Whenever a compliance issue has been identified, through monitoring, reporting of possible issues, investigations, or otherwise, the Chief Compliance Officer has the responsibility and authority to take or direct appropriate action to address that issue. The corrective action will be set forth in a written plan. In developing a corrective action plan, the Chief Compliance Officer should obtain advice and guidance from the University’s legal counsel. There should also be consultation with the Director and with appropriate clinical and billing personnel. Copies of corrective action plans should be provided to the Dean, the Office of General Counsel and to the Internal Auditor.
Corrective action plans should be designed to ensure not only that the specific issue is addressed but also that similar problems do not occur in other areas or departments. Corrective action plans may require that billing be handled in a designated way, that billing responsibility be reassigned, that certain training take place, that billing restrictions be imposed on particular physicians or other health professionals, or that the matter be disclosed externally. The Chief Compliance Officer may direct that refunds be made. If it appears that certain individuals have exhibited a propensity to engage in practices that raise compliance concerns, the corrective action plan should identify actions that will be taken to prevent such individuals from exercising substantial discretion with regard to billing.
A corrective action plan may recommend that the Dean impose a sanction or disciplinary action. Moreover, if the Chief Compliance Officer determines that any non-compliance has been willful, the Dean should be informed of that finding. University employees who have engaged in willful misconduct will be subject to disciplinary action in accordance with University process, including termination. A policy to address hiring and retention of persons who have been sanctioned by Medicare or another government program has been established.
Columbia University Billing Compliance Plan
September 9, 1996 (with amendments to October 2003)
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