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1st appeared 8 September 1999

UC Health Sciences Corporate Compliance Program Proposal on Review

The University of California proposes to implement a Corporate Compliance Program for the University's health sciences clinical enterprise. The purpose of the Program is to demonstrate the University's commitment to ethical and legal behavior and to clearly communicate the specific standards of conduct that address those potential areas of risk that have been identified by the Federal government. The Program will apply to management personnel, physicians, health professions faculty and students, and other health care professionals and staff involved in clinical services, including patient care and billing services at the medical schools and University-owned or leased hospital facilities. The proposed Program conforms to the Office of the Inspector General's (OIG) guidelines governing compliance programs for the health care industry.

Important elements of the Program include:

• a Code of Conduct, including standards of ethical conduct;

• educational and training programs;

• processes for faculty and staff to raise questions and concerns, including a toll-free hotline telephone number to anonymously report suspected violations of compliance issues;

• an emphasis on the University's existing Policy on Safeguarding Resources and Investigating Misuse of Resources, and the Policy For Reporting Improper Governmental Activities and Protection Against Retaliation, as the appropriate vehicles to report and investigate alleged improper/illegal compliance activities;

• regular self-monitoring activities to ensure compliance with the University's Program;

• an emphasis on implementation of remedial actions, corrective or disciplinary actions, or both for noncompliance pursuant to the provisions of existing personnel policies and collective bargaining agreements; and

• exclusion of sanctioned individuals from Medicare or Medicaid billing, reimbursement and patient care.

This proposed Compliance Manual has been developed to provide guidance to our location in the development of UCSF's local compliance program. The Code of Conduct contained in this Manual will be incorporated into UCSF’s Compliance Program. When UCSF’s proposed program is finalized, you will be notified and given an opportunity to provide input and feedback. This proposed Manual can be found online at www.ucop.edu/acadadv/acadpers/apm/rev-corp.html.

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