Office of Compliance Programs
Compliance Training for LSUHSC-NO Students
Revised: November 7, 2017
- Introduction to the LSUHSC-NO Compliance Program
- Improve Compliance Awareness
- Debarred and Sanctioned individuals
- Chancellor's Memorandum (CM)-56 - Student Responsibilities and
- Use of State Assets
What is a Compliance Program?
A compliance program is a voluntary undertaking by a health care
entity (like LSUHSC-NO) to ensure compliance with all federal and state
laws and regulations. The Patient Protection and Affordable Care Act
(Obamacare) requires that all healthcare providers that bill Medicare
and Medicaid have an effective compliance program in place.
Laws, Regulations and Policies That Affect LSUHSC-NO
LSUHSC-NO is subject to numerous laws, regulations and policies.
Some examples include but are not limited to:
- Federal Laws and Regulations
- Clery Act
- State Laws and Regulations
- Public Records Law
- Ethics Code
- Civil Service Rules
- LSU Regulations and Policies
- Bylaws and Regulations
- Permanent Memoranda (PMs)
- LSUHSC-NO Policies
- Chancellor's Memoranda (CMs)
- Department Policies
History of the LSUHSC-NO Compliance Program
- December 1998 - A resolution is passed by the LSU Board of
Supervisors requiring all LSU medical campuses to have compliance
programs in place. Individual LSUHSC-NO schools name compliance
- January 2001 - A report by an ad hoc committee appointed by the
establishment of central compliance office. The Office of Compliance
Programs (OCP) was created.
- Current - OCP reports to the Chancellor.
Compliance Program Elements
The Department of Health and Human Services, Office of Inspector
General, in its Compliance Program
Guidance for Recipients of PHS Research Awards, lists the following
elements of an effective compliance program:
- Implementing written policies and
procedures including a Code of Conduct.
- Designating a compliance officer to oversee the day-to-day
operations of the compliance program.
- Conducting effective training and
- Developing effective lines of
communication including one or more methods of reporting complaints
- Conducting internal monitoring
- Enforcing standards through well publicized
- Responding promptly to detected
problems and undertaking corrective
- Clearly defining roles and responsibilities
and assigning oversight responsibility.
- Lori Ferro, CIA, CRMA, CISA, CRISC, Compliance Internal Auditor
- Roy Clay, Compliance Officer/Privacy Officer
- Kelly Guth, CHC, Compliance Educator
What is YOUR Role in Compliance?
In order for a compliance program to be successful, everyone must take responsibility
for ensuring that all university activities comply with applicable
laws, regulations and policies. Some of the things you can do
personally to ensure the university's compliance are:
- Familiarize yourself with the University’s Code of Conduct and
all policies and procedures that apply to your duties. Note: The
easiest way to do this is by completing your compliance training.
- Complete all recurring compliance training within 30 days of
- Report any suspected instance of non-compliance to your
instructor or the
Office of Compliance Programs.
Mandatory Compliance Training
As part of your enrollment at LSUHSC-NO, you are required to
complete compliance training in accordance with Federal and State laws
and regulations within 90 days after you start your program, unless
your school has a stricter requirement. Additional
information about mandatory compliance training is available here.
The training modules are automatically assigned to you based on your
current academic program through our web based training facility-KDS
(Knowledge Delivery system).
You will receive an email with an explanation of the mandatory
student training requirements as well as instructions on how to satisfy
your student training obligations once you are set up in KDS.
You will be prompted by KDS whenever any of your training expires,
or if any new training has been added to the system.
- Note that most compliance training topics are required to be
repeated annually. There are some, like the Quarterly Safety Meeting
that must be done every three months and others that only have to be
repeated every few years. The period is set by either regulation, audit
finding or demonstrated effectiveness.
For suspected privacy breaches, employee wrongdoing, noncompliance with any
federal or state laws, or University policy you can:
All reports will be kept in the strictest
confidence in accordance with Federal and State laws and LSUHSC-NO
whistleblower policy. (CM-53 Section E)
Other agencies provide hotlines to report fraud waste and abuse in
their areas of jurisdiction. A complete list can be found here.
Consequences of Non-Compliance
The consequences are not limited to those who are not compliant.
Non-compliance affects everyone at LSUHSC-NO.
- Fines and penalties (including imprisonment)
- Additional oversight/monitoring by the government
- Potential reduction or elimination of Federal funding
- Adverse publicity and loss of confidence of the community we serve
- Suspension, debarment, and exclusion of individuals or the
institution as a whole
Examples of Settlements Associated with Noncompliance
- In 2012, Tenet Healthcare agreed to pay $42.8 million to settle
allegations it overcharged Medicare from 2005 to 2007 by moving
patients from ordinary hospitals into more costly facilities intended
for those who need intensive follow-up treatment after undergoing
- In 2015, the Medical Center of Central Georgia paid the federal
government $20 million to settle allegations it billed Medicare for
more expensive inpatient services instead of the less costly outpatient
observation services it provided.
- In 2015, medical device manufacturer, Medtronics, agreed to pay
the U.S. government $4.4 million to settle a qui tam suit for violating
the Trade Agreements Act.
Debarment And Sanctioned Individuals
Prevents companies and individuals who have violated Federal laws
and regulations from participation in government contracts,
subcontractors, loans, grants, and other assistance programs.
Protects LSUHSC-NO from doing business with an individual/company
that pose a business risk.
A debarment of an individual or entity will result in no federally
funded payments for anything an excluded person or entity furnishes,
orders, or prescribes regardless of who submits the claims.
Excluded entities or individuals must apply for reinstatement before
they can participate in any Federal programs.
Actions That Lead To Debarment/Exclusion Include:
- Claims for excessive charges or services
- Obstruction of an investigation
- Failure to disclose required information
- Failure to take corrective action
- Loss or Expiration of License
- Failure to Repay Student Loans
- For a complete list of excluded individuals/entities, go to the Office of the Inspector
CM-56 – Students Responsibilities and Rights
- Comply with all policies/procedures, rules and regulations and
other information published by the Health Sciences Center.
Abide by all federal, state and local laws.
- Expected to:
the Office of Student Affairs of your respective school in the event
you are debarred from participating in any federal or state programs or
- Exhibit the highest standard of personal, academic professional
and ethical behavior.
- Treat everyone with dignity and respect.
- Abide by the Code of Conduct that applies to your specific
professional discipline as well as the university's policy.
Any student who violates this policy when
involved in any
school or school related activity/function, whether on or off campus,
will be subject to disciplinary action.
- Students have the right to a fair and impartial hearing if
accused of misconduct, or violating any federal, state, laws and
regulations, or university policies and procedures.
- Students have the right to file a complaint for alleged
mistreatment or abuse by faculty, residents, staff, fellow students,
patients, contractors, or volunteers. These issues should be addressed
to the appropriate Student Affairs Office of the school in which you
are currently enrolled. More information can be found in the Academic
Donation of State Assets
The funds, credit, property, or things of value of the State or of
any political subdivision shall not be loaned, pledged, or donated to
or for any person, association, or corporation, public or private. Some Exceptions include:
- Health care for the indigent
- Cooperative Endeavors
If you feel your activity may qualify for an exception, please check
with the Compliance Office before proceeding.
Relevant University Policies & LSU Publications
If you have
any questions, please contact the Office of