Corporate Compliance Program - Wheaton Franciscan Healthcare - Ascension Wisconsin

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Corporate Compliance Program

Ascension Wisconsin's Corporate Compliance Program helps our organization, its associates and contractors abide by all applicable laws, regulations and policies. The program is consistent with our Standards of Conduct. Our goal is to do business with individuals who abide by similar principles.

We value the vital contribution our vendor representatives make to the quality care we provide. We ask that you become familiar with a few of our most relevant compliance principles to better enable you, your company and our organization to conduct business in a mutually satisfactory manner.

If you have any questions about our compliance program, please contact Sarah Kleaveland Kupczak, Corporate Responsibility Officer, at 414-465-3508.


We hope that if you would like to acknowledge the mission of our organization that you contact our foundations to learn how you may help.

Ascension Wisconsin requires all associates, including physicians, to remain free from any actual or potential conflicts of interests, including even the appearance of a conflict. Gifts given to associates may create a potential conflict of interest.

In an effort to help our associates remain free from conflicts, we request that our vendor representatives refrain from making any offerings to our associates that might violate our policies.

Our associates may not:

  • Solicit gifts from vendor representatives other than for our foundations
  • Accept a gift during the course of negotiations
  • Accept cash or cash equivalents (such as gift certificates)

If you have any questions about gifts, please contact our Corporate Responsibility Officer at 414-465-3508.

Expectations of Vendor Representatives

When working in conjunction with our organization, vendor representatives are expected to:

  • Operate in compliance with all applicable legal requirements.
  • Never pursue any business opportunity or relationships that would compromise our ethical standards or violate a law, regulation or corporate policy
  • Respect the rights and dignity of our employees and patients
  • Protect the physical and intellectual property of Ascension Wisconsin organizations and any organizational assets against loss, theft, destruction, misappropriation, and misuse
  • Not use for personal gain any information obtained as a vendor representative, including confidential or proprietary information
  • Not offer or accept any bribes, kickbacks or inducements in connection with performing duties for any of our organizations
  • Maintain the confidentially of patient information
  • Report a suspected violation of any law, regulation or policy.

For Vendors Who Are Our HIPAA Business Associates

Please be aware that CMS issued a final rule modifying the HIPAA Privacy and Security rules as required by the Health Information Technology for Economic and Clinical Health Act (HITECH). Under the HIPAA rules, as modified, business associate will now be directly liable under HIPAA for compliance with the HIPAA security rule and certain provisions of the HIPAA privacy rule such as:

  • Failure to meet the minimum necessary standard
  • Inappropriate use or disclosure of protected health information
  • These requirements will now flow to our business associate’s subcontractors. We encourage all of our vendors who are business associates to become familiar with the modified HIPAA rules and reach out to your compliance professional and/or your legal counsel with questions that you may have.

Reporting Suspected Violations

The corporate compliance program fosters an environment in which employees and affiliates, including vendor representatives are encouraged to report concerns about business practices. A toll-free Compliance Line is available as a reporting mechanism whereby employees, medical staff, vendor representatives, and others associated with Ascension Wisconsin can report, without fear or retaliation, suspected violations or issues of non-compliance. Callers may remain anonymous, if they so desire.

To report a violation, please call the Compliance Line at 1-800-707-2198.

Vendor Obligations Related to Medicare Managed Care

The Centers for Medicare & Medicaid Services ("CMS") requires Medicare Advantage Organizations and Part D Plan Sponsors (collectively, "Sponsors") to enter into an agreement with CMS in order to offer a Medicare Advantage or Part D benefit plan. As part of this agreement with CMS and pursuant to CMS regulations, the Sponsor is required to ensure that its first tier, downstream and related entities ("FDRs") meet certain requirements of the Medicare program related to compliance. These requirements are known as the "Compliance Program Requirements" and are passed down to FDRs by virtue of their agreements with Sponsors or each other, as applicable.

Ascension Wisconsin, to the extent that it is an FDR, complies with regulations found at 42 C.F.R. §§ 422.503(b)(4)(vi) and 423.504(b)(4)(vi), Chapter 9 of the Medicare Prescription Drug Benefit Manual, and Chapter 21 of the Medicare Managed Care Manual. Ascension Wisconsin requires that its employees and Downstream Entities receive general compliance training and specific training regarding fraud, waste and abuse ("FWA"). Ascension Wisconsin also confirms that it and its Downstream Entities have structures and procedures in place to fulfill the requirements of an effective compliance program. Please review our policy related to compliance program requirements and Medicare Managed Care.

As part of our contract process, if it is determined that a vendor meets the requirements of a downstream entity as set forth in 42 CFR § 422.500, the vendor will be required to:

(a) comply with the terms and conditions set forth in Ascension Health’s Medicare Advantage Regulatory Addendum.
(b) attest that it has met all of the requirements set forth in the Medicare Compliance Program Requirements Attestation for Downstream Entities for the current calendar year and agrees to execute a similar attestation for all future calendar years during which it meets the definition of a downstream entity.
(c) represents and warrants that it does not use any Offshore Entities (as defined in the Medicare Compliance Program Requirements Attestation for Downstream Entities) to perform any services related to the Medicare Advantage program or Medicare Part D program and will not use any Offshore Entities to provide such services without Ascension Wisconsin’s prior written consent. In the event Ascension Wisconsin consents to the use of an Offshore Entity, the vendor shall execute the Attestation Concerning the use of Offshore Contractors.