2.13.3 Subject: HEALTH SCIENCES CENTER COMPLIANCE POLICY
Adopted: October 9, 1997
Amended: November 9, 1999

Preamble

As health care costs continue to increase, government scrutiny of health care institutions' activities that implicate federal reimbursements has become the norm. Many rules and regulations govern health care billing and the provision of health care which, if not strictly followed, may result in fraud charges against an institution despite a lack of intent to violate the law. Penalties for even apparently innocent violations can be very steep. Therefore, the development and implementation of health care compliance programs has become standard practice at health care institutions across the country. Operation under such a program is now a necessity for a health care institution to assure itself of its compliance with legal obligations and simultaneously to minimize the likelihood of a government investigation. Compliance programs also serve to promote a high level of ethical behavior, an equally important reason for their use.

Applicability

This policy applies to the University Health Sciences Center (HSC) and supplements Regents' Policy 2.13.

Policy

The HSC will attempt to ensure at all times that its business (internally and with outside contractors) is conducted in accordance with the highest ethical standards and in compliance with the various federal and state laws and regulations applicable to its activities. The HSC faculty and staff will conduct themselves ethically and with honesty and integrity, will understand and abide by the legal requirements related to their activities, and will act at all times in the best interests of the HSC, the University, and patients served by the HSC.

To fulfill these obligations, the HSC will develop, implement, and oversee an Institutional Compliance Program. The HSC Institutional Compliance Program will emphasize prevention of ethical and legal wrongdoing, focusing on training and open communication between management and staff, will be designed to detect and remedy any compliance problems identified by HSC officials, and will provide mechanisms for assuring the Regents and the HSC Clinical Operations Board of HSC compliance with applicable laws and regulations. The HSC Institutional Compliance Program will be an ongoing program and a critical responsibility of the HSC leadership; it will be incorporated into the day-to-day functioning of the HSC, and will be updated and revised as societal expectations, and ethical and legal norms, evolve.

HSC officers and managers will be held accountable for the conduct of employees (including volunteer employees) reporting directly to them and for their transactions with outside contractors, and therefore must have a full understanding of the ethical and legal issues affecting the responsibilities of such employees and contractors, ensure that such employees have received appropriate training, and be cognizant of such employees' and contractors' activities. All HSC faculty, staff, and students bear personal responsibility for conducting themselves in compliance with the Institutional Compliance Program, as well as the legal and ethical requirements governing their activities at the HSC, and are expected to take responsibility for educating themselves regarding the ethical and legal environment in which they perform their responsibilities. HSC faculty, staff, and students are also under an affirmative obligation to raise any and all concerns they may have regarding possible unethical or illegal behavior of others in the manner established by the HSC Institutional Compliance Program. HSC faculty, staff, and students who report suspected wrongdoing in good faith will be fully protected from any retaliatory actions.

Failure to comply with the legal and ethical norms affecting an employee's activities, as well as failure to report concerns or reasonable suspicions regarding the conduct of others, may result in disciplinary action, up to and including termination.

Implementation

The Vice President for Health Sciences will develop and implement an HSC Institutional Compliance Program and will designate an individual to serve as the HSC Compliance Director. The Regents, through the Regents' Health Sciences Committee, and the HSC Clinical Operations Board will exercise oversight of the HSC Institutional Compliance Program by receiving and evaluating periodic reports provided to the Committee and Board by the HSC Corporate Compliance Director, and by providing policy guidance to the Vice President for Health Sciences and other HSC officials with respect to development and implementation of the HSC Institutional Compliance Program.

References

Regents' Policy 2.13; University Business Policy 2200, Reporting Misconduct and Retaliation.

Comments should be sent to BRPM@UNM.edu

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The University of New Mexico
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