UW Medicine Compliance
Compliance Education and Outreach – COMP.002
This policy establishes the healthcare compliance training requirements for UW Medicine workforce members and any entity that performs covered functions on behalf of UW Medicine.
For purposes of this policy, healthcare compliance includes content areas that are within the scope of the
UW Medicine Compliance Program. This policy does not address other compliance training requirements outside the scope of the UW Medicine Compliance Program.
Applicability: UW Medicine and UW Medicine Affiliated Covered Entity
Policy Title: Compliance Education and Training
Policy Number: COMP.002
Superseded Policies: PP-04 Privacy, Confidentiality, and Information Security Training
HMC, 135.5 Compliance Education and Training
UWMC, 15-1 Employee Education and Training
UWNC, Compl004 Compliance Education and Training
VMC, Corporate Compliance Training Documentation
Date Established: October 11, 2017
Date Effective: September 21, 2018
Next Review Date: October 11, 2020
UW Medicine develops and implements healthcare compliance education and training, as required by law, regulatory changes, industry needs and trends observed through risk assessments, auditing and investigations.
Compliance department(s) develop annual training plans, document and monitor training completion, and report regularly to senior leaders. Departments throughout the enterprise provide additional healthcare compliance training to operationalize healthcare compliance policies.
|Training Type/Frequency||Audience||Content Owner||Content|
|Initial onboarding upon hire or time of engagement
(within 30 days of hire or engagement)
|Workforce who perform covered functions||UW Medicine compliance departments||Includes but is not limited to general education and awareness about the following areas:
• Clinical billing and coding.
• Clinical research billing.
• Centers for Medicare & Medicaid Services (CMS) General Compliance Training.
• Fraud, Waste and Abuse (FWA) awareness and prevention.
• Emergency Medical Treatment & Labor Act (EMTALA).
• Anti-Kickback Statute (AKS) and Stark law.
• Conflicts of interest.
• HIPAA and state patient information privacy and security.
(within 60 days of hire or engagement)
|Role-based||UW Medicine compliance departments|
(within 60 days of hire or engagement)
|Role-based by department||Enterprise departments and units|
|Workforce who perform covered functions||UW Medicine compliance departments||Refresher Training reinforces and expands upon content received at onboarding as well as new or revised policy requirements.|
|Role-based by department||Enterprise departments and units||Department-driven content includes education and awareness about procedures and practices required to implement healthcare compliance policies.|
|Ad hoc/role-based||UW Medicine, compliance departments||See II.|
- Job Changes. A role, duty or position change may trigger additional role or department-specific healthcare compliance training; training completion may be mandated by a specific date or within a certain number of days after the change.
- Regulatory and Policy Changes/Trends. Ongoing or ad hoc education and outreach is provided in response to or in preparation for developments in the legal and regulatory environment, enterprise risk levels, and institutional policies/procedures, as well as general trends in healthcare compliance.
- Audit Results and Investigations. Additional education and training may be required or recommended in response to compliance audit results and/or trends, and the outcome of compliance investigations.
|Document Type||Responsible Party|
|Training documentation. All healthcare compliance education and training documentation and records of attendance and completion.||Onboarding documentation.||Where maintained in hard copy, by Department of hire or engagement, or designee.
Where maintained in learning management systems (LMS), by the owner/operator of the specific LMS system.
|Role-based documentation.||Where maintained in hard copy, by Department of hire or engagement, or designee.
Where maintained in LMS, by the owner/operator of the specific LMS system.
|Unit specific documentation.||Department, in accordance with entity-specific records retention policies.|
|Privacy, Confidentiality and Information Security Agreement (PCISA). Signed copies of the PCISA, including those attained as digital signatures in learning management systems.||Department.
|Code of Conduct. Signed copies of the code of conduct.||Department.
|Training materials. All original healthcare compliance training materials.||Onboarding materials.||Compliance department(s).|
|Role-based materials.||Compliance department(s).|
|Unit specific materials.||Department(s) of hire or engagement.|
- Develop and distribute healthcare compliance education, training and outreach modules and materials for certain onboarding and role-based healthcare compliance training;
- Update and maintain healthcare compliance education, training and outreach materials in accordance with legal and regulatory updates, industry trends and observations of auditing, investigations and risk assessment.
Managers and Supervisors:
- Responsible to ensure assignment and completion of direct reports onboarding and role-based training;
- Responsible to identify gaps in compliance training for direct reports undergoing role, duty or position changes;
- Develop and maintain department and unit-specific procedures in support of introductory and role-based healthcare compliance training;
- Ensure workforce members and individuals who perform covered functions sign the
UW Medicine PCISA upon hire or engagement and annually, and maintain these as required;
- Convey healthcare compliance training goals and expectations; and
- Facilitate understanding of compliance issues and direct questions, as needed, to compliance departments.
UW Medicine leadership:
- Champion education, training and outreach activities and convey implementation expectations to operational areas.
Workforce members and individuals who perform covered functions:
- Complete all applicable onboarding, role-specific, unit-specific and annual refresher trainings.
- Acknowledge and sign for the receipt, review and understanding of entity-specific code of conduct at initial hire or engagement.
- Acknowledge and sign for the receipt, review and understanding of the UW Medicine PCISA and its stated privacy and information security responsibilities at initial hire or engagement and annually.
- Discuss training obligations with supervisor or manager.
- UW Medicine Compliance Glossary.
- 002.F1 UW Medicine Privacy, Confidentiality and Information Security Agreement (PCISA).
- 002.F2 UW Medicine Protecting Patient Information Training Self-Study (Paper version)/(PowerPoint version).
- COMP.201 Fraud, Waste and Abuse Prevention.
- UWP, A-03 Employee Training and Development.
- UW Medicine Required Compliance Training.
- UW Medicine Records Retention Schedule.
- United States Sentencing Commission, Guidelines Manual, §8B2.1 (Nov. 2016).
- Compliance Program Guidance for Hospitals, 63 Fed. Reg. 8987 (February 23, 1998).
- Supplemental Compliance Program Guidance for Hospitals, 70 Fed. Reg. 4858 (January 31, 2005).
- HIPAA, Pub. L. No. 104-191, 45 C.F.R. §§ 160 and 164 (1996).
- General Provisions, 42 C.F.R. §422.503.
- Contract Provisions, 42 C.F.R. §423.504.
- Deficit Reduction Act of 2005, Pub. L. No. 109-171, §6032 (2006) codified at 42 U.S.C. §1396a(a)(68).
- Centers for Medicare and Medicaid Services (CMS), Medicare Managed Care Manual, CMS Pub. 100-16, Chap. 21, Sec. 50.3 (Rev. 110, Jan. 11, 2013); available at https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/mc86c21.pdf.
- CMS, Medicare Prescription Benefit Manual, CMS Pub. 100-18, Chap. 9, Sec. 50.3 (Rev. 16, Jan. 11, 2013); available at https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/mc86c21.pdf.
- CMS, State Operations Manual: Appendix V – Interpretive Guidelines – Responsibilities of Medicare Participating Hospitals in Emergency Cases, CMS Pub. 100-07, (Rev. 60, July, 16, 2010); available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107ap_v_emerg.pdf.
- Mulcahy, G. Medicare Parts C and D Oversight and Enforcement Group. (June 17, 2015). Update – Reducing the Burden of the Compliance Program Training Requirements. Department of Health & Human Services, CMS. Available at https://www.cms.gov/Medicare/Compliance-and-Audits/Part-C-and-Part-D-Compliance-and-Audits/Downloads/Update_Reducing_Burden_CP_Training-Requirements.pdf.
- Mulcahy, G. Medicare Parts C and D Oversight and Enforcement Group. (February 10, 2016). Additional Guidance – Compliance Program Training Requirements and Audit Process Update. Department of Health & Human Services, CMS. Available at https://www.cms.gov/Medicare/Compliance-and-Audits/Part-C-and-Part-D-Compliance-and-Audits/Downloads/2016_Complaince_and_-FWA_Training_Requirement_Update.pdf.
- Washington State Ethics in Public Service Act, Revised Code of Washington 42.52.365 Executive branch agencies—Ethics advisors—Ethics training.