College of Medicine Compliance
UIPG Compliance Plan
With the advent of increase government regulations, the College of Medicine must ensure that we are compliant with applicable federal, state and other regulatory requirements. The College of Medicine (COM) Compliance Program provides a framework for adherence to all pertinent regulations, and a mechanism for preventing and/or reporting a breach in Compliance.
Purpose
The UIPG is committed to ensuring that its affairs are conducted in accordance with applicable laws, rules, regulations, policies, and procedures. The purpose of this
Compliance Plan and its component policies and procedures is to establish and maintain a culture within the UIPG that promotes high standards of ethical and business conduct and the prevention, detection, and resolution of conduct that does not conform to UIPG’s standards and policies, applicable law, and health care program or payor requirements.
This Compliance Plan applies to all UIPG personnel, including but not limited to its Board of Directors, administration, physicians and other practitioners, employees, volunteers, and other entities providing services on behalf of UIPG.
The Department of Health and Human Services, Office of Inspector General (OIG) has stated that every effective compliance program should begin with a formal commitment by the physician practice to address all of the applicable elements listed below, which are based upon the seven steps of the Federal Sentencing Guidelines.
The Plan
I. Standards of conduct, policies and procedures
The University has developed the University Code of Conduct for professional conduct by those acting on behalf of the University. The Code articulates the University’s commitment to comply with all federal and state laws and regulatory standards, and serves as a basis on which employees should make decisions related to the best interests of themselves, their co-workers and the University.
The COM Director of Compliance is responsible for coordinating the development, approval and distribution of written compliance policies that address specific areas of risk. Once approved by the Board of Directors of the Medical Service Plan, the compliance policies will be placed on the COM Compliance website, making it available to all individuals including the University’s agents and independent contractors who are affected by the particular policy at issue.
II. Oversight and Accountability
Compliance Officer
Implementation and oversight of the UIPG Compliance Program is delegated to the College of Medicine (COM) Director of Compliance. The COM Director of Compliance collaborates with the University of Illinois Hospital & Health Science System (UIHHSS) Chief Compliance Officer.
The COM Director of Compliance:
- Oversees and monitors the UIPG Compliance
- Assists in the revision of the Compliance Plan to conform to changes in the needs of the organization and laws and policies of government and private payers.
- Oversees auditing and monitoring activities.
- Acts as a primary contact on matters relating to
- Develops and oversees compliance education and training for the
- Provides regular updates on compliance to impacted stakeholders, which may include the UIPG Director, Board of Directors, the COM Dean, the COM Associate Deans of Clinical Affairs, COM Associate Dean for Administration, COM Departmental Compliance Liaisons (DCL), and business managers and UIHHSS clinical departments.
- Disseminates information on compliance to clinical departments as
- Represents the UIPG on the Campus Compliance Committee, Compliance Business Committee and other related committees as necessary.
The heads of the clinical departments of the COM are ultimately responsible for the compliance within their respective departments. The clinical departments of the COM are as follows:
- Anesthesiology
- Dermatology
- Emergency Medicine
- Family Medicine
- Medicine
- Neurology & Rehabilitation
- Neurosurgery
- Obstetrics & Gynecology
- Ophthalmology
- Orthopedics
- Otolaryngology
- Pathology
- Pediatrics
- Psychiatry
- Radiology
- Surgery
- Urology
Each department head shall designate a DCL (see Appendix A for DCL listing) to handle implementation and oversight of compliance within their department with guidance and oversight from the COM Director of Compliance.
The DCL:
- Assists the Department head in the development and implementation of compliance policies that pertain to the laws, regulations, and common practices within their department and clinical specialty as
- Assists in any auditing and monitoring functions specifically developed by the department as well as those co-managed by the COM Director of
- Submits biannual audit results to the COM Director of Compliance based on findings of auditing/ monitoring activities.
- Acts as a primary contact to faculty and staff within the department on matters relating to compliance.
- Attends quarterly DCL compliance meetings held by the COM Compliance Office. If the DCL or substitute is absent for a meeting, the department head will be notified.
Compliance Committee
Purpose: As a subcommittee of the UIPG Executive Committee, the purpose of the UIPG Compliance Committee is to oversee the implementation and operation of the UIPG Compliance Program as administered by the COM Director of Compliance. The Committee will review effectiveness of policies, procedures, and educational programs, as well as make recommendations for program improvement. The Committee will review internal reviews and reporting processes to promote effective program management and Compliance Plan compliance.
Duties:
- Oversee the Compliance Plan, including training of faculty and staff, to assure that billing and collection comply with all government statutes, regulations and guidelines.
- Review compliance reports and make appropriate recommendations to the Board of Directors.
- It is the Committee Chair’s responsibility to provide reports and recommendations to the Board of Directors.
- Comply with the Compliance
Composition of the Committee Chair:
- George Kondos, MD, Vice Chair for Clinical Affairs of the Department of Medicine
Committee Members:
- Fady Charbel, MD, Head, Department of Neurosurgery
- Louis Papoff, Chief Business Officer, UIPG
- Lisa Lenz, CMPE, Chief Executive Officer, WWT
- Ari Rubenfeld, MD, Associate Chief Medical Officer, UI Health
- Heather Prendergast, MD, Associate Dean of Clinical Affairs
Ex-officio Members:
- Sandy Young, COM Interim Director of Compliance
- Marilu Luna, COM Associate Director of Compliance
- Steve Figge, Chief Operating Officer, WWT Committee Meetings
- The Committee will meet quarterly at predetermined times and dates. In addition, the COM Compliance Officer and/or the Chair will have the authority to call special meetings as warranted.
- A summary of items addressed and actions taken at each meeting will be recorded and retained by the COM Compliance
- A minimum of one-half of membership will constitute a
Committee Member Responsibilities
- Regular attendance at scheduled meetings is
- Ability to maintain sensitive information in a confident manner, unless otherwise directed by counsel.
- Commitment to the stated objectives and goals of the
III. Training and Education
- Purpose: The purpose of the COM training and education program is to heighten the awareness of the UIPG Compliance Program and to incorporate the Program and its policies into daily practice. The major component of the Program is the UI Health General Compliance and the Fraud, Waste and Abuse
- Both the UI Health General Compliance and Fraud, Waste, and Abuse modules shall be required for UIPG faculty and staff and WWT coders/billers.
- The LMS modules shall be conducted within thirty (30) days of hire or contract date, within such other times as communicated by COM Compliance staff, and annually.
- Individual clinical departments within the COM may choose, at their discretion, to institute additional compliance training requirements to address specific risk areas or training needs.
- Completion of the compliance training LMS modules is documented electronically and shall be available to the COM Compliance Officer upon
- Providers and staff may also be required to undergo supplemental training based upon results of audit activities.
IV. Open Lines of Communication
Communication lines to the COM Compliance Office shall be in place and accessible to all employees and persons associated with UIPG to allow compliance issues to be reported directly to COM Compliance staff or anonymously, if desired, via the UI Health compliance hotline at 1-866-665-4296 and UIHealth.UIC.ethicspoint.com
The COM Compliance Office has an “open door” policy for employee access to compliance staff. Moreover, compliance update emails are sent to all COM faculty and staff as applicable, and a compliance newsletter, the Compliance Communique, is produced biannually and provided to all COM employees electronically.
V. Monitoring, Auditing and Risk Assessment
- Biannual DCL Reviews
The COM Compliance Office shall request biannual audit results of each DCL. Audit topics will be selected by the DCL with input from the COM Office of Compliance. COM Office of Compliance will collect this data from the 17 departments and provide results to the UIPG Compliance Committee for their review and input. - Annual Concurrent Reviews
The COM Compliance office shall draft an annual audit work plan for review and approval by the UIPG Compliance Committee. If reviewing claim data accuracy, to the extent possible, the reviews will be concurrent or a prospective/pre-bill review process whereby claims undergo review prior to their submission to a third-party for reimbursement. All audit results will be provided to the UIPG Compliance Committee for their review and input. - Investigational/For-cause Audits
In response to issues or concerns that might arise within a department or across the college, the COM Compliance will audit to monitor compliance with applicable laws, regulations, and University policies and procedures.
VI. Consistent Discipline
Considerable effort has been made in the development of the COM Compliance Office, which is charged with the responsibility of responding to allegations of improper activities. The University Code of Conduct, Article IX, Section 6 of the University Statutes, as well as this Compliance Plan have been established to ensure COM employees are aware that compliance shall be treated seriously, and that violations and non-compliance shall be dealt with fairly, consistently, and uniformly.
VII. Corrective Action
Reasonable and prompt steps shall be taken to respond to all violations detected through audits and monitoring, and those that are reported by individuals.
Implementation of a corrective action plan shall take place for any violations confirmed by an investigation. Examples of corrective action include repayment of overpayments and disciplinary action against responsible parties.
Endorsement
The UIPG Board of Directors fully endorses this Compliance Plan and supports the efforts of all our employees as they continue to promote a culture of compliance and ethics.
George Kondos, MD
Chair, Compliance Subcommittee of UIPG Executive Committee
Appendix A: Departmental Compliance Liaisons
| Contact | Phone | ||
|---|---|---|---|
| Anesthesiology | Michelle Lazzara | michelel@uic.edu | 355-0558 |
| Dermatology | Jeanette Agustin | Jagust2@uic.edu | 413-7448 |
| Emergency Medicine | Rhea Begeman | rheab@uic.edu | 413-0002 |
| Family Medicine | Hayley Evans | hayley@uic.edu | 996-1102 |
| Medicine | |||
| Neurology- Rehabilitation | David Katz | davkatz@uic.edu | 355-1748 |
| Neurosurgery | Jeff Jopes | jajopes@uic.edu | 996-9018 |
| OB/GYN | Cathy Driscoll | driscoll@uic.edu | 996-5994 |
| Ophthalmology | Lisa Graben | lgraben@uic.edu | 996-7774 |
| Orthopedics | Jonathan Bode | jbode@uic.edu | 355-3828 |
| Otolaryngology | Kamile Karpyte | kamilek@uic.edu | 996-6519 |
| Pathology | Preyal Patel | preyal@uic.edu | 996-2135 |
| Pediatrics | Myrna Grant | myrnag@uic.edu | 996-0984 |
| Psychiatry | Juliana Falloon | jfallo2@uic.edu | 413-7590 |
| Radiology | Kunal Vora | kvora2@uic.edu | 355-5258 |
| Surgery | Arlin Ospina | aaldab1@uic.edu | 996-6771 |
| Urology | Kamile Karpyte | kamilek@uic.edu | 996-6519 |
Key Elements of the COM Compliance Program
- Implementing written policies/procedures and guidelines;
- Designating a compliance officer/contact;
- Conducting comprehensive training and education;
- Developing accessible lines of communication;
- Conducting internal monitoring and auditing;
- Enforcing standards through well-publicized disciplinary guidelines; and
- Responding promptly to detected offenses and undertaking corrective Action
COM compliance personnel audit, monitor and conduct investigations into Compliance issues as necessary. Yearly concurrent and retrospective provider documentation audits are conducted by the compliance auditors and OCC coders per set schedules determined on an annual basis.
In addition, individual and group training on compliance issues is available by contacting the Director of Compliance or any of the compliance/coding auditors listed under the resources section.
Each department has designated a Departmental Compliance Liaison (DCL) to handle implementation and oversight of compliance with the guidance and oversight from the COM Director of Compliance. (See Resources).
UIHHS Compliance Hotline
Please use the UIHHS Compliance Hotline to report improper conduct, illegal actions, fraud and abuse.
CALL: 1-866-665-4296
- Available 24 hours a day
- Anonymous and Confidential
UI Health Corporate Compliance Week
Corporate Compliance & Ethics Week is celebrated annually to highlight the importance of compliance and ethics. The core principles of the week are awareness, recognition, and reinforcement.
Events
Compliance Crossword Puzzle: How Well Do You Know Compliance Terms?
Office of Compliance
Contact
Marilu Luna
Phone:
Email:
Useful Resources
5-Minute Training Videos
View the training videos:
Compliance Educational Tools/Tips
Definitions
Documentation Guides
Tools
Department Compliance Liaisons
Please click on the link below to see the list of liaisons.
Frequently Asked Questions
How do I bill a discharge day management code when I discharge my patient on day one, but dictate my notes on day 2? Which day do I use for submitting the claim?
The discharge day management service is billed under the actual discharge date. The medical records should clearly state the date of the actual discharge, and also indicate that the dictation was made on the following date.
How do you bill for a patient that has expired?
The Centers for Medicare and Medicaid Services (CMS) advises that according to established legal principles, an individual is not considered deceased until there has been official pronouncement of death. Reasonable and necessary medical services rendered up to and including pronouncement of death by a physician are covered diagnostic or therapeutic services.
Why are our claims for Hospital Discharge Day Management being reduced from 99239 to 99238?
Hospital discharge day management codes 99238 (30 minutes or less) and 99239 (more than 30 minutes) are time based so it is imperative that the medical documentation reflect the total time spent by a physician during the discharge of a patient. The codes include, as appropriate, final examination of the patient, discussion of the hospital stay, (even if the time spent by the physician on that date is not continuous), instructions for continuing care to all relevant caregivers, and preparation of discharge records, prescriptions and referral forms.
Can a physician bill for an initial visit when a patient goes from observation to admission?
Yes, an initial inpatient visit may be billed. Medicare payment for the initial hospital visit includes all services provided to the patient on the date of admission by that physician, regardless of the site of service. The physician may not bill an initial observation care code or an observation discharge management code for services on the date that he or she admits the patient to inpatient status.
If the physician states same/unchanged from last visit, will he receive credit for reviewing the last visit information?
Credit may be taken only if the physician includes the documentation from the previous visit.