Name of Policy: Government Inquiries andInvestigations Involving UTMC

Policy Number: 3364-15-11

Approving Officer: President

Responsible Agent(s): Compliance Officer for Health AffairsDeputy General Counsel for Health AffairsChief Executive Officer of UTMCExecutive Vice President for ClinicalAffairs and Dean of the College ofMedicine and Life Sciences

Review date: September 25, 2017

Original Effective (late:May 1, 2013

Scope: University of Toledo Medical Center andHealth Science Campus

New policy proposal XMajor revision of existing policy

Minor/technical revision of existing policyReaffirlnation of existing policy

(A) Policy statement

The University of Toledo hospitals, clinics and its health care science campus and theirrespective employees, faculty and students (collectively referred to as "UTMC") will cooperatewith any authorized government inquiries and investigations. While doing so, the organizationthrough its authorized representatives will assert all protections and privileges afforded by lawduring any such inquiries and investigations.

(B) Purpose of policy

UTMC may receive inquiries for information or documents from the Federal and State agencies("Government Investigators") or such Govermnent Investigators may appear unannounced atUTMC's facilities or at the homes of present or former employees for purposes of interviewingand obtaining documents. Accordingly, this policy serves to establish a mechanism for theorderly response to government investigations to enable the organization to protect its interestwhile cooperating with any govermnent inquiries and investigations.

(C) Roles and Responsibilities

(1) Government Investigator Request for Interview

(a) If approached by a Government havestigator, the employee, staff or studentshould immediately:

(i) Obtain the name, title, agency, phone number and address of theInvestigator (business card should suffice);

(ii) Immediately notify the Chief Executive Officer of UTMC whoshould then notify the Compliance Officer and the Office of LegalAffairs, Health Science Campus or the Director of EnvironmentalHealth & Radiation Safety, Safety and Health if appropriate.

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(iii) Employees should direct the Investigator to wait until a representativearrives as directed by the Chief Executive Officer of UTMC.

(b) If a Government Investigator requests an interview with an employee, staff orstudent, such persons in most instances have the right to:

(i)(ii)(iii)(iv)

(v)(vi)(vii)

Participate in the interview;Refuse to answer any questions;Request that legal counsel be present before answering questions;Have the interview conducted during normal business hours at theorganization's offices;Stop the interview at any time;Take notes during the interview; andRetain an attorney to be present during the interview (costs may beborne by the individual).

(c) During the interview with a Government Investigator, employees, faculty andstudents should follow the guidelines:

(i)(ii)

(2)

(iii)(iv)

Tell the truth;Respond to all questions with statements of fact - do not speculateor guess or offer opinions. If the person does not recall somethingnor has no knowledge of what is being asked, the person shouldsay so.

Answer questions completely, accurately and concisely.Executive Director of UTMC, Compliance Officer or Legal counselmay be present at any interview.

Govermnent Search Wan'ant, Subpoena, Court Order or Authorized InvestigativeDemand

(i) Employees, faculty and students are not authorized to provide,send, copy or distribute UTMC's documents to GovernmentInvestigators without approval through the appropriateadministrative channels.

(ii) The Chief Executive Officer of UTMC or the Office of LegalAffairs will conduct disclosure of documents and other information. Thismay include payment and claims information, patient charts, remittanceadvice, con'espondence, transactional documents, policy and procedures or

other requested documents.

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(iii) Employees, faculty and students must not change, move, alter or

destroy any records, including paper, tape and electronic recordsthat are the subject of any government investigation.

(iv) The university's legal counsel may be present during allgovernment searches.

(v) Employees, faculty and students must not obstruct or interfere withany government searches.

(3) Scheduled surveys, site visits, OSHA visits, audits by third-party payors, tax audits andrequests for medical records are excluded from this policy.

(D) Definitions

Government Investigator means any employee of the government who seeks information fromthe University that is investigative or criminal in nature.

Federal or State Agency means a variety of agencies may be involved in investigating theuniversity, including: Office of Inspector General ("OIG"), Centers for Medicare and MedicaidServices ("CMS"), Federal Bureau of Investigations, ("FBI"), Department of Defense, UnitedStates Attorney General's Office, United States Department of Justice ("DOJ"), Food and DrugAdministration ("FDA"), Centers for Medicare and Medicaid ("CMS") or Ohio Department ofHealth for CMS or itself ("ODH") and state Medicaid agencies.

(E) Procedure/References

UT's Institutional Compliance Webpage:http://www.utÿedÿ.edu/ÿces/cÿmpÿiance/pdf/ÿvernlnentinvestiÿatiÿnschecklistIbrlegalcÿunselandcomplianceofficer.pdf

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Approved by:

Sharon L. Gaber, Ph.D.

President

Policies Superseded by This Policy:

* Previous 3364-15-11, effecth,e date Moo, 1,2013

Initial Effective Date.' November 18, 2008Review/Revision Date: September 25, 2017Next review date: September 25, 2020

September 25, 2017Date

Review/Revision Completed by.

Senior Leadership Team