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University of Utah Health Care
Billing Compliance Office
675 Arapeen Drive, Suite 104
Salt Lake City, UT 84108

801-213-3948
801-585-3608 fax

Brian Watts, Director

Diana Snow, Manager

Jamie Ross, Administrative Manager

Jeannine Engel M.D., Physician Advisor

Michelle Densley, Senior Compliance Officer

Jennica Burke, Compliance Officer

Dana Frederiksen, Compliance Officer

Lisa Whittaker, RN,Clinical Compliance Officer

Morgan Walker, Compliance Analyst

Sara Feltz, Clinical Compliance Officer

Carri Aguiar, Compliance Officer

Jesica Jensen, Compliance Officer

Jenna Duff, Medical Records Clerk

Holly Stevens, Administrative Assistant
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University Healthcare Compliance Plan

PART 1: INSTITUTIONAL POLICIES CONCERNING COMPLIANCE

(A) Departmental and Institutional Responsibility

The University of Utah and its Health Science Center (University Healthcare), including but not limited to its medical and other clinical faculty, staff, students, residents, fellows, medical group, departments, Clinics, Schools, and Hospitals shall undertake all necessary efforts and implement any necessary policies and structural changes to bring University Healthcare into full and ongoing compliance with all Federal payor standards and practices. It is the responsibility of each Department, Dean and supervisor in the Health Sciences Center (i.e. each person exercising line management authority) to undertake and implement compliance activities as directed by the Senior Vice President, Associate Vice President, and Director of the University Healthcare Compliance Office, and to use his or her own best efforts to discover, investigate, and correct compliance deficiencies within his or her area of responsibility. All compliance activities will be carried out with the coordination and involvement of the Director of the University Healthcare Compliance Office.

(B) Required Compliance Activities: The compliance activities required of each department include: (C) Full Cooperation, Assistance, and Access to All Records

In order to meet its obligations to assure full compliance with such regulations and standards, including private payor standards, the Health Sciences Center, its executives, Director of University Healthcare Compliance, Compliance Committee, and auditors shall have full and complete access to all records of episodes of patient care rendered by any provider, and all billing systems and records, in connection with services provided under the auspices of, as an employee or agent of, or on the premises (including leased premises or premises leased to others) of the Health Sciences Center, its divisions, departments, schools, subsidiaries, contractors, or affiliated organizations. The purposes for such access shall be compliance oversight, as a function of Health Care Operations. All records of any type for such episodes of care are the property of the University of Utah Health Sciences Center, the University of Utah, and the State of Utah, notwithstanding any provision of any agreement, policy, regulation, or practice to the contrary. Granting such access, and full cooperation with compliance activities, shall be considered a condition of affiliation or employment with the Health Sciences Center.

(D) Authority to Promulgate Policies and Procedures in Furtherance of this Plan

The Senior Vice President for Health Sciences, Associate Vice President for Health Sciences, and Director of University Healthcare Compliance, respectively, may develop and promulgate policies and procedures consistent with this Plan and in furtherance of its goals and objectives; such further policies may include departmental compliance plans and committees. Any such policies and procedures may be placed in University Healthcare Policies and Procedures Manuals and shall be effective for all employees of University Healthcare.

PART 2: COMPLIANCE OFFICE

(A) Compliance Office

The University Healthcare Compliance Office is a special staff office assigned to the Associate Vice President for Health Sciences. The office shall exist as a special investigatory, training, policy-making, and advisory office as detailed in this plan. The Director of the University Healthcare Compliance Office shall report to, and operate under the direction of, the Associate Vice President for Health Sciences, with additional access directly to the Senior Vice President for Health Sciences or President of the University as deemed necessary.

(B) Director of University Healthcare Compliance, and Duties of Compliance Oversight Committee.

The Director of University Healthcare Compliance will be assisted in his/her duties by the Compliance Oversight Committee, with membership as designated from time to time by the Associate Vice President for Health Sciences and Director of University Healthcare Compliance. The Director of University Healthcare Compliance shall chair the Compliance Oversight Committee. The Director of University Healthcare Compliance has primary responsibility for the creation, implementation, operation, and revision (as necessary) of the Compliance Plan and its related functions and operations. In addition to the Compliance Oversight Committee, the Director of University Healthcare Compliance may, in his/her discretion, form such other operational committees or working groups as may be necessary of appropriate to the implementation and operation of compliance activities. Such groups may be organized as standing committees or ad hoc groups.

(C) Compliance Office Goals and Objectives

Each Calendar Year, the Director of University Healthcare Compliance shall develop an annual plan of goals and objectives for the Compliance Program including an audit calendar. The Director of University Healthcare Compliance will periodically report to the Associate Vice President and Compliance Oversight Committee on progress toward these goals.

(D) Operations of the Compliance Office: PART 3: EXERCISING DUE DILIGENCE OVER PERSONS WITH DISCRETIONARY AUTHORITY

The Health Sciences Center will undertake careful evaluation of prospective and current employees who have discretionary authority to make decisions that may involve billing compliance. PART 4: COMPLIANCE TRAINING

The Health Sciences Center will provide training and periodic re-training for all employees and supervisory staff to whom the plan is applicable, as well as for contract physicians and clinicians providing on-site services, to familiarize their employees with all pertinent provisions of the Standards of Conduct and University Healthcare compliance- related policies. PART 5. MONITORING AND AUDITING

PART 6: ENFORCEMENT AND DISCIPLINE

PART 7: CONTINUED COMPLIANCE

PART 8: AMENDMENTS

This Plan may be amended from time to time as necessary. Should an amendment occur, each department chair and departmental compliance liaison shall receive a copy of the amended plan. Three types of amendment of this compliance plan are recognized: