It is the policy of PIH that all employees and affiliated staff will fully comply with all Pakistani and provincial laws and will conduct themselves in accordance with the hospital policies as well as the highest ethical standards.

To help achieve this mission, PIH has created a Code of Conduct which describes PIH policies concerning certain laws and regulations affecting many of our business operations. PIH has established this Code of Conduct to help its employees understand some of the specific laws and policies they are required to adhere to.

PIH policy is to provide quality services to patients, their families and all business partners at the highest professional, ethical and legal standards. Employees who fail to do so will be subject to discipline up to and including termination of employment. Any person who learns of, or suspects that, someone has violated a law, this Code of Conduct, or has acted unethically or improperly, must report that information to their supervisor, a Human Resource representative or the Corporate Compliance Office. Supervisors are required to ensure compliance by their staff.

If you are uncomfortable discussing your concerns with a supervisor or feel those concerns are being ignored, you are encouraged to call your Human Resource representative or Corporate Compliance Office to report your concern and seek resolutions. You may also call the PIH Compliance Hotline to report information regarding unethical or illegal conduct, violations of PIH Code of Conduct or the Corporate Compliance Program. The PIH Compliance Hotline allows anonymous reporting of actual or perceived violations. You are not required to leave your name, although you may do so if you wish. The PIH Compliance Hot Line number is 021-111-744-744. Your telephone number will not be identified in any message.

Confidentiality

All patient information (including medical records, in any form) must be kept strictly confidential and not released to anyone outside the provider without written patient consent. PIH employees are prohibited from disclosing patient health information to anyone other than the patient, for treatment, payment, healthcare operations, or with authorization from the patient. Internal access by PIH employees to patient medical records or other protected information is not permitted unless there is a legitimate, work-related need to see the information.

Discrimination

It is against our corporate practice to discriminate against an employee or patient on the basis of race, background, gender, age or origin. Patients also cannot be discriminated against because of their ability or inability to pay for care. Any person with information that a provider or individual is improperly discriminating or being discriminated against must report such information to the human resources officer at the hospital.

Financial and Business Reporting

PIH provides various financial and business reporting processes to ensure accurate and timely recordkeeping for internal transactions, government and client reports. These can include, but are not limited to, employee time and expense reports, internal financial and activity reports, audits, insurance claims reports and performance reports for clients. All reporting processes must be complete and accurate. Employees who intentionally misrepresent or falsify required information on hospital documents will be subject to disciplinary action up to and including termination of employment. Employees who suspect misrepresentation or false reporting are required to immediately notify their manager, the Human Resource Officer or the Compliance Manager. Failure to do so may result in disciplinary action up to and including termination of employment.

Conflicts of Interest

All PIH employees must avoid conflicts of interest and situations that even appear to be a conflict of interest. This means that employees will not personally benefit from doing business with PIH nor have independent formal or informal business relationships with those who deal with PIH. They cannot use hospital property for personal benefit without the expressed approval of their supervisor. PIH employees cannot compete with PIH. Any potential for conflict of interest should be disclosed to your supervisor. You must also inform your supervisor if, within a year of your employment, you worked for a Medicare Practioner or healthcare provider.

Record Retention

Pakistani law requires that relevant departments within PIH keep certain records for specified periods of time. It is our policy to keep records for as long as the hospital requires. The legal requirements are many. Before you discard or delete any information it is important to check with the management, medical records or the Corporate Compliance Officer regarding any record retention requirements that might exist. All employees must follow existing record retention policies.

Cooperation with Law Enforcement

Pakistani federal and provincial agencies have extensive rights to investigate matters involving patient care, billing and audits. PIH policy is to cooperate with investigations and activities within the bounds permitted by local law. Employees, affiliates, Directors or representatives of PIH who are approached by governmental enforcement are to cooperate at all times. The Compliance Officer will instruct the person as to his/her rights and obligations to speak to the representatives of the government. The Compliance Officer or Administrative Officer will contact legal counsel immediately. If you are presented with a warrant, or court order you have the right to hire an attorney when speaking with the government agent. The Corporate Compliance Office will coordinate the disclosure of documentation. Any person who elects to speak with a law enforcement officer must tell the complete truth. Employees across all departments at the hospital are encouraged to cooperate or assist with any governmental investigations, after notifying the Compliance Officer or Administration.

Payments, Discounts, Gifts and Kickbacks

It is generally illegal to pay for patient referrals or to pay for a recommendation that someone leases or buys something (like equipment, drugs or services) from you, if a government health program (such as Medicare) is paying for the patient services or item. It is PIH policy not to pay for referrals or recommendations or to accept payment for referrals we make.

“Payment” does not have to be cash; it can be anything of value, such as a discount, a free service or piece of equipment. Employees must avoid entertaining or giving gifts or gratuities of more than nominal value to those who can refer patients or business to a PIH healthcare facility, provider or other business unit. Additionally, employees are prohibited from accepting or soliciting gifts or gratuities of any kind as an incentive or reward for conducting business at any Pioneer facility or business unit.

Billing

It is against law and PIH policy to knowingly submit or cause to submit false claims for payment. This requirement applies to all employees and affiliated professional staff at our healthcare facilities, employees in our billing and collections department, accounting department and any other employees who create and submit bills for payment. Submitting a false claim might include intentionally using the wrong billing codes, falsifying the medical record, billing for services not provided and / or not medically necessary.

It is each and every employee’s personal responsibility to prevent fraud, waste, and abuse. Fraud is the intentional and false statement or claim made to obtain some benefit to which one is not entitled. Abuse is a practice or incident that is inconsistent with sound medical practice and may result in failure to meet recognized standards of care or improper payment. Violating these policies or failing to report violations could subject an employee to disciplinary action, up to and including termination of employment.

Referrals and Physician Recruitment

It is generally against the law for a doctor to refer patients to providers (such as labs) in which he or she (or a family member) has a financial interest or relationship. An example might be a physician referring patients to a lab that he or she owns. Violations can result in fines and exclusion from Medicare or Medicaid. The law is complex and applies only to certain services and has many exceptions. If you suspect that a physician is referring patients illegally, it is best to report this to your supervisor or the Compliance Representative. PIH sometimes recruits physicians to become part of its rural healthcare systems. It is our policy to comply with the Stark Law, to pay fair market value compensation to recruit and retain physicians and not to offer physicians anything of value in exchange for referrals to PIH healthcare facilities.

Patient Transfers

Pakistani law requires that an emergency department not transfer a patient who needs emergency treatment (including psychiatric) unless the patient is stable. The PIH Emergency Department cannot refuse or delay treatment on the basis of the patient’s insurance or ability to pay, race, colour, religion, gender, age or handicap. All individuals presenting to the Emergency Department shall receive a medical screening examination to determine if an emergency medical condition does exist. If such a condition does exist PIH will provide further medical examination and treatment, within the capabilities of it staff and facilities, to stabilize the medical condition of the patient. Transfers can only be done with appropriate medical personnel approval if the medical benefits of transfer outweigh risk to the patient.

Controlled Substances

PIH will not tolerate handling and dispensing of controlled substances, including narcotics. PIH will not tolerate unauthorized distribution or possession of narcotics or banned substances. Anyone having information about a violation of this policy must report it promptly, or they may be subject to disciplinary action.

Use of Hospital Assets

PIH provides employees with the assets and other resources necessary to achieve hospital objectives. These may include, but are not limited to, office and cellular telephones, computers, email and internet systems, photocopiers, fax machines, vehicles and other equipment specific to individual jobs or functions. Assets also include confidential and proprietary information, goodwill and hospital financial and business strategic information. PIH expects that all employees will use these assets solely for the benefit of the hospital and will not use them in any way that interferes with hospital processes, inconveniences others, harms the hospital in any way or creates waste.

Individual Responsibility

Each employee is personally responsible to act in accordance with the policies of PIH as set forth in this Code of Conduct and all other employment policies. Violating these policies or failing to report violations could subject an employee to disciplinary action, up to and including termination of employment. PIH will use a progressive disciplinary process to correct job performance and work habit problems in the work place. Our objective is to eliminate the unacceptable behaviours and provide guidance for improvement. Penalties may vary based on the severity of the policy violation or work place misconduct.

Employee Participation

In order to have an effective Corporate Compliance Program, PIH and its affiliates must depend upon the complete participation of all of its employees. Therefore, all employees must comply with all the policies and procedures under the Corporate Compliance Handbook and Code of Conduct. Specifically, all employees must attend required educational and training sessions relating to the Compliance Program and adhere to the policies of the Program. There will be general employee training and job-specific training, if required, by the employee’s position at PIH.

All employees must sign a form acknowledging their receipt of the Corporate Compliance Handbook and Code of Conduct. In addition, at an employee’s exit interview, he/she must sign a document confirming that the employee has conformed to the policies and procedures as directed in the Corporate Compliance Handbook and Code of Conduct.

Failure to comply with the policies and procedures of the program is a violation of PIH policy and may be grounds for disciplinary action.