Corporate Compliance Program Manual

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Chapter 1: Introduction

  1-1 Executive Vice President for Health Affairs' Policy Statement (PDF)
  1-3 Purposes and Objectives (PDF)

CHAPTER 2: STANDARD OPERATING PROTOCOL (PDF)

  Table of Contents (PDF)
  2-1 I. Compliance Program Oversight
    A. Operational Duties of the Compliance Officer
    B. Annual Report to the Executive Vice President for Health Affairs
    C. Evaluation of the Compliance Officer

  2-4  II. Investigation of Potential Violations
    A. Reports of Illegal, Unethical or Abusive Conduct
    B. Protocol

  2-6  III. Employee Credentialing 

  2-7  IV. Contractor and Vendor Credentialing

  2-9  V.  Transaction Review

  2-9  VI. Education and Training

  2-11  VII. Monitoring and Auditing
    A. Protocol
    B. Audits

  2-14  VIII.  Communication and Reporting
    A. Mandatory Good Faith Reporting of Misconduct
    B. Comply-Line
    C. Confidentiality
    D. Reporting Channels
    E. Inquiries or Allegations
      1. Questions and Inquiries
      2. Allegations of Misconduct
    F. Anti-Retaliation

  2-18  IX. Enforcement and Discipline
    A Protocol
    B Sanctions
    C Misconduct of Subordinates
    D Abuse of Compliance Program Procedures
   

  2-20  X. Post-Violation Response
    A Response Protocol
    B Prevention of Repeated Violations

  2-21  XI. Amending the CCP

CHAPTER 3: STANDARDS OF CONDUCT (PDF)

Patient Care Care and Treatment

• Medical Staff Credentialing
• Patient Information Maintenance and Confidentiality
• Mandatory Testing and Reporting
• Patient Transfer and Discharge
• Drug and Device Usage

• General Requirements
• Billing Practice
• Services Furnished by Teaching Physicians and Residents
• Services of Residents

• Personal Relationships and Conflicts of Interest
• Buying or Selling Influence
• Business Practice
• Financial Reporting and Record Keeping
• Kickbacks/Illegal Remuneration
• Self Referrals
• False Statements and Representations
• Fraudulent Use of the Mails/Wires
• Conspiracy
• Theft
• Research
• Prescription Medications and Controlled Substances
• Facility Certification

• Responding to Government Investigations
• Whistle blower Protection
• Failure to Adhere to Compliance Program Standards
• Abuse of Compliance Program Procedures

CHAPTER 4: POLICIES AND PROCEDURES

• Government Inquiries and Request for Documents, Number: 04-01 (PDF)
• Contracts Compliance, Number 04-02 (PDF)

CHAPTER 5: COMPLIANCE DIRECTIVES AND MEMORANDUM

Developed as needed through the Office of Compliance.

Although every effort is made to ensure that this Corporate Compliance Program Manual is accurate and up to date, it is provided for the convenience of the user and should not be considered official. The official version of this material is available in the UK Clinical Enterprise Office of Compliance, 2333 Alumni Park Plaza, Suite 200, Lexington, KY 40517. The user is advised to refer to and rely upon the official version of this material when making significant decisions or judgments.

To make an appointment or find a physician, please call UK HealthCare at 859-257-1000 or toll free 1-800-333-8874.
Copyright © 2007, University of Kentucky, 800 Rose St., Lexington, Kentucky, USA 40536.

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Page last updated Wednesday, August 20, 2008 12:19 PM