The healthcare environment is a complicated one that continues to rapidly evolve, creating increasing complexity and a very highly regulated environment. The UBMD Compliance Plan was created to assist employees in conducting themselves in a manner that ensures successful compliance with all healthcare laws, rules and regulations. It is not just a binder to be placed on a shelf and forgotten, but a living document that is a part of all daily operations.
It is the responsibility of all UBMD practice personnel to always follow UBMD’s Compliance Plan. Without exception, the UBMD Policies & Procedures and Code of Conduct within the Compliance Plan apply to every colleague, physician/provider, staff member, Governing Board member and Board of Director member.
For easy reference, some of the most often asked about policies are availble to the left. Click here to view the entire UBMD Compliance Plan.
The UBMD Compliance Plan was created based on the OIG’s Seven Essential Elements of an Effective Compliance Program, which are based on the Federal Sentencing Guidelines. An 8th element is now often included: Non-Retaliation.
Written Code of Conduct and Policies and Procedures are required to promote commitment to compliance. Both demonstrate UBMD’s organization-wide emphasis on ethical attitudes and compliance with all applicable laws and regulations. They provide guidance for employees and others on decision-making, doing the right thing, dealing with potential compliance issues, and communicating such issues to appropriate personnel. They also describe how potential compliance problems are investigated and resolved. UBMD’s Code of Conduct and Policies and Procedures are part of UBMD’s Compliance Plan.
The OIG and Federal Sentencing Guidelines require the designation of a compliance professional “to serve as the focal point for compliance activities.” This person is responsible for the day-to-day operations of the compliance program, and reports directly to the president or other senior administrator, and periodically reports directly to the Executive Committee and Governing Board, on the activities of the compliance program. UBMD has a Chief Compliance Officer (CCO) to perform these duties.
All OIG guidance and Federal Sentencing Guidelines identify the need for training and education, which are the first, and probably the most, important lines of defense for an effective compliance program. Education is the best strategy for preventing non-compliance. As such, and according to guidelines, all UBMD employees, including executives, governing body members, providers and staff, will be trained on compliance issues, expectations, and the compliance program operation. Training will be included as a part of orientation for new employees, annually for existing personnel, and periodically as deemed necessary.
An effective compliance program is one with a process of constant evaluations. UBMD Compliance has a system in place that demonstrates a process for continually improving on compliance activities with routine identification of compliance risk areas. Regular internal audits, and annual risk assessments are performed for the evaluation of potential or actual non-compliance.
Open lines of communication to the Chief Compliance Officer and his/her staff is important for an effective compliance program. Open communication can help reduce incidents of potential fraud, waste and abuse. Employees must feel comfortable approaching supervisors, the Chief Compliance Officer and compliance office personnel. A method for anonymous and confidential good faith reporting should also be available.The UBMD Compliance Office has an open door policy, and encourages all UBMD personnel to call, email or visit in person any time, with any questions or concerns. UBMD also has an anonymous Compliance Hotline.
Enforcing the standards of conduct and the policies and procedures must be fair, equitable and consistent. The Compliance Office is charged with the responsibility of responding to allegations of improper activities. The Code of Conduct and other Policies are established to ensure all UBMD employees are aware that compliance will be treated seriously, and that violations and non-compliance will be dealt with fairly, consistently and uniformly.
If misconduct or wrongdoing ever found to have actually occurred, organizations must respond appropriately and in a timely manner. A delay or failure in response can result in serious consequences for the organization. According to the OIG, violations of the compliance program and other types of misconduct threaten an organization’s as a reliable, honest and trustworthy provider capable of participating in federal health care programs. Therefore, at UBMD, reasonable and prompt steps will be taken to respond to all violations detected through audits and monitoring, as well as those reported by individuals. Implementation of a corrective action plan shall take place for any violations confirmed by an investigation.
For reporting methods to be effective, employees must feel confident that there will be no retaliation or retribution if they come forward with concerns. At UBMD, retaliation for reporting compliance concerns in good faith will not be tolerated, regardless of whether or not a violation is found as a result of the initial report. Reports of retaliation will be investigated thoroughly, and can result in disciplinary action for the retaliating party up to and including termination of employment.
The various sections of our Compliance Plan focus on these elements, describing them in more detail, and providing the policies and procedures that all UBMD employees are expected and required to follow at all times while performing their daily work.
The Compliance Plan is not a binder to just be placed on a shelf and gather dust. It is a living document. An active application of the Compliance Plan’s policies and procedures on a daily basis, by all UBMD employees, will ensure that full compliance is achieved in our organization.
All UBMD employees should have easy access to a copy of the Compliance Plan, and are strongly encouraged to use it as a tool to guide them in the activities and services they perform each and every day on behalf of UBMD.
All new hires should be given a copy of the Compliance Plan, and complete Compliance Plan training. They should also be given a “Compliance Plan and Code of Conduct Employee Acknowledgement” to sign, acknowledging that they received the Compliance Plan and understand their responsibilities. The signed acknowledgement should be kept in their Human Resources file.