The Compliance Committee, working in consultation with the Dean and CEO of the Medical Center, has appointed a Vice President for Audit and Compliance (the “Compliance Officer”) as the executive in charge of the continued development, implementation and operation of the Program:

Thomas Feuerstein
Vice President, Audit and Compliance, NYU Medical Center
Phone: (212) 404-4078; Fax: (212) 404-4095
Email: Thomas.Feuerstein@nyumc.org

The performance of the duties and responsibilities of the Compliance Officer shall be reviewed at least annually by the Audit and Compliance Committee.

Duties
The Compliance Officer and the Management Compliance Steering Committee shall prepare, and revise as necessary, a job description for the Compliance Officer. The Compliance Officer’s primary responsibilities set out in the job description shall include:

• Overseeing and monitoring the implementation of the Compliance Program;
• Reporting on a regular basis to the Board of Trustees, the CEO and Dean and the Management Compliance Steering Committee on the progress of implementation, and assisting the Board, the CEO and Dean and the Management Compliance Steering Committee in establishing methods to improve the Medical Center’s efficiency and quality of services, and to reduce the Medical Center’s vulnerability to fraud, abuse and waste;
• Periodically revising the Compliance Program as required by changes in the law and policies and procedures of government and private payor health plans;
• Developing, coordinating, and participating in an educational and training program that focuses on the elements of the Compliance Program, and seeks to ensure that all appropriate employees are knowledgeable of, and comply with, pertinent federal and state standards;
• Ensuring that independent contractors and agents who furnish medical services to the Medical Center are aware of the requirements of the Medical Center’s Compliance Program with respect to coding, billing and marketing, among other things;
• Coordinating personnel issues with the Director of Human Resources and the Medical Staff Office to ensure that the National Practitioner Data Bank and Cumulative Sanction Report have been checked with respect to all employees, medical staff and independent contractors, as applicable;
• Assisting in coordinating internal compliance review and monitoring activities, including annual or periodic reviews of departments and audits;
• After consultation with legal counsel, investigating and acting on matters related to compliance, including the flexibility to design and coordinate internal investigations (e.g., responding to reports of problems or suspected violations) and any resulting corrective action with all Medical Center departments, providers and sub-providers, agents and, if appropriate, independent contractors; and
• Developing policies and programs that encourage managers and employees to report suspected fraud and other improprieties without fear of retaliation.

Authority
The Compliance Officer shall have direct access to the CEO and the Chairman of the Audit and Compliance Committee of the Board of Trustees. The Compliance Officer shall have access to all documents and information relevant to compliance activities including but not limited to patient records, billing records, marketing records, and contracts and written arrangements or agreements with others. The Compliance Officer shall seek advice of the General Counsel and other legal counsel as may be retained by the General Counsel and may retain necessary consultants or experts.

Reports
The Compliance Officer shall report to the Board periodically, at least annually, on the status of compliance in the Medical Center. Such repports may be written or oral.