1.3.3 Compliance & Ethics
1.3.3. – Compliance & Ethics (Revision 10/2020)
The Amerimed Corporate Compliance Program serves to address and resolve known or suspected illegal or unethical matters within the organization. It is the responsibility of the Compliance Officer to oversee, implement, assess, review, revise, and enforce all compliance policies within all departments of Amerimed.
These policies have been adopted by our leadership team and summarize the virtues and principles that are to guide our actions in the delivery of health care. We expect our agents, consultants, contractors, representatives, and suppliers to be guided by them as well.
There are numerous resources available to assist you in meeting the challenge of performing your duties and responsibilities. There can be no better course of action for you than to apply common sense and sound judgment, based on established industry standards, to the manner in which you conduct yourself. However, do not hesitate to use the resources that are available whenever it is necessary to seek clarification.
The elements of Amerimed’s AMERIMED Compliance Program which impacts all associates are outlined below. In addition to this overview, the Compliance Program contains policies associated with specific services that will be communicated to the associates to whom they pertain.
Questions regarding this policy or the Compliance Program can be addressed by the Compliance Officer, or the OCEAMERIMED.
Amerimed Guidelines on Ethical Conduct – Commitment to Lawful and Ethical Behavior
Amerimed established this program to support our commitment to the provision of health care services in full compliance with all federal, state and local laws and regulations, and to set forth proactively preventing, detecting, and reporting violations of the laws and regulations which govern this organization and the services we provide. The guiding principles for the provision of those services are summarized in this policy.
The Compliance Program describes the mechanism by which management exercises due diligence in seeking to prevent and detect any behavior contrary to those principles. Perhaps most important, it supports the existence of a corporate culture that places the highest value on integrity in the achievement of its mission.
Standards of Conduct and Compliance Policies
In addition to the Guidelines on Ethical Conduct that applies to all associates, standards of conduct pertinent to some of the services provided by Amerimed have been developed. Written policies are in place addressing specific areas of potential fraud, such as claims development and submission processes, coding accuracy, and financial relationships with insurance companies, facilities, and other health care professionals.
The objectives of those standards of conduct and policies are to:
- (1) Establish the high values expected of associates;
- (2) Provide explicit guidelines for associates to follow;
- (3) Ensure all associates understand what is expected;
- (4) Ensure associates are implementing those standards as a daily practice;
- (5) Enhance a corporate culture supporting compliance with federal and state law, and federal, state and private payer health care program requirements, as well as AMERIMED’s ethical and business policies; and
- (6) Build trust in the community using Amerimed’s services.
Special attention is given to those health care services and activities that represent the most significant exposure to fraud and abuse of laws and regulations that govern federally funded programs.
The Guidelines on Ethical Conduct & Compliance policies will be made available to and in a form that is understandable by all associates. Annually, each associate will be required to complete and sign an attestation that he/she has received and understands the Guidelines on Ethical Conduct policy and the Compliance Policy.Amerimed’s Compliance Program will be regularly updated as the policies and regulations addressed in the Program are modified.
Standards and Methods for Delegating Authority
Amerimed will exercise due care not to delegate substantial discretionary authority to individuals whom the organization knew, or should have known, through the exercise of due diligence, had a propensity to engage in illegal activities. This will be accomplished by conducting a reasonable and prudent background investigation, including a reference check, as part of every such employment application.
Amerimed prohibits the employment of individuals who have been convicted of a criminal offense related to health care or who are listed by a federal agency as debarred, excluded or otherwise ineligible for participation in federally funded health care programs. Associates who are charged with criminal offenses related to health care or proposed for exclusion or debarment will be removed from direct responsibility for or involvement in any federally funded health care program. If resolution results in conviction, debarment, or exclusion of the individual, Amerimed will terminate its employment of that individual.
Effective Communication of Standards and Procedures
The compliance policies and standards contained in the Compliance Policy will be effectively communicated on a regular basis to those associates and other agents to whom they pertain through training programs or publications that explain in a practical manner what is required. Communications with associates will emphasize
- (1) Amerimed’s commitment to compliance;
- (2) The importance of complying with the laws and regulations governing the services which Amerimed provides;
- (3) The specific requirements of the regulations as they relate to an individual’s job; and
- (4) The obligation of each associate to behave in a manner consistent with the principles articulated in the Guidelines on Ethical Conduct and the Compliance Program.
Monitoring and Auditing Systems
Amerimed will take reasonable steps to assess the effectiveness of the Compliance Program by utilizing audits and other evaluation techniques to monitor compliance and assist in the resolution of problems identified. The results of those monitoring and auditing activities will be reported on a regular basis to the leadership. A detailed report on the results of all monitoring and auditing activities will be maintained by the Compliance Officer.
Internal Reporting and Responding to a Suspected Violation
Amerimed is committed to providing an environment that encourages and allows associates to seek and receive prompt guidance before doing anything that may violate the Guidelines on Ethical Conduct, and to report conduct that a reasonable person would suspect to be a violation of internal compliance policies, applicable statutes, regulations, or federal health care program requirements. Amerimed absolutely prohibits retaliation against any employee who makes a good faith report of a compliance issue.
A telephone number (800-902-3300 option 8) is provided for associates and agents of Amerimed as an optional mechanism to report any activity and/or conduct they suspect is not in adherence to the Amerimed Guidelines on Ethical Conduct or Compliance Program. Information received will be used to investigate and verify whether or not improper activity has occurred, and to correct and prevent inappropriate conduct. To the extent possible and appropriate, Amerimed will endeavor to conceal the identity of anyone reporting a possible violation. Complete confidentiality, however, cannot be guaranteed.
When the Compliance Officer or management personnel learn of a potential violation or misconduct the matter will be promptly investigated. Associates are expected to cooperate in the investigation of possible violations but should NOT try to investigate by themselves without involving the compliance officer. Investigations may raise complex legal issues and Amerimed could lose important privileges if an investigation is carried out without legal advice. Also, an investigation may lead to judicial, administrative, or legislative action, for which Amerimed needs legal representation at the earliest stage.
If any person who identifies himself or herself as a government investigator approaches an associate, the associate should contact a supervisor immediately. An appropriate representative of the leadership team will verify the credentials of the investigator, determine the legitimacy of the investigation, and ensure that proper procedures are followed for cooperating with the investigation.
Associates contacted by persons presenting themselves as government investigators outside of the work place, during non-work hours, or at home, should not feel pressured to talk with the person under such circumstances without contacting a supervisor or their personal attorney. It is the legal right of associates to contact legal counsel before responding to questions by an investigator.
During a government investigation associates must never conceal, destroy, or alter any documents, lie, or make misleading statements to government investigators. All efforts to cooperate with the government should be coordinated through Amerimed legal counsel.
If an investigation reveals misconduct did occur corrective action will be immediately initiated. Amerimed will take all reasonable steps to respond appropriately to the offense and to prevent further similar offenses, including any necessary modification of the Guidelines on Ethical Conduct and/or the Compliance Program. If an investigation reveals that Amerimed received payments to which it was not entitled, Amerimed will make prompt restitution of such sums to the appropriate federally funded health care program. The responsibility for investigating, reporting, and correcting problems that have been identified lies with the Compliance Officer and other senior leadership of Amerimed.
Enforcement and Disciplinary Action
Disciplinary action will be initiated against individuals who have failed to comply with the Guidelines on Ethical Conduct and Compliance Program, thereby impairing Amerimed’s status as a reliable, honest, trustworthy provider.