Western Maryland Health System
Corporate Compliance
Policy Statement

Western Maryland Health System (WMHS) has a policy of maintaining the highest level of professional and ethical standards in the conduct of its business. WMHS places the highest importance on its reputation for honesty, integrity, and ethical standards. This Policy is a reaffirmation of the importance of the highest level of ethical conduct and standards. This Policy is consistent with the Core Values of WMHS, which include: Respect, Integrity, Quality, Community Advocacy, and Resourcefulness.

These standards can be achieved and sustained only through the action and conduct of all personnel of WMHS. Each and every employee including management of WMHS is obligated to conduct themselves in a manner to ensure the maintenance of these standards. Such actions and conduct will be important factors in evaluating an employee's judgment and competence, and an important element in the evaluation of an employee for raises and for promotion. Employees who ignore or disregard the principles of this Policy will be subject to appropriate progressive disciplinary action up to and including dismissal.

Employees must be cognizant of all applicable federal and state laws and regulations that apply to and affect the documentation, coding, billing, and competitive practices, as well as the day-to-day activities of WMHS and its employees and agents. Each employee who is materially involved in any of these activities must familiarize themselves with all such applicable laws and regulations and adhere at all times to the requirements thereof. These laws can be found in the WMHS Corporate Compliance Manual or the Standards of Conduct. Where any question or uncertainty regarding these requirements exists, it is incumbent upon, and the obligation of, each employee to seek guidance from a knowledgeable source within WMHS.

Key Standards of Conduct

WMHS is committed to full compliance with all federal health care program requirements, including the obligation to prepare and submit accurate claims consistent with such requirements;

WMHS expects, as a condition of employment or any business relationship, that all covered employees, directors, officers, contractors, suppliers or vendors will comply with the WMHS' Standards of Conduct, Compliance Policy and any additional requirements, such as the Office of Inspector General Corporate Integrity Agreement (OIG-CIA) agreed to by WMHS on November 6, 2006. Compliance with these policies is component of an employee's job performance evaluation;

WMHS employees and other covered persons are expected to report to the WMHS Corporate Compliance Officer, or other individual designated by WMHS, any suspected violations of the WMHS Standards of Conduct or Compliance Policy, or any of the requirements of federal health care programs;

Any failure to report non-compliance puts WMHS and its covered employees, directors, officers, contractors, suppliers and vendors at risk for legal exposure for violations of administrative, civil or criminal statutes and further jeopardizes WMHS' right to seek payments for health care services rendered to federal health care program beneficiaries.

WHMS is required to and will undertake appropriate disciplinary action or other reporting obligation as a consequence of any employee or other covered person failing to report noncompliance issues with federal health care programs or the WMHS Standards of Conduct and Compliance Policy;

WMHS maintains a confidential disclosure program for reporting non-compliance issues. All WMHS employees and other covered persons have the right to report non-compliance issues or concerns in a confidential and anonymous manner. WMHS pledges to maintain a non-retaliatory and non-retribution environment for non-compliance reporting. The WMHS toll-free hotline is 1-866-463-2246. All concerns or issues reported will be reviewed and appropriate corrective action will be taken in response to any concerns or issues raised.

WMHS shall not retaliate in any way against an employee who reports these actions to his or her supervisor and/or to the Corporate Compliance Officer.

Specific Compliance Issues

The following conduct shall be prohibited:

1. Improper Claims
   Presenting or causing to be presented to the U. S. Government or any other healthcare payor a claim:
   1. Item or Service Not Provided as Claimed
      For a medical or other item or service that such person knows or should know¹ was not provided as claimed, including a pattern or practice of presenting or causing to be presented a claim for an item or service that is based on a code that such person knows or should know will result in a greater payment to the claimant than the code such person knows or should know is applicable to the item or service actually provided;
   2. False Claim
      For a medical or other item or service and such person knows or should know that the claim is false or fraudulent;
   3. Service by Unlicensed Physician
      For a physician's service (or an item or service incident to a physician's service) when such person knows or should know the individual who furnished (or supervised the furnishing of) the service:
      1. was not a licensed physician;
      2. was licensed as a physician, but such license had been obtained through a misrepresentation of material fact (including cheating on an examination required for licensing); or
      3. represented to the patient at the time the service was furnished that the physician was certified in a medical specialty board when the individual was not so certified;
   4. Excluded Provider
      For a medical or other item or service furnished during a period in which such person knows or should know the claimant was excluded from the program under which the claim was made;
   5. Not Medically Necessary
      For medical or other items or services that such person knows or should know are not medically necessary;
2. False Statements in Determining Rights to Benefits
   Making, using, or causing to be made or used any false record, statement, or representation of a material fact for use in determining rights to any benefit or payment under any healthcare program;
3. Conspiracy to Defraud
   Conspiring to defraud the U. S. Government or any other healthcare payor by getting a false claim allowed or paid;
4. Patient Dumping
   Refusing to treat, transferring, or discharging any individual who comes to the emergency department, and on whose behalf a request is made for treatment or examination, without first providing for an appropriate medical screening examination to determine whether or not such individual has an emergency medical condition, and, if such individual has such a condition, stabilizing that condition or appropriately transferring such individual to another facility in compliance with the requirements of 42 U. S C. § 1395dd;
5. Provision of Care to Contract HMO Patients
   Knowingly failing to provide covered services or necessary care to members of a health maintenance organization with which WMHS has a contract;
6. Healthcare Fraud/False Statements Relating to Healthcare Matters
   Executing or attempting to execute a scheme or artifice to defraud any healthcare benefit program or to obtain, by means of false, fictitious, or fraudulent pretenses, representations or promises, any of the money or property owned by, or under the custody or control of, any healthcare benefit program;
7. Referral Restrictions and Prohibitions
   Presenting or causing to be presented a claim for reimbursement to any individual, third-party payor, or other entity for designated health services² that were furnished pursuant to a referral by a physician who has a financial relationship with WMHS, as such is defined in 42 U. S. C. § 1395nn;

   Except as otherwise provided in 42 U. S. C. § 1320a-7b (b), knowingly and willfully;

   1. Soliciting or receiving any remuneration (including any kickback, bribe, or rebate) directly, overtly or covertly, in cash or in kind either:
      1. in return for referring an individual to a person for the furnishing or arranging for the furnishing of any item or service for which payment may be made in whole or in part under a federal healthcare program; or
      2. in return for purchasing, leasing, ordering, or arranging for or recommending purchasing, leasing, or ordering any good, facility, service or item for which payment may be made in whole or in part under a federal healthcare program; or
   2. Offering or paying any remuneration (including any kickback, bribe, or rebate) directly or indirectly, overtly or covertly, in cash or in kind to any person to induce such person either:
      1. to refer an individual to a person for the furnishing or arranging for the furnishing of any item or service for which payment may be made in whole or in part under a federal healthcare program; or
      2. to purchase, lease, order, or arrange for or recommend purchasing, leasing, or ordering any good, facility, service, or item for which payment may be made in whole or in part under a federal healthcare program;
8. Failure to Report Violations to Corporate Compliance Officer
   Failing to promptly report to the Corporate Compliance Officer (as defined in the WMHS Corporate Compliance Manual) any instance of noncompliant conduct, including, without limitation, violations of the standards described in subparagraphs one through seven above, with respect to WMHS or any of its employees which is known to such person.

¹For purposes of this Policy, the term "should know" means that a person, with respect to information (1) acts in deliberate disregard of the truth or falsity of the information or (2) acts in reckless disregard of the truth or falsity of the information.

²The term "designated health services" means any of the following items or services: clinical laboratory services; physical therapy services; occupational therapy services; radiology services, including magnetic resonance imaging, computerized axial tomography scans, and ultrasound services; radiation therapy services and supplies; durable medical equipment and supplies; parenteral and enteral nutrients, equipment, and supplies; prosthetics, orthotics, and prosthetic devices and supplies; home health services; outpatient prescription drugs; or inpatient and outpatient prescription drugs; or inpatient and outpatient WMHS services.