Compliance Program

Gundersen Health System's Compliance Program was established in 1998 to ensure and formalize organizational compliance with all applicable federal and state laws and regulations. This objective is consistent with the mission, values and culture of Gundersen in promoting quality and integrity.

The Compliance Program applies to the entire organization and includes detailed Standards of Conduct, which defines and governs the expected conduct of employees.

The Compliance Program is modeled after the United States Sentencing Guidelines and the Office of Inspector General's Compliance Program Guidance for Hospitals. As recommended in these guidelines, Gundersen's Compliance Program includes the following seven elements:

  1. Designations of a Chief Compliance Officer and Compliance Committees
  2. Written Policies, Procedures and Standards of Conduct
  3. Training and Education
  4. Effective Lines of Communication
  5. Monitoring and Auditing
  6. Enforcement of Standards and Sanctions for non-compliance
  7. Responding to Detected Offenses

Gundersen's Compliance Program includes emphasis on:

  • Government billing regulations, including, but not limited to, coding, documentation, supervision and the hospital cost report
  • Other government program regulations
  • Contractual billing requirements
  • Stark and Anti-Kickback regulations
  • False Claims Act
  • Emergency Medical Treatment and Labor Act
  • Conflict of Interest requirements

The objectives of the Compliance Program are to reduce the potential for fraud and abuse by:

  • Providing additional oversight of Gundersen’s compliance with laws, regulations and special conditions imposed upon it by licensing and regulatory authorities
  • Identifying and preventing compliance violations and unethical conduct
  • Identifying and avoiding transactions or business practices which might result in irregularities in payment or reimbursement
  • Minimizing the loss to the government from false claims, and thereby avoiding sanctions and administrative remedies, such as exclusion from the Medicare and/or Medicaid programs
  • Encouraging employees to report potential compliance violations
  • Improving operations
  • Maintaining Gundersen’s commitment to provide quality patient care

Gundersen Standards of Conduct describes the general policies and procedures that all medical staff, employees and volunteers must adhere to. The Standards of Conduct booklet is the cornerstone document of our Compliance Program.

Love + Medicine

Every day, Gundersen Health System delivers great medicine plus a little something extra—we call it Love + Medicine.

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