Compliance & Ethics Corporate Compliance Program It is CoxHealth’s policy to conduct all of its business and other practices in compliance with all applicable laws and regulations, and to act with Integrity, Respect and Compassion in all of our business dealings. CoxHealth, and its employees, volunteers, medical staff members and Board of Directors have a reputation in the community of being a quality organization; operating in an honest manner; and offering both respect and compassion to those we serve. CoxHealth will protect this reputation and our integrity through the enforcement of its policies and procedures.The purposes of the CoxHealth (“Cox”) Corporate Compliance Program are to: Describe the policies of CoxHealth with respect to certain legal and ethical conductEstablish a mechanism to detect, correct and prevent errors that result in violations of the laws and regulations governing health care and violations of CoxHealth policiesEncourage the members of CoxHealth (employees, volunteers, medical staff, members of the Board of Directors and vendors who do business with Cox) to report any incidents that they, in good faith, believe: 1) could lead to fraud, waste and abuse against federal and state health care programs, 2) could lead to CoxHealth being in violation of the conditions of participation for inclusion in health care programs funded by the state and federal government, 3) could expose CoxHealth (or its members) to penalties for violation(s) of any federal or state health care programs, or are violations of CoxHealth policiesPromote self-auditing and self-policing of our practicesPromote voluntary disclosure of violations of laws and regulations Establish, monitor and enforce the Code of Conduct of CoxHealth The Corporate Compliance Program encompasses not only Lester E. Cox Medical Centers, d/b/a CoxHealth, but the following corporate entities of which Lester E. Cox Medical Centers is the sole member or shareholder. Each entity shall have a designated compliance officer and their own written Compliance Plan/Program. Those entities are: Cox HPS of the Ozarks, Inc.; Cox Health Systems Insurance Company, Inc.; Cox Health Systems HMO, Inc.; Cox HealthPlans, L.L.C.; Cox Monett Hospital, Inc.; CoxHealth Foundation; Medical Developments, Inc., d/b/a Convenient Care Pharmacy; Lester E. Cox Medical Centers encompasses many different locations (Cox South, Cox Walnut Lawn and Cox North), as well as departments such as Regional Services, Ferrell Duncan Clinic, Home Support, and Ozarks Dialysis Services. This program applies not only to the employees of CoxHealth, but also its Volunteers, Students, Medical Staff, Board of Directors and Vendors doing business with CoxHealth, all referred to as members of CoxHealth. Any reference to “members of CoxHealth” should be considered to include each of these groups. CoxHealth is committed to doing the RIGHT THING. Our success and future depend on it. Corporate Compliance Program View All Corporate Compliance Program Elements The CoxHealth Board of Directors directed the development and implementation of an effective Corporate Compliance Program which includes the following elements, many of which are recommended by the Office of Inspector General in its Compliance Program Guidance for Hospitals and the Supplemental Guidance issued in January 2005. 1. Policies and Procedures. The policies and procedures which encompass the Corporate Compliance Program at CoxHealth include: a. Corporate Compliance Program, policy GO. 4. A copy of the Corporate Compliance Program is distributed to all members of CoxHealth. b. Code of Conduct[LINK], policy GO. 5. A copy of the Code of Conduct is distributed to all members of CoxHealth. c. Prohibition of False Claims [LINK], GO.6. A copy of the Prohibition of False Claims is distributed to all members of CoxHealth. d. Compliance with the Stark and Anti-Kickback Physician Referral Laws, GO. 7. 2. Designation of a Compliance Officer and Compliance Committee.3. Education and Training Program Development and Implementation. 4. Creation of a Method of Reporting that is free from retaliation. The Corporate Integrity Department will make every effort to ensure that those reporting concerns are protected from retaliation and that their comments are kept confidential. To further that commitment, an anonymous Hotline has been established. 5. Sanctions or Disciplinary Action Enforcement. 6. Ongoing Audit and Monitoring of Activities.7. A program for Investigating, Resolving and Refunding, where appropriate. Members of CoxHealth are not expected to have expert knowledge of all legal and regulatory requirements that may apply to their work. However, it is expected that members of CoxHealth will be sensitive to legal and ethical issues. The goal of this Plan is to give them the foundation to know enough to ask questions if they are uncertain about any given situation, and whom to ask. Each employee shall ask questions before engaging in any conduct which is causing concern to them. Corporate Compliance Officer and Compliance Committees The Corporate Compliance Officer for CoxHealth, is designated as Betty Breshears, Vice President of Corporate Integrity. The Corporate Integrity Department is located on the 4th Floor of the Hulston Cancer Center, Suite 450. The mailing address is: 3801 S. National, Springfield, MO 65807. The main phone number is: 417-269-7655. The Corporate Compliance Officer is responsible for the coordination of the Corporate Compliance Program of CoxHealth and its affiliated entities. There are designated Compliance Managers/Officers for each affiliate of CoxHealth. To ascertain who these individuals are, please call the Corporate Integrity Department at 417-269-7655. The following Committees have been designated to assist with the compliance efforts at CoxHealth; the prevention and detection of possible fraud and abuse; and the implementation of the Program. Board of Directors, Compliance Committee Board of Directors, Compliance Committee. The Board of Directors has a designated Compliance Committee which meets bi-monthly, or as needed, to review the Compliance Program. The Corporate Compliance Officer has a responsibility to report activities and concerns to this committee. The Corporate Compliance Committee shall ensure that CoxHealth maintains a comprehensive program to (a) comply with all laws and regulations governing its business and activities, and (b) conduct its affairs in an ethical and responsible manner. The Committee shall receive a thorough report from the Internal Auditor at least annually, together with such other information as the Committee from time to time requires. The Committee shall inform the Board of the reports it receives from the Compliance Officer regarding the activities of the Compliance Program. Executive Compliance Committee Executive Compliance Committee. This Committee meets monthly and is made up of the President and CEO, the Senior Vice President and CFO, the Vice President of Corporate Communications, General Counsel, Corporate Compliance Officer, Vice President/Chief Medical Officer, Chairman of the JOC/Chief Integrated Physicians and Senior Vice President/Chief Hospital Officer, Vice President Chief Clinical Officer, Vice President Chief Nursing Officer, Vice President Regional Services, Vice President Ferrell-Duncan Clinic, Vice President Chief Business Development, Assistant Compliance Officer. Their responsibility is to provide guidance, advice and oversight to the Corporate Compliance Program. Billing Compliance Committee Billing Compliance Committee. This Committee meets monthly and is made up of representatives from Internal Audit, Health Information Management, Patient Financial Services, Regional Service Billing, Ferrell Duncan Clinic Business Office, SNI Billing, Regional Services, Quality Resource Department, Health Information Management, Audit and Compliance, and the Corporate Integrity Department and other individuals as deemed appropriate. Their responsibility is to evaluate and identify possible areas of concern or risk of inappropriate billing practices, review new regulations where applicable, monitor government audit activity and provide guidance to the Corporate Compliance Officer as appropriate. Home Support/HPS Compliance Committee This Committee meets quarterly and includes representatives from the Billing Department, Director of Home Support, President of HPS,Compliance Manager/Officer, and other individuals as deemed appropriate. The Committee reviews compliance issues specific to the provision of home services through HPS and Home Support and evaluates changes in guidance and regulations governing the provision of these services. Monett Compliance Committee Monett Compliance Committee. This Committee meets quarterly and includes (but is not limited to) representatives from the following CoxHealth Departments: Patient Financial Services, Audit and Compliance and Corporate Integrity; as well as representatives from the following Cox Monett Departments/areas: Billing, Medical Records, Medical Staff Credentialing/Utilization Review, the Compliance Manager, the Administrator/CEO, the CFO and the Chief Nursing Officer. The Committee reviews compliance issues specific to the provision of services through Cox Monett Hospital and evaluates changes in guidance and regulations governing the provision of these services. Contract Compliance Committee Contract Compliance Committee. This committee includes representatives from the Legal Department and Corporate Integrity. Others may be included on an as-needed basis. The Committee has responsibility to review contracts with any actual or potential source of health care business or referrals to Cox; ensure services rendered by physicians are detailed in appropriate contracts; and that the provisions of the Contract Manual are followed. HIPAA Compliance Committee This committee includes representatives from a broad range of disciplines, including Information Technology, Health Information Management, Nursing, Pharmacy, Radiology, Laboratory, the Privacy Officer for CoxHealth, the Security Officer for CoxHealth and the Privacy/Security Officer for the affiliated entities (with the exception of Cox HealthPlans). The purpose of the committee is to provide guidance to the CoxHealth Compliance Officer and others responsible for ensuring compliance with the HIPAA regulations and protecting PHI and personal information. Oxford Compliance Committee This committee includes representatives from the management team at Oxford, including the President and CEO, departmental and divisional vice presidents and the CoxHealth Compliance Manager. The purpose of the committee is to provide guidance to the CoxHealth Compliance Officer and others responsible for ensuring compliance with the various federal regulations and guidelines governing home health care. Financial Compliance Financial Compliance. Financial Compliance is generally handled by the Internal Auditor. Information is shared on a regular basis with the Corporate Compliance Officer, as needed. Other An additional asset to the Corporate Compliance Program and Committee structure is the Audit and Compliance Department. The Audit and Compliance Department provides ongoing auditing and monitoring of a variety of billing functions at CoxHealth; including the Regional Services clinics, Springfield Neurological and Ferrell Duncan Clinic. Compliance Officer's Responsibility and Authority: The CoxHealth Corporate Compliance Officer has the responsibility to: Provide overall leadership for the Corporate Compliance Program. Ensure the evaluation and investigation of each and every issue brought forward without prejudice and in a timely manner. Ensure that either appropriate action is taken or make appropriate recommendations to the Chief Executive Officer, or the Executive Compliance Committee, or the Compliance Committee of the Board of Directors of CoxHealth. Review/revise/formulate policies and procedures as necessary. Remain current on federal, state and local regulations affecting the provision of health care and the services provided by CoxHealth and its affiliates. Ensure compliance with all guidelines regarding research involving human subjects. Monitor the development of education and training processes and their implementation. Initiate and supervise internal and external audits to evaluate compliance. Ensure there are monitoring processes and practices to identify possible areas of concern regarding compliance. Periodically (at least quarterly) report on the status of the Compliance Program and its activities to the Compliance Committee of the Board of Directors. The Compliance Officer may report concerns directly to the Board of Directors as necessary. The Corporate Compliance Officer shall have ultimate administrative authority for implementing, monitoring and enforcing the Program. Additionally, the Corporate Compliance Officer shall have the authority to coordinate with legal counsel, and or outside contractors (i.e., auditors) as he/she deems necessary. Education and Training Members of CoxHealth will receive a copy of this Program, the Code of Conduct and the Prohibition of False Claims policy. Members of CoxHealth will be educated as to their content and any substantive changes that may be made. The Policies outlining the Corporate Compliance Program at CoxHealth are available through the Corporate Integrity Department. Orientation of all new employees, volunteers, medical staff members and Board members within CoxHealth will include an introduction to the Program. Copies of the policies will be distributed to the new medical staff members, board members, volunteers and vendors as appropriate. All employees will receive Fraud, Waste and Abuse compliance training upon hire and annually each year thereafter. Further, all employees will be provided with general information concerning compliance issues. Some employees will receive additional specialized training appropriate to the areas in which they work, for example, laboratory, home care and billing. Education will be provided in a variety of ways, including but not limited to orientation, written materials, newsletters, staff meetings and through formal education. The Program will be reaffirmed at each annual performance review. Additional/ongoing training will be provided periodically as appropriate for the member of CoxHealth's area of interaction with the Board. Failure to participate in compliance education and re-education will result in disciplinary action, up to and including termination. All compliance education will be documented in the Corporate Integrity Department. Method of Reporting Members of CoxHealth employees shall report any possible information regarding a known or suspected violation of any applicable laws, regulations, ethical standards or CoxHealth policy as soon as they become aware of such. If an employee has difficulty interpreting a procedure or law, he or she should consult with his or her supervisor todetermine whether consultation with the Corporate Compliance Officer is appropriate. The employee may report to any one of the following: Immediate Supervisor Vice President Entity Compliance Manager CoxHealth Corporate Compliance Officer Betty Breshears, Vice President of Corporate Integrity Phone: 417-269-8806Email: Betty.Breshears@coxhealth.comMailing Address: 3801 S. National, Springfield, MO 65807 Office Address: 3850 S. National, Suite 450 (Hulston Cancer Center) Corporate Counsel CoxHealth's Chief Executive Officer Compliance Hotline (may be reported anonymously)Phone: 417-269-LAWS (5297)Toll Free: 888-340-5297 Corporate Compliance Hotline. The Corporate Compliance Hotline is a key element of the Corporate Compliance Program. Calls coming into the Corporate Compliance Hotline (and the Corporate Integrity Department) will be held in the strictest of confidence. The Hotline is a completely confidential resource that can be called anonymously to allow all members of CoxHealth to voice concerns over any situation that may conflict with CoxHealth's commitment to ensuring the reputation and corporate integrity of CoxHealth. The Hotline calls are recorded in the same manner that voice mail messages are recorded. The phone resides in the Corporate Integrity Department and is not generally answered. The incoming phone number, even if displayed is not recorded in the Hotline Log, or in the Corporate Compliance files or database which may be generated as the investigation proceeds. Disciplinary Action Enforcement Intentional actions by any member of CoxHealth which result in violations of the federal and state regulations governing health care; cause CoxHealth to submit a false claim for payment to any payer; or violate CoxHealth policies and procedures will result in disciplinary action according to the appropriate policies, (e.g., Medical Staff Bylaws, Human Resource Policies, Board of Director Bylaws, etc.) Additionally, actions will be reported to the appropriate authorities as deemed necessary. No member of CoxHealth who reports a compliance issue in good faith will be subject to disciplinary action or punished in any way for making a report. Any member of CoxHealth who attempts to retaliate against another who in good faith reported a compliance issue will be subject to disciplinary action, including termination if appropriate. Failure to report a known compliance issue is a violation of policy and may subject an employee to disciplinary action, including termination, where appropriate. Monitoring and Auditing As defined above this policy, one of the responsibilities of the Corporate Compliance Officer is to initiate and supervise internal and external audits to evaluate compliance. Another responsibility is to ensure the monitoring of processes and practices to identify possible areas of concern regarding compliance. The Corporate Compliance Officer will work with the various committees to develop a risk assessment for CoxHealth and to then develop a plan to address those risks through audit and investigation of possible non-compliance. The risk assessment will be updated annually and the Audit Plan will be monitored and activities reported to the Board of Directors, Compliance Committee, and other appropriate committees. Periodic audits will be performed on those areas within CoxHealth that have been identified in the Risk Assessment and Audit Plan. Additionally audits to assess compliance with the standards and policies established at CoxHealthshall be conducted under the authority and direction of the Corporate Compliance Officer. Specifically, ongoing billing compliance monitoring will be conducted by the Audit and Compliance Department of CoxHealth and as requestedthrough the Internal Auditor or Ferrell Duncan Clinic Auditors outside auditors. Periodic reviews will be made of available benchmarking data and directives and alerts, e.g., the PEPPER Report, OIG Advisory Opinions, FraudAlerts, Medicare Alerts and correspondence from Medicaid to ensure compliance with all areas of health care. Monitoring in those areas where issues were identified will be undertaken as deemed appropriate by the Corporate Compliance Officer. Investigators/Resolutions The Corporate Compliance Officer will review reports of possible violations to determine the appropriate action to be taken. The action taken shall be designed to ensure that the specific issue is addressed and, to the extent possible, that similar problems do not occur in other departments or areas or re-occur in the original area. If the report was received in a method other than personal communication directly with someone in the Corporate Integrity Department or by anonymous call, then the person filing the concern shall be contacted within forty-eight (48) hours to let them know that the report was received. An internal investigation will be undertaken within 10 days and shall be completed within ninety (90) days if at all possible. All investigations will be documented and reported as appropriate to the President and CEO and Board Compliance Committee. Files will be retained by the Corporate Compliance Officer, in a confidential manner. In the situation where the employee making the report has identified him/herself, the employee will be notified of the investigation's disposition as soon as practical. If the investigation reveals improper monies were received by CoxHealth, the appropriate payor will be notified and reimbursement will be made. Disclosure to state or federal officials or law enforcement will also be made if deemed appropriate. Throughout the course of investigations, the Corporate Compliance Officer has authority with Corporate Counsel to engage the assistance of outside counsel where s/he deems necessary. Further, any report made to payors, government agencies or law enforcement is to be done by the Compliance Officer or party authorized by the Compliance Officer to make the report. Miscellaneous If an employee is contacted by a representative of any government agency, the employee should immediately consultwith his or her supervisor for guidance to ensure that the government agency receives full cooperation and the interest of CoxHealth is protected. The supervisor should immediately contact the Corporate Compliance Officer and/or General Counsel. If the event occurs during the evening or night hours and the employee does not know how to contact the Corporate Compliance Officer, contact the hospital operator and ask to speak to the Nursing Supervisor on call, or the Administrator on call. The Corporate Compliance Officer or General Counsel for CoxHealth should be contacted before responding to any requests from an investigator for documents. Copies of all documents provided must be maintained. All CoxHealth employees have the duty and obligation to cooperate fully with the Board of Directors, the Compliance Officer and his/her designee(s), in their investigations. The employee may identify him/herself or remain anonymous. Every attempt will be made to keep the employee's identity confidential unless he/she gives permission or requests that his/her identify be revealed through the process of investigation. It is recognized that there may be situations where the direction of the investigation inevitably leads to identification of the reporter. CoxHealth is committed to acting with Integrity, Respect and Compassion in all of our business dealings. CoxHealth, and its employees, volunteers, medical staff members and Board of Directors have a reputation in the community of being a quality organization; an organization that operates in an honest manner; an organization that has both respect and compassion for those we serve.