Compliance

1. Compliance It is Everyone’s Job!

2. What is Compliance? • The state of being in accordance with relevant federal or regional authorities and their regulatory requirements. • Most large financial services companies have compliance departments that are charged with making sure that the company is following all the necessary rules and regulations.

3. What is Compliance? • Doing the right thing • Complying with rules and laws • We all have a responsibility to report anything that could be considered illegal or unethical

4. Compliance • Part of HGA (HealthGroup of Alabama) • Compliance Officer @ ALH Traci Collins, RN • Reports to Administration and Board of Directors • Gives update to Board annually • Chairs Compliance Committee • Consist of Administration, Employees, Physician, and Board Member

5. Compliance • Ensures the facility or company meets the requirements for the Department of Justice and the OIG (Office of the Inspector General) • Written policies, procedures, and standards of conduct • On-going training program • Open communication between Compliance Officer and All Staff • Internal monitoring and auditing • Prompt response to detected offenses and corrective action

6. Confidentiality & Patient Relations Fraud and Abuse Filing false claims Incorrect coding Incorrect charging Record Keeping “need to know basis” Dignity and Respect in the workplace Equal Opportunity Employer Relationships with Vendors & Competitors ALH business matters are private Illegal or Questionable Gifts Conflicts of Interest When personal interest differs from the best interest of ALH Ex: Holding a financial interest in a company with whom ALH does business General Laws Code of Conduct

7. Computer and Information Usage • Respect privacy and rules governing the use of any information through the computer system or network • All access to the system is monitored • Do not operate any non-licensed software on the computer.

8. E-Mail • Always be professional! • Do not use email to broadcast confidential information • Never send user names or passwords via email • Follow the same hospital and HIPAA guidelines for patient privacy and confidentiality for email that you would for any Protected Health Information

9. HIPAA • Health Insurance Portability and Accountability Act • Enacted by Congress in 1996 • Privacy Officer • Brenda Moody 256-233-9539 • Security Officer • Kim Hoback 256-233-9117

10. How to Report • If you think someone has committed fraud or taken a wrong action, please contact: • Your supervisor • Compliance Officer • Compliance Hotline

11. Important Numbers • Compliance Officer • 216-9645 • HGA Compliance Hotline • 1-800-442-0959 • 1-800-HGA-0959 • ALL calls are confidential

12. Questions?? • Presented by: Traci Collins, RN Compliance Officer

13. ALH Code of Conduct • The code of conduct tells how Athens-Limestone Hospital employees conduct business. We expect everyone to understand and obey the Code of Conduct and do their jobs honestly, ethically, and legally. If you know about conduct that may be illegal or unethical, you must report it to your supervisor or to the Health group of Alabama alert line number at 1-800-HGA-0959 or to the Compliance officer at 256-216-9645. Please be aware that calling the alert line can be performed anonymously and you will be given a code number to follow up with your concern.

14. ALH Code of Conduct • STANDARDS • Confidentiality and Patient Relations: We strive to provide quality care to our patient and their families. We do not ignore mistakes, and we take steps to correct them. We are responsible to patients and their families. We treat emergencies whether they can pay or not. We do not share confidential patient information with anyone who does not have a need to know. • Fraud and Abuse: The law punishes fraud and abuse. For example, filing false claims by using the wrong billing codes, providing unnecessary services, or paying for patient referrals may be fraud and abuse. We strive to see that all services are medically necessary, are documented correctly, and that billing and coding are accurate. • Record Keeping: Athens-Limestone Hospital ensures that records are only given to individuals with a “need to know”. The hospital does not falsify facts or make false records. The hospital maintains appropriate record retention policies.

15. ALH Code of Conduct • Dignity and Respect in the Workplace: Athens-Limestone Hospital is an equal opportunity employer. We do not allow discrimination based on race, creed, color, religion, gender, national origin, age, disability, marital status or any other legal classification. Sexual harassment is strictly prohibited. You as an employee are responsible for respecting the rights of your co-workers and reporting discrimination to your supervisor, or Human Resources, or the Compliance Officer at 256-216-9645. • Relationships with Competitors, Vendors, Etc. Information about Athens-Limestone business such as strategy, prices, costs, finances, and similar matter is private. You may not discuss Athens-Limestone business information with people outside Athens-Limestone Hospital. • Illegal or questionable gifts: We never accept bribes or illegal gifts. Only vendors who already do business with us can offer gifts, and then only small ones. Gifts cannot affect our business decisions

16. ALH Code of Conduct • Conflicts of Interest: A “conflict of interest” happens when your personal interest are different from the best interest of Athens-Limestone Hospital. You must tell us about all possible conflicts of interest. The following examples might be conflicts of interest: accepting gifts or entertainment for another organization, holding a financial interest in a company with which Athens-Limestone Hospital does business. • General Laws: You must comply with all laws and rules affecting your job, not just the ones mentioned here. When in doubt, ask for clarification from your supervisor, the Compliance Officer, or General Counsel, • Athens-Limestone Hospital wants to follow all rules and do the right thing both legally and ethically. Violations of the Code of Conduct or company policy may lead to disciplinary action, including termination of employment.

17. Corporate Compliance Receipt and Acknowledgment • I have been instructed, received a copy of the Code of Conduct, and received a copy of the Corporate Compliance material from Athens-Limestone Hospital. I understand that I am responsible for knowing understanding, and following it. If I don’t understand something or if I have questions, I will ask the appropriate person for the answer. • Excluded Part Status: • I affirm that I am not an excluded party from participating in Federal health programs, nor am I under Investigation which may lead to sanctions. • Conflict of Interest: • I affirm that I do not have any conflict of interest nor am I aware that any conflicts of interest occurring at Athens-Limestone Hospital • ______________________________ __________________________ _______________________ • Print Name Signature Date

18. Confidentiality • Athens-Limestone Hospital has a firm policy that all information concerning a patient’s diagnosis, condition, treatment, and financial status must be held strictly confidential. • It is my ethical and legal responsibility to recognize and protect any information used and obtained in the course of my job. Release of this information without the patient’s written permission is strictly forbidden by law. • I understand that my password(s) is the equivalent to my signature. I will not attempt to access information using a password other than my own or attempt to access information except to meet needs specific to my job.

19. Confidentiality • I, the undersigned, agree that the consequences of a violation of the above statement will result in disciplinary that include immediate discharge. • ______________________________ __________________________ _______________________ • Print Name Signature Date

20. Personnel Policy Statement • My signature confirms that I am not aware of any workplace policy violation to include harassment, equal opportunity, workplace violence, or controlled substances and alcohol abuse. I understand that it is my ethical and legal responsibility to report any violations of these policies. • Print Name______________________________ Signature__________________________ Date_______________________

21. COMPUTER AND INFORMATION USAGE AGREEMENT FOR HOSPITAL STAFF • Security and confidentiality is a matter of concern for all persons who have access to Athens-Limestone Hospital Information Systems. Each person accessing Athens-Limestone Hospital resources and data holds a position of trust relative to this information and must recognize the responsibilities entrusted in preserving the security and confidentiality of this information. Therefore, all persons who are authorized to access data and resources through information systems must read and comply with Athens-Limestone Hospital policy. • Use of a computer network that is shared by many users imposes many obligations in particular; data, software, and computer capacity have value and must be treated accordingly.

22. COMPUTER AND INFORMATION USAGE AGREEMENT FOR HOSPITAL STAFF • As a user of Athens-Limestone Hospital Information Systems I will abide by the following: • Respect the privacy and rules governing the use of any information accessible through the computer system or network and only utilize necessary for the performance of my job. • Understand that electronic mail is a hospital resource and is provided as a business communication tool. Employees with legitimate business purposes may need to view your electronic messages. It is also possible that others may view your messages inadvertently. Therefore, there is no guarantee of privacy for electronic mail.

23. COMPUTER AND INFORMATION USAGE AGREEMENT FOR HOSPITAL STAFF • Respect the ownership of proprietary software. For example, do not make unauthorized copies of such software for your own use, even when the software is not physically protected against copying. • Respect the finite capabilities of the systems, and limit your own use so as not to interfere unreasonably with the activity of others. • Respect the procedures established to manage the use of the system. • Prevent unauthorized use of any information in files maintained, stored, or processed by Athens-Limestone Hospital.

24. COMPUTER AND INFORMATION USAGE AGREEMENT FOR HOSPITAL STAFF • Not seek personal benefit or permit others to benefit personally by any confidential information or use or equipment available through my work assignment. • Not operate any non-licensed software on any computer provided by Athens-Limestone Hospital. • Not exhibit or divulge the contents of any record or report except to fulfill work assignment and in accordance with Athens-Limestone Hospital policy. • Not remove any record or report from the office where it is kept except in the performance of my duties. • Report any violation of the policy and procedure. • Not release system/application/network passwords in order to access Athens-Limestone Hospital information systems.

25. COMPUTER AND INFORMATION USAGE AGREEMENT FOR HOSPITAL STAFF • Ensure that all computer equipment (i.e. monitors, printers) is positioned in a manner so as confidential information is not viewable by unauthorized individuals. • Respect the confidentiality of any reports printed from any information system containing patient/member information and handle, store, and dispose of the reports appropriately. • Not divulge any information identifying a patient or employee. • Understand that all access to the system will be monitored. • Understand that my obligations to this agreement will continue after termination of my employment or relationship with Athens-Limestone Hospital. I understand that my privileges hereunder are subject to periodic review, revision, and if appropriate, renewal.

26. COMPUTER AND INFORMATION USAGE AGREEMENT FOR HOSPITAL STAFF • Those who cannot accept these standards of behavior may be denied access to relevant computer systems and networks. Violators may also be subject to penalties, including disciplinary action, under policies of Athens-Limestone Hospital and under laws of the State of Alabama or the United States of America to the extent applicable. By signing this, I agree that I have read, understand and will comply with the agreement. • Print Name___________________________________ Signature_________________________________ • Department___________________________________ Date_________________________________