THE UNIVERSITY HOSPITAL
CORPORATE COMPLIANCE PROGRAM

1. INTRODUCTION

   University Hospital has a reputation for conducting itself in accordance with high standards in carrying out its educational, research, public service and clinical care missions. Its activities are conducted consistent with community ethics and in compliance with applicable governing laws. University Hospital recognizes the problems that both deliberate and accidental misconduct in the healthcare industry can pose to society. University Hospital is committed to ensuring that it operates under ethical and moral standards.

   University Hospital's Corporate Compliance Program has been developed in accordance with applicable law, with guidance from state and federal authorities, including the Federal Sentencing Guidelines. With this program, the University Hospital will promote full compliance with all legal duties applicable to it, foster and assure ethical conduct, and provide guidance to each employee and agent of University Hospital for his or her conduct. The procedures contained in this program are intended to generally define the scope of conduct which the program is intended to cover and are not to be considered as all inclusive. The Compliance Program is based on University Hospital's determination that it and all associated with it will do right.

   This program is designed to prevent accidental and intentional noncompliance with applicable laws, to detect such noncompliance if it occurs, to discipline those involved in noncompliant behavior, to restore to the payor any payments which have been made inappropriately and to prevent future noncompliance. This Compliance Program will be updated periodically to keep University Hospital's employees and agents informed of the most current information available pertaining to compliance requirements for the healthcare industry.

   The Board of Trustees of the University of Arkansas (The Board) acting for and on behalf of the University Hospital of Arkansas and as its governing body has directed the preparation of a comprehensive written compliance plan by Resolution dated June 25, 1998.
    

2. APPOINTMENT OF A COMPLIANCE OFFICER

1. In an effort to ensure compliance with all policies and regulations, the Board has adopted a formal Compliance Program for University Hospital.

1. To oversee and implement this program, the Vice Chancellor of Clinical Programs, with the approval of the Board, shall appoint a Hospital Compliance Officer.

2. The Compliance Officer will be chosen based on his or her outstanding record of commitment to honesty, integrity, and high ethical standards and on his or her knowledge and understanding of the applicable laws and regulations.

3. The Compliance Officer has the authority to review all documents and other information that are relevant to all compliance activities as well as authority relating to recommendations concerning discipline.
    

2. Duties and Responsibilities of the Compliance Officer.

1. Oversee and monitor the implementation of the compliance program to ensure compliance with the law;

2. With the advice of legal counsel, supervise the preparation and development of guidelines on specific federal and state legal and regulatory issues and matters involving ethical and legal business practices;

3. Assist in establishing methods to improve the University Hospital's efficiency and quality of services, and reducing the hospital's vulnerability to fraud, abuse and waste;

4. Revise the program periodically to include the changes of the laws and regulations, and procedures of the federal and state government and private payor health plans;

5. Develop, coordinate, and participate in various educational and training programs that focus on the elements of the compliance program, and ensure that all appropriate employees and management are knowledgeable of, and comply with pertinent federal and state laws and regulations;

6. Ensure that all independent contractors and agents who furnish medical services to University Hospital are aware of the requirements of the compliance program with respect to coding, billing, marketing, referrals and kickbacks;

7. Coordinate with the Department of Human Resources to ensure that no employees have been excluded from participation in any government health care plans;

8. Plan and oversee regular, periodic compliance audits of University Hospital's operations in order to identify and rectify any possible barriers to the efficacy of the Compliance Program;

9. Chair the Hospital Compliance Committee to utilize resources and talents throughout the University Hospital;

10. Independently or with the advice of legal council, investigate and act on matters relating to compliance including designing and coordinating internal investigations;

11. Make use of all University Hospital resources by referring appropriate complaints to existing investigative offices. For example, complaints of discrimination or sexual harassment may normally be referred to the office of Human Resources.

12. Provide guidance and interpretation to all Hospital personnel, in conjunction with University Hospital's legal counsel, on matters relating to the compliance program; and

13. Develop policies and programs that encourage all University Hospital employees to report suspected improprieties without fear of retaliation.

14. The Compliance Officer may be terminated only by joint act of the Board and the Vice Chancellor of Clinical Programs.
     

3. Reporting by Compliance Officer

1. The Compliance Officer shall prepare a report to the Vice Chancellor of Clinical Programs and the Board concerning the compliance activities and actions undertaken during the preceding year, the proposed compliance program for the next period and any recommendations for changes in the compliance program. This report shall be submitted annually.

2. In general, the recommendations of the Compliance Officer regarding compliance matters shall be directed tot he appropriate officer or manager of University Hospital.

1. If the Compliance Officer is not satisfied with the action taken pursuant to his or her recommendations, he or she will report such concern to the Vice Chancellor of Clinical Programs.

2. In no case will University Hospital endeavor to conceal unlawful activities verified after appropriate investigation.

3. In the event that the Vice Chancellor of Clinical Programs or the Chancellor is the subject of an investigation, or the Hospital Compliance Officer is not satisfied with the action taken pursuant to his or her recommendations, the Compliance Officer shall report to the Chairperson of the Joint Hospital Committee of the Board.

3. The Compliance Officer shall report at a minimum on a monthly basis to the Vice Chancellor for Clinical Programs on the progress of implementation and compliance.

4. The Hospital Compliance Officer shall meet with the Joint Hospital Committee Board at its regularly scheduled meetings.
    

3. COMPLIANCE COMMITTEE

1. The Hospital Compliance Officer will chair the Hospital Compliance Committee. The Hospital Compliance Committee shall support the Hospital Compliance Officer with the following duties:

1. Ensure the Hospital billing affairs are conducted in accordance with applicable laws through implementation and monitoring of the compliance program.

2. Review, revise, approve, and oversee implementation of the Hospital departmental compliance plans.

3. Review, revise and approve training and educational programs for Hospital employees, vendors, and agents.

4. Develop, to the extent permitted by law, a confidential hotline and review inquiry responses provided by the Hospital Compliance Officer.

5. Review the Hospital departmental compliance audits and the departmental responses to the audit findings.

6. Assist in developing standardized corrective action plans.

7. Review, revise, and approve an annual report prepared by the Hospital Compliance Officer that describes the general compliance efforts and offers specific actions to improve compliance.

2. The Hospital Compliance Committee shall be comprised of an Executive sub-committee and an operational sub-committee. The Operational sub-committee shall report to the Executive sub-committee. The Executive sub-committee will include the following members:

   Vice Chancellor of Clinical Programs
   Chief Operating Officer
   Chief Financial Officer
   Director of Outpatient Services
   Chief Nursing Executive
   Hospital Medical Director
   Compliance Officer, Chairperson

   The Operational sub-committee will be chaired by the Hospital Compliance Officer and consist of the following members:

   Associate Hospital Director of Outpatient Services
   Chief Nursing Executive
   Director of Medical Records
   Director of Laboratory Services
   Director of Financial Management
   Director of Patient Business Services
   Director of Education for Clinical Programs
   Manager of Cost Accounting and DSS
   Compliance Billing Manager
   

   FGP Compliance Officer and Hospital Legal Counsel shall be notified of and invited to attend all meetings.
    

3. Both the Executive and Operational sub-committees shall meet at least monthly
    

4. The Compliance Officer shall be authorized to require that any member of the Executive Committee or the Operational sub-committee refrain from considering a matter before the committee whenever the Compliance Officer determines that such member has a conflict of interest.
    

4. EDUCATIONAL AND TRAINING PROGRAMS

   1. Purpose
      The educational and training programs are intended to provide each employee of University Hospital with an appropriate level of information and instruction regarding ethical and legal documentation regarding compliance issues.
       

   2. Responsibility for Educational Programs

      1. The Compliance Officer shall be ultimately responsible for ensuring that the compliance program and appropriate policies concerning compliance are disseminated in a manner to be understood by all employees.

      2. To accomplish this objective, the Compliance Officer and his or her designees shall be responsible for presenting the compliance program to the appropriate administrative areas within University Hospital.

      3. In addition, the Compliance Officer will work with the Human Resource department and appropriate department and administrative personnel to ensure that there are systematic and ongoing training programs that teach employees how to perform their duties lawfully.

      4. The programs shall educate and maintain awareness of the compliance program and compliance policies among existing and newly obtained employees and third party affiliates and such education shall be appropriately documented.
          

   3. Subject Matter of Educational Programs.

      1. The educational and training programs shall explain the applicability of pertinent laws, including, without limitation, applicable provisions of the following:

         1. False Claims Act (31 U.S.C. Sec 3729);

         2. Civil and Criminal Provisions of the Social Security Act (42 U.S.C. Sec. 1320a - 7a and Sec. 120a - 7b, respectively);

         3. Criminal Offenses concerning false statements relating to health care matters (18 U.S.C. Sec. 1035);

         4. Criminal Offense of Health Care Fraud (18 U.S.C. Sec. 1347);

         5. Federal Anti-Referral Laws (42 U.S.C. Sec. 1320a- 7b(b);

         6. Sherman Antitrust Act (15 U.S.C. Sec. 1, 2, and 18) and

      2. As additional legal issues and matters are identified by the Hospital Compliance Officer, those areas will be included in the educational program.

      3. Each education and/or training program conducted hereunder shall reinforce the fact that compliance with the law and University Hospital's program is a condition of employment with the Hospital.

      4. Education should always include directions to any employee who suspects unlawful or unethical activity as to how to proceed.

      5. Education must include the positive effect of compliance and will be a factor in determining the employees salary, job performance, promotional opportunities and other terms and conditions of employment.
          

   4. In particular, and without limitation, the Policy prohibits University Hospital, its administrators and employees or agents from directly or indirectly engaging or participating in any of the following:

      1. Improper Claims

         Improper claims include those presenting or causing to be presented to the United States government or any other health care payor a claim for a[n]

         1. Item or Service Not Provided as Claimed
            For a medical or other item or service that such person knows or should know was not provided as claimed, including a pattern or practice of presenting or causing to be presented a claim for an item or service that is based on a code that such person knows or should know will result in a greater payment to the claimant that the code such person knows or should know is applicable to the item or service actually provided;

         2. False Claim
            For a medical or other item or service and such person knows or should know the claim is false or fraudulent;

         3. Service by Unlicensed Physician
            For a physician's service (or an item or service incident to a physician's service) when such person knows or should know the individual who furnished (or supervised the furnishing of) the service:
            was not a licensed physician;
            was licensed as a physician, but such license had been obtained through a misrepresentation of material fact;
            represented to the patient at the time the service was furnished that the physician was certified in a medical specialty by a medical specialty board when the individual was not so certified;

         4. Excluded Provider
            For a medical or other item or service furnished during a period in which such person knows or should know the claimant was excluded from the program under which the claim was made;

         5. Not Medically Necessary
            For a pattern of medical or other items or services that such person knows or should know are not medically necessary.
             

   5. Scope and Frequency of Employee Training

      1. Employee training will occur, at the minimum, on an annual basis and shall be mandatory.

      2. Some employees may receive specialized training as a result of the areas in which they are employed focusing on complex areas or on areas in which the Compliance Officer has determined a need exists for additional training.

      3. As new developments arise, the Compliance Officer may require additional training sessions for some or all of University Hospital's employees.

      4. University Hospital's orientation for new employees will include discussions of the compliance program and an employee's obligation to maintain ethical and legal conduct and standards.

      5. Supervisors shall be trained to recognize and report problems with compliance.
          

5. MONITORING AND AUDITING SYSTEMS

   1. Compliance Audits

      1. The Hospital Compliance Officer shall supervise compliance auditing systems.

         1. Audit procedures shall determine accuracy and validity of coding and billing submitted to Medicare and Medicaid, other federal health programs and other payors, and detect possible instances of potential misconduct by University Hospital employees and agents as well as inadvertent errors as quickly as possible.

         2. Qualified persons shall conduct regular, periodic audits, at the Hospital Compliance Officer's direction.

         3. Such audits shall evaluate University Hospital's compliance with its compliance program and determine what, if any, compliance issues exist.

         4. Areas that the Hospital Compliance Officer regards as complex shall be reviewed at least once annually.

         5. The Executive and the Operational sub-committees of the Hospital Compliance Committee may determine areas which require review and monitoring.

         6. Any employee may identify to the Compliance Officer an issue that he or she believes requires reviewing or monitoring.

         7. All suggested issues should be channeled through the Hospital Compliance Officer, who shall determine when a review or monitoring is required.
             

      2. Compliance audits shall be conducted in accordance with the comprehensive audit procedures established by the Compliance officer and shall include at a minimum:

         1. interviews with personnel involved in management, operations and other related activities;

         2. periodic review of the entire claims development and submission process beginning with a patient's registration and ending with the submission of the claim to the government payor or third party payor;

         3. sampling protocols;

         4. review of backup records on a random basis to assess reliability of billings to programs;

         5. on-site reviews; and

         6. special attention will be given to reviewing frequent billings of certain procedure codes, and to analyzing fact, which may suggest inappropriate conduct.
             

   2. Review of Contracts

      1. All contracts and other arrangements with physicians, laboratories, providers, vendors, referral sources and other persons shall be reviewed by Hospital Legal Counsel in accordance with University of Arkansas contracting policy and shall be consistent with the compliance plan.

      2. Existing contracts identified by the Hospital Compliance Officer will be reviewed to ensure compliance. Such review will be undertaken under the direction of Hospital Legal Counsel.
          

   3. Reporting of Compliance Issues

      1. The Hospital Compliance Officer shall have an open door policy with respect to receiving reports of violations, or suspected violations, of the law or of the Compliance Plan and with respect to answering employee questions concerning adherence to the law and to the Compliance Plan.

      2. A confidential hotline will serve as a reporting option for employees and agents with information about suspected misconduct.

         1. Questions about compliance standards and legal duties will be forwarded by the hotline to the Hospital Compliance Officer, who will respond or direct a response from the appropriate person within University Hospital.

         2. The Hospital Compliance Officer, or his or her designee, shall investigate all reports of suspected misconduct received through the Hotline.

         3. The Hospital Compliance Officer shall refer all legal issues to the University Hospital Legal Counsel for advice.

         4. Hotline reports will be assured of confidentiality to the extent permitted by law.

         5. Any employee or agent who develops concerns over unethical practices, improper employee conduct, the integrity of University Hospital's billing/coding practices or other improper practices described throughout this program, is encouraged to report such concern through the Hotline or directly to the Hospital Compliance Officer or his or her designee.

         6. Under no circumstances shall the reporting of any such information or possible impropriety serve as a basis for any retaliatory actions to be taken against any employee, patient or other person making the report to the Hotline. However, employees or agents shall be educated not to make an intentionally false statement or otherwise misuse the Hotline.

         7. The telephone number for the Hotline shall be posted in conspicuous locations throughout University Hospital.

         8. The Hospital Compliance Officer, or his or her designees, will educate all persons associated with University Hospital as to the availability of the Hotline.
             

      3. All reports will be responded to and such response will be documented.
          

   4. Formal Audit Reports

      1. Formal compliance reports shall be prepared by the Hospital Compliance Officer, reviewed by University Hospital's Legal Counsel and submitted to the Board, the Vice Chancellor of Clinical Programs and appropriate administrative staff to endure that management is aware of the results and can take any necessary corrective actions.

      2. The reports shall specifically identify areas where corrective actions are needed and should identify in which cases, if any, subsequent audits or studies would be advisable to ensure that the recommended corrective actions have been implemented and are successful.

      3. The reports shall specify the previous period's compliance activities.

      4. The reports shall be made at least annually.
          

   5. Compliance with Applicable Fraud Alerts

      1. The Hospital Compliance Officer shall regularly monitor the issuance of fraud alerts by the Office of the Inspector General of the Department of Health and Human Services. The Compliance Officer shall revise and amend this compliance program, as necessary, in accordance with such fraud alerts.

      2. In addition, the University Hospital shall immediately cease and correct any conduct publicized in any such fraud alert.
          

6. DISCIPLINARY PROCEDURES

   1. Failure to comply with this program, or the laws and/or regulations applicable to participants in federally funded health care programs and third party payors, will result in discipline up to and including termination from employment or association with University Hospital.
       

   2. The Hospital Compliance Officer and/or the University Hospital Legal Counsel shall investigate claims of suspected misconduct reported to them, and shall determine if any University Hospital employee was involved in verified misconduct.
       

   3. The Hospital Compliance Officer shall refer verified misconduct or failure to report noncompliant conduct to the appropriate Administrator of the employee concerned. The Administrator shall take such action as he or she deems appropriate and shall report disciplinary action taken to the Hospital Compliance Officer.
       

   4. Appropriate disciplinary measures shall be on a case by case basis according to policies of the Board, UAMS and University Hospital.
       

   5. If the Compliance Officer and/or University Hospital's Legal Counsel determine, after investigation, that noncompliant conduct occurred as a result of gross misconduct, the matter shall be forwarded to the appropriate Administrative personnel for appropriate disciplinary action. Such disciplinary action may include, but not be limited to, terminating the individual(s) involved, revising this program to prevent the occurrence of future misconduct in the area, increasing review and monitoring procedures, reassigning supervisors who, although not involved in the misconduct, nonetheless failed to adequately supervise and control University Hospital's personnel, and reporting the responsible individuals to the appropriate government agency whenever it is determined that such action is required by law.
       

7. PROCEDURES FOLLOWING DETECTION OF MISCONDUCT

   1. In addition to disciplinary action, University Hospital will respond to each specific situation on a case by case basis using methods including:

      1. Re-training University Hospital employees;

      2. Modification of the charges, coding and billing system where necessary;

      3. Adjustment to policies and procedures; and

      4. Engaging in steps necessary to reduce the error rate.
          

   2. Reimbursement through appropriate methods shall be made to the government or other appropriate payors.
       

   3. University Hospital is committed to full compliance with all state and federal laws and shall cooperate with all government investigations of UAMS, and its employees or agents, including investigations of suspected criminal conduct.

      1. The legal rights of UAMS, employees and agents shall be protected.

      2. University Hospital, in such investigations, shall proceed as required by law and will not engage in activities that obstruct justice.
          

8. DEPARTMENTAL APPENDICES

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