UTMB HANDBOOK OF OPERATING PROCEDURES

Section 6 Compliance Policies	June 10, 2005-Originated
Subject 6.1 General Compliance	-Reviewed w Changes
	-Reviewed w/o Changes
Policy 6.1.13 Commitment to Compliance	Compliance Office -Author

Commitment to Compliance

Audience	The information here is intended for all faculty, students, employees, contract employees, and volunteers.
Definitions	Fraud and Abuse: Fraud is defined as knowingly and willfully attempting to receive financial gain by making false statements or developing a scheme to receive anything of value. Abuse is defined as activities that result in excessive or unreasonable costs to UTMB or other state or federal agencies.
Policy	UTMB is committed to full compliance with the laws and regulations that apply to our institution, including all federal health care programs (such as Medicare and Medicaid) requirements, and is committed to prepare and submit accurate claims consistent with such requirements. All officers, managers, administrators, and employees are expected to comply with: 1. UTMB policies and procedures 2. all federal health care program requirements 3. all other applicable federal and state laws, rules, and regulations 4. requirements in UTMB’s Institutional Compliance Agreement (ICA) whether or not specifically addressed in UTMB’s Institutional Compliance Program. Herein after called the program) Misconduct of any type threatens our status as a reliable, honest, and trustworthy provider capable of participating in federal health care programs. Detected but uncorrected misconduct can seriously endanger our mission, reputation, and legal status. Therefore, prompt steps to investigate and correct any conduct in question will be taken. Depending on the nature of the alleged violations, the investigation may include interviews, a review of relevant documents, and involvement of outside legal counsel, auditors, or health care experts. It is the responsibility of each University employee, student, contract employee, and volunteer to act honestly and with integrity in all matters involving UTMB and to seek appropriate guidance when necessary. The standards of conduct set forth in UTMB’s Institutional Compliance Program cannot cover every legal situation. All employees will be subject to appropriate and fair disciplinary action for the substantiation of wrongful conduct or failure to comply with this policy.

Policy, continued

Corporate officers, managers, supervisors, medical staff, and other health care professionals will be held accountable for failing to comply with, or for the foreseeable failure of their subordinates to adhere to, the applicable standards, laws, and procedures. Please refer IHOP Policy 3.10.1, Discipline and Dismissal for details on disciplinary actions. http://www.utmb.edu/policy/ihop/search/03%2D10%2D01.pdf

Required Reporting of Suspected Wrongful Conduct

Violations of applicable laws, rules or regulations subject UTMB to exclusion from participation in the Medicare or Medicaid program. Failure to comply with standards of conduct, policies and procedures, or federal and state laws, or otherwise engaging in wrongdoing will result in disciplinary action, up to and including termination, whether such failure of compliance was intentional or reckless. Additionally, reports or allegations of non-compliance that may constitute an intentional violation or reckless disregard of criminal, civil, or administrative law shall be given to UTMB authorities for investigation and disposition. All UTMB employees are required to report possible wrongdoing or suspected violations of applicable federal and state laws and regulations. UTMB has an open door policy available to all employees acting in good faith to encourage communication, dialogue and the reporting of incidents of potential wrongdoing or suspected violations. A “suspected violation” occurs when an employee has reasonable cause to believe that a violation of a law, rule, or regulation has occurred or will occur. UTMB will not retaliate or discriminate against any employee who makes a good faith report of a suspected violation regarding the observed conduct or actions by another person by reason of such a report being made, for additional information see IHOP Policy 6.1.2, Non-Retaliation Policy. While UTMB strives to maintain the confidentiality of an employee’s identity, it may become necessary for such employee’s identity to become known or revealed during the investigation process. It will be a violation of UTMB policy to make a report of a suspected violation which is knowingly false. Reports of suspected violations of applicable laws, rules or regulations should be made using one of the reporting methods set forth below. Other issues should be reported through the normal reporting structure. Immediate Supervisor. The first option for reporting suspected violations of law is to make the report to the employee’s immediate supervisor or next in line supervisor, who can in turn, work with the Executive Director of Institutional Compliance to investigate and rectify any problems. If reporting to the supervisor or next in line supervisor is inappropriate because the supervisor is absent, does not know the answer or does not respond in a timely manner,

Required Reporting of Suspected Wrongful Conduct, continued

or because the supervisor is suspected of condoning the activity, reports can be made pursuant to one of the other options set forth below. Executive Director of Institutional Compliance. UTMB desires to establish an open line of communication between all employees and the Executive Director of Compliance or his/her designee to provide for the successful implementation and operation of the Program. The Executive Director of Institutional Compliance can be reached by telephone at (409) 747-8700 or during ordinary office hours at 4.238 Rebecca Sealy Hospital or fax (409) 747-8720. A message may also be sent to the Executive Director of Institutional Compliance via regular or electronic mail. Hotline. If an employee wishes to remain anonymous while reporting potential wrongdoing, an employee may call the Compliance and Privacy Hotline, which will be available 24 hours a day, at 1-800-898-7679. The call will not be traced and the person need not give his/her name. Additionally, the Program depends to some extent upon self-reporting and acceptance of responsibility by UTMB employees who may have made mistakes out of lack of knowledge or inattention. To the extent a UTMB employee self-reports a potential wrongdoing; both the self-reporting and the acceptance of responsibility will be taken into account as a mitigating factor in determining the form of action taken. Employees can use the Compliance and Privacy Hotline to self-report or they may contact the Executive Director of Institutional Compliance directly. All reports will be kept confidential to the extent possible and will be thoroughly investigated. Prior to conducting the investigation, all relevant information will be obtained from the disclosing individual. UTMB will not tolerate any threat of or actual retribution for making a good faith report of suspected wrongful conduct.

Responding To and Correcting Detected Offenses

Where fraud and abuse is substantiated, UTMB may immediately refer the matter to law enforcement authorities in addition to reporting the incident(s) to state and federal regulatory authorities. Further, while the investigation is pending, UTMB may remove any employee from their current work activities and location to maintain the integrity of an investigation. In the absence of substantiated misconduct, UTMB may require corrective actions that include restitution, education, training or other appropriate steps necessary to remedy any institutional concerns.