Code of Ethics

Purpose

To provide certain standards for Shepherd Center’s Business Ethics & Compliance Program. These standards are expectations for all Shepherd Center employees to follow. Some departments or programs may have more specific policies that address these standards.

Policy

It is the policy of Shepherd Center to have certain standards to follow in the daily operation of the organization. The Business Ethics & Compliance Program has set forth these standards as follows:

1. Standards of ethical conduct
   1. There is a Code of Conduct that is applicable to all employees.
   2. These standards articulate Shepherd Center’s commitment to ethical practices.
   3. These standards, as contained in Shepherd Center’s Code of Conduct, are distributed and/or made available electronically to all employees and are updated as needed.
2. Claims development and submission
   1. All clinical documentation must be proper, accurate and timely prior to all billing.
   2. Claims are submitted only with appropriate documentation to support the claim.
   3. This documentation is maintained for the appropriate time periods required by law and shall remain available for audit and reviews.
   4. Diagnosis and procedures reported on all claims are solely based upon medical records and other appropriate documentation.
   5. Outpatient services shall provide all Medicare patients with an Advance Beneficiary Notification (ABN) prior to receiving services not covered by Medicare.
   6. A system is in place to monitor billing in order to not bill for outpatient services rendered in connection with an inpatient stay.
   7. All CPT or HCPCS codes used by coding and billing staff must accurately describe the service that was ordered and performed.
   8. Appropriate documentation must be placed into the patient medical record and signed by the healthcare professional that provided or supervised the service to the patient.
   9. Coding staff must contact the appropriate personnel to obtain information in the event that the individual ordering the procedure or service failed to provide adequate justification for the procedure or service.
   10. A physician who provides evaluation and management services is responsible for ensuring a patient’s medical records include all appropriate documentation to match the evaluation and management services provided.
3. Cost reporting
   1. A cost identified on cost reports must not be claimed unless there is appropriate and accurate documentation to support the cost.
   2. Any allocation of costs to various cost centers must be accurately made and be supported by verifiable and auditable data. Such costs must also be properly classified.
   3. Bad debts reported on cost reports must be in strict accordance with all applicable federal statutes and regulations.
   4. The Medicare fiscal intermediary or other applicable payor must be promptly notified of errors in submitted cost reports.
4. Anti-kickback, self-referral, and marketing
   1. All Shepherd Center contracts with referral sources must comply with applicable statutes and regulations.
   2. Shepherd Center will not enter into contracts or financial arrangements with physicians or hospitals designed to provide financial incentives for referrals.
   3. Shepherd Center will market through promotional activities and materials, events and interactions in a truthful and accurate representation of our program capabilities, outcomes and populations served and in accordance with applicable law.
5. Bad debts and credit balances
   1. There is an annual review of all Medicare bad debt expenses claimed to ensure that these claims are in accordance with applicable statutes and regulations.
   2. Shepherd Center will provide timely and accurate reporting of Medicare and other federal health care program credit balances.
6. Record retention
   1. Shepherd Center will maintain policies and procedures in place for the creation, distribution, retention, storage, retrieval and destruction of documents.
   2. Record documentation retention must meet all applicable federal and state laws.
7. Performance evaluation
   1. Shepherd Center will endeavor to evaluate all employees on their adherence to all elements of the Business Ethics & Compliance Program via annual performance reviews.
   2. Shepherd Center will endeavor to inform all new employees, upon employment, that strict compliance with all elements of the Business Ethics & Compliance Program is an ongoing condition of employment.
8. Training and education
   1. Shepherd Center will require all employees to complete annual refresher education and/or training on the Business Ethics & Compliance Program/Code of Conduct and sign the appropriate compliance attestation(s) associated with such education and/or training.
   2. Shepherd Center will require all new employees to be educated and/or trained in the aspects of the Business Ethics & Compliance Program/Code of Conduct via new employee orientation.
   3. All Shepherd employees and agents will be provided electronic access to the Code of Conduct.
   4. Records will be maintained on the education and/or training of all employees regarding the Code of Conduct.
9. Reporting and information
   1. Shepherd Center will have several independent paths available for employees to report potential or actual fraud, waste or abuse including, without limitation: in person to the Compliance Department; the Chief Compliance Officer via telephone (404-367-1281); the 24-hour toll-free Compliance Hotline (1-800-860-0085); and, email (Error! Hyperlink reference not valid.).
   2. All reported information will be held in strict confidence to the greatest degree possible and as the law otherwise permits, and employees will have the ability to make reports anonymously.
   3. The Center will maintain a 24-hour toll-free telephone number for employees or agents to call to report suspected fraud, abuse or waste or any other concerns. This system will allow the employee to report anonymously if they so desire.
10. Corrective actions
    1. All employees are made aware of the progressive corrective action process for failure to follow Shepherd Center’s Business Ethics & Compliance Program and Code of Conduct.
    2. Instances of non-compliance with the Business Ethics & Compliance Program and/or Code of Conduct will be fairly enforced at all levels of personnel.
    3. All management and supervisory staff are held responsible for progressive corrective action plans for employees in non-compliance of Business Ethics & Compliance Program and/or Code of Conduct.
11. Auditing and monitoring
    1. Shepherd Center will endeavor to perform periodic compliance audits. All such audits shall be overseen by, or conducted in coordination with, Shepherd Center’s Chief Compliance Officer.
    2. The Chief Compliance Officer will review all findings from any such audit and, in the event of significant deficiencies identified by such audit, perform a reasonable inquiry to determine the cause of the deficiencies.
    3. All significant deficiencies and/or findings will be reported by the Chief Compliance Officer to the Chief Executive Officer, the Business Ethics & Compliance Committee, the Compliance Committee of the Board of Directors and/or the Board of Directors.
    4. The Chief Compliance Officer will oversee the development of an action plan to correct significant deficiencies or findings discovered during audits or reported by individuals.
    5. The Chief Compliance Officer will, upon verification of a violation of law, report the violation to the appropriate authorities; provided, however, that the Chief Compliance Officer shall be entitled to consult with outside legal counsel prior to any such report being made.
    6. The Business Ethics & Compliance Program shall strive to have an external evaluation of its effectiveness completed every three years.
12. Investigation
    1. The Chief Compliance Officer will initiate steps to investigate any reasonable suspicion of non-compliance and determine if a violation of law or Shepherd Center policy has occurred.
    2. If necessary, the Chief Compliance Officer, in coordination with Shepherd Center’s Department of Human Resources, may have employees under investigation removed from their current duties if there is a reasonable suspicion that the given employee may compromise the integrity of the investigation if they continue to perform their assigned duties during the performance of the investigation.
    3. Shepherd Center will take prompt corrective action should an investigation reveal an employee has performed outside the standards of the Business Ethics & Compliance Program and/or Code of Conduct.

Purpose

Develop an effective program to address ethical and compliance actions in all business functions with Shepherd Center.

Policy

The Board of Directors of Shepherd Center has delegated to the Chief Executive Officer of Shepherd Center the authority to develop and implement a program addressing ethical and compliant business practices. The Chief Executive Officer has appointed a Chief Compliance Officer to ensure the successful development and implementation of this program, to be entitled the “Business Ethics & Compliance Program.”

Objective

The following primary objectives are to be established and carried out through the Business Ethics & Compliance Program.

1. Provide explicit guidelines to all staff and authorized agents of Shepherd Center to follow in all business practices.
2. Endeavor to have all staff aware of their ethical and compliance responsibilities in all business- related activities.
3. Enhance staff’s ability to put ethical and compliant business practices into daily use and support a culture of proper business conduct.
4. Monitor Shepherd Center’s performance in all business relationships.
5. Maintain and enhance a high level of trust with the community that purchases Shepherd Center’s services.
6. Provide a system for proper decision making in all business-related affairs.
7. Ensure staff have the ability and autonomy to report any questionable business activities.
8. Investigate promptly and thoroughly all allegations and complaints of improper business practices.

Purpose

To provide a functional group of individuals within Shepherd Center, Inc. (the “Organization”) who most appropriately represent all divisions, programs and departments throughout the Organization and its applicable affiliates (e.g., Shepherd Center Foundation, Inc. and SSC Affiliates, Inc.). These individuals will serve as a forum for the operation of the Business Ethics & Compliance Program and provide guidance to the Chief Compliance Officer.

Policy

The Business Ethics & Compliance Committee (the “Compliance Committee”) shall be nominated by the Chief Compliance Officer and be appointed by the CEO of the Organization. The Organization’s Compliance Committee addressed within this policy is separate and distinct from the Organization’s Board of Director’s Compliance Committee, with the understanding that the latter committee, on behalf of the Organization’s Board of Directors, shall ultimately provide overall compliance and ethics oversight, guidance and direction to the Organization.

The Compliance Committee shall advise the Chief Compliance Officer regarding all aspects of the Organization’s Business Ethics & Compliance Program.

Committee functions

1. Advice to the Chief Compliance Officer regarding any potential risk areas to the Organization as otherwise identified by the Compliance Committee and/or the Chief Compliance Officer.
2. Review of any audits and/or monitoring activities as presented by the Chief Compliance Officer.
3. Work with the Chief Compliance Officer to assist divisions, programs, or departments in addressing issues that arise in any manner by and through the Organization’s compliance program.
4. Forward appropriate compliance/ethics issues that arise to the Chief Compliance Officer or, as necessary, to the President/CEO of the Organization.
5. Make recommendations regarding the development of internal systems and controls to carry out the Business Ethics & Compliance Program.
6. Provide review and direction, as necessary, for compliance issues and/or concerns identified and provided to the Compliance Department (whether via the telephonic Hotline, via the Hotline “website,” in-person or otherwise).
7. Review results and provide assistance, as needed, regarding ongoing or completed investigations.
8. Provide any other necessary guidance and assistance that enables the Organization to develop and/or maintain an effective Business Ethics and Compliance Program.

Membership

• Chief Compliance Officer (Chairperson)
• Chief Executive Officer
• Chief Operating Officer
• Chief Information Officer
• Chief Financial Officer
• Chief Medical Officer
• Senior Vice President, Office of Advancement
• Vice President of Human Resources
• Vice President of Research & Innovation
• Vice President of Facility Services
• Vice President of Patient Experience
• Other ad hoc members as needed

Meeting schedule

The Compliance Committee will meet at least quarterly. Minutes will be taken and used as documentation to evidence the Annual Compliance Work Plan. Meetings may be held more frequently as necessary. On behalf of the Compliance Committee, the Chief Compliance Officer should endeavor to share relevant and timely information regarding the Organization’s Business Ethics and Compliance Program with members of the Organization’s Senior Management Team.

Agenda

1. Hotline reports (whether telephonic, via website, in-person or otherwise, with appropriate redaction as necessary).
2. Audit/monitoring results, as available.
3. Investigation reports.
4. Policy discussion/approval.
5. Industry-wide compliance updates.
6. Other Business.

Purpose

To provide written guidelines to all employees on their responsibility in the operation of Shepherd Center’s Business Ethics & Compliance Program.

Policy

Shepherd Center will comply with all applicable Federal and state statutes and regulations that pertain to the prevention, detection and correction of fraud, waste or abuse in the provision of health care services and reimbursement claims related thereto. Shepherd Center employees will utilize all available means to prevent, detect and correct (and, if necessary, report to the Chief Compliance Officer) any instances of fraud, waste or abuse in their department/program.

Definition

1. Fraud – an intentional deception designed to unlawfully deprive an individual or institution of something of value.
2. Waste – the extravagant, careless or needless expenditures of funds due to erroneous practice systems, controls or decisions.
3. Abuse – intentional, wrongful or improper use of position, financial arrangement or authority to the benefit of one entity over another.

Procedure

Shepherd Center employees will:

1. Support the Business Ethics & Compliance Program, particularly as it relates to the prevention, detection and correction of fraud, waste and abuse.
2. Follow applicable department/program internal controls pertaining to Shepherd Center’s Business Ethics & Compliance Program.
3. Maintain, and assist in maintaining, proper documentation for billing purposes.
4. Follow applicable department/program internal controls to ensure proper accounting of all patient charges that could affect reimbursement from third-party payors.
5. Assist their Department/Program Directors in the prevention, detection and resolution of instances of conduct that do not conform to Federal and state law(s) or the Business Ethics & Compliance Program.
6. Review annually, and adhere to daily, Shepherd Center’s Code of Conduct.
7. Be familiar with the objectives of the Business Ethics & Compliance Program.
8. Alert applicable supervisory personnel, Senior Management and/or the Chief Compliance Officer to any questionable or potentially unethical/unlawful business practices.
9. All employees are expected to alert the Compliance Department or Human Resources immediately if they believe that any of their activities may constitute a Conflict of Interest with Shepherd Center.
10. Report suspected fraud, waste or abuse to one or more of the following
    1. Immediate Supervisor
    2. Chief Compliance Officer
    3. 24-hour toll-free Compliance Hotline*

*Note: The employee may remain anonymous when reporting incidents of fraud, waste or abuse.

Purpose

To provide written guidelines to Shepherd Center management staff on their responsibility in the operation of Shepherd Center’s Business Ethics Program.

Policy

Shepherd Center will comply with all applicable Federal and state statutes and regulations that pertain to the prevention, detection and correction of fraud, waste or abuse in the provision of health care services and reimbursement claims related thereto. As such, Shepherd Center management will ensure and oversee that staff under their supervision will utilize available means to prevent, detect and correct any instances of fraud, waste or abuse within the scope of their services.

Definition

1. Fraud – an intentional deception designed to unlawfully deprive an individual or institution of something of value.
2. Waste – the extravagant, careless or needless expenditures of funds due to erroneous practice systems, controls or decisions.
3. Abuse – intentional, wrongful or improper use of position, financial arrangement or authority to the benefit of one entity over another.

Procedure

Shepherd Center management will:

1. Support the Business Ethics Program, particularly as it relates to the identification, correction and prevention of fraud, waste and abuse.
2. Develop or assist in the development of written standards of conduct, policies and procedures that address specific areas of potential fraud, waste and abuse in their department/service/program.
3. Develop or assist in the development of effective internal controls and monitoring to identify, correct and prevent fraudulent, wasteful or abusive activities within their scope of responsibility.
4. Include in the evaluation process of their employee’s adherence to compliance and the Business Ethics Program.
5. Oversee and monitor the proper documentation of all activities for billing purposes.
6. Establish internal controls to ensure proper accounting of all patient charges, independent contracts, etc. that could affect reimbursement from third-party payors.
7. Provide their personnel effective education and training programs on an ongoing basis to ensure that they are knowledgeable about compliance and Shepherd Center’s Business Ethics Program.
8. Provide their personnel with appropriate guidance in the prevention, detection and resolution of instances of conduct that do not conform to federal and state laws or the Business Ethics Program.
9. Properly display compliance posters with “Compliance Hotline” phone numbers and other related contact information within their area(s) of responsibility.
10. Provide a mechanism for furnishing and disseminating information and guidance on Federal
    and state statues, regulations and other requirements to their personnel.
11. Ensure that their personnel are knowledgeable on reporting suspected fraud, waste and abuse violations without the fear of retaliation.
12. Ensure that policies and procedures are established pertaining to documentation (creation, distribution, retention, storage, retrieval, destruction, etc.) within their department/service/program.
13. Provide their employees with the established corrective action plans for improper conduct to ensure consistent application and enforcement of the standards throughout Shepherd Center.

Purpose

The purpose of this policy is to guide the business behavior of Shepherd Center’s vendors and contractors in an effort to ensure their ethical conduct.

Policy

In contracting with or selling goods and/or services to Shepherd Center, the vendor/contractor and their respective agents agree to act in compliance with all applicable laws, regulations and Shepherd Center’s Code of Ethical Conduct. Further, in contracting with or selling goods and/or services to Shepherd Center’s inpatients and outpatients (and their respective families), the vendor/contractor and their respective agents are expected to comply with all applicable laws, regulations and Shepherd Center’s Code of Ethical Conduct.

Primary objectives

1. The following general control procedure applies to commercial business representatives who visit Shepherd Center during normal business hours
   1. Shepherd Center/employee related
      1. Prior to entering Shepherd Center premises, all vendor/contractor representatives must have a scheduled appointment with an employee of Shepherd Center. All such representatives are required to check in with the security officer at the Security Desk on the first floor of the Marcus Building, log into Reptrax and receive an identification sticker prior to proceeding to their scheduled appointment.
      2. Construction contractors are required to report to Plant Maintenance to receive an identification badge.
      3. In the event of emergency circumstances that require a visit to Shepherd Center after normal business hours by vendor/contractor representatives, the representative must check in with the security guard at the Security Desk on the first floor of the Marcus Building, log into Reptrax, receive an identification sticker and provide a reason for the emergency visit.
   2. Patient/family related
      1. Any vendor/contractor representative who desires to meet with a Shepherd Center patient or their family must schedule an appointment through the applicable Program (e.g., SCI, ABI, MS, etc.) scheduler.
      2. When arriving at Shepherd Center for an appointment with a patient or their family, the representative is required to check in with the security guard at the Security Desk on the first floor of the Marcus Building, log into Reptrax and receive an identification sticker.
      3. Any representative invited to events such as seminars, equipment demonstrations, shows, etc. is allowed to give out information about their products and their company but is not allowed to ask for any personal information from patients and their family, such as their name, address, phone number, e-mail address, etc.
2. The following will be expected of all vendors/contractors and their respective representatives who conduct business with Shepherd Center:
   1. Familiarity with Shepherd Center’s Code of Ethical Conduct.
   2. It is mandatory for any vendor/contractor to report any actual, suspected or possible violation of fraud and abuse laws to Shepherd Center’s Chief Compliance Officer.
   3. Failure to follow the standards of the Code of Ethical Conduct will result in action by Shepherd Center up to and including termination of Shepherd Center’s business relationship with the vendor/contractor.
   4. All vendors/contractor representatives are expected to comply with any and all infection control measures that are currently in effect at Shepherd Center and that are deemed applicable to the vendor/contractor representative during their visit to Shepherd Center (e.g., masks, gloves, goggles, etc.).

Policy

It is the policy of Shepherd Center and Affiliates to ensure full compliance with all applicable federal and state statutes, regulations concerning anti-kickback and self-referrals as well as Stark laws.

Procedure

To ensure that Shepherd Center and Affiliates are in complete compliance with regulations concerning anti-kickbacks, self-referrals and Stark laws, the Business Ethics Program provides that:

1. All Shepherd Center contracts and arrangements with referral sources comply with all applicable statutes and regulations.
2. Shepherd Center will not submit or cause to be submitted to any governmental program (including, without limitation, any health care program funded in whole or in part by any federal, state or local government) any claim for reimbursement for services provided to any patient who was referred to Shepherd Center in violation of any statutes or regulations pertaining to kickbacks and/or referrals of patients.
3. Shepherd Center will not enter into any financial arrangement with another entity or individual that is designed to provide inappropriate remuneration to either party.

Purpose

It is the policy of Shepherd Center to obey the law and and eliminate fraud, waste and abuse with respect to payments to Shepherd Center from any organization (specifically including federal and/or state health care programs) providing payment for patient care or services. This policy applies to all employees, management, contractors and agents of Shepherd Center.

This policy and the information contained in it shall be made available to all current and new employees and to all current and future contractors of Shepherd Center.

This policy includes information concerning tools federal and state agencies use to fight fraud, waste and abuse in the administration of federal and state health programs at Shepherd Center: Specifically, this policy addresses the following:

• A summary of the Federal False Claims Act
• A summary of administrative remedies found in the Program Fraud Civil Remedies Act
• A summary of laws of the state of Georgia addressing fraud and abuse and training requirements on policies and procedures.
• The role of such laws in preventing and detecting fraud, waste, and abuse in federal and state health care programs
• Shepherd Center’s existing policies and procedures for detecting and preventing fraud.

Federal law

The federal false claims act

Summary of provisions: The Federal False Claims Act (FCA) prohibits knowingly making a false claim against the government. False claims can take the form of overcharging for a product or service, delivering less than the promised amount or type of service, delivering less than the promised amount or type of goods or services, underpaying money owed to the government and charging for one thing while providing another.

Penalties:The FCA imposes civil penalties and is not a criminal statute. Therefore, no proof of specific intent as required for violation of a criminal statute is necessary.

Persons (including organizations such as hospitals) may be fined a civil penalty of not less than $5,000 nor more than $10,000, plus three (3) times the amount of damages sustained by the government for each false claim. The amount of damages in health care terms is the amount paid for each false claim that is filed.

Qui Tam (Whistleblower) provisions

Any person may bring an action under this law (called a qui tam realtor or whistleblower suit) in federal court. The case is initiated by causing a copy of the complaint and all available relevant evidence to be served on the federal government. The case will remain sealed for at least 60 days and will not be served on the defendant so the government can investigate the complaint. The government may obtain additional time to investigate for good cause. The government on its own initiative may also initiate a case under the FCA.

After the 60 day period, or any extensions, has expired, the government may pursue the matter in its own name, or decline to proceed. If the government declines to proceed, the person bringing the action has the right to conduct the action on their own in federal court.

If the government proceeds with the case, the qui tam relator bringing the action will receive between 15 and 25 percent of any proceeds, depending upon the contributions of the individual to the success of the case. If the government declines to pursue the case, and the qui tam realtor successfully prosecutes the claim, the relator will be entitled to between 25 and 30 percent of the proceeds of the case, plus reasonable expenses and attorneys fees and costs.

Any case must be brought within six years of the filing of the false claim.

Non-Retaliation: Anyone initiating a qui tam case may not be discriminated or retaliated against in any manner by their employer by virtue of bringing the claim. The employee is authorized under the FCA to initiate court proceedings to make themselves whole for any job related losses resulting from any such discrimination or retaliation.

Program fraud civil remedies act

The Program Fraud Civil Remedies Act creates administrative remedies for making false claims separate from, and in addition to, the judicial or court remedy for false claims provided by the Civil False Claims Act.

The Act is quite similar to the Civil False Claims Act in many respects, but is somewhat broader and more detailed, with differing penalties. The Act deals with submission of improper “claims” or “written statements” to a federal agency.

• Specifically, a person violates this act if they know or have reason to know they are submitting a claim that is
  • False, fictitious or fraudulent; or,
  • Includes or is supported by written statements that are false, fictitious or fraudulent; or,
  • Includes or is supported by a written statement that omits a material fact; the statement is false, fictitious or fraudulent as a result of the omission; and the person submitting the statement has a duty to include the omitted facts; or
  • For payment for property or services not provided as claimed.

A violation of this prohibition carries a $5,000 civil penalty for each such wrongfully filed claim. In addition, an assessment of two times the amount of the claim may be made, unless the claim has not actually been paid.

• A person also violates this act if they submit a written statement which they know or should know:
  • Asserts a material fact which is false, fictitious or fraudulent; or,
  • Omits a material fact and is false, fictitious or fraudulent as a result of the omission. In this situation, there must be a duty to include the fact and the statement submitted contains a certification of the accuracy or truthfulness of the statement.

A violation of the prohibition for submitting an improper statement carries a civil penalty of up to $5,000.

Georgia law

Georgia anti-fraud law and training requirements related to health care

1. O.C.G.A 49-4-146.1. Unlawful to obtain benefits and payments under certain circumstances; penalties; procedures
   This Georgia statute can be described as Georgia’s Medicaid Unlawful Payment Statute. Only part of the statute is included in this policy.

   O.C.G.A. 49-4-146.1 (b) provides that it shall be unlawful:

   1. For any person or provider to obtain, attempt to obtain, or retain for himself, herself, or any other person any medical assistance or other benefits or payments under this article, or under a managed care program operated, funded, or reimbursed by the Georgia Medicaid program, to which the person or provider is not entitled, or in an amount greater than that to which the person or provider is entitled, when the assistance, benefit, or payment is obtained, attempted to be obtained, or retained, by:
      1. Knowingly and willfully making a false statement or false representation;
      2. Deliberate concealment of any material fact; or
      3. Any fraudulent scheme or device; or
   2. For any person or provider knowingly and willfully to accept medical assistance payments to which he or she is not entitled or in an amount greater than that to which he or she is entitled, or knowingly and willfully to falsify any report or document required under this article.

      Any person violating paragraph (1) or (2) shall be guilty of a felony and, upon conviction thereof, shall be punished for each offense by a fine of not more than $10,000.00, or by imprisonment for not less than one year nor more than ten years, or by both such fine and imprisonment. The statute is a criminal statute and, the state has the burden of proving beyond a reasonable doubt that the defendant intentionally committed the acts for which he or she is charged. In addition to criminal penalties, any person committing abuse shall be liable for a civil monetary penalty equal to two times the amount of any excess benefit or payment.

      ‘Abuse’ is defined in the statute as a provider knowingly obtaining or attempting to obtain medical assistance or other benefits or payments under this article to which the provider knows he or she is not entitled and the assistance, benefits, or payments directly or indirectly result in unnecessary costs to the medical assistance program.” Isolated instances of unintentional errors in billing, coding, and costs reports shall not constitute abuse. Miscoding shall not constitute abuse if there is a good faith basis that the codes used were appropriate under the department’s policies and procedures manual and there was no deceptive intent on the part of the provider.

      In addition to any other penalties provided by law, each person violating this law shall be liable for a civil penalty equal to the greater of (1) three times the amount of any such excess benefit or payment or (2) $ 1,000.00 for each excessive claim. Additionally, interest on the penalty shall be paid at the rate of 12 percent per annum.

2. Georgia has a Patient Self Referral Act which, while similar to the federal Stark law in some ways, is significantly different in terms of when it applies and to whom it applies. It can be found at O.C.G.A. § 43-1B-1. It is not included in this policy since it addresses financial arrangements and investment interest issues by physicians.
3. GA ADC 290-9-7-.12. Human Resources Management.
   Georgia hospital licensing regulations require hospitals to train its employees on the hospital’s policies and procedures. Specifically, GA ADC 290-9-7.12 pertains to Personnel training programs. The hospital shall have and implement a planned program of training for personnel to include at least:
   1. Hospital policies and procedures;
   2. Fire safety, hazardous materials handling and disposal, and disaster preparedness;
   3. Policies and procedures for maintaining patients’ medical records;
   4. The infection control program and procedures; and
   5. The updating of job-specific skills or knowledge.
4. GA ADC 290-9-7-.41. Enforcement of Rules and Regulations.
   Georgia’s hospital licensing regulations also contains enforcement provisions. GA ADC 290-9-7.41 provides “A hospital that fails to comply with these rules and regulations shall be subject to sanctions and/or permit revocation as provided by law. The enforcement and administration of these rules and regulations shall be as prescribed in the Rules and Regulations for Enforcement of Licensing Requirements, Chapter 290-1-6, pursuant to O.C.G.A. Sec. 31-2-6.”

Role in preventing and detecting fraud, waste & abuse in federal and state health care programs

The laws described in this policy create a comprehensive process for controlling fraud, waste and abuse in federal and state health care programs by giving appropriate governmental agencies the authority to seek out, investigate and prosecute violations. Enforcement activities are pursued in three available forums: criminal, civil and administrative. This provides a broad spectrum of remedies to address the fraud and abuse problem.

Moreover, whistleblower protections, such as those included in the federal False Claims Act, provide protections for individuals reporting fraud and abuse in good faith.

Shepherd Center’s policies for detecting and preventing fraud

All policies and procedures relating to fraud and abuse (Business Ethics & Compliance Program) are available to all employees in the Shepherd Center intranet-based policy and procedure manual database. Any business ethics concerns may be reported through the chain of command or to the Compliance Hotline (1-800-860-0085). Reports made to the Compliance Hotline may be done so on an anonymous basis.

Purpose

To establish a process to report and return identified and quantified overpayments from Federal healthcare programs.

Responsiblity

It is the responsibility of every Shepherd Center employee or agent to report any suspected business- related fraud, waste or abuse immediately to their supervisor, the Chief Compliance Officer or the 24- hour toll-free Compliance Hotline (800-860-0085). It is the responsibility of the Chief Compliance Officer to evaluate and investigate all reports of suspected business-related fraud, waste or abuse.

Policy

Shepherd Center will exercise reasonable diligence to review potential payment errors. If a potential overpayment is identified, appropriate efforts will be exerted in an expeditious manner to confirm whether an overpayment exists. If an overpayment is actually confirmed (i.e., “identified”), the scope and monetary extent of the overpayment will also be determined (i.e., “quantified”) in an expeditious
manner. Overpayments that have been identified and quantified will be reported and refunded to the appropriate Federal healthcare program within 30 days, when practicable, but in no event later than 60 days from the date of identification and quantification of the overpayment. Shepherd Center will likewise report errors that require collection of underpayments to the appropriate Federal healthcare program in a timely manner.

Definitions

Federal healthcare program: Any plan or program that provides health benefits, whether directly, through insurance, or otherwise, which is funded directly, in whole or in part, by the United States Government (other than the health insurance program under chapter 89 of title 5 of the United States Code — the Federal Employees Health Benefit Program); or any State health care program, as defined in 42 U.S.C. § 1320a-7(h).

Federal healthcare programs include, at a minimum, the following:

• Medicare Program, Parts A, B and C (managed Medicare)
• Medicaid (Title XIX of the Social Security Act), including managed Medicaid
• Federal Prison Hospitals (prisoners);
• Indian Health Service;
• OWCP (workers’ compensation for federal employees);
• Public Health Service;
• Railroad Retirement Board;
• The Black Lung Program;
• TRICARE/CHAMPUS/Department of Defense healthcare programs (Chapter 55 of Title 10, United States Code); and
• Veterans Administration (VA).

Identified: The date on which Shepherd Center has determined, or should have determined through the exercise of reasonable diligence, that an overpayment has been received from a Federal healthcare program, and has quantified the overpayment amount.

Overpayment: Any funds that Shepherd Center has received or retained under a Federal healthcare program to which Shepherd Center, after applicable reconciliation, is not entitled.

Reasonable diligence: In response to obtaining credible information of a potential overpayment, conducting both proactive compliance activities in good faith by qualified individuals at Shepherd Center to monitor for the receipt of overpayments; and research in good faith and in a timely manner by qualified individuals at Shepherd Center. Shepherd Center efforts to review, report and return a potential overpayment should typically be completed within a period of up to eight months (six months for the timely review and up to two months for reporting and returning the identified and quantified overpayment). However, complex matters and refund calculations may result in extending this time frame.

Procedure

1. Anyone who has credible information about a pattern of potential overpayments from a Federal healthcare program must immediately report the information to (i) a supervisor, (ii) the Chief Compliance Officer (CCO), and/or (iii) the 24-hour toll-free Compliance Hotline (800-860-0085). This notification should include a narrative description of the matter based on current knowledge, with as much specificity as possible, to assist in further review. For example, a detailed description of the issue, the type of service (inpatient, outpatient, hospital, physician, etc.), and the affected service line(s) (e.g. , radiology, pharmacy, lab, etc.).
   Generally, isolated clerical errors, unintended patient specific coding/charging/billing errors, or any other non-repetitive errors (i.e. , errors that only affect a single claim or handful of claims) resulting in an overpayment should be dealt with in the ordinary course of business and shall be refunded within 60 days.
2. Compliance Department personnel, along with the appropriate personnel with operational responsibility for the areas involved, will engage in, or facilitate, the exercise of reasonable diligence, including conducting a review into the matters at issue.
3. Based upon the findings of the reasonable diligence, the Compliance Department will consult, as necessary and appropriate, with responsible operators, outside legal counsel and other relevant parties with substantive knowledge of the issue, to determine if an overpayment has been identified. This would include a determination as to the initial matter and the appropriate time frame to be addressed.
4. If an overpayment is identified:
   1. The Compliance Department will take prompt action to (i) notify the appropriate personnel with operational responsibility for the impacted claims of the overpayment amount, and (ii) coordinate with such personnel regarding the method for reporting and returning the overpayment.
   2. Management of the areas with operational responsibility will correct the cause of the overpayment on a going forward basis and take other remedial actions as may be necessary to minimize recurrence. In addition, other appropriate corrective actions should be undertaken, which may include education and training of staff, revisions to policies, processes or systems, information system changes, ongoing monitoring and auditing, and disciplinary actions for personnel consistent with Shepherd Center policies and procedures.
5. The Compliance Department will endeavor to ensure that the overpayment will be timely reported and returned within 30 days, when practicable, but in no event later than 60 days from the date of identification and quantification. Depending on the situation, the refund may be made by check, claims adjustment, charge correction, credit balance or other government-approved process for reporting and returning of overpayments.
6. If an underpayment error is identified, Shepherd Center may request additional payment, as permissible.

Purpose

To provide guidelines to all Shepherd Center and affiliates staff on the use of the Ethics in Business Compliance Hotline (the “Compliance Hotline”).

Policy

It is the policy of Shepherd Center for all employees, agents, contractors and vendors to report any ethical concerns and/or suspected fraud or abuse activities to one or more of the following: a Supervisor, Manager, Director, Vice-President, the CEO, the Chief Compliance Officer or through the Compliance Hotline.

Responsibility

1. It is the responsibility of the Chief Compliance Officer to ensure that all Executive Management and Senior Management are completely knowledgeable in the operation and use of the Compliance Hotline.
2. It is the responsibility of Senior Management to ensure that all staff under their direction understand the availability and use of the Compliance Hotline.

Procedure

1. All employees of Shepherd Center and affiliates will be trained in the use of the Compliance Hotline, as well as given a card with number and information. The Compliance Hotline number will be posted throughout employee areas and on bulletin boards.
2. During employee orientation and at such other times as may be appropriate, employees will be provided with information (e.g., a Compliance Hotline business card) that indicates the various ways to contact the Compliance Hotline. The Compliance Hotline can be contacted via telephone, internet website or QR code.
3. Employee may call or contact the Compliance Hotline at any time 24 hours a day from any telephone or computer anywhere in the United States toll free. The toll free phone number is (800) 860-0085 and the applicable internet website is saysomethingshepherd.ethicspoint.com.
4. The employee may contact the Compliance Hotline to reach a trained communication specialist, who is employed by an independent third-party vendor retained by Shepherd Center to monitor our Compliance Hotline. This individual, who has no affiliation with Shepherd Center, will accept, debrief, document and report all incoming compliance line calls.
5. Employees may choose either to give their name and position or they may remain anonymous at which point they will be given a control number.
6. Calls dealing with issues other than business compliance (e.g., Payroll, Human Resources, etc.), may be referred to the appropriate department when applicable.
7. All anonymous callers who use the Compliance Hotline will be given a follow-up date to call back to the Compliance Hotline to receive a response from Shepherd Center on the caller’s concerns.
8.  The Compliance Department shall keep a log of all Compliance Hotline matters, including any applicable resolution or outcome of the given matter.

Anonymity

If the Compliance Department determines that an anonymous call cannot be investigated without additional information, the Chief Compliance Officer will determine what appropriate action may be taken. Appropriate action may consist of informing our independent third-party vendor that insufficient information has been provided and the identification of the additional information required. Until the additional information is provided, the case will ordinarily be closed.