Compliance Program
Revised Feb 2007

Mission Statement

Southern Illinois University at Carbondale (University) Southern Illinois University School of Medicine ("SOM"), and SIU Physicians & Surgeons ("SIU P&S"), the approved clinical faculty practice plan of the School of Medicine, wish to ensure that its affairs are conducted in accordance with applicable laws relating to health care compliance, including but not limited to, professional fee billing and reimbursement. Compliance in this area is challenging because the regulatory requirements governing such matters are complex and changing.

The Compliance Program is hereby established and shall be implemented by the University, SOM and SIU P&S as a means of assuring that professional care rendered to patients is in compliance with promulgated rules of Health and Human Services governing Medicare payment for physician services as well as guidelines issued by the Illinois Department of Healthcare and Family Services  and other federal and state laws and regulations.

Implementation of the Compliance Program shall be under the direction of the University Office of Compliance in close cooperation with the Dean and Provost of the University’s School of Medicine and the Administrative Offices of SIU P&S and its Compliance Office.

This Compliance Program shall be applicable to all those full-time and part-time employees of the University and/or SIU P&S whose job descriptions include the provision of medical services or employees who provide the related business and operations functions to carry out medical services for which billings may be submitted under federal and state health care programs and/or third party payors.

Introduction

The Compliance Program described in this document is intended to establish a framework for legal and administrative compliance by the University. It is not intended to set forth all of the substantive programs and practices of the University that are designed to achieve compliance. The Compliance Program will apply in full force and affect to any successor clinical faculty practice plan to SIU P&S approved by the Board of Trustees of Southern Illinois University. The Compliance Program has the following key features:

• Designation of a University official responsible for directing the effort to enhance compliance, including implementation of the Compliance Program through the University’s Office of Compliance.

• Designation of a Compliance Office within SIU P&S for directing the effort to enhance compliance and implement the Compliance Program in conjunction with the University Office of Compliance.

• Development of written standards of conduct, policies and procedures that guide personnel at all applicable levels of the University.

• Training of applicable clinical and billing personnel, SIU P&S members and graduate medical trainees concerning compliance, and any other appropriate personnel.

• A mechanism for employees to raise questions and receive appropriate guidance concerning compliance.

• Establishment of a mechanism for regular chart and billing reviews to assess compliance with guidelines, rules and regulations.

• A process for employees to report instances of possible non-compliance and for such reports to be fully reviewed and acted upon.

• A process for formulating corrective action plans to address any instances of non-compliance.

Code of Conduct

The following are the general provisions and standards of the University, SOM and SIU P&S’s Code of Conduct.

General Provision and Standards

1. All business will be conducted in conformance with sound ethical standards. Achieving business results by illegal acts or unethical conduct is not acceptable.

2. All personnel shall act in compliance with the requirements of applicable laws and this Code of Conduct and in a sound ethical manner when conducting business and operations.

3. All personnel are responsible for acquiring sufficient knowledge to recognize potential compliance issues applicable to their duties and for appropriately seeking advice regarding such issues.

4. Personnel shall not offer or give any bribe, payment, gift, or thing of value to any person or entity with whom the University, SIU SOM and/or SIU P&S has or is seeking any business or regulatory relationship except for gifts of a nominal value which are legal and given in the ordinary course of business.

5. Personnel shall be completely honest in all dealings with government agencies and representatives. No misrepresentations shall be made, and no false bills or requests for payments or other documents shall be submitted to government agencies or representatives. Personnel certifying the correctness of records submitted to government agencies, including bills or requests for payment, shall have knowledge that the information is accurate and complete before giving such certification.

Reporting of Violations

1. Illegal acts or improper conduct may subject the University, SIU SOM and/or SIU P&S to severe civil and criminal penalties, including large fines and being barred from certain types of business. It is, therefore, very important that any inappropriate activities or violations of the Code of Conduct be promptly brought to the University, SIU SOM and/or SIU P&S’s attention. In many cases, if illegal acts are discovered and reported to the appropriate governmental authorities, lesser penalties may result.

2. Any director, officer, or employee who believes or becomes aware of any violation of the Code of Conduct or any inappropriate activity by a director, officer, or employee or another person acting on the University, SIU SOM, and/or SIU P&S’s behalf shall promptly report the violation or activity in person, by phone, or in writing to the University Office of Compliance or other appropriate offices or personnel of the SOM and/or SIU P&S. A report may also be made by calling the Compliance Hotline at 217.545.7479.

3. It is a violation of this Code of Conduct for personnel not to report a possible violation of the Code of Conduct or other inappropriate activities. If you have a question about whether particular acts or conduct may be inappropriate or a violation of the Code of Conduct, you should contact the University Office of Compliance or other appropriate SOM or SIU P&S offices and/or personnel. It is a violation of this Code of Conduct for personnel to whom a potential inappropriate act or violation of the Code of Conduct is reported to not ensure that the suspected act or violation of the Code of Conduct comes to the attention of those responsible for investigating such reports. If the suspected acts or conduct may be in violation of the Code of Conduct involve a person to whom such acts or violations might otherwise be reported, the individual should report such activities to another person to whom reporting is appropriate.

4. It is the University, SIU SOM and/or SIU P&S’s policy to promptly and thoroughly investigate reports of illegal activity or violations of this Code of Conduct. Personnel must cooperate with these investigations. You must not take any actions to prevent, hinder, or delay discovery and full investigation of any suspected acts or violations. It is a violation of this Code of Conduct for personnel to prevent, hinder or delay discovery and full investigation of matters under this Code of Conduct.

5. Personnel may report suspected acts or violations of this Code anonymously. To the extent permitted by law, the University, SIU SOM and/or SIU P&S will take reasonable precautions to maintain the confidentiality of those individuals who report such activities or violations of this Code and of those individuals involved in the alleged improper activity, whether or not it turns out that improper acts occurred. Failure to abide by this confidentiality obligation is a violation of this Code of Conduct.

6. No reprisals or disciplinary action will be taken or permitted against personnel for good faith reporting of, or cooperating in the investigation of, suspected violations of this Code of Conduct. It is a violation of this Code for personnel to punish or conduct reprisals in regard to personnel who have made a good faith report of, or cooperated in the investigation of, illegal acts or violations of this Code of Conduct.

7. Personnel who violate the Code of Conduct or commit illegal acts are subject to discipline up to and including dismissal. Personnel who report their own illegal acts or improper conduct, however, will have such self-reporting taken into account in determining the appropriate disciplinary action.

Compliance Program

Organization

The University has established an Office of Compliance under the Office of the President and SOM and SIU P&S have established a Compliance Office within the Administrative Office of SIU P&S. The SIU P&S Compliance Office shall work in close cooperation with the University’s Office of Compliance, the Dean and Provost, and the CEO of SIU P&S in the development and enforcement of policies, procedures and guidelines related to compliance issues.

University Office of Compliance. The University Office of Compliance shall consist of the following personnel and committees:

• University Director of Compliance is responsible for the oversight of compliance for the University, including the SOM and SIU P&S. Reports directly to the President of the University and serves as chairperson of the University Compliance Committee. Quarterly reports shall be provided to the Board of Trustees, or as the need may arise.

• Health Care Compliance Officer oversees day-to-day activities of compliance at the SOM and SIU P&S. The Health Care Compliance Officer reports to the University Director of Compliance.

• Compliance Committee comprised of faculty and staff representatives from each clinical area and business support unit. The primary function of the committee is to develop, review and disseminate policies, procedures and guidelines for the compliance department. Meets every other month.

SIU P&S Compliance Office. The SIU P&S Compliance Office shall be under the administrative direction of the SIU P&S Chief Financial Officer who reports to the Chief Executive Officer of SIU P&S. The Office works in close cooperation with the SOM’s Dean and Provost and the University Office of Compliance on matters related to compliance. The SIU P&S CFO works with the SIU P&S Coding and Reimbursement Coordinator (Chairs the Coding User Group) and the Director of Patient Business Services (Chairs the Billing Users Group). The Clinical Departments shall maintain and have on file applicable policies and procedures regarding coding, billing and documentation practices, as prescribed by the University Office of Compliance and SIU P&S Compliance Office.

Joint Executive Compliance Committee consists of University Director of Compliance, Health Care Compliance Officer, SIU P&S Coding and Reimbursement Coordinator, Director of Patient Business Services, and the SIU P&S Compliance Officer (SIU P&S CFO). Discusses day-to-day operations, current reviews, plans reviews and provides staff support to the full Compliance Committee. Meets monthly.

Compliance reviews and other special analyses related to the University Office of Compliance will be submitted in writing to the Dean of the School of Medicine and the CEO of SIU P&S. The Office of the President will be provided such information as deemed necessary. Each will review the documents and transmit appropriate comments where applicable.

Joint Administrative Responsibility

The University Office of Compliance and the SIU P&S Compliance Office have the following primary duties and responsibilities:

• Address compliance issues and responsible for implementation of the Compliance Program;

• Provide for and make available to the SOM community, repository of documents and reference materials relating to compliance requirements;

• Review applicable rules and guidelines on an on-going basis and implement needed modifications to existing policies and procedures or prepare additional policies and procedures or guidelines as may be necessary so as to promote awareness of compliance requirements;

• Conduct internal reviews and audits of physician and non-physician professional charges and medical records on a bi-annual basis.

Education and Training

As applicable based upon job description or as determined by the University Office of Compliance and/or SIU P&S Compliance Office, all SIU P&S Members/Employees, medical residents and clinical/departmental personnel will be required to attend an annual education and training session. The education and training session will include a review of the written compliance policies and procedures. Orientation sessions for new employees will be provided on an as needed basis.

In-house training sessions on proper professional fee coding (CPT-4 and ICD-9), proper medical record documentation requirements, and other compliance issues will be periodically offered to the SOM community.

Compliance Review

The University, SOM and SIU P&S are committed to the implementation of the following procedures for internal monitoring of compliance to applicable laws, rules, policies and guidelines governing professional fee billings.

• The University Office of Compliance and the SIU P&S Compliance Office will conduct internal reviews of professional fee billings submitted for reimbursement under Medicare and Medicaid or other government programs by SIU P&S members for adherence to applicable regulations and guidelines. External expertise may be brought under contract to assist the University, SOM, and/or SIU P&S in meeting this objective.

• The University Office of Compliance and the SIU P&S Compliance Office will periodically review contracts and other written agreements to ensure compliance with federal and state self-referral laws.

• A sample audit of every clinical department and division’s professional fee billings will be conducted on at least an annual basis. The outcome of these reviews will be shared with the individual SIU P&S member or University employee and clinic/department administrator.

Corrective Action

• If there are deficiencies found during an audit, the following steps will be initiated, or if errors are of such nature that other steps need to be taken immediately, the Office of Compliance will take such action in conjunction with the SIU P&S Compliance Office and in consultation with the Dean and Provost of SIU SOM and the CEO of SIU P&S:

  1. Review with the faculty member the details of the deficiencies found, educate and provide corrective action. A re-audit of the same faculty member(s) will be conducted within three (3) months to confirm compliance.

  2. If, at the conclusion of the second review, similar deficiencies are found, the faculty member will be required to attend a full education and training program as is offered to new clinical faculty and residents. Until completion of the education and training session, all professional fee billing for that provider will be suspended. A claim-by-claim, pre-submission audit will occur for no less than thirty (30) days.

  3. A second follow up audit will be conducted within thirty (30) days of billings being reinitiated. This audit will be done subsequently to billing. If there are no similar deficiencies found, the individual will revert back to the annual review. However, if the re-audit shows continued and similar deficiencies, the individual’s professional fee billings will be immediately suspended and necessary refunds will be made. An external consultant may be hired to review professional fee billing and the consultant will review all future billings. The full cost of this process, which may include but is not limited to, fees for external consultants, overtime for SOM employees, refunds to Federal health care programs and/or third party payers, will be borne by the individual faculty member.

• Faculty, residents or staff who suspect inappropriate practices are encouraged to bring the matter to the attention of the University Office of Compliance, University, SOM and/or SIU P&S administrative personnel. All reports are to be followed up and reviewed using appropriate internal analysis.

Appeal Procedure

Any faculty, resident or staff member shall have an opportunity to appeal decisions made by the University Director of Compliance, the Health Care Compliance Officer, or the SIU P&S Compliance Office. Appeals shall be made to the University Compliance Committee whose decision shall be final and exclusive of any rights that may exist in the employee policies and procedures. The University Director of Compliance, Health Care Compliance Officer, or SIU P&S Compliance Officer must recuse themselves in any appeals in which their final determination is being appealed.

Decisions that may be appealed are those that a final determination in which noncompliance has occurred that requires corrective action. The faculty, resident, or staff has thirty (30) days to appeal the decision and such appeal shall be made in writing. Any appeal not received within thirty (30) days shall be deemed untimely and will not be considered. The notice of appeal must contain a description of the relevant facts and an explanation of the reason for the appeal. The appeal shall be considered at the next University Compliance Committee meeting, or sooner at the discretion of the University Director of Compliance. The appealing party may provide all documentation or materials supporting the appeal and may request the opportunity to be heard which shall be granted. The University Compliance Committee shall consider all evidence before it when deciding an appeal. It may also request the presence of the appealing party, and any other additional information that may be necessary. A written record of the appeal, minutes from the meeting, and any other documentation shall be considered the record. The record shall be considered confidential, unless disclosure is deemed necessary to Dean of the School of Medicine, CEO of SIU P&S or other appropriate University administration. A decision after the meeting shall be communicated in writing to the appealing party within ten (10) days.

Reporting Possible Compliance Issues

Reporting mechanisms for faculty, residents and staff will be developed to allow these individuals to raise concerns about possible issues regarding compliance.

• Reports may be submitted either verbally or in written form with anonymity for the individual. These may be directed to:

  • University Compliance Officer

  • Health Care Compliance Officer

  • SIU P&S Compliance Officer

  • Dean and Provost

  • CEO of SIU P&S

  • University or School of Medicine Legal Counsel

  • Hotline

  • Other high-ranking administrative positions within the University, SOM and/or SIU P&S, such as clinic managers or clinic administrators.

• Allegations will be acted upon as deemed appropriate and a written report of the alleged irregularities, subsequent findings and actions taken will be presented to the University Office of Compliance, Dean and Provost of the SOM and the CEO of SIU P&S. Internal Audit staff or other outside experts may be called upon to assist in the review if deemed necessary.

If a deficiency is confirmed, the follow-up steps outlined under Corrective Action will be initiated.