UW Medicine Compliance
Compliance Auditing and Monitoring – COMP.003
This policy establishes baseline requirements for auditing and monitoring activities conducted in support of the UW Medicine Compliance Program, and applies to the UW Medicine compliance department.
Applicability: UW Medicine and UW Medicine Affiliated Covered Entity
Policy Title: Compliance Auditing and Monitoring
Policy Number: COMP.003
Superseded Policies: N/A
Date Established: July 26, 2010
Date Effective: November 4, 2019
Next Review Date: November 4, 2021
UW Medicine Compliance develops and maintains annual auditing and monitoring plans based on an assessment of the compliance requirements within its specific scope and jurisdiction. Factors that contribute to the likelihood and impact of noncompliance are considered in determining audit priorities, and audit plans are approved by the appropriate governance body. UW Medicine compliance audits are performed by compliance officials and their designees who are subject matter experts and have scope and jurisdiction in the following areas:
- Facility and professional billing integrity
- Emergency Medical Treatment and Active Labor Act (EMTALA).
- Health Insurance Portability and Accountability Act (HIPAA) and State patient information privacy laws.
- Research billing
- Other compliance audits as deemed necessary by regulatory need and risk assessments.
Annual compliance audit plans are reprioritized periodically in response to emerging risks, communicated to the appropriate stakeholders and coordinated with other internal audit departments to avoid duplication of efforts.
Compliance audits conform to the procedures established for each subject area with regard to initiation, notifications, review of results, documentation requirements, reporting of outcomes and remediation management.
UW Medicine Compliance analyzes audit outcomes to identify trends, evaluates remediation effectiveness and determines the need for program enhancements. This information is reported to the appropriate leadership and compliance committee(s).
UW Medicine Compliance responds to noncompliance identified during the course of audits in an effective and timely manner, including, but not limited to the following steps:
- Stop the noncompliant activity;
- Assess reasons for and results of noncompliant activity;
- Report noncompliance to relevant leadership and oversight bodies;
- Notify external government entities in accordance with regulatory requirements;
- Recommend actions to improve compliance and/or correct deficiencies;
- Coordinate effective and meaningful management responses;
- Provide targeted education and outreach;
- Repay or otherwise remediate any overpayment;
- Verify that remediation activities have been successfully deployed; and
- Re-audit to ensure that the remediation has been successful
- United States Sentencing Commission, Guidelines Manual, §8B2.1 (Nov. 2018).
- Compliance Program Guidance for Hospitals, 63 Fed. R 8987 (February 23, 1998).
- Supplemental Compliance Program Guidance for Hospitals, 70 Fed. R 4858 (January 31, 2005).