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Required Role-based Training

The Office of Compliance & Audit Services (OCAS) is responsible for administering the compliance training program. It is the responsibility of Downstate Health Sciences University (Downstate) workforce members to comply with training requirements. Workforce members include employees of New York State, University Physicians of Brooklyn (UPB) & the Research Foundation (RF), as well as affiliated physicians, allied health professionals, residents, interns, fellows, students, trainees, volunteers, consultants, contractors and subcontractors.

The following is an outline of the web- based Compliance training topics offered via Downstate's learning management platform - Healthstream.  Courses are assigned based on the job or role of the workforce member. Please contact the Office of Compliance & Audit Services at Compliance@downstate.edu for more information about the subjects below.

Training Topics

  • Anti-Kickback Statute

Basics of the Anti-Kickback Statute, including its prohibition, essential components, and concepts such as referral, remuneration, safe harbors, reporting, and penalties.

  • Attending & Non-Physician Provider (NPP) Split Shared and Incident To Services

The scenarios under which Split Shared and Incident To Services may apply and the appropriate documentation that must be included in the medical record.

  • Compliance Program & Deficit Reduction Act 

The purpose and the basic makeup of Downstate's compliance program, including the seven essential elements on which it is based. High-level review of common compliance risk areas, fraude, waste and abuse prevention and explains the importance of an employee’s duty to report issues and concerns.  Intros the learner to the basics of the False Claims Act, including its prohibition, key components, and concepts such as the definition and examples of a false claim, fraud, reporting, penalties, the qui tam or whistleblower provision, and protection from retaliation. 

  • Conflicts of Interest

Describes the meaning of conflict of interest, how to identify a conflict of interest, and ways in which to manage it.

  • Documentation in Medical Records

Introduces the learner to the fundamental elements of effective documentation as well as examples of common documentation failures.

  • EMTALA

Basics of EMTALA: the obligations of Medicare - participating hospitals with a dedicated Emergency Department when an individual presents and the different ways an individual may present.  The EMTALA definition of hopsital property with respect to an individual presenting for a medical exam or treatment, the importance of a medical screening exam and stabilizing treatment regardless of an individual's ability to pay.  

  • Ethics in Healthcare

Defines ethics and reviews the principles that can guide healthcare workers in their daily work; including strategies for responding to ethical dilemmas.

  • Evaluation & Management Coding

Describes how and when CPT codes apply to services rendered by a physician or other healthcare professional in the evaluaton or management of a patient's health.

  • HIPAA

Provides an introduction to the HIPAA Privacy Rule, HIPAA Security Rule, breach notification requirements, applicable violations and penalties that may apply for non-compliance, and the patient rights afforded by law.  

  • Medical Identity Theft

Patient-related and practitioner-related medical identity theft, how it occurs, the risks it presents, and how it might be avoided. Informs the learner of tax fraud resulting from identity theft, a risk for both patients and practitioners when their identity is stolen.

  • Stark Law

Basics of the Stark Law, including its prohibition, essential components, and concepts such as designated health services, exceptions, fair market value, reporting, and penalties.

  • Research Misconduct

Defines research misconduct and describes the eithical and legal obligations for researchers, and laboratory staff in the conduct of research.