The purpose of the UW Medicine Compliance Program (the Program) is to assist UW Medicine in achieving its financial, operational and strategic goals while maintaining compliance with all applicable laws and regulations. The scope, structure, core functions and activities of the Program are updated as necessary to reflect organizational and policy changes, programmatic refinements and best practices for addressing compliance risk.
The following content areas are within the scope of the Program:
- Clinical billing and documentation (facility and professional fee billing for all clinical services including clinical research);
- Compliance with the provisions of Health Insurance Portability and Accountability Act (HIPAA) governing patient privacy and information security;
- Identity theft prevention;
- Stark law and Anti-Kickback Statute (AKS);
- Conflicts of interest (COI);
- Ethics; and
- Emergency Medical Treatment & Labor Act (EMTALA).
Compliance programs for other content areas (for example, research, health and safety, pre- and post-award research grants and contracts, employment), other entity partners (for example, SCCA, FHCRC, Children's), or University of Washington (UW) healthcare components (for example, Dentistry, Public Health, Nursing) are within other jurisdictions. However, UW Medicine collaborates with its external entity partners and other parts of the UW system for any number of reasons, including but not limited to:
- Addressing compliance issues crossing institutional or jurisdictional lines;
- Enforcing compliance;
- Harmonizing policies, procedures and guidance;
- Engaging in mutually beneficial initiatives, process improvements, and risk assessments;
- Sharing best practices; and
- Monitoring regulatory developments, analyzing industry trends; and identifying risk mitigation strategies.
The Program is founded on both risk-based and proactive core components designed to promote and support compliance and detect noncompliance. Activities and program elements are documented in writing, readily available for review and regularly reported.
Specific program elements are aligned with standards established by the Office of Inspector General (OIG) for the healthcare profession and the United States Federal Sentencing Guidelines, and include:
- Senior leadership commitment and high level oversight, including the designation of a chief compliance officer to oversee enterprise-wide compliance systems, and initiatives and establishment of board-level compliance committees;
- Standards, policies and procedures to prevent and detect violations of law;
- Education and outreach activities to ensure that policies are effectively disseminated and understood by enterprise members;
- Periodic risk assessments, development of risk mitigation strategies and work plans;
- Internal monitoring and auditing;
- Reasonable due diligence to confirm that UW Medicine does not delegate substantial discretionary authority to individuals who the organization knows or should know, are likely to engage in illegal conduct;
- Maintaining lines of communication, including an anonymous reporting mechanism for employees to report possible compliance issues without fear of retribution;
- Prompt investigation and appropriate corrective action to prevent similar offenses when detected;
- Enforcement of standards and policies through well-publicized disciplinary guidelines; and
- Periodic evaluation of the effectiveness of the Program.
The commitment to compliance is imbedded in the expectation that all members of UW Medicine will meet the professional, ethical and regulatory standards associated with their individual roles. Faculty, staff, residents and students are all expected to understand the rules governing their work, comply with UW Medicine policies and procedures, act in a professional and ethical manner, and contact appropriate institutional offices when questions or concerns about compliance arise.
UW Medicine's commitment to compliance demonstrates a deep awareness of its accountability to the public and the people it serves.
If you have questions about UW Medicine Compliance, call 206.616.5248 (local) or 866.964.7744 (toll free). For information about your privacy rights and responsibilities, please see the Notice of Privacy Practices.
Most other patient questions and concerns can be resolved by contacting one of the departments listed at Important Patient Care Phone Numbers .