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Enforcement of Medicare and Medicaid Laws and Prevention of Engaging in Activities Contrary to their Regulations Policy


Please see the respective policy directly below.

SIU School of Medicine

SIU HealthCare           



Enforcement of Medicare and Medicaid laws and prevention of engaging in activities contrary to their regulations




To provide guidance in the area of investigating reports of individual(s) engaging in activities which are contrary to applicable Medicare and Medicaid laws or regulations.


I. Background:


The purpose of this policy is to set forth the procedures that will be used by SIU, (collectively SIU SOM and SIU HealthCare), to respond to reports by SIU employees or others that (an) individual(s) may be engaging in activities which are contrary to applicable Medicare and Medicaid laws or regulations or that such persons or departments may be submitting claims in a manner which does not meet the Medicare and/or Medicaid program requirements, as applicable.


II. Policy


A. Investigation


1. Purpose of Investigation


The purpose of the investigation shall be to identify those situations in which the laws, rules and standards of the Medicare and Medicaid programs may not have been followed; to identify individuals who may have knowingly or inadvertently caused claims to be submitted or processed in a manner which violated Medicare or Medicaid laws, rules, or standards; to facilitate the correction of any practices not in compliance with the Medicare or Medicaid laws, rules and standards; to implement those procedures necessary to insure future compliance; to protect SIU SOM and SIU HealthCare in the event of civil or criminal enforcement actions, and to preserve and protect SIU’s assets.


2. Control of Investigations


Any employee or learner may report instances of possible illegal conduct to the Office of Compliance and Ethics. SIU has established a mechanism to receive reports of possible illegal conduct from any employee or other persons as well as provide an access point for persons to receive information or ask questions concerning the compliance program.


Failure to report knowledge of wrongdoing may itself result in disciplinary action. All reports received regarding non-compliance with Medicare and Medicaid laws or regulations, regardless of by whom received, shall be forwarded to the Compliance Officer. The compliance Office may consult with SIU legal counsel. The Compliance Office, in conjunction with management and/or legal counsel, will be responsible for directing the investigation of the alleged compliance matter. In undertaking this investigation, the Compliance Office may solicit the support of internal auditors, external auditors, and internal and external resources with knowledge of the applicable laws and regulations and required policies, procedures or standards that relate to the specific problem in question.


These persons shall function under the direction of Compliance Officer and/or management and shall be required to submit relevant evidence, notes, findings and conclusions to the Compliance Officer and appropriate management.


3. Investigative Process


Upon receipt of an employee complaint or other information (including audit results) which suggests the existence of a pattern of conduct in violation of compliance policies or applicable laws or regulations, an investigation, under the direction and control of the Compliance Officer and/or management, shall be commenced. Steps to be followed in undertaking the investigation shall include, at a minimum: 

a. Notification of the Dean and Provost of SIU SOM, CEO and CFO of SIU HealthCare, and SIU legal counsel of the nature of the complaint, if determined necessary by the Compliance Officer. The Compliance Officer may consult with legal counsel or request assistance to conduct the investigation. Investigations may be directed by management or referred by the Compliance Officer to the CEO of SIU HealthCare and investigations may be conducted jointly by the Compliance Officer and the CEO.


b. The investigation shall be commenced as soon as reasonably possible but in no event more than 10 business days following the receipt of the complaint or report. The investigation shall include, as applicable, but need not be limited to:


1) An interview of the complainant and other persons who may have knowledge of the alleged problem and any related process and a review of the applicable laws and regulations which might be relevant or provide guidance with respect to the appropriateness or inappropriateness of the activity in question, to determine whether or not a problem actually exists.


2) If the review results in conclusions or findings that the complaint is invalid and is permitted under applicable laws, regulations or policy or that the complained of act did not occur as alleged or does not otherwise appear to be a problem, the investigation shall be closed.


If the initial investigation concludes that there is improper billing occurring, that practices are occurring which are contrary to applicable law, that inaccurate claims are being submitted, or that additional evidence is necessary, the investigation shall proceed to the next step.


3) The identification and review of representative bills or claims submitted to the Medicare/Medicaid programs to determine the nature of the problem, the scope of the problem, the frequency of the problem, the duration of the problem and the potential financial magnitude of the problem.


4) Interviews of the person or persons who appear to play a role in the process in which the problem exists. The purpose of the interview will be to determine the facts related to the complained of activity, and may include, but shall not be limited to:

      a.  Individual understanding of the Medicare and Medicaid laws, rules and regulations;

      b.  The identification of persons with supervisory or managerial responsibility for the process;

      c.  The adequacy of the training of the individuals performing the functions within the process;

      d.  The extent to which any person knowingly or with reckless disregard or intentional indifference acted contrary to the Medicare or Medicaid laws, rules or regulations;

      e.  The nature and extent of potential civil or criminal liability of individuals or SIU SOM and SIU HealthCare; and

      f.  Preparation of a summary report which:

  1. defines the nature of the problem,
  2. summarizes the investigation process,
  3. identifies any person whom the investigator believes to have either acted deliberately or with reckless disregard or intentional indifference toward the Medicare/Medicaid laws, rules, regulations and policies,
  4. if possible, estimates the nature and extent of the resulting overpayment by the government, if any, and
  5. follow-up recommendations.

g.  A complete and accurate record of each investigation shall be maintained for a period of 10 years in accordance with the SIU Records Management Policy.



Adopted:  December 21, 1998

Contact:  Compliance Officer


Approved by OCP: 1/11/2017

Approved by Quality and Safety:  2/21/2017             


SIU Records Management Policy