Standards of Conduct — General Standards
Numerous Federal and State laws and regulations define and establish obligations for the health care industry with which the Company and each of its Employees and Contractors must comply.
Set forth below are several fundamental standards of conduct applicable to all Employees and Contractors under this Plan. The Company not only expects, but requires, that each Employee and Contractor abide by each of these fundamental standards of conduct in conducting his or her employment and/or other relationship with the Company.
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No False Billing or other False Statements
Examples of prohibited conduct include misrepresenting services which were rendered; billing for items or services not provided; billing for medically unnecessary services; billing for items or services not ordered; resubmission of denied claims with different and incorrect information in an attempt to be reimbursed; altering medical records; manipulating a patient’s diagnosis in order to receive payment; failing to maintain medical necessity documentation; falsely certifying that services were medically necessary; utilizing a code to bill for a higher level of service or procedure, causing an increase in the reimbursement rate, when the medical record reflects that a lower level of service or good was actually provided to the patient (often referred to as “up-coding”); billing for services not actually rendered. In addition to billing related activity, making false statements to governmental agencies about the Company’s compliance with any federal or state rules (e.g. making false statements concerning the condition or operation of the Company facilities for which certification is required) is prohibited.
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No Fraudulent or Unnecessary Claims for Payment
Neither the Company nor any of its Employees or Contractors shall knowingly present a claim to any health care program or health care benefit program for an item or service the person knows or should have known, was not provided, was fraudulent, or was not medically necessary. Neither the Company nor any of its Employees or Contractors shall offer to transfer, or transfer, any remuneration to a beneficiary under a health care program, that the person knows or should know is likely to influence the beneficiary to order or receive any item or service from a particular provider, practitioner, or supplier, for which payment may be made, in whole or in part, under a health care program. Remuneration includes the waiver of coinsurance and deductible amounts except as otherwise provided, and transfers of goods or services for free or for less than fair market value.
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Retention of Records
Documentation is the “heart and soul” of any Compliance Plan, including this Plan. The Compliance Officer shall ensure that adequate and necessary records with respect to the operation of this Plan are maintained for a minimum of seven (7) years.
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Cooperation in All Investigations and Audits; Special Fraud Alerts
The Company is committed to full compliance with all Federal and State laws, and shall cooperate, as shall all Employees and Contractors, with all reasonable demands made in any government investigation of the Company and/or its Employees and Contractors. However, the Company deems it essential that its legal rights and those of its Employees and Contractors are adequately protected. Therefore, if any Employee or Contractor receives a subpoena, inquiry or other legal document regarding the Company’s business, whether at home or in the workplace, from any governmental agency, the Employee or Contractor shall first notify his/her supervisor who then should alert the Company Counsel as soon as possible. If any Employee or Contractor is contacted at home by a governmental agency concerning the Company business, the individual is instructed to ask the government representative to return later, and then immediately shall contact his or her supervisor who then shall alert the Company’s Corporate Counsel as soon as possible to discuss the matter.
Furthermore, all Employees and Contractors shall cooperate in good faith with all internal or other external investigations, audits, etc., regarding the matters set forth in this Plan or otherwise related to such person’s employment by or relationship with the Company. In addition, the Compliance Officer or the Company’s Corporate Counsel shall carefully consider any OIG Special Fraud Alerts that relate to health care providers to which the Company offers services. Any failure to cease and correct any conduct applicable to the Company criticized in a Special Fraud Alert shall be subject to enforcement and penalties as described in Section VII below, and the Company shall take reasonable actions to prevent such conduct from recurring in the future.
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Legal Review of All Contracts with Physicians and Other Referral Sources
Every contract or proposed contract between the Company and any physician, medical group, hospital, clinic or other health care provider, and any agreement pursuant to which the Company shall manage the practice or purchase the assets of any such provider shall be reviewed and approved by the Company’s Corporate Counsel. Any Company Employee or Contractor that receives any such contract shall forward it immediately to Company Counsel. Counsel shall then review all such contracts for compliance with all applicable fraud and abuse laws and regulations and other concerns addressed in this Plan.
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Adherence to Plan is a Critical Component of Employee Evaluations
The promotion of, and adherence to, the elements of this Plan shall be a factor in evaluating the performance of all Employees. All Company managers and supervisors shall discuss with all supervised Employees and Contractors the compliance policies and other legal requirements applicable to their functions, inform all supervised Employees and Contractors that strict compliance with this Plan is a condition to their employment and/or other relationship with the Company, and that the Company will take disciplinary action (including termination) for violation of the policies and procedures embodied in this Plan. Furthermore, the Company managers and supervisors who fail to instruct adequately their subordinates or who fail to detect noncompliance with this Plan (where reasonable diligence on the part of the manager or supervisor would have led to the discovery of any problems or violations) may, themselves, be subject to sanctions (including termination).
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No Kickbacks
Neither the Company nor any of its Employees or Contractors shall knowingly or willfully solicit, offer to pay, pay, or receive any remuneration, either directly or indirectly, overtly or covertly, in cash or in kind, in return for:
- Referring an individual to a person for the furnishing, or arranging for the furnishing, of any item or service for which payment may be made, in whole or in part, under any health care program; or
- Purchasing, leasing, ordering, or arranging for, or recommending the purchasing, leasing, or ordering of any good, facility, service or item for which payment may be made in whole or in part, under any health care program.
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Coordination with Physicians, Other Providers
All physicians and other providers with whom the Company contracts, or otherwise does business with, shall be expected to comply with its restrictions and provisions, to the extent applicable to such physicians and/or other providers. All Employees and Contractors hereby are notified of this requirement and shall be required to conduct business with such physicians and other providers accordingly. The Company’s Compliance Officer shall be responsible for ensuring that all physicians and other providers are given copies of this Plan and that they comply with its restrictions and provisions in conducting business with the Company, to the extent applicable.
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Highest Quality Health Data
The Company is committed to obtaining, recording and submitting the highest quality health data in all aspects of its operations, and shall use all reasonable means available to it to ensure that all health data is accurate, valid, reliable and submitted in a timely manner. As part of this commitment, the Company has established a comprehensive set of policies that delineate the Company’s billing and coding procedures. These policies include education and training requirements for billing and coding personnel; the risk areas for fraud, waste and abuse; the integrity of the Company’s information systems; the methodology for resolving ambiguities in physicians’ and other providers’ documentation; the procedures for identifying and reporting credit balances; the procedures to ensure that duplicate bills are not submitted in an attempt to gain duplicate payment; and additional procedures related to the specific risk areas discussed below. These policies, as updated from time to time, will be provided to all relevant Employees and Contractors, who shall be required to comply with them at all times. Employees and Contractors will be subject to periodic and random “spot checks” of billing and coding methodologies and procedures and will be provided with additional training and education in this area to that the Company can continue to provide the highest quality health data to providers and payors.