UTMB HANDBOOK OF OPERATING PROCEDURES

Section 6 Compliance Policies	06/10/05-Originated
Subject 6.1 General Compliance	05/07/09-Reviewed w Changes
	-Reviewed w/o Changes
Policy 6.1.13 Commitment to Compliance	Compliance Office -Author

Commitment to Compliance

Definitions

Fraud – Any intentional act or omission with the purpose of obtaining an unauthorized benefit, such as money or property, through deception or other unethical means. Examples include, but are not limited to, such things as: • Theft of any UTMB, federal, or state asset including money, tangible property, rebates, time, trade secrets and intellectual property • Embezzlement • Bribery/kick-back • Misappropriation, misapplication, destruction, removal or concealment of UTMB, federal, or state property • Forgery, alteration or falsification of documents. Abuse – Occurs when an individual with intent to obtain a benefit or harm another uses his/her employment or association with UTMB to misapply anything of value (including services, personnel, or resources) belonging to UTMB. Examples of abuse include, but are not limited to: • Excessive or improper use of a UTMB resource (occasional local phone calls, and incidental use of UTMB email are allowable) • Misuse of authority or position for personal interests or to harm another individual • Awarding contracts to friends or relatives • Scholarships/grants awarded based on relationships (personal/financial) vs. merit • Seeking or accepting gifts or favors from vendors or contractors in exchange for placing orders or awarding contracts.

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

Policy, continued

3. all other applicable federal and state laws, rules, and regulations 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. UTMB’s standards of conduct address a number of specific laws, policies, rules and regulations, but it is not intended to be a comprehensive list of all legal and ethical principles and cannot cover every legal situation. It does provide information about some of the laws, policies, rules, and regulations that have a direct effect on daily UTMB activities and operations. It is also an educational tool and informational directory to guide employees regarding conduct required in the workplace. Specific employee compliance questions should be directed to your supervisor first and then to the Office of Institutional Compliance. Violation of this policy may result in disciplinary action up to and including termination for employees; a termination of employment relationship in the case of contractors or consultants; or suspension or expulsion in the case of a student. Additionally, individuals may be subject to loss of access privileges and civil and/or criminal prosecution.. 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.

Required Reporting of Suspected Wrongful Conduct

All UTMB employees are required to report possible wrongdoing or suspected violations of applicable federal and state laws and regulations. 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. Reports of suspected violations of applicable laws, rules or regulations should be made in accordance with IHOP 6.1.9 Reporting Suspected Wrongdoing.

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. Please refer to IHOP 6.1.5 Investigating Allegations of Non-Compliance for additional information.

References

IHOP Policy 6.1.5 Investigating Allegations of Non-Compliance IHOP Policy 6.1.9 Reporting Suspected Wrongdoing UTMB Standards of Conduct Guide