to the Voting Faculty at each general meeting all actions taken by the Executive Council - Keep minutes of all meetings and to distribute such minutes to the President, the Provost and all members of the Executive Council. CLINIC BUDGET The Clinic Budget (formerly Finance Committee) facilitates clinical operations through the maximization of patient fee income. Members of this committee also serve to educate students about the importance of fiscal control. This committee makes recommendations on ways to increase student productivity, increase collections, and serves to monitor clinic expenditures and waste through such tools as clinic inventory system and internal audits. QUALITY ASSURANCE The purpose of the Quality Assurance Committee is to provide a structured process through its Quality Assurance Plan to assure that patient care provided within the UBSDM s educational programs regularly meets or exceeds reasonable expectations based on accepted parameters of care as defined by the American Dental Association and the New York State Department of Health (NYSDOH). CLINIC MANAGEMENT COMMITTEE The Clinical Management Committee meets bi-weekly and is responsible for resolving day-to-day clinic issues and developing new clinic policies for the predoctoral

clinics. Changes and clarifications from these bi-weekly meetings are disseminated in the monthly Clinic Newsletter. Any policy changes requiring significant curricular changes are referred to the Curriculum Committee for approval. ADVANCED EDUCATION PROGRAM DIRECTORS This group meets bi-weekly and is responsible for resolving day-to-day clinic issues and developing new clinic policies for the advanced education clinics.