University of Nebraska Medical Center

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== Procedures ==
== Procedures ==
#'''Regulatory Agency Visits'''         
#'''Regulatory Agency Visits'''         
#* UNMC staff members who are notified of a visit by a regulatory agency should notify their supervisor, director and/or dean (as appropriate to the type of visit) and the Compliance Officer at 402-559-9576 or 402-559-6767.
#* UNMC staff members who are notified of a visit by a regulatory agency should notify their supervisor, director and/or dean (as appropriate to the type of visit) and the Chief Compliance Officer at 402-559-9576 or 402-559-6767. Notify Nebraska Medicine when a patient care area is involved or could be involved.
#* Any requests for information related to a patient, patient’s care or billing, also known as protected health information (PHI) pursuant to an investigation by a regulatory agency require notification of the Privacy Officer at 402-559-5136 or [mailto:privacy@nebraskamed.com] prior to providing patient information.
#* Any requests for information related to a patient, patient’s care or billing, also known as protected health information (PHI) pursuant to an investigation by a regulatory agency require notification of the Privacy Officer at 402-559-5136 or [mailto:privacy@nebraskamed.com Privacy Officer] prior to providing patient information.
#* During the visit, the regulatory agency official(s) should be escorted at all times by an individual who is knowledgeable about the area(s) visited.
#* During the visit, the regulatory agency official(s) should be escorted at all times by an individual who is knowledgeable about the area(s) visited.
#* Most regulatory agency visits are permitted pursuant to state or federal law, and the regulator may request copies of documents to assess compliance without providing a subpoena. Staff who are unsure about whether documents should be provided to regulators should ask their supervisor, the Compliance Officer at 402-559-9576 or 402-559-6767 or the Associate General Counsel for Health Sciences (care of the University’s General Counsel’s office at Varner Hall at 402-472-1201) for guidance.
#* Most regulatory agency visits are permitted pursuant to state or federal law, and the regulator may request copies of documents to assess compliance without providing a subpoena. Staff who are unsure about whether documents should be provided to regulators should ask their supervisor, the Chief Compliance Officer at 402-559-9576 or 402-559-6767 or the Associate General Counsel '''''for Health Sciences (care of the University’s General Counsel’s office at Varner Hall at 402-472-1201)''''' for guidance.
#* Supervisory personnel and the Compliance Officer should be informed of any serious compliance issues that may arise during the visit as soon as possible, and shall be provided with reports of findings at the end of all visits.
#* Supervisory personnel and the Chief Compliance Officer should be informed of any serious compliance issues that may arise during the visit as soon as possible and shall be provided with reports of findings at the end of all visits.
#'''Inspections/Investigations by Government Officials/Law Enforcement/Other Third Parties'''         
#'''Inspections/Investigations by Government Officials/Law Enforcement/Other Third Parties'''         
#* If a UNMC staff member becomes aware of any contact by an agent, representative, investigator, auditor or attorney from any governmental agency, law enforcement agency, or other third party (hereinafter, "investigator"), the staff member should ask to see the investigator's identification and business card for name and agency affiliation. If contact is by telephone, ask the investigator to fax a business card or other identification. Ask for the investigator's agency name and phone number and call them back to verify identity.
#* If a UNMC staff member becomes aware of any contact by an agent, representative, investigator auditor or attorney from any governmental agency, law enforcement agency, or other third party (hereinafter, "investigator"), the staff member should ask to see the investigator's identification and business card for name and agency affiliation. If contact is by telephone, ask the investigator to fax a business card or other identification. Ask for the investigator's agency name and phone number and call them back to verify identity.
#* Inquire as to the reason for the visit if rationale has not already been provided.
#* Inquire as to the reason for the visit if rationale has not already been provided.
#* Contact a supervisor, director or dean, and the Compliance Officer at 402-559-9576 or 402-559-6767. If the Compliance Officer is unavailable, contact the Associate General Counsel for Health Sciences (care of the University’s General Counsel’s office at Varner Hall at 402-472-1201). The Compliance Officer and/or Associate General Counsel for Health Sciences shall notify the University of Nebraska Office of the Associate General Counsel of the investigation and coordinate with them as necessary.
#* Contact a supervisor, director or dean, and the Chief Compliance Officer at 402-559-9576 or 402-559-6767. If the Chief Compliance Officer is unavailable, contact the Associate General Counsel '''''for Health Sciences (care of the University’s General Counsel’s office at Varner Hall at 402-472-1201)'''''. The Chief Compliance Officer and/or Associate General Counsel '''''for Health Sciences''''' shall notify the University of Nebraska Office of the Associate General Counsel of the investigation and coordinate with them as necessary. Notify Nebraska Medicine when a patient care area is involved or could be involved.
#* If the subject matter of the investigation is not in the staff member's area of responsibility, the Compliance Officer should be contacted, so the investigator can be directed to the correct area.
#* In the case of a possible concern for safety or compliance investigation disruption, Compliance may contact public safety for assistance at 402-559-5111.
#* In the case of a possible concern for safety or compliance investigation disruption, Compliance may contact public safety for assistance at 402-559-5111.
#* '''Subpoenas/Search Warrants'''. If the investigator asks to search a UNMC facility or obtain any documents from UNMC, ask if there is a subpoena or search warrant to be served; and if so, make a copy of the document. Immediately contact the Associate General Counsel for Health Sciences to review the subpoena or warrant to verify it is valid and to provide advice on responding to it. If they are unavailable, the University of Nebraska Office of the Associate General Counsel should be contacted to review the documents. The Compliance Officer and/or Associate General Counsel for Health Sciences shall escort the investigator, along with personnel familiar with the area to be searched.
#* If the subject matter of the investigation is not in the staff member's area of responsibility, the Chief Compliance Officer should be contacted, so the investigator can be directed to the correct area.
#: If documents are subpoenaed, the records custodian for the documents shall be consulted if they are not already involved (i.e. [https://www.nebraskamed.com/patients/medical-records Medical Records Department] for patient information; Human Resources Department for employee information, Student Success for student information). The Information Technology Security Office shall be contacted at [https://support.security.unmc.edu https://support.security.unmc.edu] if computer information, files or hardware is requested.
#* '''Subpoenas/Search Warrants'''. If the investigator asks to search a UNMC facility or obtain any documents from UNMC, ask if there is a subpoena or search warrant to be served; and if so, make a copy of the document. Immediately contact the Associate General Counsel '''''for Health Sciences''''' to review the subpoena or warrant to verify it is valid and to provide advice on responding to it. If they are unavailable, the University of Nebraska Office of the Associate General Counsel should be contacted to review the documents. The Chief Compliance Officer and/or Associate General Counsel '''''for Health Sciences''''' shall escort the investigator, along with personnel familiar with the area to be searched.
#: Individuals intending to serve subpoenas to employees for non-work-related matters should be instructed to report to the Human Resources Employee Relations Department to arrange service.
If documents are subpoenaed, the records custodian for the documents shall be consulted if they are not already involved (i.e. [https://www.nebraskamed.com/patients/medical-records Medical Records Department] for patient information; Human Resources Department for employee information, Student Success for student information). The Information Technology Security Office shall be contacted at [https://support.security.unmc.edu https://support.security.unmc.edu] if computer information, files or hardware is requested.<br />
#* '''Conditions of Search'''. If a search is conducted pursuant to a valid search warrant, the search shall be confined to the areas specified in the search warrant. If the investigator attempts to enter areas not specified in the search warrant, staff should object. Staff shall remain with the investigator at all times. If the search warrant is valid, the search may not be stopped. No staff member is required to speak to the investigator other than to provide administrative assistance with the search and provide the documents specified in the warrant. Under no circumstances should staff obstruct or interfere with the search.
#* '''Record of Search'''. During the search, staff shall keep a written record of areas searched and documents and items seized, including a summary of their content. Staff should ask the investigator if they are willing to accept copies of documents instead of originals. Staff should coordinate closely with General Counsel for direction, and specifically with the  Director of University of Records.
#* '''Interviews'''. Staff members who shall be interviewed pursuant to an investigation may consult with the Associate General Counsel for Health Sciences before any requested interview. When responding to questions asked by investigators, staff shall always tell the truth. If staff do not recall something or have no knowledge about the topic, they should say so. Staff should not guess or speculate. Staff should be very careful to answer questions completely, accurately, and concisely so that there will be no misunderstanding.
#* '''Debriefing'''. After the investigator departs the premises, staff involved in the investigation shall take part in a debriefing with the Compliance Officer and/or Associate General Counsel for Health Sciences. Reports of the investigation shall be provided to senior personnel as appropriate.
#* '''After Hours'''. In the unlikely event that an investigator requests information after hours, staff should contact the Associate General Counsel for Health Sciences or the Compliance Officer through the operator at 402-559-4000.


Individuals intending to serve subpoenas to employees for non-work-related matters should be instructed to report to the Human Resources Employee Relations Department to arrange service.
:* '''Conditions of Search'''. If a search is conducted pursuant to a valid search warrant, the search shall be confined to the areas specified in the search warrant. If the investigator attempts to enter areas not specified in the search warrant, staff should object. Staff shall remain with the investigator at all times. If the search warrant is valid, the search may not be stopped. No staff member is required to speak to the investigator other than to provide administrative assistance with the search and provide the documents specified in the warrant. Under no circumstances should staff obstruct or interfere with the search.
:* '''Record of Search'''. During the search, staff shall keep a written record of areas searched and documents and items seized, including a summary of their content. Staff should ask the investigator if they are willing to accept copies of documents instead of originals. Staff should coordinate closely with General Counsel for direction, and specifically with the '''''Director of University of Records'''''.
:* '''Interviews'''. Staff members who shall be interviewed pursuant to an investigation may consult with the Associate General Counsel '''''for Health Sciences''''' before any requested interview. When responding to questions asked by investigators, staff shall always tell the truth. If staff do not recall something or have no knowledge about the topic, they should say so. Staff should not guess or speculate. Staff should be very careful to answer questions completely, accurately and concisely so that there will be no misunderstanding.
:* '''Debriefing'''. After the investigator departs the premises, staff involved in the investigation shall take part in a debriefing with the Chief Compliance Officer and/or Associate General Counsel '''''for Health Sciences'''''. Reports of the investigation shall be provided to senior personnel as appropriate.
:* '''After Hours'''. In the unlikely event that an investigator requests information after hours, staff should contact the Associate General Counsel '''''for Health Sciences''''' or the Chief Compliance Officer through the operator at 402-559-4000.
==Additional Information==
==Additional Information==
*[mailto:sarah.glodencarlson@unmc.edu Chief Compliance Officer], 402-559-9576 or 402-559-6767
*[mailto:sarah.glodencarlson@unmc.edu Chief Compliance Officer], 402-559-9576 or 402-559-6767
*Associate General Counsel for Health Sciences, (care of the University’s General Counsel’s office at Varner Hall at 402-472-1201)
*[mailto:privacy@nebraskamed.com Privacy Officer], 402-559-5136
*Director of University of Records??
*Associate General Counsel '''''for Health Sciences, (care of the University’s General Counsel’s office at Varner Hall at 402-472-1201)'''''
'''*Director of University of Records??'''
*[https://support.security.unmc.edu Office of Information Security]
*[https://support.security.unmc.edu Office of Information Security]
*[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/policy-on-records-requests-and-contacts-by-law-enforcement.pdf University of Nebraska Executive Memorandum 43]
*[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/policy-on-records-requests-and-contacts-by-law-enforcement.pdf University of Nebraska Executive Memorandum 43], Policy on Records Requests and Contacts by Law Enforcement
*[https://nebraskalegislature.gov/laws/statutes.php?statute=84-712 Nebraska Revised Statute §84-712]
*[https://nebraskalegislature.gov/laws/statutes.php?statute=84-712 Nebraska Revised Statute §84-712]
*[https://www.ama-assn.org/practice-management/medicare-medicaid/physician-financial-transparency-reports-sunshine-act Sunshine Act]
*[https://www.ama-assn.org/practice-management/medicare-medicaid/physician-financial-transparency-reports-sunshine-act Sunshine Act]
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