Business integrity program: Ensuring UW Health is complying with federal and state regulations

UW Health has a strong and abiding commitment to ensure its compliance with the regulatory requirements that govern our missions of Education, Research, Patient Care and Community Service.

The main function of the Business Integrity Program is to create a comprehensive strategy to ensure UW Health is consistently complying with the federal and state regulations relating to our missions. The department of Business Integrity has five offices that assist with this function: Professional Services Compliance, Hospital Services Compliance, Research Services Compliance, Privacy and Internal Audit.

Corporate compliance

The primary function of the Corporate Compliance Department is to ensure UW Health complies with federal and state regulatory requirements, provides compliance oversight to UW Health for matters that span the organization and promote corporate responsibility.

The Corporate Compliance Department is responsible for central policy development including the Code of Conduct and the UW Health Compliance Plan. This department also monitors the Conflicts of Interest process for UW Health staff and coordinates Interactions with Outside Industries.

Professional and hospital services

The mission of the Professional and Hospital Compliance Offices is to ensure UW Health medical staff and employees comply with the regulatory requirements including but not limited to documentation, coding and billing, HIPAA, Fraud & Abuse Laws, Stark and Anti-Kickback regulations. This mission is accomplished through educational sessions, clarification of specific regulatory issues and the completion of internal reviews/audits.

Research services

The mission of the Research Compliance Office is to promote and support ethical research practices at UW Health, by partnering with the research community so that we are compliant with federal, state and local laws and regulations as well as University policies. This mission is accomplished through educational sessions, clarification of specific regulatory issues, establishing study billing parameters and the completion of internal reviews/audits.

Privacy

The mission of the Privacy Office is to ensure UW Health medical staff and employees comply with the regulatory requirements of the Health Insurance Portability Accountability Act (HIPAA), state privacy regulations and the privacy policies and procedures of UW Health. The Privacy Office's primary duty is to protect the confidentiality and privacy of patients' protected health information (PHI) within UW Health. The mission is accomplished through educational sessions, clarification of specific regulatory issues and the completion of internal reviews and audits.

Internal audit

The UW Health Internal Audit function is an independent and objective resource of UW Health, providing assurance and consulting services designed to assist UW Health in achieving its mission by evaluating and offering recommendations to improve the effectiveness of financial accounting and reporting, information technology, internal control and operational- and compliance-related activities.

External audit

The primary functions of the UW Health External Audit Office are coordinating Responses to all governmental audits received by UW Health, as well as identifying potential upcoming audits by reviewing issues determined to be important or “high-risk” by the different auditing entities.

Pharmacy compliance

Pharmacy Compliance ensures UW Health employees from all disciplines adhere to expectations regarding controlled substance handling defined by, but not limited to, the Drug Enforcement Administration, The Joint Commission, Centers for Medicare and Medicaid Services, UW Health policies and procedures, and other advised best practices when handling controlled substances. The team also acts as a consultant to ensure this handling is adequate and effective to prevent or detect diversion and provides a safe place for reporting potential theft or diversion of medications.

General contact information

UW Health Compliance
(608) 203-2201
businessintegrity@uwhealth.org

Questions?

Troy Lepien
Vice President/Business Integrity and Chief Compliance & Privacy Officer

Mary Waldo Compliance Director - Professional Services

Gabe Jensen
Compliance Director - Hospital Services

Scott Houtakker
Internal Audit Director

Nancy Lutz
Program Manager, Clinical Research Billing