A guide for physicians and other practitioners who bill for services at the UConn Health
What is the purpose of the UConn Health Compliance Program?
As part of the University’s Office of Audit, Compliance & Ethics, the UConn Health Compliance Program assists clinicians to understand and adhere to relevant federal, state, and local laws and regulations as well as federal reimbursement guidelines.
What type of laws, standards, and regulations apply to the health care industry?
Examples include, but are not limited to: Federal False Claims Act, regulations governing participation in the Medicare/ Medicaid Programs, Physician Self-referral Law (Stark), Federal Anti-kickback Statute, Emergency Medical Treatment and Active Labor Act (EMTALA), Health Insurance Portability and Accountability Act (HIPAA), federal regulations governing protection of human and animal research subjects, state licensure laws for hospitals, accreditation standards, and various environmental and safety laws.
Who is responsible for the UConn Health compliance program?
Everyone in the organization is responsible for compliance. You must:
- Adhere to the standards outlined in the University’s Code of Conduct which promotes the Health Center’s core values of the pursuit and sharing of knowledge, honesty, integrity, respect, and professionalism.
- Comply with laws, standards, and regulations including the State Code of Ethics.
- Comply with all relevant policies and procedures.
- Protect the confidentiality of all sensitive and proprietary information.
- Document accurately in the medical record and all other reports.
- Avoid, if possible, or disclose and appropriately manage conflicts of interest.
- Adhere to proper business and marketing practices.
- Maintain a safe and drug and alcohol free workplace.
How is the compliance program carried out?
Education is the cornerstone of the Compliance Program. UConn Health offers faculty members and practitioners an understanding of relevant compliance issues and their accountability to do the right thing in their everyday work responsibilities. Monitoring activities are also conducted to ensure that key processes are carried out appropriately.
What types of activities may be associated with compliance risks?
All health insurance programs, including Medicare, are guided by “reasonableness” and “medical necessity.” Certifying medical necessity of items or services fraudulently or with reckless disregard may result in prosecution under the Federal False Claims Act.
Documentation of services provided to patients is required in conjunction with accurate diagnostic and treatment codes to ensure proper claims submission.
Attending M.D.s must supervise the activities of residents in order to bill for services. Documentation in the medical record must reflect the attending’s presence and active participation.
Providers cannot knowingly and willfully solicit, offer, pay or receive remuneration in exchange for referring an individual for items or services covered by federal or state health care programs. Various exceptions (and safe harbors) may apply, but these require careful consideration.
Physician Self-Referral and Stark Prohibition:
Physicians cannot refer patients to an entity with which the physician (or their family members) has a financial relationship to receive designated health services (DHS) reimbursed by federal health care programs. DHS includes: laboratory or radiologic testing, physical therapy, durable medical equipment or supplies, prosthetics, home health services, and inpatient/outpatient hospital services. Entities cannot bill for goods or services rendered pursuant to a prohibited referral. Various exceptions (and safe harbors) may apply, but
Documentation must be legible, chronologically correct and factual, with no whiteouts or alterations. In order to bill for services provided to patients, documentation must include medical appropriateness, the patient’s diagnoses, and orders for and a full description of the services provided. This applies to inpatient and outpatient settings. All entries must include a legible signature and date.
What are the consequences of non-compliance?
Individual practitioners may be subject to civil and criminal penalties or exclusion from the Medicare/Medicaid programs. The Health Center may also be subject to fines and exclusion from these programs. UCHC may take disciplinary action against non-compliant individuals up to and including termination.
What do I do if I have a compliance related concern?
Practitioners have a duty to report compliance concerns. If you are uncertain whether a policy, procedure or established business practice is appropriate, seek clarification. If you are not comfortable using the internal resources available, you may anonymously call the REPORTLINE (1-888-685-2637) which is operated by an independent (non-University) company.
Resources for your compliance concerns:
- Your Supervisor
- Compliance Program Iris Mauriello R.N.
Compliance Integrity and Privacy Officer
- Reportline: 1-888-685-2637
- Billing policies and “Tip of the Month” may be accessed in the Clinical Business Systems shared folders in UConn Health email.
- The UConn Health Compliance Program manual is available in the Compliance Office shared folder in UConn Health email.