The CoxHealth Board of Directors directed the development and implementation of an effective Corporate Compliance Program which includes the following elements, many of which are recommended by the Office of Inspector General in its Compliance Program Guidance for Hospitals and the Supplemental Guidance issued in January 2005.
1. Policies and Procedures. The policies and procedures which encompass the Corporate Compliance Program at CoxHealth include:
a. Corporate Compliance Program, policy GO. 4. A copy of the Corporate Compliance Program is distributed to all members of CoxHealth.
b. Code of Conduct policy GO. 5. A copy of the Code of Conduct is distributed to all members of CoxHealth.
c. Prohibition of False Claims, GO.6. A copy of the Prohibition of False Claims is distributed to all members of CoxHealth.
d. Compliance with the Stark and Anti-Kickback Physician Referral Laws, GO. 7.
2. Designation of a Compliance Officer and Compliance Committee.
3. Education and Training Program Development and Implementation.
4. Creation of a Method of Reporting that is free from retaliation.
The Corporate Integrity Department will make every effort to ensure that those reporting concerns are protected from retaliation and that their comments are kept confidential. To further that commitment, an anonymous Hotline has been established.
5. Sanctions or Disciplinary Action Enforcement.
6. Ongoing Audit and Monitoring of Activities.
7. A program for Investigating, Resolving and Refunding, where appropriate.
Members of CoxHealth are not expected to have expert knowledge of all legal and regulatory requirements that may apply to their work. However, it is expected that members of CoxHealth will be sensitive to legal and ethical issues. The goal of this Plan is to give them the foundation to know enough to ask questions if they are uncertain about any given situation, and whom to ask. Each employee shall ask questions before engaging in any conduct which is causing concern to them.