Corporate Compliance Manual
& Code of Ethics
Dear PIH Associate:
PIH is committed to delivering quality health services. It is our intent to provide these services in alignment with our vision and values while complying with legal and regulatory requirements. A corporate compliance program has been developed which is designed to help all associates make good decisions in patient care, particularly those decisions related to legal and regulatory requirements. The principles involved apply to all associates (employees and any members who act on behalf) of PIH. Every Associate is encouraged to raise questions about any part of their job if or when they feel that any work processes or actions are not in line with our vision and standards of conduct.
The intent of the Corporate Compliance Program at PIH is to develop policies, procedures, staff education and internal controls that promote adherence to applicable federal and state laws and the program requirements of Pakistan government and private health plans. Our compliance efforts are designed to establish a culture within our hospital that promotes prevention, detection and resolution of instances of conduct that do not conform to these standards. The adoption and implementation of voluntary compliance programs at Pak International Hospital significantly advances the prevention of fraud, abuse and waste in these health plans while at the same time furthering the fundamental vision of our hospital, which is to provide quality care for our patients. PIH’s Corporate Compliance Program is also designed to ensure conformity with Pakistani law.
Effective compliance policies guide the actions of our managers, employees, physicians, hospital boards and other health care professionals in the efficient management and operation of the hospital. They are especially critical as an internal control in the reimbursement and payment areas, where claims and billing operations have been a focus of government regulations, audit and scrutiny.
It is incumbent upon the management of PIH to provide ethical guidance to the hospital and to assure that adequate systems are in place to facilitate ethical and legal conduct.
This Compliance Manual and Code of Conduct provides general ethical guidance and is intended to serve as a resource to help resolve questions and appropriate hospital conduct. Review this thoroughly. Your adherence to the specific provisions, as well as the spirit of this code, is required and is necessary for our hospital to continue to provide quality services. No code is substitute for each person’s internal sense of values including fairness, honesty, and integrity.
We believe that all individuals associated with PIH contribute value, and their support helps assure that our hospital fulfills its vision and provides quality care, services and employment. We also believe that the key to our success is working together to ensure compliance in every area of the healthcare services that we provide.
Muhammad Hamza Afridi
CEO / Managing Director
PIH CORPORATE COMPLIANCE PROGRAM
CODE OF ETHICS
It is the policy of PIH that the Corporate Compliance Program is considered as a guideline to be followed by all members of Corporate, the Hospital Board of Trustees, medical staff, administrative officers, directors, managers, employees at all levels and in all business units. PIH and its affiliates require that its board members, medical staff, administrative officers, managers and employees maintain high standards of integrity, and business ethics. Furthermore, it is the duty of each employee to encourage other employees to maintain this same high level of integrity. The Hospital Board of Trustees, medical staff, administrative officers, directors, managers, employees at all levels and in all business, units must avoid any actions that are, or appear to be, inconsistent with such standards.
The Corporate Compliance Program is an on-going process designed to prevent and detect violations of the law, particularly fraud and abuse. If a situation should arise where there is a question about whether a proposed action is in compliance with a law, regulation or policy, all individuals associated with PIH and its affiliates should contact the Corporate Compliance Officer or a member of the Corporate Compliance Committee.
Conflicts of interest must be avoided. PIH and its affiliates have policies concerning conflicts of interest, which must be followed and any conflicts of interest must be fully disclosed.
PIH and its affiliates are committed to protecting those who report actions in good faith and strictly prohibits retaliation in any manner.
All issues reported will be treated confidentially and may, at request, be anonymous, as discussed in the designated sections of this manual.
This manual outlines the process PIH (PIH) and its affiliates will utilize to assure that they are in compliance with the various laws and regulations established by both the Federal government as well as all of the States PIH and its affiliates operate in. This manual is part of an ongoing process; it will be updated and expanded as the program evolves.
PIH CORPORATE COMPLIANCE PROGRAM
STATEMENT OF COMMITMENT TO CORPORATE COMPLIANCE
The PIH and its affiliates Vision is to:
Integrity and Ethical Conduct
We are truthful and trustworthy, striving to provide quality services to patients, their families and every business partner at the highest professional, ethical and legal standards.
We are committed to assuring the integrity and operations of our alliances across all communities we serve.
Employees and Families
We know that our success depends on our people. We are committed to providing workplace practices, resources and a healthy working environment so they can make a meaningful contribution and maintain a healthy life and work balance.
We bring creative solutions to healthcare that ensures high quality services to our patients, business partners and employees.
Caring and Compassion
We strive to understand the needs of every patient and offer quality clinical services that ensure those needs are fulfilled.
In order to achieve this vision, PIH and its affiliates are committed to maintaining a work environment that promotes integrity and trust in order that its employees, medical staff, and agents may perform their tasks with the highest ethical standards. These ethical standards require strict adherence to all Pakistani laws and regulations.
In order to avoid any violations of laws and regulations, a formal Corporate Compliance Program is in force at PIH. This program is a continuing effort to improve quality and performance. Corporate Compliance means that everyone associated with the hospital will make every effort to understand all legal and any other requirements that relate to their positions; and, will comply with them. Any exceptions are to be immediately reported to a supervisor, the human resources officer or the Managing Director in order to allow immediate and appropriate actions to be taken. If you have any question or concern, please call human resources on__________. In addition, you may also log onto the website at www.pih.com.pk.
PIH CORPORATE COMPLIANCE PROGRAM
In recent years, there has been significant concern regarding “fraud and abuse” in the healthcare industry in Pakistan. In light of this, the administration at PIH will follow a procedure by the name of “Compliance Program Guidance.”
The program plan will constitute 7 elements:
- The development and distribution of written standards of conduct, as well as written policies and procedures that promote the Hospital’s commitment to compliance and that address specific areas of potential fraud, such as claims development and submission processes and financial relationships with physicians and other health care professionals;
- The designated human resources officer and other appropriate departments are charged with the responsibility of operating and monitoring the compliance program, and who report directly to the Managing Director and the advisory group;
- The development and implementation of regular, effective training programs for all employees;
- The maintenance of a process, such as a hotline and/or P.O. Box, to receive complaints, and the adoption of procedures to protect the anonymity of complainants and to protect complainants from retaliation;
- The development of a system to respond to allegations of improper or illegal activities and the enforcement of appropriate disciplinary action against employees who have violated internal compliance policies, applicable statutes, regulations or provincial health care program requirements;
- The use of periodical audits to monitor compliance and assist in the reduction of identified problem areas; and
- The investigation and correction of identified systemic problems and the development of policies addressing the non-employment or retention of individuals.
Pak International Hospital
CODE OF CONDUCT
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 __________. Your telephone number will not be identified in any message.
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.
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.
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.
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.
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.
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.
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.
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.
COMPLIANCE OFFICER JOB DESCRIPTION
The primary responsibilities of the Corporate Compliance Officer shall include:
- Overseeing and monitoring the implementation of the Compliance Program;
- Reporting on a regular basis, to the PIH Advisory Board, the Managing Director and the Compliance Committee regarding the progress of implementation; and, assisting them in establishing methods to improve efficiency, quality of services, and to reduce vulnerability to fraud, abuse and waste;
- Periodically revising the program in light of changes in the organizational needs, in the law and policies and procedures of government and private payer health plans as approved by the Corporate Compliance Committee and/or the Managing Director;
- Developing and coordinating an educational training program which focuses on and includes the elements of the compliance program;
- Ensuring that all medical staff members are aware of the requirements of the compliance program and all policies and procedures relating to the same;
- Assisting the Finance Department in coordinating internal compliance review and monitoring activities, including annual or periodic audits and reviews;
- Independently investigating and acting on matters related to compliance, including the flexibility to design and coordinate internal investigations (e.g., responding to reports of problems or suspected violations) and any resulting corrective action with all hospital departments, providers, sub-providers and if appropriate, independent contractors; and developing policies and programs that encourage managers and employees to report suspected billing errors, suspected fraud and other possible problems without fear of retaliation.
The Compliance Officer shall have authority to review all documents and other information that are relevant to compliance activities, including, but not limited to, patient records, billing records, and records concerning marketing efforts and arrangements with other parties, including employees, independent contractors, suppliers, agents, physicians and other professionals on staff.
The Compliance Officer shall have the full resources of the organization at his or her disposal to carry out these functions and to implement the Corporate Compliance Program. The Compliance Officer, with the approval of the Managing Director, may retain legal counsel or other consultants as deemed necessary or desirable to assist in carrying out these functions. It is the intention of the Board that all communications between the Compliance Officer and counsel be privileged to the fullest extent of the law.
PIH COMPLIANCE COMMITTEE
STRUCTURE, FUNCTIONS AND DUTIES
The Compliance Committee shall be appointed by the Managing Director and shall consist of:
Chief Financial Officer
Manager of Hospital Operations
Manager, Human Resources
Vice President of Business Development
Patient Services Officer
Chief Medical Officer
Corporate Legal Counsel
Other individuals may be requested to serve on the Committee at the discretion of the Managing Director or advisory board.
The Compliance Committee’s functions shall include:
- Analyzing the environment in which PIH or its affiliates do business, the legal requirements with which it must comply and specific risk areas;
- Assessing existing policies and procedures that address these areas for possible incorporation into the Compliance Program;
- Working with appropriate departments to develop standards of conduct, policies and procedures which promote the Compliance Program;
- Recommending and monitoring, in conjunction with the relevant departments, policies and procedures as part of its daily operations;
- Determining the appropriate strategy and approach needed to ensure compliance with the program, detection of any potential violations; and
- Developing a system to solicit, evaluate and respond to all complaints or problems.
FOR COMPLIANCE AND CODE OF CONDUCT
I am acknowledge that I have received and read a copy of the Corporate Compliance Manual and Code of Conduct. I agree to completely adhere to its instruction which is required of every PIH employee.
I certify that I will cooperate with the Compliance Program and responsibilities as described in the Corporate Compliance Manual and in the Code of Conduct.
I also agree to discuss any questions or concerns regarding the PIH Corporate Compliance Manual and Code of Conduct with my Supervisor, Manager, Director, or Corporate Compliance Officer.
I understand that I have an obligation, as a PIH employee, to report any suspected misconduct to my Supervisor, Manager, Human Resources Officer or Corporate Compliance Officer; or, through any one of the reporting mechanisms. Furthermore, I understand that PIH will not retaliate against me for making a good-faith report.
I understand that violations of the Compliance Program, as described in this manual, are subject to disciplinary action that may include termination.
I understand that the Compliance Manual and this affirmation statement do not represent any type of employment agreement or contract and that my employment is on an “at will” basis. I also understand that these guidelines may be amended, modified, or clarified at any time and that I will receive any updates that occur related to any material within this manual.
The original executed copy of this document will be filed in your Human Resource personnel file. Should you request a copy please contact your Human Resource Representative.
If applicable I understand that PIH will conduct an excluded provider background check prior to my employment and periodically thereafter. I understand that PIH reserves the right to terminate my employment or other association if I am an excluded provider.
Name (print): ______________________ Department: ___________________________
Job Title: _______________________________________________________________
Signature: ________________________ Date: _________________________________