ACOE_Self-Study

All clinical faculty and staff as well as interns and residents are required to take an on-line business integrity course, including a test, annually. A primary focus of this program is the appropriate billing and coding of insurance claims. For the period of January 2017-December 2017, the CBI Officer conducted audits which can be found in Appendix VIII-11 . Education and training were provided to faculty as a result of this audit and additional audits continue throughout the year to ensure compliance is maintained, training topics reflect pertinent areas of potential concern and that deficiencies noted have been addressed. The Patient’s Bill of Rights is posted in the patient reception area of each of the four clinical services and included in the UEC Welcome Brochure that is given to every new patient at their first appointment and annually thereafter ( Appendix VIII-12 ). It is also included in the University Eye Center’s Policy and Procedure Manual (P-1: Patient Bill of Rights; Appendix VIII-6 ) that is accessible by faculty, staff and students. Each patient signs a general consent document (C-10: Consent Form, General of the UEC Policy and Procedure Manual) . Additional written informed consent may be obtained for secondary and tertiary procedures (C-11: Consent, Informed of the UEC Policy and Procedure Manual ). In addition, payment and insurance policies are also delineated in educational materials available on the clinical floors and on our website. This information assists patients to understand their responsibilities with regard to insurance coverage issues. 8.2.7 The clinic must have written procedures for receiving and resolving patient complaints, grievances and appeals. The University Eye Center’s (UEC) policy and procedure on Compliments and Complaints addresses three specific areas: 1. Resolution of Verbal Complaints 2. Responding to Patient Satisfaction Surveys 3. Responding to Written Patient Compliments and Complaints The aforementioned policy and procedure can be found in the UEC Policy and Procedure Manual ( Appendix VIII-6 ) under C-9: Compliments and Complaints. Copies of all compliments and complaints are filed in the Office of Clinical Administration and are available for review to applicable regulatory and/or accreditation agencies and their representatives. 8.2.6 The clinic must publish or post policies and procedures on the patient’s rights and responsibilities. 8.2.8 Clinic programs must utilize established procedures to address risk management such as liability, security and safety. Clinical faculty (including on-site residents) and staff, as employees of the State of New York, are covered under section 17 of the NYS Public Officers Law (Policy M-3: Malpractice/Professional Liability of the UEC Policy and Procedures Manual ; Appendix VIII-6 ). Under this statute, employees are covered for their acts or omissions and are both indemnified and defended by the

101