Compliance Plan for the

_______________________________________

Signature

_______________________

Date

_______________________________________

Print/Type Name

_______________________________

Position

September 20, 2000

OIG Compliance Program for Individual and Small Group Physician Practices

Compliance Plan for the

University of Missouri-St. Louis

Center for Eye Care

COMPLIANCE RESOURCE AND REPORTING LINE: 4393

I. Preamble

The University of Missouri School of Optometry Center for Eye Care (Center) is strongly committed to ensuring compliance with all applicable laws, regulations, and policies with which we conduct our daily business activities. The compliance program that is described in this document is intended to establish a framework for adherence to all pertinent laws and regulations, and a mechanism for preventing and reporting any breach of those laws and regulations. This plan is not intended to set forth all of the substantive programs and practices of the Center designed to achieve compliance in the many areas we operate. Rather, it is intended to further our day to day commitment that the operations of this organization will comply with the ethical and legal standards established in the applicable laws and regulations.

A Code of Conduct has been established and adopted which, together with the University of Missouri’s Collected Rules and Regulations, sets forth the general policies and procedures with which all Center employees and agents must comply to ensure that their conduct is legal and ethical.

II. Compliance Oversight

The Center recognizes that the University of Missouri has already put in place policies and procedures that address compliance with federal and state laws and regulations that impact the routine activities of the entire University including the Center. This Compliance Plan incorporates these existing policies by reference herein and intends to follow them in the ordinary course of business as part of the University of Missouri. This Compliance Plan seeks to focus more narrowly on those laws, regulations and policies that more specifically affect the activities of an eye care delivery entity. In case of conflict between this Compliance Plan and the University’s Collected Rules and Regulations, the Collected Rules and Regulations will govern.

Compliance oversight will be the responsibility of the Compliance Director of the Center. The Compliance Director will mandate general guidelines for compliance and will receive all reports on compliance efforts and results. The Compliance Director has the duty to conduct audits of billing and compliance matters, and to report compliance violations and/or deviations to the Dean of the University of Missouri-St. Louis School of Optometry and the University’s legal counsel on a timely basis, and to assist with the execution of the appropriate corrective action as needed.

The Compliance Director’s scope of responsibilities include the following:

Provide overall leadership for all compliance efforts at the Center.
Coordinate efforts to facilitate compliance objectives.
Formulate effective internal controls to assure and achieve compliance objectives.
Ensure development of overall curriculum, education, and training to facilitate compliance objectives.
Review and investigate reports of actual or perceived compliance violations, and recommend appropriate disciplinary actions to the Dean as needed.
Implement all non-disciplinary corrective actions.
Prepare annual reports pertaining to compliance matters.
Coordinate regular and special compliance audits.

University legal counsel may be consulted by the Compliance Director as needed. In addition, the Compliance Director may request that an investigation be conducted by University legal counsel. All such consultations and investigations by or at the direction of University legal counsel will be privileged and work product.

III. The Center Compliance Council

A Compliance Council will be created to assist in the education, implementation and operation of the Center’s Compliance Plan. The Compliance Council will formulate compliance policies and procedures, propose amendments and modifications to the Compliance Plan as needed, and will consult with the Compliance Director on compliance matters. The membership of this Council will consist of the Compliance Director, the Center Managers, the Center Directors, and the Director of the Center for Eye Care. A representative from the University’s legal counsel and from the Chancellor’s office shall be ex-officio members of the Council.

IV. Education and Training

The Compliance Director will ensure that the appropriate curriculum, education and training are provided and attended by the applicable employees and agents. All Center employees will receive annual mandatory compliance training and education. New employees shall receive mandatory orientation to this Compliance Program and Plan. Additional training and education may be provided to those employees with responsibility for coding and billing matters. Special educational programs will be scheduled as HCFA or other appropriate agencies identify new risk areas and concerns.

V. Reviews

The Compliance Director, together with the Compliance Council, will periodically monitor compliance with all applicable laws, regulations and policies. Such monitoring will include regular and special audits. In areas where deviations from the regulations or policies are identified the responsible employees will be notified of those deviations with a report to their supervisor and the Compliance Director. The Compliance Director, with the advice of the Compliance Council, will then determine the appropriate non-disciplinary corrective actions to be taken including, but not limited to additional education and supplementation/ modification of the compliance policies and Plan. The Compliance Director will also forward a recommendation of appropriate disciplinary actions to be taken to the Dean. The Dean will report all significant compliance violations to the Chancellor of UM-St. Louis.

VI. Reporting

In compliance with all applicable laws, regulations and policies, the Center will self-report material violations that have been documented by review to the appropriate party or agency in a timely manner.

REPORTING OF POTENTIAL ISSUES

OR AREAS OF NONCOMPLIANCE

POLICY: This policy provides a method for employees, agents or other parties to report potential or actual violations of the Compliance Plan, or applicable laws, regulations and policies.

PURPOSE: To provide a uniform framework for reporting an actual or potential violation of the Compliance Plan, or applicable laws, regulations or policies.

PROCEDURE: The Center has developed a Code of Conduct for all employees and agents to follow. Adherence to this Code of Conduct and the general principles set forth in the Code of Conduct is essential. Supervisors are responsible for ensuring that employees are aware of and adhere to the provisions of this Code of Conduct. For clarification or guidance on any point in the Code of Conduct, please consult your supervisor or the Compliance Director.

All employees have an affirmative obligation to report any suspected violation of the Code of Conduct, this Compliance Plan, or any applicable law, regulation or policy. Employees and agents are expected to report any suspected violations or other irregularities to their supervisor, the Compliance Director, or through the Compliance Resource and Reporting Line at 4393. Every effort will be made to maintain the identity of all reporting persons as confidential. However, confidentiality cannot be guaranteed. Retaliation against any employee or agent because they reported an actual or potential compliance violation in good faith shall be prohibited. Any person retaliating against an employee or agent because they in good faith reported a potential or actual compliance violation shall themselves be subject to discipline, including but not limited to termination.

All reports must contain sufficient information for the Compliance Director, or his designee, to investigate the concerns raised. Upon receipt of credible reports of suspected violations or irregularities, the Compliance Director shall immediately begin a detailed investigation. If appropriate, the Compliance Director may request that the University’s legal counsel conduct the investigation. Upon completion of an investigation, the Compliance Director, with the advice of the Compliance Council, shall implement appropriate non-disciplinary corrective action to remedy the violation and ensure future compliance. In addition, the Compliance Director, with the advice of the Compliance Council, shall recommend to the Dean appropriate disciplinary action. The Dean will make all final decisions as to the disciplinary action to be taken. The Dean will report all significant compliance violations to the Chancellor.

Managers, supervisors and compliance officers may be disciplined for failing to detect compliance in their departments or areas of responsibility, where reasonable diligence on their part would have led to the discovery of any problem or violation and given the organization the opportunity to address that issue earlier.

GOVERNMENT AGENCY AUDITS, INTERVIEWS

AND SEARCHES

IMPORTANT PHONE NUMBERS:

University of Missouri General Counsel’s Office: (573) 882-3211

Compliance Resource and Reporting Line: 4393

POLICY: The Center and its employees will cooperate fully with any government audit, interview, search or other investigation.

PURPOSE: To provide employees with a procedure that ensures cooperation while protecting the rights of the Center and its employees.

PROCEDURE: There are various ways in which government agencies, or others, may carry out an investigation or audit. The Center has a policy of cooperating fully with all legal investigations, while protecting the rights of the Center and its employees. The following procedures should be followed in responding to government inquiries:

Search warrants: A search warrant is a written court order entitling law enforcement officers to search a defined premise. A properly executed search warrant must clearly identify a) the officer who is entitled to conduct the search; b) the specific areas or facilities to be searched; and c) the specific items to be reviewed or seized. In addition to search warrants, certain government agencies such as the Office of the Inspector General have the authority to demand immediate access to pertinent records of Medicare/ Medicaid providers.

In the event that Center employees are served with a search warrant or other request for immediate access to records, the following steps shall be taken:

Note the date and time that the warrant or other request is made, and by whom.
Immediately notify your supervisor or the Compliance Director. Either you or your supervisor should also immediately notify the University’s legal counsel.
Turn the matter over to your supervisor / Compliance Director, or follow the directions of the University’s legal counsel.

Center employees should not interfere with a search.

Subpoenas: A subpoena is an order directing a person to appear and to testify at a given time and place. A subpoena duces tecum requires you to bring certain documents and things with you when you testify. Subpoenas may be issued by a court, a grant jury, a lawyer representing a party in a civil or criminal matter, or by government agencies.

In the event that a Center employee is served with a subpoena concerning or related to their employment, the following steps shall be taken:

Note in writing, by date and time, exactly when the subpoena was received and how it was served.
Contact your supervisor or the Compliance Director. The University’s legal counsel should be immediately notified of the subpoena.
Follow the directions of your supervisor/ Compliance Director, or the directions of legal counsel.

Note: You may only accept service of a subpoena that specifically identifies you or your job title. You may not accept a subpoena issued or served on another person.

Talking with Investigators: Center employees may be contacted by investigators either on or off the work site. Employees have the right to talk or not talk to these investigators. Employees have the right to consult an attorney before answering questions, and to have counsel present during the interview. Employees should not speculate about matters beyond their direct knowledge.

If an employee chooses to talk to investigators, the employee must tell the truth.

CODE OF CONDUCT

Policy: The Center is committed to providing quality eye care to its patients, while operating lawfully and ethically.

Purpose: To assure uniformity in the standards of conduct by employees and agents, The Center establishes this Code of Conduct as part of its Corporate Compliance Program.

I. Mission and Values Statement: The Center is committed to the care and improvement of the health of our patients. To this end, the Center will strive to ensure an ethical and compassionate approach to eye care delivery.

This Code of Conduct establishes the general policies and principles with which all Center employees and agents must comply to ensure that their conduct is ethical and is in accordance with all applicable laws, rules and regulations. While this Code of Conduct cannot cover all situations that might arise, it is the duty of all employees and agents to adhere to the principles set forth in this Code of Conduct.

II. Compliance with All Laws: The Center is committed to full compliance with all statutes, regulations and guidelines applicable to health care programs. Employees are required to be knowledgeable about and comply with the legal requirements and restrictions applicable to their respective positions and duties. The Center will implement programs necessary to further such knowledge and to monitor and promote compliance with such laws and regulations.

III. Compliance with All Policies and Procedures: Center employees and agents must comply with all rules, regulations, policies and procedures set forth in the University of Missouri Collected Rules and Regulations, the Human Resources Policy Manual, and all other policies and procedures applicable to the Center.

IV. Relationships with the Health Care Community

Patients:

Compliance with Patient’s Rights: Center employees and agents are expected to comply with and recognize patient’s rights. Patients are to be treated in a manner that preserves their dignity, autonomy, self-esteem, civil rights, and involvement in their own care. The Center makes no distinction in the acceptance for care, transfer or discharge of patients based upon the patient’s race, color, religion or national origin. Care is based upon identified patient health care needs, not on patient or organizational economics.

Patient Records: Patient’s medical records are confidential, and Center employees are required to protect and preserve that confidentiality. Information about patients will not be released or discussed with others unless it is necessary to that patient’s medical care or required /permitted by law.

Other providers:
Anti-kickbacks: Center employees must never accept or offer payment from/to another in exchange for patient referrals. The Center and its employees are prohibited by federal law from offering or accepting money, or other remuneration, to or from any person or entity to induce that entity or person to purchase service from or to refer patients to the Center or that person/entity, except as permitted by law. If employees are requested/ offered such "kickbacks", they should immediately report the incident to the Compliance Director, or through the Compliance Resource and Reporting Line.
Third Party / Government Payers

False Claims Issues: The Center and its employees are prohibited by federal and state law from filing or making claims for reimbursement for services which were not rendered (in whole or in part) or which were medically unnecessary. The Center and its employees are also prohibited from submitting reimbursement claims which contain information which is false or misleading. If employees become aware of a situation in which a "false claim" has been or is to be submitted, they should immediately report the incident to the Compliance Director or through the Compliance Resource and Reporting Line.

The Center is committed to ensuring that its billing and reimbursement practices are consistent with health care program regulations and procedures or instructions otherwise communicated by the Health Care Financing Administration (HCFA) (or other appropriate regulatory agencies) and/or its agents, and that bills are accurate and reflect current payment methodologies. The Center is committed to ensuring that patients and customers receive timely bills and that all questions regarding bills are answered fully and truthfully.

V. Workplace Conduct: The personal conduct at all times of any Center employee shall be of such a nature as not to bring discredit upon the institution. Conduct contrary to this policy may result in termination or other disciplinary action.

Conflict of Interest: Center employees shall faithfully discharge their duties and shall refrain from knowingly engaging in any outside matters of financial interest incompatible with the impartial, objective, and effective performance of their duties. A conflict of interest may occur if an employee’s outside activities or personal interests influence or appear to influence his or her ability to make objective decisions in the course of their job responsibilities. A conflict of interest may also exist if the demands of outside activities hinder or distract the employee from the performance of his/her job, or causes the employee to use Center resources for other than Center purposes. Conduct by an employee that violates the University’s policies, regulations or rules pertaining to conflicts of interest will lead to disciplinary action. Questions about actual or potential conflicts of interest should be directed to the employee’s supervisor or the Compliance Director.

Insider Trading: No Center employee shall trade in the securities of any company, or buy or sell any property or assets, on the basis of non-public, confidential information acquired through employment at the Center, whether such information comes from the Center or from any other source with which the Center has a confidential relationship.

Controlled Substances: As a part of their job duties, Center employees may have access to prescription drugs, controlled substances, and other medical supplies. Many of these substances are governed by and monitored by specific regulatory bodies. Center employees must report any actual or perceived diversion of drugs to the Compliance Director or through the Compliance Resource and Reporting Line, and as required by Center policies.

Substance Abuse: The Center has an obligation to provide a healthy and safe environment for all students, employees and visitors to its facilities. The unlawful manufacture, distribution, dispensation, possession, or use of a controlled substance is prohibited on all University-owned or controlled property and at University sponsored or supervised activities. The unlawful possession, use and/or distribution of alcohol is also prohibited on all University-owned or controlled property and at University sponsored or supervised activities. Violations of this policy may result in discharge or other discipline in accordance with University policies and procedures covering the conduct of employees.

Confidential Information: Employees must strictly safeguard all confidential information with which they are entrusted and must never discuss such information outside the normal and necessary course of Center business. Employees shall not use confidential information about the Center obtained by reason of their employment with intent to cause financial gain to themselves or unfair advantage for another person.

Political contributions: Center employees may not contribute or donate Center funds, products, services or other resources to any political cause, party or candidate without advance written approval of the Compliance Director. Employees may make voluntary personal contributions to any lawful political causes, parties or candidates as long as the individual does not represent that such contributions come from the Center or the University, and as long as the employee does not obtain the money for such contributions from the Center for the sole purpose of making such a contribution. Center employees may also engage in lawful political activities so long as the activity, like any other personal, non-official undertaking, is done on the individual’s own time and does not interfere with the employee’s Center duties.

Equal Opportunity: Equal opportunity is and shall be provided for all employees and applicants for employment on the basis of their demonstrated ability and competence without discrimination on the basis of their race, color, religion, sex, national origin, age, disability, or status as a Vietnam era veteran.

The Center will not hire or grant staff privileges to any person who is currently excluded, suspended, debarred or otherwise ineligible to participate in the Federal health care programs, or has been convicted of a criminal offense related to the provision of health care items or services and has not been reinstated in the Federal health care programs after a period of exclusion, suspension, debarment or ineligibility.

Sexual harassment: Sexual harassment in the workplace is unacceptable conduct. Sexual harassment is subject to discipline, up to and including separation from the University.

Non-Retaliation: Retaliation against any person who brings an accusation of discrimination or sexual harassment or who assists with the investigation or resolution of sexual harassment / discrimination is strictly prohibited. Retaliation against any person because they reported, in good faith, an actual or perceived violation of the Compliance Plan, or other applicable laws, regulations or policies is prohibited.

VI. Business Information and Relationships

Advertising: In conducting all marketing and advertising activities, Center employees may offer factual, fully informative and non-deceptive information. Marketing and advertising activities may be used to educate the public, provide information to the community, increase awareness of the services offered by the Center, and to recruit colleagues. All marketing materials will accurately reflect services available and the level of licensure and certification.

The University shall not be used for commercial or promotional advertising purposes, nor will the name of the University be identified in any way with the aims, policies, programs, products or opinions of any organization or its members. An exception may be made by the President of the University System. When an exception is made, the conditions for using the name will be prescribed.

Acceptance of Business Courtesies: Center employees should not accept anything of value, even nominal value, from someone doing business with the Center or someone whose services are subject to the Center’s review if the gratuity is offered or appears to be offered in exchange for any type of favorable treatment or advantage. In accordance with Section 30.040 of the University Collected Rules and Regulations, the Board of Curators of the University of Missouri and the President of the University, under the power delegated by the Board, are the only authorities that can accept gifts or grants on behalf of the University. The receipt of a gift by an employee of the University does not constitute acceptance and is conditional, pending Presidential and/or Board acceptance. Any employee who receives such a gift must report it immediately to the Compliance Director or their supervisor. All grants offered to or received by employees must be reported to the appropriate campus office.

Competitor information: It is not improper to gather information about other organizations, including our competitors, through legal and ethical means, such as through public documents, and other published and spoken information. Employees shall not obtain proprietary or confidential information about a competitor through illegal or unethical means.

Contract negotiations: The Center will comply with all applicable disclosure rules and regulations honestly and completely. Employees involved in the negotiation of a contract must ensure the accuracy, completeness and currency of all data generated and supplied, or representations made to, all customers and suppliers, both government and commercial. The submission of a representation, quotation, statement or certification that is false or misleading may result in civil or criminal liability for the Center, the involved employee, and any supervisors who condone such a practice. The Center will not contract with any individual or company who has been convicted of a criminal offense related to health care or who is listed by a Federal Agency as debarred, excluded or otherwise ineligible for participation in federally-funded health care programs.

VII. The Compliance Plan and Program

A. Structure: A Compliance Director will be appointed by the Dean of the University of Missouri-St. Louis School of Optometry, who shall have overall responsibility for compliance of the Center. The Compliance Director shall report directly to the Dean on all compliance matters. The Dean shall report directly to the Chancellor of the University of Missouri—St. Louis, who reports directly to the President of the University of Missouri System and the Board of Curators. There shall also be established a Compliance Council, with responsibility for working with and advising the Compliance Director.

B. Obligation to Report: Center employees have an affirmative obligation to report actual or potential violations of the law, governmental regulations and policies, University of Missouri Collected Rules and Regulations, and all University and Center policies and procedures. Such reports should be made to the Compliance Director, or through the Compliance Resource and Reporting Line.

C. Training: The Compliance Director shall ensure that the employees of the Center have, on a yearly basis, attended an inservice seminar, or other comparable training, dealing with compliance with applicable laws, regulations, policies and the Compliance Program. All new employees must receive mandatory orientation to the Compliance Program.

The Compliance Director shall establish such other training or dissemination of information to employees of the Center as deemed necessary to comply with all applicable laws, regulations and policies.

D. Reporting Violations-Procedure: Adherence to this Code of Conduct and the general principles set forth herein is mandatory. Managers, supervisors, and compliance officers are responsible for ensuring that employees are aware of and adhere to the provisions of this Code of Conduct. Employees should consult the Compliance Director for guidance or clarification on any point in the Code of Conduct.

Employees must report any actual or potential violations of this Code of Conduct, the Compliance Program, or any other law, regulation or policy, to their supervisors, the Compliance Director, or through the Compliance Resource and Reporting Line. To enable and encourage such reporting, a Compliance Resource and Reporting Line will be established at 4393. Every effort will be made to keep such reports confidential, but confidentiality cannot be guaranteed. No adverse action or retaliation of any kind will be taken by the Center against any employee because he or she reports in good faith a suspected violation of the Code of Conduct, the Compliance program or any other law, regulation or policy by any person other than the reporting person.

The Compliance Resource and Reporting Line phone number will be posted throughout the Center. All reports must contain sufficient information for the Compliance Director, or his/her designee, to investigate the concerns raised. Upon receipt of a credible report of a suspected violation, the Compliance Director will immediately begin a detailed investigation. All employees are expected to cooperate with investigations by the Compliance Director or his/her designee.

E. Investigation/ Discipline: Upon completion of an investigation, the Compliance Director, in consultation with the Compliance Council, may make recommendations to the Dean as to appropriate disciplinary action to be taken. Violations of the Code of Conduct, the Compliance Program, or any other law, regulation or policy, may result in discipline ranging from oral or written warnings, to termination of employment. All forms of discipline available under the University of Missouri’s Collected Rules and Regulations are available here. Managers, supervisors, and compliance officers may be subject to discipline for failure to adequately instruct their subordinates or for failing to detect non-compliance with applicable policies and laws, where reasonable diligence on their part would have led to the discovery of any problems or violations and given the Center the opportunity to correct them earlier.

Employees subject to discipline may file grievances, in accordance with the procedures set forth in the University of Missouri’s Collected Rules and Regulations and the Personnel Policy Manual.

F. Acknowledgment: All Center employees will be provided with a copy of this Code of Conduct, and will be expected to read, understand and acknowledge the provisions herein. All employees will be required to sign the acknowledgment set forth below:

Acknowledgment of Receipt and Understanding of the Code of Conduct

I certify that I have received and read, or had read to me, a copy of the Center for Eye Care Code of Conduct. I have been afforded the opportunity to ask questions or seek clarifications where needed. I understand and will abide by the Code of Conduct during my employment with the Center. I understand that I have an obligation to report any alleged or suspected violation of this Code of Conduct or any other law, regulation or policy to my supervisor or the Compliance Director. I am not presently aware of any violation of this Code of Conduct or of any other law, regulation or policy which has not been reported to my supervisor or the Compliance Director. I hereby certify that I have not been convicted of, or charged with, a criminal offense related to health care, nor have I been listed by a federal agency as debarred, excluded or otherwise ineligible for participation in any federally funded health care programs. I understand that any violation of the Compliance Plan, the Code of Conduct or any other law, regulation or policy, may subject me to discipline, up to and including discharge from employment. I understand that this Code of Conduct is not an employment contract.