CODE OF CONDUCT Providers, Suppliers and Contractors
Table of Contents Code of Conduct... Honesty and integrity... Quality and Service... Responsibilities of Providers, Suppliers and Contractors... Compliance with Laws... Anti-Kickback Laws... False Claims Act... Fraud Enforcement and Recovery Act... Sanctions Screening... HIPAA... Reporting of Violations... Non-retaliation... Investigation of Violations... Disciplinary Actions... Conflicts of Interest... Gifts and Entertainment... Bribes, Lobbying or Political Donations... Safeguarding PUP s Confidential Information... Fraud, Waste and Abuse... Accuracy of Information... Doing Business with the Government... Accreditation... Fair Competition... Work Environment... Resolving Code of Conduct or Ethics Issues... Pg. 5 Pg. 6 Pg. 6 Pg. 7 Pg. 7 Pg. 7 Pg. 7 Pg. 8 Pg. 8 Pg. 8 Pg. 9 Pg. 9 Pg. 9 Pg. 10 Pg. 10 Pg. 11 Pg. 11 Pg. 11 Pg. 12 Pg. 13 Pg. 13 Pg. 14 Pg. 14 Pg. 14 Pg. 14
A Letter To Our Providers, Suppliers or Contractors Dear Valued Provider, Supplier or Contractor: Thank you for your partnership with Physicians United Plan (PUP). PUP is committed to exemplifying strong values and ethical standards in the conduct of our business. The key to upholding these values and standards is your actions and those of every employee at PUP. We require everyone who does business with us and all PUP employees to adhere to our Purpose, Our Values and Our Code of Conduct ( Code ). Your commitment to these business principles is the foundation of our mutually beneficial business relationship. The purpose of this Code of Conduct for Providers, Suppliers and Contractors is to help you fully understand PUP s expectations of business conduct by our Providers, Suppliers and Contractors. By Providers, Suppliers and Contractors, we mean participating providers, suppliers, pharmacies, sales agents, delegated entities, and any one acting on behalf of PUP. This includes any first-tier, downstream or related entity acting on behalf of PUP, either directly or indirectly. Please read this document carefully and provide this information to your employees and subcontractors. We ask all our Providers, Suppliers and Contractors to affirm that they and their employees, representatives and subcontractors will comply with the business principles stated in this Code of Conduct. Thank you for your continued participation as a valued partner of PUP. Let s together do something purposeful and special in the best interests of our mutual Constituents. Sincerely, Imtiaz (MT) Sattaur President & CEO 4
Our Purpose, Our Values and Our Code of Conduct PUP and its employees are guided by Our Purpose, Our Values and Our Code of Conduct. Our Purpose To improve our Members health and well-being. Our Values Leadership, Partnership, Stewardship Leadership The capacity or ability to guide and direct in the best interest of others. We take responsibility for our actions to deliver excellence in the work that fulfills our Purpose and serves our Constituents. Partnership The state or condition of being a partner; participation; association; joint interest. We build trusting relationships that promote teamwork to achieve win-win results for our Constituents. Stewardship The careful and responsible management of something entrusted to one s care. We drive a culture of service that values quality, compliance and accountability to our Constituents. 5
Code of Conduct for Physicians United Plan Providers, Suppliers and Contractors All Physicians United Plan ( PUP ) employees receive a copy of PUP s Code of Conduct upon hire. They also receive general compliance training, including training on the Code of Conduct, upon hire and annually and attest that they will uphold Our Purpose, Our Values and Our Code of Conduct. It is vital that our Providers, Suppliers and Contractors understand that PUP expects the same commitment from anyone who acts on our behalf. That s why we ve developed this Code of Conduct for Providers, Suppliers and Contractors to ensure that those representing us maintain a commitment to creating an ethical culture that promotes honesty, integrity and responsible behavior. This Code of Conduct for Providers, Suppliers and Contractors is intended to provide overall guidance on ethical behavior; it is not a comprehensive set of rules and is not intended to constitute legal advice. You should have your own code of conduct and provide Code of Conduct as well as general compliance training to your employees and subcontractors. Honesty and Integrity Each of us must conduct business morally and ethically. We must not do anything that violates our Values or principles of conduct that will jeopardize our reputation in the community or puts PUP at risk with its regulatory agencies. No one is ever authorized to commit, or direct another person to commit, an unethical or illegal act. Quality and Service PUP will treat all its Employees, Members, Providers, Suppliers, Contractors and Government partners with dignity and respect. We will not ignore deficiencies or mistakes and will always strive to correct problems of which we are aware. Each of you must ensure that our Members receive all the services they are entitled to and pay only the amounts required under their benefit plans. We will not offer inducements to providers to improperly reduce or limit utilization and access to care. We will avoid inappropriate discrimination in our benefit plan designs, employment, contracting, credentialing, claims adjudication, enrollment or marketing practices. PUP expects its Providers, Suppliers and Contractors to communicate these standards to their employees and business partners and to ensure they are followed. 6
Responsibilities of Providers, Suppliers and Contractors Compliance with Laws Each of us must understand the laws and regulations that apply to our business and immediately report any suspected wrongdoing. We must comply not only with the letter but also the spirit of all applicable laws and regulations. Some federal laws applicable to PUP s business include: Anti-Kickback Statute (s.1128(b) of the Social Security Act, 42 U.S.C. 1320a-7b(b)): The federal anti-kickback statute prohibits knowingly offering, paying, soliciting or receiving remuneration of any kind to induce the referral of business under a federal program. This includes waiving a Medicare deductible, coinsurance or copayment. Federal acquisition regulations forbid gratuities, in the form of entertainment, gifts or otherwise, or kickbacks, to any employee or contractor of the government with a view toward securing favorable treatment. Violators are subject to imprisonment, fines, exclusion from government contracts, Medicare and Medicaid, civil monetary penalties, and possible prosecution under many similar state laws. False Claims Act: The Federal False Claims Act (31 U.S.C. s3729-3733) is the primary federal law used by the federal government to fight Medicare and Medicaid fraud. Under the False Claims Act, anyone who knowingly submits or causes another person to submit false claims for payment by the government is liable for treble damages plus civil penalties of $5,000 to $10,000 per false claim. The Whistleblower provisions of the False Claims Act protect employees who assist the federal government in investigation and prosecution of violations of the False Claims Act. A whistleblower is someone, such as an employee, who reports suspected misconduct that would be considered an action against company policy, federal laws or regulations. Whistleblower protections apply only to actions taken in furtherance of a viable False Claims Act case which has been, or is about to be, filed. The provisions prevent retaliation against the employee, such as firing him/her for assisting in the investigation and prosecution. If any retaliation does occur, the employee has a right to obtain legal counsel to defend his/her actions taken. 7
Responsibilities of Providers, Suppliers and Contractors (cont.) Fraud Enforcement and Recovery Act of 2009: The Fraud Enforcement and Recovery Act ( FERA ) of 2009 strengthens the federal False Claims Act and boosts the federal government s power to investigate and prosecute any financial fraud against the government. Healthcare providers and physicians are also subject to increased risk of potential liability if they knowingly and improperly retain or conceal an overpayment. Sanctions Screening: PUP is prohibited from contracting with, or making payment to, anyone who has been: Convicted of a criminal offense related to health care. Identified and listed on Executive Order 13224 (Blocking Property and Prohibiting Transactions with Persons Who Commit, Threaten to Commit or Support Terrorism). Listed on the Department of Health and Human Services Office-of-Inspector- General (OIG) and General Services Administration (GSA) exclusion lists (excluded from participation in federal programs). PUP conducts sanctions screenings of all its Employees, Providers, Suppliers and Contractors upon hire/initial engagement and monthly thereafter. PUP will request an attestation or proof from its Providers, Suppliers and Contractors that they also screen their own employees, representatives and subcontractors on a monthly basis to ensure that anyone providing service to PUP or a PUP member is not on the OIG or GSA exclusion lists. In addition, Providers, Suppliers and Contractors must notify PUP if any of their employees, representatives or subcontractors is on the OIG or GSA exclusion list. 8
Responsibilities of Providers, Suppliers and Contractors (cont.) Reporting Violations We promote relationships based on mutual trust and respect and provide an environment in which PUP Employees, Members, Providers, Suppliers and Contractors may question a PUP practice or report non-compliance without fear of adverse consequences. PUP has a duty to report Medicare program noncompliance, violations of law, criminal misconduct and FWA to the appropriate regulatory agency. Similarly, our Providers, Suppliers and Contractors are responsible for reporting suspected ethical violations in their dealings with other entities and with PUP. Ethical violations include, but are not limited to: violations of laws or policies, dishonest or unethical behavior, conflicts of interest, fraud and abuse, questionable accounting and internal controls, criminal misconduct or any suspicious activity. You should immediately report all violations to your PUP contract or account manager, PUP s Compliance or Legal Officer, PUP s compliance email box (compliance@pupcorp. com) or PUP s confidential Hotline for anonymous reporting (1-866-461-5075). Non-retaliation PUP strictly prohibits retaliation against any employee or subcontractor of a Provider, Supplier or Contractor who, in good faith, reports an actual or potential violation of legal or ethical standards. Investigation of Violations PUP promptly investigates all reported or suspected violations of the Code of Conduct and PUP policies and procedures. We will maintain confidentiality to the extent possible. All Providers, Suppliers or Contractors must cooperate fully, and ensure that their employees and subcontractors cooperate as well, with any investigation involving their company, employees or subcontractors. 9
Responsibilities of Providers, Suppliers and Contractors (cont.) Disciplinary Actions PUP holds all of its directors, officers, employees, Providers, Suppliers and Contractors accountable for complying with the law, our policies and Code of Conduct. Violation of PUP s Code of Conduct, or other policies and procedures, could compromise PUP s integrity and reputation, and may result in termination of contract, and depending on the violation, reporting to the appropriate authorities. Each Provider, Supplier and Contractor must take appropriate disciplinary actions against their own employees and subcontractors found to be in violation, up to and including termination of contract or employment. All such actions should be reported to PUP. Some examples include: Authorization or participation in actions that violate the law or PUP s Code of Conduct. Failure to report a violation of the law or PUP s Code of Conduct. Refusal to cooperate in an investigation of an alleged violation of the law or PUP s Code of Conduct. Failure to detect and report a violation of PUP s Code of Conduct, if such failure reflects inadequate supervision or lack of oversight. Retaliation against an individual for reporting or participating in the investigation of a violation or possible violation of PUP s Code of Conduct. Conflicts of Interest Business decisions and actions must be based on independent and sound business judgment, and not on personal interests or relationships. All Providers, Suppliers and Contractors, and their employees and subcontractors who support PUP business, should avoid conflicts of interest. Some PUP employees have special relationships with PUP s Providers, Suppliers or Contractors: they may evaluate, select or manage them. Providers, Suppliers and Contractors must not place PUP employees in situations that would create a conflict of interest for the PUP employee or influence PUP employees to violate PUP s Code or policies. Providers, Suppliers and Contractors should not offer or provide, directly or indirectly, anything of value including cash, bribes or kickbacks, employment to any PUP employee, agent, Member, government official (or one of their family members or significant others) in connection with any PUP transaction or business dealing. 10
Responsibilities of Providers, Suppliers and Contractors (cont.) Gifts and Entertainment No gift, favor or entertainment is needed to conduct business with PUP. It is our policy that PUP employees cannot give to, or accept from, Providers, Suppliers or Contractors gifts or business entertainment that has more than a nominal value. Any nominal gifts or courtesies must be lawful, unsolicited and infrequent. Gifts of money or cash equivalents are strictly prohibited. A PUP Provider, Supplier or Contractor should not offer any business entertainment to a PUP employee if it would create a conflict of interest or any appearance of impropriety. Bribes, Lobbying or Political Donations PUP prohibits all bribes, kickbacks or other unlawful or improper methods of remuneration to be given to any of our employees and PUP will not make any such payments to anyone. PUP s income is solely from federal funds and PUP is prohibited from using federal funds for lobbying or any activities designed to influence legislation or appropriations pending before Congress or any state legislature. Therefore, Providers, Suppliers or Contractors also may not use any income received from PUP for such purposes. Safeguarding PUP s Confidential Information PUP s Confidential Information includes, but is not limited to, its internal business and marketing practices and records, financial information, network, electronic and media software and hardware, information concerning our Members, providers, products, pricing and health information. You must retain PUP s Confidential Information in strictest confidence and will neither use it nor disclose it to a third party, other than employees having a need to know, without the explicit written permission of PUP. Unauthorized disclosure of, or access to, PUP s Confidential or proprietary Information may result in termination of our contract, and also may result in civil and criminal penalties. 11
Fraud, Waste and Abuse ( FWA ) It is PUP s policy to help protect the Medicare program from FWA. PUP has implemented a FWA program to help detect, correct and prevent FWA and make referrals to the appropriate governmental agencies for further investigation and follow-up. The following are definitions of fraud, waste and abuse: Fraud means an intentional deception or misrepresentation that the individual knows to be false or does not believe to be true, and that the individual makes knowing that the deception could result in some unauthorized benefit to himself or herself or some other person. It includes any act that constitutes fraud under applicable federal or state law. Waste is the inappropriate utilization and/or inefficient use of resources, e.g., prescribing a medication for 30 days with a refill when it is not known if the medication will be needed. Abuse occurs when an individual or entity unintentionally provides information to Medicare which results in higher payments than the individual or entity is entitled to receive. Anyone who assists PUP in the administration of our core functions or in the delivery of our benefits to PUP Members is required to receive FWA training, unless deemed to have met the FWA training through enrollment into the Medicare program as a Medicare participating provider. Training for your employees must include, at a minimum, the following: Overview of the laws and regulations related to the Medicare Advantage and Prescription Drug program (e.g., False Claims Act, Anti-Kickback statute) Obligation to have appropriate policies and procedures addressing FWA A process to report suspected FWA to PUP Protections for employees who report suspected FWA Types of FWA that can occur in your particular industry setting If you are a Medicare participating provider, you are deemed to have met this FWA training requirement. All other PUP Suppliers and Contractors may use Medicare s online FWA training (available at CMS Medicare Learning Network website), your own FWA training materials or the training PUP has developed for you (available in the provider section of our website www.navigateyourmedicare.com). If you are not a Medicare participating provider, we will ask you to provide us with an attestation that you provide annual FWA training your employees and subcontractors. If you become aware of any potential FWA that affects or may affect PUP Members or the services they receive, you should immediately report it to PUP s Compliance Department (compliance@pupcorp.com) or to our Hotline (1-866-461-5075). 12
Accuracy of Information PUP is committed to providing accurate and truthful information in all of its reports to regulatory agencies, Members, providers and all its other business partners. We have internal controls and practices to ensure the accuracy and integrity of our data. This includes internal accounting controls designed to maintain the integrity and reliability of our financial reporting to the State of Florida Office of Insurance Regulation and other regulatory agencies. PUP s financial reporting system also provides assurance to these regulatory agencies, PUP s Board of Directors and PUP management that our assets are safeguarded and transactions are appropriately authorized and recorded. We expect and require accurate and truthful encounter, claims, medical, utilization, accounting and financial data from each our Providers, Suppliers, and Contractors. You must maintain accurate and complete records of all matters related to your PUP business. All records related to PUP s business must be retained for a period of ten (10) years in addition to the contracting year. Doing Business with the Government PUP is licensed by the State of Florida and has contracts with the State of Florida and with CMS to offer Medicare Advantage plans to Medicare and Medicaid beneficiaries. As such, PUP complies with federal and state laws, rules and regulations governing the offering of such products. As a PUP Provider, Supplier or Contractor, you are also responsible for knowing and complying with the laws and regulations that govern PUP s business. These include the Anti-Kickback laws and the False Claims Act. PUP, its participating Providers, Suppliers and Contractors, and their employees, representatives and subcontractors, must never: Destroy or alter any document or record in anticipation of a request for the document or record by a government agency or court; Lie or make false or misleading statements to any government investigator; Persuade any employee or any other person to provide false or misleading information to a government investigator. 13
Accreditation PUP is fully accredited by URAC. URAC requires our participating Providers and delegated entities to meet certain standards. Some of you may have your own or additional accreditation. We must all deal openly and honestly with our accrediting bodies and provide all requested information and documentation in a timely manner. Fair Competition PUP is committed to a policy of vigorous, lawful and ethical competition which is based on the quality of our services. We will maintain the trust of our Members and all our constituents by providing quality service in a fair, ethical and legal manner. Work Environment PUP is committed to a work environment that is free of harassment of any type, in which all employees are treated with respect and dignity. Harassment by, or of, an employee, a Health Care Provider, Supplier or Contractor or anyone else on PUP premises or in the course of PUP business, is absolutely prohibited. Violation of the PUP harassment policy may result in termination of contract, and also may result in civil and criminal penalties. Resolving Code of Conduct or Ethics Issues PUP s Compliance Officer is available to anyone who has questions or concerns about maintaining ethical behavior, or identifying and preventing fraudulent or criminal misconduct. If you become aware of any violations, please contact our Compliance Officer directly, via email or our hotline. We take all calls very seriously; we will investigate all reports and take appropriate action. Please provide enough information regarding the potential violation to allow us to review the situation and respond appropriately. Anonymity will be respected to the extent possible. PUP Hotline for anonymous reporting: 866-461-5705 PUP compliance email address: Compliance@pupcorp.com 14
Toll-Free: 866-571-0693 TTY/TDD: 866-671-0693 8:00 am - 8:00 pm, Mon - Sun www.uaskpup.com PUP Compliance Hotline Toll-Free: 866-461-5705 Available 24/7 07172012