Compliance Plan

COMPLIANCE PLAN

COMPLIANCE PLAN

FOR

______”PRACTICE NAME______

I. INTRODUCTION

It is a fundamental policy of ______("the Practice") that all of its business and other practices be conducted at all times in compliance with all applicable laws and regulations of the United States, the State of ______, all other applicable local laws and ordinances and the ethical standards/practices of the industry and the practice of medicine.

The Governing Body of the Practice, at its regularly scheduled meeting on ______, 20___, adopted the resolution attached hereto as EXHIBIT A and approved the development of a Compliance Plan ("the Plan"). A Compliance Committee was formed to review and modify the Plan as appropriate. The Plan was approved and adopted by the Practice's Governing Body on ______, 20___.

The Compliance Plan is intended as a guide to help implement this policy of compliance with all applicable standards. The laws, regulations and ethical rules that govern health care are too numerous to list in the Plan. Fundamentally, all parties (as defined below) of the Practice are expected to conduct all business activities honestly and fairly. Any form of lying, cheating or misrepresentation is forbidden.

The Plan applies to all members of the governing body of the Practice, employed or contracted physicians, all other health care providers employed or contracted with the Practice, all Practice employees, consultants and others doing business with the Practice (hereinafter "Employees or Contractors"). Each Employee or Contractor is responsible for his or her own conduct in complying with the Plan's content.

The Plan will be distributed and explained to all Employees and Contractors. In addition, supplemental data dealing with specific topics may be distributed to Employees or Contractors in certain areas as deemed appropriate.

The Plan is monitored on a regular basis and reviewed no less than annually by the Compliance Officers ("CO"). In coordination with the Compliance Committee ("CC"), the Compliance Officer may add or delete subjects as and if warranted.

II. LETTER FROM COMPLIANCE OFFICER

______, 20___

To: Practice Employees

The Governing Body of the Practice, at its regularly scheduled meeting on ______, 20___ named me as the Compliance Officer. The specific duties, responsibility and authority of the Compliance Officer are more fully set forth in the Plan. I will be responsible for corporate compliance training for the Practice. That training includes instruction regarding the Practice-wide standards of conduct and the appropriate means of communicating or reporting known or suspected violations of the Plan. I will have responsibility for initiating appropriate investigations (in coordination with legal counsel and other experts if so warranted) of reports of violations.

The Plan [at Exhibit F] provides for a method of reporting violations of the Plan or other improper behavior. You, as employees or contractors, are responsible for reporting a known or suspected violation of the Plan using any one of the methods of reporting therein described.

There will be no retaliation or retribution against an employee or contractor solely for reporting a violation or suspected violation. Anyone engaging in such retaliation or retribution for reporting will be subject to discipline up to and including termination.

______PRACTICE NAME______

______

______NAME______, COO

______NAME______, CEO

Practice Compliance Officers

/_INITIALS OF COO__

III. THE PRACTICE CODE OF CONDUCT

A. MISSION AND VALUES STATEMENT OF THE PRACTICE

The Practice believes that dedication to high ethical standards and compliance with all applicable laws and regulations is essential to its mission. Our Code of Conduct provides guidance to all Practice colleagues and assists us in carrying out our daily activities within appropriate ethical and legal standards. These obligations apply to our relationships with patients, affiliated physicians, third-party payors, subcontractors, independent contractors, vendors, consultants, and one another.

The Code of Conduct is a critical component of our overall Compliance Program. We have developed the Code as part of an ongoing process to ensure that we meet our ethical standards and comply with all applicable laws and regulations.

B. QUALITY OF PATIENT CARE AND PATIENT BILL OF RIGHTS

The Practice has standards of patient care that reflect Federal and state law and regulations, respective medical, professional and clinical practice guidelines (if any), professional standards and accrediting body standards (if any). The standards are approved by the Practice's Governing Body.

The Practice's patients deserve care with concern for personal dignity and independence, and the Practice views these as important factors in the healing process. It is the responsibility of the staff at the Practice to respect and preserve these rights for those who come to the Practice for medical care.

C. FRAUD AND ABUSE, ANTI-KICKBACK, AND SELF-REFERRAL LAWS

The Practice is subject to numerous Federal and state laws regulating practices and relationships within the health care industry. These laws are designed to prevent fraud in the Medicare and Medicaid programs and abuse of the public funds supporting the programs, regulate patient referrals, and prohibit false statements to the government. The Practice is committed to compliance with the Medicare and Medicaid rules. All employees should be aware of these laws and notify the Compliance Officer of any potential violations by the Practice.

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1. The Federal Fraud and Abuse Statute, 42 U.S.C. §1320a-7b(b).

Generally, the federal fraud and abuse statute makes it a criminal offense to knowingly and willfully offer, pay, solicit or receive any remuneration, directly or indirectly, in return for referrals or to induce referrals, or to arrange for or recommend goods, facilities, services or items for which payment may be made under a federal health care program.

The fraud and abuse statute has been expanded from Medicare, Medicaid and certain state programs to include all federal health care programs. "Federal health care programs" is broadly defined to include any plan or program that provides health benefits funded in whole or in part, by the federal government, with the exception of federal employee health benefit programs. The fraud and abuse statute has been interpreted to cover arrangements where one purpose of the remuneration is to induce referrals, even though other business purposes may exist. A number of statutory and regulatory exceptions exist. Legal counsel should be consulted whenever a fraud and abuse issue exists, and prior to entering into relationships with hospitals.

2. The Ethics in Patient Referrals Act ("Stark Statute"), 42 U.S.C. § 1395nn.

The Stark Statute provides that if a physician (or a family member) has a "financial relationship" with an entity, then the physician is prohibited from referring patients to that entity for "designated health services" that are paid for by Medicare or Medicaid, unless an exception applies. The Stark Statute also prohibits entities that receive a prohibited referral for billing for such services. A "financial relationship" includes direct or indirect ownership or investment interests and direct or indirect compensation arrangements between a physician (or the physician's family member) and an entity that provides designated health services.

"Designated health services" ("DHS") include:

a. clinical laboratory services;

b. physical therapy services;

c. occupational therapy services;

d. radiology or other diagnostic services;

e. radiation therapy services;

f. durable medical equipment and supplies;

g. parenteral and enteral nutrients, equipment, and supplies;

h. prosthetics, orthotics and prosthetic devices and supplies;

i. home health services;

j. outpatient prescription drugs; and

k. inpatient and outpatient hospital services.

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The Stark Statute includes a number of statutory exceptions and regulatory exceptions have been proposed. The clinical lab regulations have been made final. Legal counsel should be consulted regarding the availability of these exceptions.

Most medical group practices must be structured to fit within the "group practice" definition under the Stark Statute to claim the physician services and in-office ancillary services exception. Our Practice meets this definition of "group practice."

D. CONTRACTING FOR SERVICES

All business relations with vendors, contractors and other third-parties, including physicians and other clinicians, are to be conducted at arm's length.

E. FINANCIAL ACCOUNTING RECORDS; INTEGRITY AND ACCURACY

All financial reports, accounting records, research reports, expense accounts, time sheets, and other financial documents shall accurately represent the performance of operations. The Practice's employees shall be trained and their work shall be monitored to assure proper maintenance of information to comply with the practice's policy standards, and any other such laws, statutes, or regulations.

The Practice shall establish procedures to assure a system of internal controls which provides reasonable assurance that financial records are executed and retained consistent with local, state, and Federal regulatory requirement and accounting industry guide lines, and the Practice shall assure that all records are prepared timely and are properly supported.

F. CLAIMS DEVELOPMENT AND SUBMISSION; BILLING AND COLLECTIONS

The Practice has an obligation to its patients, third party payors, and the state and Federal governments to exercise diligence, care, and integrity when submitting claims for payment for services rendered. To uphold this obligation, the Practice shall maintain honest, fair, and accurate billing practices. All individuals involved in the billing functions of the Practice, most importantly its physicians, shall have experience and knowledge and shall be trained to perform all billing functions in accordance with Federal, state, and local law.

The Practice shall develop and maintain written billing policies and procedures manuals to provide guidance to billing and coding staff. With respect to reimbursement claims, the Practice's written policies and procedures should reflect and reinforce current Federal and state statutes and regulations regarding the submission of claims. These policies must create a mechanism for the billing or reimbursement staff to communicate effectively and accurately with the clinical staff.

To avoid potential criminal and civil liability for violations of the False Claims Act, 18 U.S.C. § 287; the False Statements Act, 18 U.S.C. § 1001; or the Medicare and Medicaid False Claims Statute, 42 U.S.C. § 1320a-7b-(a), the Practice's billing policies and procedures should particularly emphasize the following:

1. Bill third-party payors only for those services provided, as supported by medical record documentation;

2. Avoid any duplicate billing;

3. Provide for proper and timely documentation of the services of health care providers;

4. Emphasize that claims should be submitted only when appropriate documentation supports the claims and only when such documentation is maintained and available for review;

5. Provide that the compensation for any employee or contractors including the billing coders and billing consultants should not provide any financial incentive to improperly up-code claims; and

6. The written policies and procedures concerning proper coding should reflect the current reimbursement principles set forth in the applicable regulations and be developed in tandem with private payor and organizational standards. Particular attention should be paid to issues of medical necessity and appropriate diagnosis.

G. MEDICAL NECESSITY: REASONABLE AND NECESSARY SERVICES

While physicians and other licensed health care professionals are able to order any services that are appropriate for the treatment of their consumers, Medicare and other government and private health care plans will only pay for those services that meet medical necessity standards established by each plan (as in the case of Medicare, "reasonable and necessary services"). Providers may not bill for services that do not meet the applicable standards.

Therefore, the Practice should ensure that claims are submitted only for services that the Practice believes are medically necessary and that were ordered by a physician or other appropriately licensed individual. Upon request, the Practice should be able to provide documentation to support the medical necessity of a service (or recertification) that the Practice has provided.

H. CONFLICTS OF INTEREST

The Practice recognizes that conflicts of interest often arise in the course of normal business activities, however, employees of the Practice should make every effort to avoid all potential conflicts of interest. To achieve our goals and to maintain the integrity of the Practice, any individual associated with the Practice who can potentially benefit from the contract shall not participate in the Practice's decision-making process relative to that business entity.

1. Conflict of Interest Disclosure Statement.

All members of the Practice shall complete a conflict of interest disclosure statement as part of the initial employment application. These forms should be updated on a regular basis.

2. Gifts, Bribes, and Gratuities.

Acceptance of gifts, gratuities, favors or other benefits from persons or entities that do business with the Practice or to whom the Practice or its physicians make referrals shall not be permitted. Solicitation of such gifts, favors, or other benefits, regardless of value, shall likewise be prohibited. Notwithstanding, the foregoing, the acceptance of common business hospitality such as occasional meals, entertainment, or nominal gifts with a value of $25.00 or less shall not be considered a violation of this section.

3. Kickbacks and Rebates.

Improper payments and practices of kickbacks or rebates are unethical and in many cases illegal. Practice physicians and other Practice health care providers and their families are prohibited from receiving personal gains or remuneration from any person or entity that might receive a patient referral from the Practice. Kickbacks and/or rebates can take many forms and are not limited to direct cash payment or credit.

I. ANTITRUST AND TRADE REGULATION

It is the policy of the Practice to avoid any activities that unfairly or illegally reduce or eliminate competition, control prices, allocate markets, or exclude competitors in violation of state or Federal antitrust and trade regulation laws.

1. All Practice employees or contractors shall comply with the letter and spirit of all antitrust laws of the United States and of the State of Florida. No employee or contractor of the Practice shall have any authority to engage in conduct that does not comply with this policy or to authorize, direct, approve, or condone such conduct by any other person.

2. Employees or contractors shall not enter into understandings or agreements (whether written or oral) that could unfairly or illegally reduce or eliminate competition, control prices, allocate markets, or exclude competitors. This includes agreements or information sharing with other practices or carriers that affect prices, charges, profits, and service or supplier selection.

3. Employees or contractors who negotiate or enter into contracts with competitors, potential competitors, contractors or suppliers shall do so on a competitive basis based upon such factors as price, quality, and service. This policy is especially important for employees or contractors having purchasing, planning or marketing responsibilities.