Compliance System Management Integrity and Compliance Program Policy Number: Approval Date: Approved by: Nancy Oetinger

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1 Compliance System Management Policy Name: Integrity and Compliance Program Policy Number: Approval Date: Approved by: Nancy Oetinger POLICY Consistent with our core values of Integrity and Stewardship, it is the policy of Mercy Health System (MHS) to implement a system-wide Integrity and Compliance Program designed to ensure MHS' operations fully comply with the applicable laws, regulations and professional standards and in a manner consistent with its Mission and Core Values. The Integrity & Compliance Program will meet requirements for effective corporate compliance programs as established by the United States Sentencing Commission and adopted by health care industry regulators and will be modified, as necessary to address changes in such requirements that may occur over time. The Integrity & Compliance Program will function in accordance with policies and procedures established by Trinity Health. The purposes of the Integrity and Compliance Program are to: 1. Educate MHS officers, directors, employees, affiliated professionals, volunteers, agents and other persons employed directly or providing services under the direction of MHS concerning the Integrity & Compliance Program; 2. Ensure MHS managers seek appropriate counsel regarding business and operational practices and to conduct those activities within the requirements of the law and ethical standards of conduct for MHS employees; 3. Secure compliance with the Federal Sentencing Guidelines and all applicable laws and regulations; and 4. Foster an environment in which employees and affiliated professionals comply with all relevant laws and regulations and report any concerns about non-compliance. SCOPE Mercy Health System and all its Subsidiaries. PROCEDURES A. Integrity and Compliance Program Positions (Structure and Organization) 1. MHS Board of Trustees Compliance Committee The Mercy Health System Board of Trustees Integrity and Compliance Committee will provide strategic direction to the Integrity and Compliance Program, and be responsible for approving the annual Compliance Work Plan and provide input on the annual Risk Assessment and Internal Audit Services Plans. The Chief Integrity and Compliance 1

2 Officer or designee will update and report progress to the Committee at its regular meetings. 2. Chief Integrity and Compliance Officer The Mercy Health System Chief Integrity and Compliance Officer shall be a MHS employee who is delegated authority for day to day operation of the Integrity and Compliance Program. The Chief Integrity and Compliance Officer shall report directly to the Chief Executive Officer for Mercy Health System and to the Senior Vice President of Compliance and Audit for Trinity Health in an A2 relationship as defined by the Trinity Health Operating Model. The Chief Integrity and Compliance Officer shall update the Board of Trustees as to implementation of and on-going operations of the Integrity and Compliance Program. The MHS Board of Trustees shall receive periodic reports, not less than annually, on the status and effectiveness of the program. The Chief Integrity and Compliance Officer shall have sufficient authority, funding and resources to perform his/her responsibilities. The Chief Integrity and Compliance officer shall communicate directly and promptly to the Board Compliance Committee as necessary to report any matters of actual or potential misconduct. 3. Operating Unit Integrity and Compliance Officer The Operating Unit Integrity and Compliance Officer shall be a designated Operating Unit executive. The Operating Unit Integrity and Compliance Officer shall be accountable jointly to the Chief Integrity and Compliance Officer concerning ethics and compliance issues, and for the effective operation of the Integrity and Compliance Program at the Operating Unit. The Operating Unit Integrity and Compliance Officer shall also be responsible for keeping the Operating Unit Executive Director/CEO informed of the activities of the Integrity and Compliance Program at such Operating Unit. Given the diversity of services provided at the Operating Units, compliance activities may vary, i.e. Medicare Part D Compliance for Mercy LIFE, privacy issues, etc. 4. Management Integrity and Compliance Committee The Management Integrity and Compliance Committee shall include as members: Operating Unit Integrity and Compliance Officers and key compliance advocates. This Committee will have the responsibility of assisting the Integrity and Compliance Officer in the implementation of the Integrity and Compliance Program. The Committee shall provide support and feedback for the development of priorities and policies for the Integrity and Compliance Program and the implementation of the Program at MHS and MHS Subsidiaries. In addition, the Committee shall participate in setting priorities for educational programs to be provided as part of the Integrity and Compliance Program. Each Operating Unit shall have its own Integrity and Compliance committee that meets at least quarterly and is led by the Operating Unit Integrity and Compliance Officer. 2

3 5. Internal Audit Trinity Health s Integrity and Audit Services shall work with the Chief Integrity and Compliance Officer in auditing compliance throughout MHS as determined jointly. On an ongoing basis the internal auditors shall assist the Integrity and Compliance Officer with reporting to the MHS Board Integrity and Compliance Committee the results of their compliance audits. 6. Legal Affairs The Chief Integrity and Compliance Officer shall work cooperatively with the Senior Vice President Government and Legal Affairs in the development and implementation of the Compliance Work Plan. The Legal Affairs Department shall be responsible for: (i) providing legal counsel and support to the Chief Integrity and Compliance Officer; (ii) actively participating in the training and educational programs that are implemented as a part of the Compliance Work Plan; and (iii) where requested, investigating complaints and issues that are raised concerning the monitoring of compliance activities. B. Elements of the Integrity and Compliance Program 1. Core Elements- MHS will implement the Core Elements as defined by Trinity Health and shown in Attachment A. 2. Integrity and Compliance Policies and Procedures In addition to those provided by Trinity Health, the MHS Integrity and Compliance Program will establish written policies and procedures to address areas of identified risk, and develop standards. 3

4 Leadership and Oversight Attachment A Integrity and Compliance Program Core Elements 1. The Ministry has appointed an Integrity & Compliance Officer, a senior member of management, to lead the Integrity & Compliance Program. 2. Sufficient resources are allocated to support the effective operation of Ministry s Integrity & Compliance Program, including resources to address unanticipated compliance issues. 3. A Privacy Official has been appointed responsibility for the Ministry s HIPAA privacy and security program. 4. The Ministry Board and/or Board Committee receive regular (e.g. quarterly) reports from the Integrity & Compliance Officer on the operations of the Integrity & Compliance Program. 5. The Ministry has established a multi-disciplinary management committee (the Integrity & Compliance Committee ), chaired by the Integrity & Compliance Officer, that meets regularly (minimum quarterly) to support the effective operation of the Integrity & Compliance Program. Code of Conduct 1. A Code of Conduct describing expected behaviors and conduct, and the organization s commitment to adhering to all laws, regulations and professional standards, is provided to all colleagues upon hire. 2. The Code of Conduct, or a summarized version thereof, is provided to members of the Ministry s medical staff upon credentialing. 3. The Code of Conduct, or a summarized version thereof, is provided to suppliers, agents and contractors upon commencement of business relationships. 4. The Code of Conduct is distributed to Board and Board committee members upon appointment. 5. The Code of Conduct is made available through the Ministry s intranet site. Education and Training 1. New colleagues receive orientation training on the Integrity & Compliance Program, Code of Conduct generally within 30 days of hire or otherwise as required by law or regulation. 2. Colleagues receive annual training to reinforce awareness and understanding of the Integrity & Compliance Program, the privacy and security program, their responsibilities thereto, the role and identity of the Integrity & Compliance Officer and Privacy Official, and resources available to report issues and concerns. 3. Colleagues whose positions require additional and/or ongoing compliance education and training specific to their job responsibilities receive such training annually or as needed in response to changing laws or regulations. 1

5 4. Board members and senior managers receive periodic education (e.g. minimum annually) on current compliance issues relevant to their respective leadership and governance responsibilities. 5. Information required by the Deficit Reduction Act is included within the Code of Conduct as well as any separately provided employee handbook or similar document provided to employees, medical staff, suppliers and other agents and contractors. Risk Assessments, Auditing and Monitoring 1. Periodic (minimum annual) risk assessments are conducted to identify potential risks in Ministry operations relating to compliance with federal health care program requirements, including the evaluation of specific areas identified by regulators such as DHHS OIG, CMS, DOJ, IRS, etc. 2. A compliance auditing and monitoring plan is developed responsive to the periodic risk assessments and is approved by the Ministry Board / Board Committee annually. Sufficient resources (internal audit, Ministry internal and external) are allocated to support completion of the auditing and monitoring plan. 3. Corrective action plans, with management responsibilities and timelines identified, are developed in response to the results of compliance auditing and monitoring activities. 4. The Ministry Integrity & Compliance Committee assists the Integrity & Compliance Officer in monitoring the timely completion of corrective actions taken in response to the results of auditing and monitoring activities. 5. The results of compliance auditing and monitoring activities are reported regularly (e.g. quarterly) to Ministry Board / Board Committee. Reporting Systems 1. The Ministry has established a hotline reporting system for use by colleagues, medical staff, and others to report issues and concerns, including potential violations of law and regulations, on an anonymous basis. 2. The Ministry has an established and publicized process for the direct reporting of issues, concerns and/or incidents to the Integrity & Compliance Officer and Privacy Official. 3. Policies strictly forbidding retaliation against individuals for reporting issues and concerns, including potential violations of laws and regulations, have been established and communicated by the Ministry. 4. The availability of the hotline, as well as other means for reporting issues and concerns, is continuously communicated to Ministry colleagues, medical staff and others through posters, newsletters, Intranet, etc. 5. Appropriate resources are allocated to support the timely (e.g. within 30 days) investigation and resolution of reports received through the hotline system or by other means. 6. Summary information regarding hotline and other compliance reports received and the results of investigations and actions taken in response, as appropriate, is reported regularly to 2

6 the Ministry s Integrity & Compliance Committee and to the Board / Board Committee. Response and Prevention 1. The Ministry has established procedures requiring colleagues and medical staff members to attest/certify they have not been debarred or otherwise excluded from participation in federal and state health care programs and have not been convicted of a health care criminal offense prior to hiring and credentialing, respectively. 2. The Ministry has established procedures requiring screening for eligibility to participate in federal health care programs as required by law or regulation as follows: a. Colleagues (at hire and monthly) b. Medical staff physicians and other credentialed providers (credentialing/re-credentialing and monthly) c. Vendors, agents and contractors (at initiation of business relationships, annually or more frequently as required by law or regulation) d. Board members/trustees (at appointment and annually) 3. The Ministry has established procedures for the timely investigation of potential compliance issues identified as a result of regulatory audits or investigations or through hotline or other reports received from colleagues, medical staff, suppliers or others, including coordination with internal and external legal counsel. 4. The Ministry has established procedures to ensure timely corrective actions are taken in response to audits or investigations resulting in the determination that overpayments were received from federal and state health care programs, including the processing of corrected claims and/or notification and repayment to appropriate payers including Medicare, Medicaid and other federal and state health care programs. Enforcement and Discipline 1. The completion of required compliance education and training programs by colleagues is linked to the Ministry s performance management procedures. 2. The Ministry s performance management procedures include documented confirmation of colleagues understanding of and adherence to the Integrity & Compliance Program and Code of Conduct. 3. Ministry procedures include specific reference to disciplinary actions that may be taken for violations of the Code of Conduct, up to and including termination of employment. 4. The Ministry has established procedures for the handling of disciplinary matters involving members of the independent medical staff for violations of the Code of Conduct, consistent with the organization s medical staff bylaws. 3