Healthcare Compliance Policy

Letter from Chief Medical Officer

At Midwest Express Clinic, it is our mission to provide the highest quality management services to our affiliated medical practices, and to maintain a safe environment for our employees and for their patients. Our employees, contractors and other affiliated persons all contribute to the continuing success of our company, including its success in complying with all applicable laws and requirements.

Attached you will find the Midwest Express Clinic Code of Conduct. This Code of Conduct is an important document, as it reflects our commitment to compliance with all applicable federal, state and local laws, rules and regulations and with Midwest Express Clinic’s policies and procedures. Each member of the Midwest Express Clinic team should read and understand the Code of Conduct. Each member has a duty to abide by the Code of Conduct and to carry out his or her responsibilities in accordance with the expectations set forth therein.

Midwest Express Clinic is committed to creating an environment where open and honest communication is the expectation, not the exception. We encourage you to report any issues or potential instances of non-compliance that you may come across to your supervisor or to the Compliance Officer. Should you prefer to raise a concern to an independent third party, we have launched a toll-free Compliance Hotline number or On line Reporting portal through which you can raise any concerns you may have about ethics and compliance. Midwest Express Clinic has a firm policy of non-retaliation, which protects you from retaliation, retribution or harassment resulting from reporting a compliance concern.

We thank you for your continuing efforts on behalf of Midwest Express Clinic. Working together, we can achieve our goal of providing the highest quality management services to our affiliated medical practices.

Sincerely,

Linda A. Palumbo, M.D., Chief Medical Officer

Code of Conduct

Section 1: Introduction

1.1 Introduction

Midwest Express Clinic (herein referred to as the “Company”) is dedicated to providing the highest quality management services to our affiliated practices in an environment that is positive and patient-centered. This, in turn, allows our affiliated practices and professionals to focus on the provision of superior medical care services in a safe and compassionate manner. We are committed to full compliance with all applicable federal, state and local laws, rules, and regulations. This Code of Conduct is designed to be a reference in complying with all applicable legal requirements and Company policies and procedures. As this is just a reference, we expect you to act with the high ethical and legal principles and always encourage you to ask questions on these topics and any others that impact our Company and the people we serve. 

1.2 Vision, Mission and Values

VISION

Assist in creating and building healthy relationships within our communities.

MISSION

Create a thriving and healthy community by delivering the highest quality of care for our patients by world-class physicians and staff.

VALUES

Quality, Compassion, Growth, Responsibility, Collaboration, Community, Diversity/Inclusion.

1.3 Compliance Program

Company has established a Compliance Program which includes policies and procedures that cover:

• Establishing a Compliance Committee and Compliance Officer;
• Regularly educating employees on compliance policies, procedures and expectations;
• Identifying compliance issues through standardized internal auditing procedures;
• Conducting Compliance Program Assessments to determine effectiveness;
• Processes to respond to governmental investigations and external audits;
• Enforcing and disciplining investigated compliance violations;
• Non-retaliation against employees who report compliance violations; and
• Regularly reporting compliance monitoring and remedial actions to the Board of Directors and the Compliance Committee.

1.4 Duty of Compliance

Every officer, director, employee, contractor, and individual affiliated with Company has a duty to fully comply with all applicable federal, state and local laws, rules, regulations, policies and procedures, including this Code of Conduct. Your compliance obligations are not limited to those standards set forth in this Code of Conduct; rather, you are expected to be aware of and comply with all laws that affect the performance of your responsibilities. Any questions regarding legal or compliance issues related to the performance of your work responsibilities should be referred to your supervisor or to the Compliance Officer.

Each officer, director and supervisor has a special responsibility to ensure that their areas of responsibility reflect Company’s commitment to compliance and providing the highest quality services. Supervisors are expected to create a work environment in which concerns regarding compliance can be identified and openly discussed.

Section 2: Patient Care and Providers

2.1 Quality Patient Care

Ensuring the quality of patient care and patient safety is an obligation of every employee, contractor and affiliated individual. Patients and their families must be treated with dignity and respect at each and every encounter. In providing our services, Company does not discriminate based on any protected category (e.g., age, gender, disability or race).

Company is also open to and welcomes comments from patients and their families regarding the services that Company provides, including comments pertaining to quality of care and patient safety of our affiliated practices. Both negative and positive feedback can be useful in enhancing the quality of services provided. Company will work diligently to resolve patient and family concerns. We have a dedicated Patient Services team to respond, help resolve issues, and improve the quality of our service.

2.2 Corporate Practice of Medicine

Company provides management and administrative services to affiliated medical practices. Company does not engage in the practice of medicine, nor does Company provide any medical health care service for which licensure is required. All such medical health care services are provided by licensed physicians and other practitioners, and Company will not interfere with the professional judgment of any physician or other clinical practitioner.

2.3 Licensure and Certification

Every individual providing medical services that require licensure, certification or other professional credentials is responsible for obtaining and maintaining current licensure, certification or credentialing and is responsible for compliance with all federal and state requirements related thereto. Each provider is checked with the National Practitioner Data Bank for any adverse issues prior to hire.

2.4 Privileges, Credentials and Enrollment

Company has policies and procedures regarding the screening, hiring and employment of individuals. All applicable employees are required to be properly credentialed in accordance with Company policies and procedures. Company may conduct background checks on individuals who provide services for Company, to ensure that such individuals do not have criminal backgrounds.

Company will not knowingly hire, employ or otherwise engage any individual or entity who or which is currently suspended, deactivated, excluded, debarred, or otherwise ineligible to participate in any federal or state health care program, including Medicare and Medicaid.

You are required to report to Company if you become suspended, deactivated, excluded, debarred or otherwise ineligible to participate in any such federal or state health care program. You are also required to immediately report to Company if you have been convicted of a federal offense related to the provision of health care items or services.

Company will remove any such ineligible person from any position for which the compensation of the ineligible individual, or the items or services furnished, ordered or prescribed by the ineligible individual, are paid in whole or in part, directly or indirectly, by a federal or state health care program at least until such time as the ineligible individual is reinstated in the federal or state health care program.

2.5 Patient Relationships

Each employee, contractor or affiliated individual must seek to provide comfortable and convenient services to each patient and to act in a professional, appropriate and cooperative manner.

Further, Company strives to provide culturally-competent care, and will work to overcome cultural, linguistic or socioeconomic barriers. Company is committed to ensuring that personnel are sensitive to the diverse needs of all patients.

2.6 Patient Records

Company will maintain records of patient care in accordance with applicable federal and state laws. Each employee, contractor or affiliated individual must follow all of Company’s policies and procedures when documenting patient care.

Section 3: Business Practices

3.1 Billing, Coding and Documentation

Company is committed to compliance with all federal and state fraud and abuse laws and regulations, including, but not limited to, federal and state false claims and anti-kickback laws. It is expected that all Company and affiliated practice personnel will refrain from any conduct in violation or the appearance of violating of these laws.

Company, and all employees, contractors and other affiliated individuals, must ensure that claims submitted to federal and state health care programs, third-party payors and patients, are accurate and in conformance with federal and state laws, rules and regulations. Company has a zero tolerance policy regarding improper billing.

Company bills in a manner that is timely and complete, and accurately reflects the services rendered. As such, physicians and staff must commit to complying with the law and with Company’s policies and procedures when coding, billing or submitting claims for reimbursement, including but not limited to the following:

• Only bill for services that were actually provided, documented and medically necessary as determined by an appropriately licensed practitioner;
• Only collect appropriate co-payments, in accordance with applicable federal and state laws, rules, regulations and agreements with third-party payors;
• Assign billing codes (e.g., [CPT ®]][CDT ®] codes, ICD-10-CM) that we believe, in good faith, accurately represent the services provided and are supported by documentation in the record in accordance with applicable requirements;
• Implement controls to prevent improper coding and/or billing errors;
• Implement audit policies and procedures to identify claims and billing inaccuracies in a timely manner;
• Respond to billing and coding inquiries and resolve inaccuracies on previous claims discovered, in a timely and accurate manner;
• Make every effort to hire and employ qualified individuals to perform billing and coding; and
• Not knowingly present, or cause to be presented, claims for payment that are false or fraudulent.

Company is committed to submitting accurate and truthful claims. If you become aware of a false claim, contact our Compliance Officer or call the Compliance Hotline immediately. Failure to notify the Compliance Department of a false claim may lead to disciplinary action, up to and including termination.

3.2 Referral Source Relationships

Company is committed to not providing or accepting illegal remuneration in exchange for referrals of patients covered by Medicare, Medicaid or other federal or state health programs. Illegal remuneration can take the form of a kickback, bribe, rebate or anything of value.

The federal Anti-Kickback Statute makes it a crime for any person to knowingly and willfully offer, pay, receive, or solicit any remuneration, directly or indirectly, overtly or covertly, in cash or in kind, to induce, or in return for, federal health care program business. In addition, certain states have enacted anti-kickback laws that prohibit the knowing or willful offering or paying of remuneration in return for or to induce the referral of patients or business, regardless of payor. 

The Stark Law prohibits a physician from making referrals for designated health services to an entity if the physician or the physician’s immediate family members has a financial relationship with the entity, unless an exception applies.

Any agreements involving patient referral sources must be reviewed for compliance prior to the execution of the agreement.

3.3 Overpayments and Refunds

Company will promptly investigate all potential overpayments and refunds from payors. In the event that Company identifies an actual overpayment or refund after investigating, Company will take appropriate corrective action including, for example, notifying the relevant payor and working with the payor to process an offset or issue a refund. Personnel must report any potential overpayment from a payor to the Compliance Officer or the Compliance Hotline.

3.4 Outside Activities / Conflicts of Interest

Company requires each individual associated with Company to conduct operations in a manner that avoids any actual or potential conflict of interest. A conflict of interest arises where your personal interests or activities are advanced at the expense of Company’s interests or activities.

Business conduct must always advance Company’s interest, and Company’s interests shall always be placed ahead of individual, personal interests.

Each individual is required to disclose any actual or potential conflicts of interest. Failure to disclose an actual or potential conflict of interest may result in disciplinary action, up to and including termination.

3.5 Professional Courtesy and Gifts

Offering or accepting gifts may influence decisions or the decisions of others, and may constitute a conflict of interest. As such, individuals affiliated with Company may not solicit personal gifts intended for individual or personal use from a patient, referral source, vendor, industry partner or any outside entities or persons doing or seeking to do business with Company.

In general, the appropriateness of offering or accepting gifts is determined in light of the specific circumstances, including who is offering the gift and who is receiving the gift. Company employees and contractors are expected to use common sense and good judgment in accepting or rejecting gifts. If you have any questions regarding the giving or receiving of gifts, please contact your supervisor, manager, the Compliance Officer or the Compliance Hotline for specific advice.

Company prohibits offering, giving or receiving gifts to or from government officials.

3.6 Personal Use of Assets

Company assets may not be used for personal benefit. Individuals may only use confidential business or patient information, company assets and property to perform the responsibilities of their job and must commit to maintaining the integrity of such information for legitimate business purposes.

3.7 Vendor Relationships

Company enforces policies and procedures that monitor contractual relationships between affiliated medical practices and other providers and suppliers to ensure conformity with federal and state laws and regulations.

We will not offer, give, solicit or receive any bribe or other improper payment or inducement. Company discounts, rebates and the like are appropriate and customary if they are consistent with applicable laws and with Company policies and procedures.

All contractor, subcontractor and supplier relationships must be managed in a fair and reasonable manner, free from conflicts of interest or inducements, and be consistent with applicable laws and with sound business practice. Company selects contractors, subcontractors, suppliers and vendors based on objective criteria, including quality, technical excellence, experience, price and ethical standards.

3.8 Sales and Marketing

Company expects that all employees, contractors, and individuals affiliated with Company will be honest in communicating with all of those with whom Company does business, including current and prospective patients. 

Company markets its products and services in a fair and honest manner. Any materials used by Company in connection with marketing or sales activities will reflect Company’s actual available services. Employees, contractors and agents of Company are expected to be honest and are expected to refrain from making misleading statements about Company or the services offered by Company when engaged in sales and marketing activities.

3.9 Charitable Contributions

Company may make reasonable and valid charitable contributions, as may be permitted by applicable federal and state laws. Company will not make or offer to make, directly or indirectly, any charitable contribution to any third party as an inducement for referrals, as a kickback, bribe or other impermissible remuneration. All charitable contributions will be made in accordance with Company policies and procedures.

3.10 Payment Plans/Financial Hardship

Discounts are generally not permitted by Company. Company does not waive patient cost-sharing responsibilities, including co-payments or deductibles unless first approved by the Compliance Officer. Company may offer patients the opportunity for decreased financial responsibility, such as a payment plan, if the patient demonstrates (through a financial screening conducted by Company) financial hardship.

Section 4: Confidentiality; Data Privacy and Security

4.1 HIPAA Privacy and Security

Company, including all individuals employed by or associated with Company, shall protect the privacy and confidentiality of each patient’s personal information. This information, known as “Protected Health Information” (“PHI”) includes any information created or received by Company which may be used to alone or with other information to identify an individual patient, and can include a patient’s name, address, phone number, Social Security Number, diagnoses, medical history, or other personal information.

Company is committed to the protection of PHI through compliance with applicable federal and state laws and regulations pertaining to confidentiality and protection of patient information, including the Health Insurance Portability and Accountability Act and the Health Information Technology for Economic and Clinical Health (“HITECH”) Act, as well as the implementing regulations of these laws (collectively, “HIPAA”).

We only use, disclose, or discuss patient-specific information with others in accordance with HIPAA and any other applicable federal and state laws. Specifically:

• We use, disclose and/or discuss only the minimum amount of PHI necessary to carry out our responsibilities;
• We do not discuss patient PHI with individuals who are not involved in the care of, or the conduct of care-related activities for, the patient;
• We do not allow access to a patient’s medical record to those for whom access is not necessary;
• We do not share Company-provided user IDs or passwords;
• We do not discuss patients or patient care activities in public areas where conversation may be overheard by others, and we shall ask for the permission of the patient to speak about their care when family members or friends are present;
• We appropriately dispose of PHI;
• We only use Company-approved devices to store, download or capture PHI;
• We do not mention or reference any specific patient or PHI on personal social media sites or blogs; and
• We protect the privacy and security of all patient medical, billing and claims information and other PHI through physical, technical and administrative measures to prevent unauthorized access, use or disclosure of patient information.

Each individual must complete HIPAA training on how to ensure the confidentiality and security of PHI, and will be required to attest to compliance with Company’s HIPAA policies and procedures. Anyone affiliated with Company that engages in the unauthorized use or disclosure of patient information will be subject to disciplinary action up to and including termination. Individuals that use or disclose PHI inappropriately may also be subject to civil and/or criminal penalties. 

If you become aware of an unauthorized disclosure of PHI or other breach of patient confidentiality, you must report such disclosure or breach immediately to your supervisor or manager, or to the Compliance Officer or Compliance Hotline. Company prohibits retaliation, retribution or harassment against any individual who in good faith reports an unauthorized disclosure of PHI or other privacy violation.

4.2 Documentation and Information Management

Company is committed to securely maintaining and protecting the confidentiality, availability and integrity of all Company information, as well as information for which Company is the custodian.

All confidential information, either written or electronic, must be kept secure from loss, theft, unauthorized access, use or disclosure. Company has policies and procedures in place that are designed to maintain the security and integrity of all such information.

Much of the Company’s information is stored on computer systems. In light of this, it is of the utmost importance that each individual with access to Company computers and other information systems complies with all policies on data security. All members of Company’s and its affiliated practices’ personnel will keep his or her user ID, password and other information secure and confidential. 

Any individual that has access to Company information, including Company computer and information systems, and discloses that information to unauthorized individuals will be subject to disciplinary action, up to and including termination. Such individuals may also be subject to civil and/or criminal penalties.

Section 5: Additional Issues

5.1 Controlled Substances Security and Management

Only authorized individuals may handle pharmaceutical drugs, controlled substances and prescription pads. If you become aware of any potential lapses in security pertaining to pharmaceuticals, controlled substances, or prescription management, or if you become aware of any actual violation of any federal or state law, regulation or rule pertaining to pharmaceuticals, controlled substances or prescription pads, you are required to immediately report such information to your supervisor, manager, the Compliance Officer or the Compliance Hotline. Providers are required to check each state’s controlled substance website prior to prescribing a controlled substance for a patient for any alerts.

5.2 Occupational Safety

Company is committed to protecting the health and safety of its personnel, contractors and patients, and is also committed to complying with federal, state and local laws, regulations and rules pertaining to health and safety, including the Occupational Health and Safety Act (OSHA) and associated regulations.

Each individual is responsible for reporting any unsafe acts or dangerous or hazardous conditions in a timely manner so that corrective action may be taken.

5.3 Environmental Compliance

Company is committed to compliance with all federal and state environmental laws, regulations and rules. All chemicals, waste and other materials are to be stored, maintained and disposed of in accordance with the law and any applicable Company policies and procedures.

Company understands the importance of filing accurate and timely environmental reports, as necessary, and Company shall cooperate fully with all governmental authorities in connection with any environmental incidents or concerns.

Section 6: Communications with Government Officials, Regulators and Payors

Company fully cooperates with any governmental inquiries. Company does not prohibit or prevent individuals affiliated with Company from communicating with government officials. If you receive a governmental inquiry, please contact your supervisor or the Compliance Officer immediately.

Company does not destroy, alter or change system records. Company preserves all related and applicable records upon receiving notice of an investigation, lawsuit, subpoena or request for documentation. If Company receives a subpoena or a request for documents, the subpoena or request should be referred to the Compliance Officer. The Compliance Officer will coordinate a complete and accurate response with the government agency.

Section 7: Compliance Reporting

7.1 Reporting Compliance Concerns

You are required to report any actual or perceived instances of non-compliance, including actual or perceived violations of federal or state laws, rules, regulations, policies and procedures, or this Code of Conduct. Reports regarding compliance issues are treated confidentially and will be shared with others only on a need-to-know basis.

Company operates a Compliance Hotline available 24/7 at 1-877-736-9504 or www.mwecompliancereporting.com where anonymous reports may be made. Additionally, you may contact your supervisor or the Compliance Officer. When reporting a compliance concern, please include all relevant information, including a description of the incident, the date it occurred, any individuals involved, and the location where the concern occurred or is occurring.

7.2 Response and Corrective Action

Following any investigation into a compliance issue, Company will determine whether a compliance violation has occurred, and what corrective action to take, if any. Company will determine an appropriate corrective action plan. Any such corrective action plan will be made in accordance with Company policies and procedures and will include remedial steps to address any identified compliance violations, as well as the re-education of Company and its affiliated practices’ personnel as appropriate.

7.3 Non-Retaliation

Company prohibits retaliation, retribution or harassment in any manner against an individual who in good faith reports a compliance concern or cooperates with a compliance investigation. Company will investigate all suspected acts of retaliation, retribution or harassment, and shall take appropriate action in accordance therewith. 

If, however, an individual purposefully falsifies a report, makes misrepresentations in connection with a report, makes false or misleading statements during an investigation, breaks the law, or violates Company’s policies or procedures, then such individual will not be protected by the non-retaliation policy and will be subject to disciplinary action, up to and including termination.