An Employee's Role in the Ethics and Compliance Program
USPI's Ethics and Compliance Program is integral to the company's operations. USPI works diligently to ensure that employees understand and comply with applicable laws and policies and adhere to the highest standards of ethics and integrity. It is every employee’s responsibility to engage in these activities.
Employee involvement in the program includes, among other things: reading and acknowledging the company's Code of Conduct, participating in ethics and compliance training, and adhering to relevant policies and procedures as well as the terms of Tenet's Quality, Compliance and Ethics Program Charter. USPI also may rely upon an individual's cooperation to assist its Ethics and Compliance Department in reviewing and resolving compliance issues.
Each employee and, depending on their function, many of our contractors are required to take an annual training session covering USPI’s Ethics and Compliance Program and general compliance policies and procedures. For employees and contractors involved in physician arrangements, billing, coding, or providing care to patients, USPI offers additional specialized training in these areas. New employees and certain contractors are required to take this training within their first 30 days of work and annually thereafter.
A compliance hotline (1-800-8ETHICS or 1-800-838-4427) is available at all times to every USPI stakeholder including employees, contractors, vendors, physicians, volunteers or students.
The Seven Elements of an Effective Compliance Program
While USPI's compliance program is comprised of components developed to address our specific business operations, the program is based on the seven elements of an effective compliance program described in the Office of Inspector General (OIG) Compliance Program Guidance.
These guidance documents make numerous recommendations regarding measures and specific activities that healthcare providers should implement to ensure that appropriate care is provided to federal health care program beneficiaries, and that the claims submitted for such care are correct and accurate.
USPI's program is structured to address issues raised in the OIG Guidance and meant to apply to appropriateness of care for every patient, not just federal program beneficiaries.
In addition, the Quality, Compliance and Ethics Program Charter contains specific requirements regarding training, clinical quality activities, screening for excluded parties, required policies, and a review of our Ethics and Compliance Program.
The seven major components of USPI's Ethics and Compliance program include:
- High-level oversight provided by our Chief Compliance Officer who reports directly to Tenet's Chief Compliance Officer;
- Written standards and policies;
- Auditing and monitoring;
- Open lines of communication through the Compliance Hotline;
- Response to detected deficiencies; and
- Disciplinary action as warranted.
The Chief Compliance Officer provides regular reports to the Quality, Compliance & Ethics committee of Tenet's Board of Directors.
Rules, Policies and Resource Materials
USPI's Code of Conduct is distributed to all USPI employees and certain contractors and vendors. The Code of Conduct is also available on USPI’s InSite, USPI's intranet communication system. The Code of Conduct sets forth USPI's commitment to compliance with all federal healthcare program requirements. Updates to the Code of Conduct are provided as necessary.
USPI has a comprehensive set of policies and procedures that address a wide range of compliance- related issues including but not limited to physician relationships, coding, specific billing and reimbursement topics, and human resources
General Training to All USPI Employees
All new employees must complete an initial ethics and compliance training program as part of their onboarding process. In addition, all employees must complete annual ethics and compliance refresher training. USPI’s Code of Conduct, described above, is used as the foundation for the training. Certain contract workers also are required to complete these training sessions.
Specialized Compliance Training
USPI's comprehensive training program provides relevant employees with customized compliance training, including HIPAA/information privacy and security. Additional training may be required when a new policy is adopted. Under the terms of the Charter, USPI provides additional specialized training to the following groups:
- Senior management
- Selected coding, billing and reimbursement employees
- Clinical quality personnel
- Employees involved in contracting with physicians
- Employees whose job functions place them in identified risk areas
Training may be delivered through live sessions, computer-based training or pre-recorded videos.
Quarterly Certification Process
Each quarter, USPI’s operations and financial teams sign an attestation which covers compliance with USPI’s policies, conflicts of interest, internal controls, financial statement accuracy, fraud and awareness of the Compliance Hotline. These attestations are submitted by 700+ individuals, and any exceptions noted are reviewed by USPI’s Disclosure Committee.
Auditing and Monitoring
Annually, USPI determines its monitoring and auditing priorities by conducting an annual risk assessment and developing a compliance work plan. The work plan activities includes areas such as reviews of arrangements with physicians and other referral sources, coding compliance audits, clinical quality audits, privacy and security vulnerability reviews.
Reporting and Communication
USPI’s dedicated compliance officers track responses and resolution of any issues identified through the Compliance Hotline, employee reports, external reports and internal or external auditing results. The compliance officers use a database to track progress toward issue review and resolution, and work to ensure that USPI has access to relevant documentation each time an issue is resolved.
As described throughout this summary, USPI investigates reported allegations and takes appropriate corrective action. Elements of each corrective action plan include:
- Identification of the issue;
- Revisions to policies and procedures, if necessary;
- Training on those policies and procedures, or retraining on established policies and procedures;
- Monitoring to ensure compliance; and
- Appropriate disciplinary action, consistent with USPI policy, in the event of non-compliance.
The Ethics and Compliance Department manages development and implementation of corrective action plans for compliance-related issues. In addition, resources from other corporate departments may be utilized for investigation and/or implementation of corrective action. The objective of all corrective actions is to ensure that patients receive quality care and that all USPI claims are correct and accurate.
Every individual is responsible for ensuring effective compliance within their area of visibility and USPI as a whole. This responsibility to uphold USPI’s compliance safeguards is rooted in our corporate culture and is the foundation for mitigating compliance risk.