Medical Necessity and Appropriate Services

The university's academic health centers and health systems will provide quality health care in a manner that is appropriate, medically necessary, and efficient.

The university's academic health centers and health systems shall submit claims for payment to government, private, or individual payers for those services or items that are medically necessary and appropriate.

• When ordering or providing services or items, university physicians (or other health care professionals authorized by law to order items or services) shall only order those services and items that are consistent with generally accepted medical standards for diagnosis or treatment of disease and are determined by the profession to be medically necessary and appropriate.
• In some cases, a health care professional may determine that services are medically necessary or appropriate, but the patient's health plan may not cover those services. In those cases, a patient should refer to his or her health plan administrator to receive information about the process for disallowed claims or uncovered benefits.
• Patients may request services that are not covered benefits. Such services may be provided as long as the patient has been given advance notice and has agreed to pay for the services. In these cases, the patient may request the submission of a claim for the services to protect his or her appeal rights with respect to those services or to determine the extent of the coverage provided by the payer.
• Professional coding and documentation will be consistent with the standards established in the university and campus programs and relevant policies.

Proper Coding, Billing, and Patient Accounting

University personnel involved in the coding, billing, documentation and accounting for patient care services for the purpose of billing government, private or individual payers must comply with all applicable state and federal regulations and campus policies and procedures for detecting and preventing fraud, waste and abuse.

• The university will bill only for services actually rendered and shall seek the amount to which the university is entitled. The university does not tolerate billing practices that misrepresent the services actually rendered.
• Supporting medical documentation must be prepared for all services rendered. University personnel shall bill on the principle that if the appropriate and required documentation has not been provided, then the service has not been rendered.
• All services must be accurately and completely coded and submitted to the appropriate payer in accordance with applicable regulations, laws, and contracts and campus policies and procedures. In all cases, federal and state regulations take precedence; however, campus policies and procedures must accurately reflect those regulations.
• All patients shall be consistently and uniformly charged. Discounts will be appropriately reported, and items and services consistently described so that comparability can be established among payers.
• Government-sponsored payers shall not be charged in excess of the provider's usual charges. Any questions regarding the interpretation of this standard should be directed to the chief compliance officer or university legal counsel.
• Billing and collections will be recorded in the appropriate accounts. Credit balances must be processed in a timely manner in accordance with applicable rules and regulations. When the cost report process identifies any credit balances, university personnel shall direct those issues to the academic health center, the health system's accounting or risk management departments, or other personnel responsible for patient accounts.
• University personnel should be aware of the existence of system-wide and campus Professional Fee Billing Guidelines and Clinical and Laboratory Billing Guidelines. These Guidelines, available through the campus Compliance Office, provide for the policies and procedures to be followed when the university bills payers for professional fees and laboratory services. University personnel responsible for coding, billing, and documentation should be knowledgeable about university policies and procedures, federal and state regulations regarding those activities. The university shall provide these individuals with opportunities for training to allow them to accurately code, document, and bill according to federal and state regulations and the university's policies and procedures. Management at each academic health center campus should ensure that appropriate evaluation processes have been established to assess whether university personnel understand and carry out correct procedures.
• Elective procedures that are not covered by governmental or private payer can be provided. However, before providing any elective services, the provider must inform the patient that these services may not be covered. The provider should obtain the patient's agreement to pay for the services if payers deny the claim. A patient has the right to have a claim submitted even if services are excluded from coverage.
• An accurate and timely billing structure and medical records system is critical to ensure that university personnel can effectively implement and comply with required policies and procedures. Demonstrated lapses in the information and billing systems infrastructure should be remedied in a timely manner by the campus executive management team, other designated university personnel and billing entities.

Proper Cost Reporting

University personnel who are responsible for the preparation and submission of cost reports must ensure that all such reports submitted to government and private payers are properly prepared and documented according to all applicable federal and state laws.

• In submitting and preparing cost reports, all costs will be properly classified, allocated to the correct cost centers, and supported by verifiable and auditable data.
• It is the university's policy to correct any cost report preparation or submission errors and mistakes in a timely manner and, if necessary, clarify procedures and educate employees to prevent or minimize recurrence of those errors.

Respect of Confidentiality

All efforts will be made to protect personal and confidential or privileged information concerning the academic health center and health system's patients and the respective health care practices of those entities. University personnel will abide by applicable state and federal laws, including HIPAA privacy and security regulations.

• University personnel shall not disclose confidential patient information unless authorized by the patient and/or when authorized by law. Approval for appropriate use of patient information for research purposes must be obtained from the Institutional Review Board.
• Confidential patient information should only be discussed with or disclosed to appropriate university personnel as permitted by HIPAA policies.
• Confidential patient information should not be discussed with or disclosed to non-university personnel unless authorized by the patient or permitted by law. Non-university personnel include the family or business and social acquaintances of the patient or of university personnel, customers, suppliers, or others.
• In general, patients can request and are entitled to receive copies or summaries of their records with the exception of non-emancipated minors, some mental health patients, and patients being treated for alcohol and drug abuse, who may be provided with copies of the records if it is appropriate as judged by their clinician.
• Some information may be sought under the California Public Records Act, the Information Practices Act, or other statutes requiring the release of information.
• University personnel who have any questions regarding patient confidentiality should refer to university policies for additional information and consult with appropriate supervisor, manager, the Compliance Office, or the Privacy Officer.
• University personnel shall not reveal or disclose confidential medical staff or peer review information. California and federal law bestows certain privileges and provides for confidentiality of certain records including the proceedings and records or organized committees of the medical staff and peer review bodies.
• University personnel shall not reveal or disclose proprietary or trade secret information to unauthorized non-university persons. Proprietary information may relate to university business affairs or the affairs of a vendor or contractor.
• Personnel records are considered confidential. Access to personnel files is limited to management, the human resources department staff, and internal auditors, and these individuals are held accountable for protecting the privacy of personnel records.

Creation and Retention of Accurate Patient and Institutional Records

All patient and institutional records are the property of the university. University personnel responsible for the preparation and retention of records shall ensure that those records are accurately prepared and maintained in a manner and location as prescribed by law and university policy.

• The complete and accurate preparation and maintenance of all records (medical, professional, electronic, paper, and institutional) by university physicians, clinicians, nurses, and others are important for providing quality care and conducting business of the university's clinical enterprise. Accurate records are required in order for the university hospital or clinic to retain licensure and accreditation.
• University personnel will not knowingly create records that contain any false, fraudulent, fictitious, deceptive, or misleading information.
• University personnel must not delete any entry from medical a record. Medical records can be amended and material added to ensure accuracy of a record in accordance with medical center and Medical Staff policies and procedures. Whenever university personnel amend a record, they must indicate that the notation is an addition or correction and record the actual date that the additional entry has been made.
• University personnel must not sign someone else's signature or initials on a record unless they have been authorized and clearly marked that they are signing on behalf of another (e.g., by initialing the signature).
• University records shall be maintained according to accepted standards and principles of the particular profession and applicable university policies and procedures.
• Unless authorized by university policy, university personnel shall not destroy or remove any university records from the university's premises.
• The university's record retention and record destruction policies and procedures must be consistent with Federal and State requirements regarding the appropriate time periods for maintenance and location of records.

Cooperation with Government Requests for Information

University personnel should cooperate with appropriately authorized governmental investigations and audits.

• The university has developed detailed policy to advise university personnel on the procedures to be followed when representatives of the government arrive unannounced. The policy establishes a procedure for an orderly response to the government's request to enable the Health System to protect its and its patients' interest while fully cooperating with the investigation.
• When a representative from a federal or state agency contacts university personnel for information regarding the Health System or any Health System affiliated health care entity, or any other entity with which the Health System does business, the individual should contact the hospital director immediately. If the hospital director is not immediately available, the individual should contact the Compliance Office, or Health System Counsel or General Counsel. University personnel should ask to see the government representative's identification and business card, if the government representative is there in person. Otherwise, university personnel should ask for the person's name and office, address and telephone number, identification number and then call the government representative's office to confirm his or her authority.

Prevention of Improper Referrals or Kickbacks

University personnel must not accept or offer, for themselves or for the university, anything of value in exchange for referrals of business or the referral of patients.

• Federal law generally prohibits anyone from offering anything of value to a Medicare, Medicaid or Tricare patient that is likely to influence that person's decision to select or receive care from a particular health care provider.
• University personnel may not offer or receive any item or service of value as an inducement for the referral of business or patients to or from university providers or practitioners or outside facilities. Regulations prohibit improper influence that could alter clinical decisions or purchasing decisions, increase costs, or lead to over or under utilization of services.
• In addition to the prohibition regarding exchange of goods or money to induce referral, certain prohibitions exist with regard to receipt of gifts by university personnel.
• Federal law prohibits a physician from referring a patient for certain health services to a facility where that physician (or a family member) has a financial interest (Stark regulations).
• University personnel should adhere to the university's policy as defined in the Compendium of University of California Specialized Policies, Guidelines and Regulations Related to Conflict of Interest, the university's Gifts Policy, as well as the California Political Reform Act.
• Each campus shall establish procedures for the review of all pricing and discounting decisions to assure that appropriate factors have been considered and that the basis for such arrangements are documented.
• The following types of business arrangements must be reviewed and approved by one or more of the campus executive management team to assure compliance with university policies and federal regulations. The executive management team may determine that certain business transactions must first be approved, in accordance with university policy, by the university's Board of Regents charged with taking action on such matters:
  • pursuing joint ventures, partnerships, corporations;
  • developing hospital financial arrangements with hospital-based physicians;
  • entering into an arrangement to lease or purchase equipment or supply items from a vendor; or
  • acquiring physicians practices, hospitals, and other facilities, clinical, and ancillary services, or any other entities.

Adherence to Antitrust Regulations

The university will comply with all applicable federal and state antitrust laws. For example, university personnel should not:

• Agree, or attempt to agree, with a competitor to artificially set prices or salaries.
• Divide markets, restrict output, or block new competitors from the market.
• Share pricing information with competitors that is not normally available to the public.
• Deny staff privileges to physicians or allied practitioners, individually or as a group, when there is no academic programming decision to do so and when such decisions should be based on individual qualifications.
• Agree to participate with competitors in a boycott of government programs, insurance companies, or particular drugs or products.

Avoidance of Conflicts of Interest

All university personnel shall conduct clinical enterprise and personal business in a manner that will avoid potential or actual conflicts of interest.

• University personnel shall not use their official positions to influence a university decision in which they know, or have reason to know, that they have a financial interest. University personnel should follow the Compendium of University of California Specialized Policies, Guidelines, and Regulations Related to Conflict of Interest and be knowledgeable about activities that may be an actual or potential conflict of interest. Examples of such activities may include, but are not limited to, the following:
  • Giving to or receiving gifts, gratuities, loans, or other special treatment of value from third parties doing business with or wishing to do business with the university in a manner that is not in accordance with the university's Gifts Policy and the California Political Reform Act. Third parties may include, but are not limited to, customers, patients, vendors, suppliers, competitors, payers, carriers, and fiscal intermediaries.
  • Using the university facilities or resources for other than university activities.
  • Using the university's name to promote or sell non-university products or personal services.
  • Contracting for goods or services with family members of university personnel directly involved in the purchasing decision.
• University personnel should consult with a supervisor, executive management, the campus conflict of interest coordinator, university general counsel or, if available, campus counsel prior to engaging in any activity that could raise conflict of interest issues.

Respect for Patient's Freedom of Choice

When referring patients to home health agencies, medical equipment suppliers or long term-care and rehabilitation providers, university personnel should respect the patient's right to choose his or her own providers.

• Some healthcare plans limit the patient's choice of provider, or pay less than the full cost of a provider. The patient has the freedom to choose providers not in his or her health program or insurance panel, provided the patient is willing to pay for the non-covered care.

Honest and Fair Business Practices

University personnel shall adhere to fair business practices and accurately and honestly represent themselves and the university's services and products.

• University personnel will be honest and truthful in all marketing and advertising practices pertaining to the business practices of the university's academic health centers and health systems.
• Vendors who contract to provide goods and services to the university's academic health centers and health systems will be selected on the basis of quality, cost-effectiveness and appropriateness for the identified task or need, in accordance with university policy.

Fair Treatment of Employees

The university prohibits discrimination in any work related decision on the basis of race, color, national origin, religion, sex, physical or mental disability, medical condition (cancer-related or genetic characteristics), ancestry, marital status, age, sexual orientation, citizenship, or status as a covered veteran. The University is committed to providing equal employment opportunity and a work environment where each employee is treated with fairness, dignity and respect.

• The university will make reasonable accommodations to the known physical and mental limitations of otherwise qualified individuals with disabilities. If an individual requires accommodations or needs assistance, he or she should contact the campus Employee Assistance Program or human resources.
• The university does not tolerate harassment or discrimination by anyone based on the diverse characteristics or cultural backgrounds of those who work for the university pursuant to the University of California Non-discrimination and Affirmative Action Policy Regarding Academic and Staff Employment.
• Any form of workplace violence or sexual harassment is strictly prohibited. University personnel should refer to campus specific policies dealing with workplace violence or sexual harassment.
• For employees who observe or experience any form of discrimination, harassment or violence, the university provides a number of ways to report the incident, including, but not limited to the following: a supervisor, manager, the Chief Compliance Officer, UCDHS Counsel, university general counsel, campus counsel, Human Resources, the campus Office of Equal Opportunity & Diversity, the campus Compliance hotline, and appropriate Academic Senate committee.

Clinical Research

Integrity in research includes not just the avoidance of wrong doing, but also the rigor, carefulness, and accountability that are the hallmarks of good scholarship. University policies set forth expectations for high standards of ethical behavior for faculty, staff, and students involved in research. The rights of research study participants and their well-being and privacy are protected by the university through compliance with ethical standards and all applicable university policies and federal and state regulation.

• All members of the university community engaged in research are expected to conduct their
• research with integrity and intellectual honesty at all times and with appropriate regard for human subjects.
• To protect the rights, well-being, and privacy of human subjects, all research involving human subjects is to be reviewed by institutional review boards.
• The university prohibits research misconduct. Personnel engaged in research are not to: fabricate data or results; change or knowingly omit data or results to misrepresent results in the research record; or intentionally misappropriate the ideas, writings, research, or findings of others.
• All those engaged in research are expected to pursue the advancement of knowledge while meeting the highest standards of honesty, accuracy, and objectivity and to demonstrate accountability for sponsors' funds and to comply with specific terms and conditions of contracts and grants.
• In accordance with university policy (UCOP Operating Requirement No. 95-5, "Requirements for Administration of Agreements with Private Sponsors for Drug and Device Testing Using Human Subjects"), the cost to perform clinical trials conducted for a private sponsor must always be fully funded by the sponsor and may not be supported in whole or in part by other funds, including third party insurance payments, gift or foundation funds, or charges to the subject.
• Goods and services are procured in a competitive, fair and timely manner in compliance with OMB Circular A-110 and university policies. Conflicts of interest are avoided. Educational or research grants or other funds received from commercial entities are not permitted to influence procurement decisions.
• Ongoing monitoring and auditing processes, with initiation of appropriate corrective action, ensure the university's clinical research programs are well managed.
• The records retention program for clinical research ensures documents and other necessary supporting evidence are maintained for the appropriate length of time as required by federal and other regulations. This program evaluates and verifies the effectiveness of the systems and internal procedures implemented.