Standard of Conduct

Dear Employee, Contractor, Vendor, and Agent:

You are all aware the healthcare business is becoming more and more complex. As a result, healthcare organizations cannot assume they comply with all federal and state laws. The Board of Trustees of UNC Health Southeastern and related organizations are committed to effective and efficient operations, reliable financial reporting, and compliance with all applicable laws and regulations. To that end, they have established a Corporate Compliance Program.

As an UNC Health Southeastern employee, contractor, or vendor, you play an important role in this program. If you find or know of violations, you are required to report them. If you have concerns about fraud and abuse, please feel free to see your Department Director or Manager or call our Compliance Hotline number at 1-888-398-2633. Such reports will be held confidential.

The following is a brief question-and-answer guide to the Compliance Program, followed by a more detailed discussion of the Compliance Standards of Conduct.

Thank you for your cooperation. Your support of this program is crucial to its success.

What is Corporate Compliance?

Corporate Compliance is a federal and state program. Its purpose is to detect, prevent, and correct fraud and abuse of government rules that pertain to healthcare.

Why is this program necessary?

While most health providers try to follow the rules, fraud and abuse are a serious problem. Each year, they account for between 3 and 10 percent of the nation’s $1 trillion annual healthcare cost. For that reason, the Justice Department and the Office of the Inspector General are working together to fight fraud.

Does UNC Health Southeastern have a Corporate Compliance Program?

Yes, The goals of the program are to:

• Not accept fraud. Prevent, detect, and respond to unacceptable legal risk and its financial implications.
• Route non-compliance issues to appropriate areas.

Who is responsible for Corporate Compliance at UNC Health Southeastern?

At our hospital, responsibility for this program falls into three general areas:

• The Board of Trustees must make sure the Corporate Compliance program matches UNC Health Southeastern mission, vision, and values. The Board is responsible for the program and checks its results.
• The Corporate Compliance Committee oversees the program and provides guidance and direction.
• Employees of SRMC are responsible for obeying federal, state, and local laws and regulations that apply to them.

How can I report suspected violations?

You can report suspected fraud or abuse in the following ways:

• See your department director, manager, or supervisor.
• Call the Corporate Compliance Hotline at 1-888-398-2633.

How does Corporate Compliance affect our DNV GL – Healthcare status?

• If a hospital is suspected of fraud and abuse, DNV may visit without notice.
• DNV will conduct a “for cause unannounced survey” if there is reason to think the fraud affected quality of care. If an organization is found guilty of financial fraud, DNV does a special, on-site evaluation to look at the organization’s code of ethical behavior.
• DNV may be contacted directly on compliance issues involving quality of care at 866-496-9647.

What laws, regulations, and UNC Health Southeastern formal policies cover the Compliance Program?

• The Federal False Claims Act, sections 3729 through 3733 of Title 31, United States Code and Chapter 38 of Title 31, United States Code.
• Section 6032 of the federal Deficit Reduction Act of 2005.
• North Carolina State Plan Pages 79y, 79y.1, and 79y.2, Attachment 4342-A, Page 1, TN No.: 07-005 dated 06/27/07; effective 01/01/07.
• UNC Health Southeastern Corporate Policy: “Compliance Program” (COMPLI-1).
• UNC Health Southeastern Corporate Policy: “”Reporting of Potential Issues or Areas of Noncompliance” (REP-1).
• UNC Health Southeastern Personnel Policy: “Standards of Conduct Compliance” (page 28.2).