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Table of Contents
I. The Purpose of This Compliance Program ........................................................................ 4
II. The Elements of the Program ............................................................................................. 4
III. Code of Conduct and Ethics................................................................................................ 5
A. Providing Access to Medically Necessary Services .......................................................... 5
B. Submitting Complete and Accurate Reports ...................................................................... 5
C. Avoiding Kickbacks and Referral Fees .............................................................................. 6
D. Avoiding Conflicts of Interest ............................................................................................ 6
E. Using Resources Exclusively for ICS Business ................................................................. 7
F. Using Resources Exclusively for Tax-Exempt Purposes ................................................... 7
G. Ensuring Equal Opportunity for all Members, Employees and Contractors ...................... 7
H. Maintaining the Confidentiality of Member Records ........................................................ 7
I. Complying with Government Contracts ............................................................................ 8
J. Complying with Applicable Law ....................................................................................... 8
1. False Claims Act .......................................................................................................... 8
2. Political Contributions and Activities .......................................................................... 9
K. Conducting all Business With Honesty and Integrity ........................................................ 9
IV. Compliance Oversight Personnel ....................................................................................... 9
A. Compliance Officer ............................................................................................................ 9
B. Compliance Committee .................................................................................................... 10
C. Board of Directors ............................................................................................................ 11
V. Compliance Training ........................................................................................................ 12
A. General Compliance Training .......................................................................................... 12
B. Fraud, Waste and Abuse Training (“FWA”) .................................................................... 13
VI. Effective Lines of Communication; Reporting Compliance Problems ............................ 13
A. Reporting Options ............................................................................................................ 13
B. Compliance Hotline ......................................................................................................... 14
C. Non-Retaliation ................................................................................................................ 14
D. Routine Communications ................................................................................................. 14
VII. Employee Discipline; Enforcing Standards through Well-Publicized Disciplinary
Guidelines .................................................................................................................................... 15
VIII. Routine Monitoring, Auditing and Identification of Compliance Risks .......................... 15
A. Routine Risk Assessment ................................................................................................. 15
B. Routine Monitoring and Auditing .................................................................................... 16
C. Employment of and Contracting with Ineligible Persons; OIG/GSA Exclusion ............. 18
D. Government Audits and Investigations ............................................................................ 18
E. Fraud, Waste and Abuse .................................................................................................. 19
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IX. Responding to Detected Offenses, Developing Corrective Action Initiatives and
Reporting to Government Authorities .......................................................................................... 19
A. Internal Investigations of Potential Non-Compliance ...................................................... 19
B. Corrective Action Initiatives ............................................................................................ 20
C. Self-Reporting to Government Authorities ...................................................................... 21
D. Referrals to MEDICs ........................................................................................................ 21
E. Identifying Providers with a History of Complaints ........................................................ 21
X. Addendum: Code of Conduct — First Tier, Delegated and Related Entities (FDRs) ..... 22
List of Exhibits
1. Anti-Kickback Policy ................................................................................................................24
2. Employee Conflicts of Interest Policy ......................................................................................26
3. Directors and Officers Conflict of Interest Policy ....................................................................29
4. Employee Training Policy ........................................................................................................33
5. Whistleblower Policy ................................................................................................................36
6. Employee Discipline Policy ......................................................................................................39
7. Internal Auditing Policy ............................................................................................................41
8. Government Investigations Policy ............................................................................................44
9. Overpayment Policy ..................................................................................................................48
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I. The Purpose of This Compliance Program
The Independence Care System (“ICS”) Corporate Compliance Program (the “Program”)
is designed to promote ICS’s compliance with all applicable federal, state and local laws and
regulations as well as government contracts and conditions of participation in public programs.
The Program applies to all ICS lines of business, including ICS’s Medicare-Medicaid capitated
financial alignment product. The primary goals of the Program are to:
Prevent fraud, abuse and other improper activity by creating a culture of compliance
within ICS;
Detect any misconduct that may occur at an early stage before it creates a substantial
risk of civil or criminal liability for ICS; and
Respond swiftly to compliance problems through appropriate disciplinary and
corrective action.
The Program reflects ICS’s commitment to operating in accordance not only with the
strict requirements of the law, but also in a manner that is consistent with high ethical and
professional standards. The Program applies to the full range of ICS’s activities.
All employees and contractors have a personal obligation to assist in making the Program
successful. Employees are expected to: (1) familiarize themselves with the Program’s Code of
Conduct and compliance procedures; (2) review and understand the key policies governing their
particular job functions; (3) report any fraud, abuse or other improper activity through the
mechanisms established under the Program; (4) cooperate in internal and government audits and
investigations; and (5) carry out their jobs in a manner that demonstrates a commitment to
honesty, integrity and compliance with the law.
The Program is regularly reassessed and is constantly evolving to address new
compliance challenges and maximize the use of ICS’s resources. Employees are encouraged to
provide input on how the Program might be expanded or improved.
II. The Elements of the Program
The Program’s design is based on compliance guidance provided by the U.S. Department
of Health and Human Services Office of Inspector General and the Centers for Medicare and
Medicaid Services. The key elements of the Program, which are discussed in greater detail in the
Program sections referenced below, are as follows:
A Code of Conduct that includes basic standards and references more detailed
policies that guide the ICS’s activities (Section III);
The assignment of personnel to oversee the Program, including the Compliance
Officer and Compliance Committee (Section IV);
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Compliance training for all employees (Section V);
Mechanisms for reporting compliance problems, including an anonymous reporting
option, and a prohibition on retaliation against employees (Section VI);
The imposition of disciplinary measures against employees who engage in
misconduct or fail to adhere to the terms of the Program (Section VII);
A system of internal compliance audits and reviews to detect potential fraud, abuse or
other improper activity, and procedures for cooperating in government investigations
(Section VIII); and
Procedures for investigating reports of suspected compliance problems and for taking
corrective action in response to identified compliance problems (Section IX).
III. Code of Conduct and Ethics
The Code of Conduct and Ethics sets forth the basic principles that guide ICS’s decisions
and actions. All employees and contractors are expected to familiarize themselves with the Code
of Conduct and Ethics, and should rely on the standards contained in the Code in carrying out
their duties.
The Code is not intended to address every potential compliance issue that may arise in
the course of ICS’s business. ICS has adopted more detailed written policies governing key
aspects of its operations. Some of these policies are referenced in the Program; others may be
provided to employees by their supervisors. Employees are required to review and carry out
their duties in accordance with the policies applicable to their job functions.
Providers and first tier, downstream and related entities (“FDRs”) are required to adopt
and follow a code of conduct and ethics particular to their own organization and that reflects
their own comparable commitment to ethical behavior, compliance and detecting, preventing
and correcting fraud, waste and abuse. ICS ensures this requirement is met through audits and
other monitoring of FDRs.
All non-FDR entities at ICS who have access to member PHI or who provide direct services to
our members have to go through an onboarding process where they are required to attest to
completing HIPAA, FWA and Code of Conduct trainings. They are also required to sign a non-
disclosure and a Business Associate Agreement protecting member specific information.
The Code of Conduct and Ethics’ standards are set forth below.
A. Providing Access to Medically Necessary Services
ICS is committed to ensuring that all members receive prompt access to the full range of
medically necessary health care services to which the member is entitled under the applicable
government program. All decisions regarding the medical necessity of proposed services must
be made in accordance with the standards set forth in applicable law.
B. Submitting Complete and Accurate Reports
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ICS is required to submit regular cost reports and other financial reports to government
agencies. The information in these reports may be used by the government for rate-setting and
other important purposes. All employees involved in the process of preparing and submitting
cost and other financial reports must strive to ensure that these reports are accurate and complete.
Expenses reflected on cost reports must have been actually incurred and properly allocated in
accordance with program guidelines. The same standards of accuracy and completeness apply to
any other reports or data regarding ICS’s operations submitted to government agencies or private
parties. Knowingly falsifying records is a serious breach of the ICS Code of Conduct and may
result in immediate termination from ICS.
C. Avoiding Kickbacks and Referral Fees
Under the federal Anti-Kickback Statute, it is illegal for any employee or contractor to
knowingly and willfully solicit, receive, offer or pay anything of value to another person in
return for the referral of a member, or in return for the purchasing, leasing, ordering or arranging
for any item or service reimbursed by a federal health care program such as Medicaid or
Medicare. Penalties for violating the Anti-Kickback Statute include imprisonment, criminal
fines, civil monetary penalties and exclusion from government health care programs. A similar
New York law prohibits the exchange of remuneration for referrals for items or services covered
by the state’s Medicaid program.
ICS has adopted an Anti-Kickback Policy (Exhibit 1) that describes the restrictions
imposed under the Anti-Kickback Statute in greater detail. All employees involved in
purchasing items or services from vendors, or managing relationships or conducting business
transactions with sources or recipients of member referrals, should familiarize themselves with
this policy.
D. Avoiding Conflicts of Interest
Employees are required to act solely in the best interests of ICS when carrying out their
job responsibilities and must avoid all activities that constitute or create the appearance of a
conflict of interest. Employees are prohibited from using their position with ICS for personal
benefit. For example, employees are prohibited from accepting gifts of more than nominal value
from vendors of ICS or facilitating contracts between ICS and companies in which they have a
financial interest.
ICS has adopted an Employee Conflicts of Interest Policy (Exhibit 2) that contains
standards and procedures for avoiding conflicts of interest. All employees are expected to
familiarize themselves with this policy. Employees involved in procurement or other sensitive
job duties may be required to submit annual conflict of interest disclosure forms.
ICS’s directors and officers are also required to avoid conflicts of interest. Among other
things, they are prohibited from voting on or otherwise influencing the implementation of
business arrangements between ICS and the director/officer or a company in which the
director/officer has a financial interest. ICS has adopted a Directors and Officers Conflicts of
Interest Policy (Exhibit 3). All directors and officers are expected to familiarize themselves with
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this policy. Directors and officers are required to submit conflict of interest disclosure forms.
E. Using Resources Exclusively for ICS Business
Employees may use ICS resources solely for the purpose of carrying out their job
responsibilities. ICS’s facilities, equipment, staff and other assets may not be used by an
employee for personal benefit or to engage in any outside business or volunteer activity without
the prior approval of the Compliance Officer. Employees may not use their affiliation with ICS
to promote any business, charity or political cause. Employees shall seek reimbursement for
expenses only to the extent such expenses have been incurred in the course of carrying out their
job duties and in accordance with ICS’s expense reimbursement policies.
F. Using Resources Exclusively for Tax-Exempt Purposes
ICS is a tax-exempt organization under Section 501(c)(3) of the Internal Revenue Code.
This status generally requires ICS to engage in only those activities that are within its approved
tax-exempt purpose. ICS’s primary tax-exempt purpose is operating a managed long term care
plan. Employees may not use ICS’s resources to engage in any business activity, even if for
ICS’s benefit, that is outside the scope of ICS’s tax-exempt purpose without the approval of the
legal counsel.
G. Ensuring Equal Opportunity for all Members, Employees and Contractors
ICS is committed to serving all members on an equal basis without regard to race,
nationality or ethnic origin, religion, gender, disability or any other personal characteristic with
respect to which discrimination is barred by law. Discrimination on these grounds is also
prohibited in connection with the hiring and treatment of employees and contractors. In addition,
sexual harassment of employees or clients will not be tolerated. ICS seeks to create an
environment in which the dignity of each individual is fully respected.
H. Maintaining the Confidentiality of Member Records
All member records must be kept confidential in accordance with applicable privacy laws
and regulations. As a “covered entity” under the Health Insurance Portability and Accountability
Act of 1996 (“HIPAA”), ICS must limit the use and disclosure of protected health information.
As part of limiting disclosures, it is expected that ICS employees access member records for ICS
business only. Employees must not access member records for personal or non-work related
reasons. ICS must also comply with special state confidentiality laws governing HIV-related,
mental health and genetic testing information. ICS has adopted a comprehensive privacy
compliance program governing the use and disclosure of member records. All employees who
have access to such records must familiarize themselves with this program’s policies and
procedures, and adhere to their terms.
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I. Complying with Government Contracts
ICS operates under state and federal government contracts. In this capacity, ICS may be
required by contract to comply with rules and standards governing Medicaid, Medicare and other
state and federal health care programs. Employees are expected to familiarize themselves with
the contract requirements applicable to their duties and carry out their responsibilities in a
manner consistent with these obligations.
J. Complying with Applicable Law
ICS is committed to carrying out its business in full compliance with both the letter and
spirit of all applicable local, state and federal laws and regulations. Illegal conduct by employees
will not be tolerated. Employees are expected to seek clarification from their supervisor, the
Compliance Officer or other ICS personnel whenever they are unsure about the interpretation of
applicable laws or regulations. Applicable federal law and regulations include, but are not
limited to: Title XVIII of the Social Security Act (Medicare); Medicare regulations governing
Part C found at 42 CFR §§ 422 et seq); Patient Protection and Affordable Care Act; Health
Insurance Portability and Accountability Act (HIPAA); False Claims Act (31 U.S.C.§§ 3729-
3733); Federal Criminal False Claims Statutes (18 U.S.C. §§ 287.1001); Beneficiary Inducement
Statute (42 U.S.C. §§1320a-7a(a)(5)); Civil Monetary Penalties of the Social Security Act (42
U.S.C. §1395w-27(g)); Physician Self-Referral (“Stark Statute”) (42 USC §1395nn); Fraud and
Abuse, Privacy and Security Provisions of the Health Insurance Portability and Accountability
Act, as modified by HITECH Act; prohibitions against employing or contracting with persons or
entities that have been excluded from doing business with the Federal Government (42 USC
§1395w-27(g) (1) (G); Fraud Enforcement and Recovery Act of 2009. In addition, sub-
regulatory guidance produced by CMS and HHS such as manuals, training materials, HPMS
memos and guides may apply.
1. False Claims Act
The Federal False Claims Act ("FCA") and similar state laws prohibit
knowing submission of false or fraudulent claims or the making of a false record
or statement in order to secure payment from a government sponsored program.
Violations of the FCA can produce fines of $5,500 to $11,000 per claim in
addition to penalties up to three times the value of the claim.
ICS is committed to detecting and preventing fraud, waste and abuse and
has processes and programs in place to review and ensure that billing processes
satisfy applicable government program requirements. Employees of ICS shall
adhere to all applicable federal and state laws regulations and requirements when
billing identifiable federal and state government sponsored programs. Employees
of the ICS are obligated to report any ethical misconduct, including concerns
about potential false claims, to the Compliance Officer or other appropriate
internal authority. As set forth elsewhere in this Program, any retaliation against
any individual making a report of a violation of the FCA is prohibited.
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2. Political Contributions and Activities
In the United States, federal and many state laws prohibit corporations
from making political contributions. No direct or indirect political contribution
(including the use of ICS property, equipment, funds or other assets) of any kind
may be made in the name of ICS, or by using ICS funds, unless the Compliance
Officer has certified in writing that such political contribution complies with
applicable law. When such permission is given, such contributions shall be by
check to the order of the political candidate or party involved, or by such other
means as will readily enable the Company to verify, at any given time, the amount
and origin of the contribution.
K. Conducting all Business with Honesty and Integrity
ICS is committed to conducting all of its activities with honesty and integrity.
Employees are expected to act in a manner that promotes ICS’s reputation as an organization that
exceeds the strict requirements of the law and operates in accordance with the highest ethical
standards.
IV. Compliance Oversight Personnel
A. Compliance Officer
The Compliance Officer is responsible for overseeing the implementation and
modification of the Program. The Compliance Officer’s chief duties include, but are not limited
to, completing or ensuring that Compliance Department staff complete the following:
Developing policies and procedures governing the operation of the Program;
Managing day-to-day operation of the Program;
Periodically reviewing and updating the Code of Conduct and Ethics, and related
policies;
Overseeing operation of the Compliance Hotline described in Section VI below;
Receiving, evaluating and investigating compliance-related complaints, concerns and
problems;
Ensuring proper reporting of violations to duly authorized enforcement agencies as
appropriate or required;
Working with the Human Resources Department and others as appropriate to develop
the compliance training program described in Section V below;
Regularly evaluating the effectiveness of and strengthening the Program;
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Ensuring a compliance overview is provided to the CEO, compliance committee,
and the Board of Directors at least quarterly, including status updates on Medicare
compliance program implementation, identification and resolution of suspected,
detected or reported noncompliance, and ICS compliance oversight and audit
activities;
Responding to reports of potential fraud, waste and abuse, including coordination of
internal investigations and development of appropriate corrective or disciplinary
actions, if necessary; coordinating potential fraud investigations/referrals with the
National Benefit Integrity Medicare Drug Integrity Contractor (“NBI MEDIC”),
State Medicaid programs, Medicaid Fraud Control Units, commercial payers, and
other organizations;
Developing procedures to promote FDR compliance with all applicable laws, rules
and regulations with respect to Medicare and Medicaid delegated responsibilities;
Ensuring DHHS OIG and Government Services Administration exclusion lists have
been checked with respect to all employees, governing body members and FDRs at
least monthly, and coordinating any resulting personnel issue with Human Resources,
Security, Legal or other departments as appropriate;
Maintaining documentation for each report of noncompliance or potential fraud,
waste and abuse received through any source; and
Reporting to the CEO on high-risk areas, strategies for addressing risks,
implementation results, and all governmental compliance enforcement activity.
The Compliance Officer is an employee of ICS, a member of senior management, and
reports directly to the Chief Operating Officer (the “COO”). The Compliance Officer also makes
regular oral and written reports to the Compliance Committee and the Board of Directors on the
operation of the Program. ICS will require Board approval before terminating the Compliance
Officer.
Employees and contractors should view the Compliance Officer as a resource to answer
questions and address concerns related to the Program or compliance issues. As discussed in
Section VI below, the Compliance Officer maintains an “open door” policy and may be
contacted directly by any employee or contractor regarding a compliance-related matter.
Depending on the level of resources available to ICS, the Compliance Officer may be
assisted by a Compliance Manager, Assistant Compliance Officer and/or other personnel. The
Compliance Officer may delegate certain day-to-day Program responsibilities to these
individuals. No Compliance Officer or Compliance Program functions may be delegated to
FDRs.
B. Compliance Committee
The Compliance Committee is comprised of the Compliance Officer, Chief Operating
Officer, and any other employees, with decision
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making authority in their respective areas of expertise.. ICS seeks to appoint members to the
Compliance Committee with varying backgrounds and experience to ensure that the Compliance
Committee has the expertise to handle the full range of clinical, administrative, operational and
legal issues relevant to the Program.
The Compliance Committee’s functions include, but are not limited to, the following:
Receiving regular reports from the Compliance Officer and providing him or her with
guidance regarding the operation of the Program;
Approving the internal auditing and monitoring plan carried out under the Program
(see Section VIII below);
Approving the compliance and fraud, waste and abuse training program provided to
all employees, and ensuring training is effective and appropriately completed;
Reviewing and all investigations of suspected fraud or abuse and any corrective
action taken as a result of such investigations;
Assisting in the monitoring of effective corrective actions;
Ensuring there is a system for employees, enrollees, and FDRs to ask
compliance questions and report noncompliance;
Recommending and approving any changes to the Program;
Supporting the Compliance Officer’s staffing and resource needs for carrying out
his/her duties, and
Providing ad hoc reports to the Board of Directors.
The Compliance Committee is chaired by the Compliance Officer. The Compliance
Committee meets no less than quarterly.
C. Board of Directors
The Board of Directors has ultimate authority for the governance of ICS, including
oversight of ICS’s compliance with applicable law. The Board of Directors has authority for
overseeing the activities of the Compliance Officer and Compliance Committee as well as the
general operation of the Program.
The Board of Directors receives reports on the operation of the Program directly from
the Compliance Officer at least once every six months. The Board reviews measureable
evidence that the compliance program is detecting and correcting noncompliance on a timely
basis. The Compliance Officer has the right to bring matters directly to the Board of Directors
attention at any time.
V. Compliance Training
ICS believes that in order to achieve and ensure compliance with applicable laws and
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Medicare and Medicaid guidance, it is important that directors, officers, employees, temporary
employees, providers and FDRs receive training and education. Training focuses on both
general compliance and fraud, waste and abuse. All training activities are conducted in
accordance with ICS’s Employee Training Policy (Exhibit 4). FDRs agree to conduct their own
compliance training as described below.
A. General Compliance Training
Every employee, officer and director must attend the basic compliance training session
offered by ICS within 30 days of the commencement of employment and annually thereafter.
This session covers the contents of the Code of Conduct and Ethics, and the key elements of the
Program and will identify Medicare and Medicaid requirements that apply to employee job
functions.
General compliance training includes topics such as:
Overview of the process and lines of communication for asking compliance
questions or reporting potential noncompliance;
Review of disciplinary guidelines;
Attendance and participation in formal training programs as a condition of
continued employment and a criterion to be included in employee evaluations;
Overview of HIPAA/HITECH and CMS Data Use Agreement and the
importance of maintaining confidentiality of Personal Health Information;
Review of the laws governing employee conduct in the Medicare and Medicaid
Program.
Attendees must acknowledge in writing that they have received this training and
understand the Code of Conduct and Ethics. Employees, officers and directors must also attend
annual refresher training sessions. Employees are required to participate in any advanced
compliance training sessions organized by their department, which are designed to focus on the
specific compliance issues associated with the department’s functions. Additionally, training
sessions may be required when there are material changes in regulations, policy or guidance.
ICS requires FDRs to provide their employees with compliance training at the time of
contracting, and annually thereafter, and has the right to obtain written acknowledgment that the
FDR’s employees have received training and understand the Code of Conduct at any time. ICS
provides FDRs with copies of ICS’s Corporate Compliance Program and compliance policies and
procedures, and requires FDRs to distribute comparable documents to their employees.
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B. Fraud, Waste and Abuse Training (“FWA”)
All employees, officers, directors, and FDR employees involved in the administration or
delivery of Medicare or Medicaid benefits receive FWA training within 90 days of
commencement of employment, Board service, or contracting, as applicable, and annually
thereafter.
FWA training includes topics such as:
Laws and regulations related to MA and Part D FWA (i.e. False Claims Act, Anti-
Kickback statute, HIPAA/HITECH, etc.);
Obligations of FDRs to have appropriate policies and procedures to address FWA;
Processes for reporting suspected FWA;
Protections for ICS and FDR employees who report suspected FWA; and
Types of FWA that can occur in employee work settings.
Additional or refresher training may be provided more frequently based on an
individual’s job function, when requirements change, when employees are found to be
noncompliant, as corrective action to address a noncompliance issue, or when an employee
works in an area implicated in past fraud, waste and abuse. All employees, officer, directors and
FDR employees must acknowledge in writing that they have received FWA training. ICS and
FDRs maintain records of attendance, topic, and certificates of completion, as applicable, for 10
years.
ICS accepts FDRs’ use of CMS’ standardized FWA training and education module,
available through the CMS Medicare Learning Network (MLN)
at http://www.cms.gov/MLNProduct, for purposes of satisfying the requirement that FDRs fulfill
these training requirements. FDRs that have met the fraud, waste, and abuse certification
requirements through enrollment into the Medicare program or accreditation as a supplier of
Durable Medical Equipment Prosthetics, Orthotics or Supplies (DMEPOS) are deemed to have
met the training and education requirements for FWA.
VI. Effective Lines of Communication; Reporting Compliance Problems
A. Reporting Options
In accordance with its Fraud and Abuse Reporting Policy described in the Whistleblower
Policy (Exhibit 5), ICS maintains open lines of communication for the reporting of suspected
improper activity. Employees, including employees of FDRs, are expected to promptly report
any such activity of which they become aware in one of the following ways:
Notifying their supervisor;
Notifying the Compliance Officer;
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Notifying any other member of the Compliance Committee with whom they feel
comfortable; or
Filing a report through the Compliance Hotline or [email protected] e-
mail.
Employees are made aware of these methods for reporting suspected noncompliance, and
the non-retaliation policies discussed below, through compliance training, and through the use of
posters, other prominent displays, etc.
B. Compliance Hotline
The Compliance Hotline may be accessed by dialing 1-855-427-8477 (1-855-ICS-TIPS)
and is available 24 hours a day. To encourage full and frank reporting of suspected
noncompliance, fraud, waste or abuse, ICS gives employees the option of filing complaints
through the Compliance Hotline anonymously. The Compliance Department is responsible for
reviewing all Compliance Hotline reports, assessing whether they warrant further investigation
and ensuring that any compliance problems are identified and corrected. The Compliance
Department follows-up with employees who file complaints to let them know the timing for
developing a response and that confidentiality and non-retaliation policies apply.
Employees should understand that the Compliance Hotline is designed solely for the
reporting of fraud, abuse and other compliance problems; it is not intended for complaints
relating to the terms and conditions of an employee’s employment. Any such complaints should
be directed to the Director of Human Resources. ICS requires FDRs to notify their employees
that they can report compliance or FWA issues through the Compliance Hotline.
C. Non-Retaliation and Non-Intimidation
In compliance with federal and state law, ICS will not permit any intimidation or retaliation against any
individual who raises questions or concerns about misconduct or reports violations of federal or state laws
and regulations, internal policies and procedures, or otherwise in good faith participates in ICS’s
Compliance Program. Under ICS’s Whistleblower Policy (Exhibit 5), no employee who files or wishes to
file a report of suspected fraud, waste, abuse or other improper activity in good faith will be subject to
retaliation or intimidation by ICS in any form. Prohibited retaliation or intimidation includes, but is not
limited to, the threat or the act of: terminating, suspending, demoting, failing to consider for promotion,
harassing or reducing the compensation of any employee due to the employee’s intended or actual filing
of a report. Employees and FDRs are notified that they are protected from retaliation and intimidation for
False Claims Act complaints in addition to any other applicable anti-retaliation and anti-intimidation
protections. Employees should immediately report any such retaliation or intimidation to the Compliance
Officer. The Compliance Department, in cooperation with the Human Resources Department shall take
appropriate disciplinary action against any individual found to have intimidated or retaliated against any
person who reports a concern or question as outlined in this Program.
D. Routine Communications
The Compliance Officer periodically disseminates compliance communications to all
employees, temporary employees, FDRs, providers and the Board of Directors. Examples of
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communication mechanisms used are, but are not limited to, compliance posters, periodic e- mails,
staff meetings, and compliance training.
ICS also uses communication methods such as posting information on its website and
member communications to educate members on how to identify, detect, and report suspected
fraud, waste and abuse.
ICS also utilizes exit interviews with employees, conducted by Human Resources, to
identify potential non-compliance, misconduct and/or FWA.
VII. Employee Discipline; Enforcing Standards through Well-Publicized Disciplinary Guidelines
Employees who engage in fraud, waste, abuse or other misconduct are subject to
disciplinary action in accordance with ICS’s Employee Discipline Policy (Exhibit 6). ICS
employees and FDRs are made aware of the disciplinary policy through new employee training,
ongoing training, and our Compliance Program Manual, and our Employee Handbook. Any such
sanctions will be carried out by the Director of Human Resources in consultation with the
Compliance Officer. Depending on the nature of the offense, discipline may include counseling,
oral or written warnings, modification of duties, suspension or termination. ICS maintains
records of all compliance violation disciplinary actions for ten (10) years, and periodically
reviews these records to ensure that disciplinary actions are appropriate to the seriousness of the
violation, fairly and consistently administered, and imposed within a reasonable timeframe.
VIII. Routine Monitoring, Auditing and Identification of Compliance Risks
A. Routine Risk Assessment
ICS seeks to identify compliance issues and FWA at early stages before they develop into
significant legal problems. ICS believes that monitoring (regular reviews of operations) and
auditing (formal compliance reviews) are critical components to a successful Compliance
Program and programs to detect FWA.
The Compliance Officer, with input from our e Compliance Committee as applicable,
conducts a risk assessment, at least annually, of all applicable operational areas. The risk
assessment considers the size, budget and complexity of work of each area, in addition to the
compliance training provided and past compliance issues.
In collaboration with Department Heads, the Compliance Officer then ranks the risks in
each department taking into account:
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Program areas identified by the OIG in its annual work plan and other published
reports on the Medicare program, and program areas identified in the CMS
Medicare Managed Care Manual;
Results of prior monitoring reviews by ICS or first tier, downstream and related
entities;
Results from internal audits;
Results of regulatory reviews by CMS and State Departments of Insurance;
Resources developed by the industry that identify high risk areas for
Medicare Health Plans and Prescription Drug Plans;
Aberrant behavior identified through various techniques including techniques to
identify aberrant claim trends; and
Operational areas posing heightened risk of noncompliance, including but not
limited to provider credentialing, and ensuring access to medically necessary
care.
It may be determined that all operational areas are risk areas and therefore the risk
assessment would not be necessary. As explained below, this risk assessment impacts the types
of monitoring reviews and internal audits to be performed by ICS during the year as documented
in its internal audit work plan.
B. Routine Monitoring and Auditing
Based on the annual risk assessment, and in accordance with ICS’s Internal Auditing
Policy (Exhibit 7), at the beginning of each year the Compliance Officer develops an auditing
schedule that, at a minimum, addresses risk areas that will most likely affect ICS members
and ICS compliance (including payment and financial integrity). The audit schedule includes all
auditing activities for the upcoming calendar year, and identifies the methodology, needed
resources, processes for responding to audit results, and planned follow-up reviews of
noncompliant areas. The follow-up reviews are used to assess whether corrective actions have
addressed identified underlying compliance risks.
ICS uses a combination of techniques for its reviews including desk and on-site audits,
unannounced reviews, direct observation, inquiry, data analysis and statistical sampling methods.
In certain instances the
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Compliance Officer may consider external audits to be optimal and the audit schedule will
identify planned external audits. These reviews and audits help ensure all departments are
compliant with the requirements of the Medicare and Medicaid programs and ICS's policies and
procedures. The Compliance Program is also audited; components of the audit may include
review of training, post-training testing and results, the reporting mechanisms (e.g., hotline),
investigations, sanction screenings, certifications for receipt of standards of conduct, record
retention or delegation oversight activities. Audits of the Compliance Program are not conducted
by Compliance Program staff. Results of the Compliance Program audits are shared with the
Board of Directors and the Compliance Committee.
All employees are required to participate in and cooperate with audits as requested by the
Compliance Officer. This includes assisting in the production of documents, explaining program
operations or rules to auditors and implementing any corrective action plans. No employee who
participates in audits in good faith will be subject to retaliation or intimidation by ICS.
ICS also monitors FDRs and contracted providers for compliance with regulatory
requirements and contractual obligations, and follows the guidance and recommendations in
Section 50.6.6 of Chapter 21 of the Medicare Managed Care Manual.
ICS’s Compliance work plan includes ICS audits of first tier entities. Routine monitoring
and audit reviews are included as part of ICS's contractual agreement with its FDRs and
providers. Results implicate contractual corrective actions or if corrective action is not feasible,
termination of contract.
Individuals who perform monitoring reviews and audits:
Possess knowledge of the Medicare Program;
Possess the appropriate skills and expertise to perform the monitoring reviews;
Are independent of the specific functional area examined, whenever feasible; and
Have access to existing compliance resources, internal audit resources, and relevant
personnel in all relevant areas of operation.
The results of the monitoring reviews and audits are summarized in a standard written
report that outlines the review's objective, scope and methodology, findings and
recommendations. The corrective actions required to respond to monitoring findings are
documented.
The Compliance Officer provides updates on the monitoring results to the Compliance
Committee and senior leadership periodically, but no less than quarterly.
C. Employment of and Contracting with Ineligible Persons; OIG/GSA Exclusion
ICS prohibits hiring or entering into contracts with individuals and/or entities that are
listed as debarred, excluded or otherwise ineligible for participation in Federal and State health
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programs. ICS uses government resources, including CHHS OIG list of Excluded Individuals and
Entities, and the GSA Excluded Parties Lists System, and a history of complaints to determine
whether such individuals or entities are debarred or to be excluded. These sources are used for
both potential employees and for monthly checks of current employees, providers and FDRs.
ICS will not pay for services or prescription drugs prescribed or provided by a provider
excluded by either the OIG or GSA. If ICS discovers any claims that were submitted for
services or prescription drugs that were provided by or prescribed by an excluded provider, ICS
will investigate to determine whether other claims have been submitted for services or items
provided or prescribed by the excluded provider and report the claims to the MEDIC (for
prescription drug claims).
ICS also maintains files on its direct contract providers who have been the subject of
complaints, investigations, violations, and prosecutions. This includes enrollee complaints,
MEDIC investigations, OIG and/or DOJ investigations, US Attorney prosecution, and any other
civil, criminal, or administrative action for violations of Federal health care program
requirements. This information assists in monitoring and delegation oversight efforts and risk
assessments.
D. Government Audits and Investigations
In accordance with ICS’s Government Investigations Policy (Exhibit 8), employees and
contractors are expected to fully cooperate in all government audits and investigations, including
those conducted by CMS or its designees (e.g. MEDICs), and the OIG. Any employee who fails
to provide such cooperation will be subject to termination of employment.
All subpoenas and other governmental requests for ICS documents should be forwarded
to legal counsel, who is responsible for reviewing and responding to such requests. Employees
are strictly prohibited from destroying, improperly modifying or otherwise making inaccessible
any documents that the employee knows are the subject of a pending government subpoena or
document request. Employees are also barred from directing or encouraging another person to
take such action. These obligations override any document destruction policies that would
otherwise be applicable.
If an employee receives a request from a government investigator to provide an interview,
the employee should immediately contact his or her supervisor, who will inform ICS’s legal
counsel. Legal counsel will seek to coordinate and schedule all interview requests with the
relevant government agency. Employees are expected to answer all questions posed by
government investigators truthfully and completely. ICS contracts with first tier, downstream and
related entities require such contractors to comply with similar provisions.
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E. Fraud, Waste and Abuse
The Compliance Department has developed policies and procedures to prevent detect,
and correct fraud, waste and abuse. The Compliance Department is responsible for reducing or
eliminating costs due to FWA; reducing or eliminating fraudulent or abusive claims paid for
with federal or state dollars; preventing illegal activities; referring suspected, detected or
reported cases of illegal gun activity to MEDIC and/or law enforcement and conducting case
development and support activities for MEDIC and law enforcement investigations; assisting
law enforcement by providing information needed to develop successful prosecutions.
Anonymous reports of suspicion of FWA can be reported to the Compliance Hotline at 1-855-
427-8477 (1-855-ICS-TIPS), by email to [email protected]., or by mail to
Compliance Officer, Independence Care System, 257 Park Avenue South, 2nd Floor, New York,
NY 10010.
IX. Responding to Detected Offenses, Developing Corrective Action Initiatives and Reporting to Government Authorities
ICS is committed to taking prompt corrective action to address any potential fraud, abuse
or other improper activity identified through internal audits, investigations, reports by
employees, or other means.
A. Internal Investigations of Potential Non-Compliance
All reports of fraudulent, abusive or other improper conduct, whether made through the
Compliance Hotline or otherwise, are promptly reviewed and evaluated by the Compliance
Department. The Compliance Department determines, in consultation with the legal counsel
and other ICS personnel as necessary, whether the report warrants an internal investigation. If
so, the Compliance Department coordinates the investigation, issues a written report of its
findings and proposes any corrective action that may be appropriate. Employees are expected
to cooperate with the Compliance Department in resolving reported noncompliance or FWA,
and will not be subject to retaliation or intimidation by ICS for doing so in good faith.
The Compliance Department also conducts investigations into any FWA-related
misconduct by FDRs and providers for ICS’s Medicare-Medicaid and Managed Long-Term Care
products.
Regardless of how the noncompliance or FWA is identified, ICS initiates a reasonable
inquiry within 2 weeks after the date the incident was identified. A reasonable inquiry includes a
preliminary investigation by the Compliance Officer or a delegated member of his/her staff. If
the issue involves potential fraud or abuse and ICS does not have either the time or the resources
to investigate in a timely matter, the matter will be referred to MEDIC within 30 days.
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B. Corrective Action Initiatives
The Compliance In cases involving clear fraud or illegality, the Compliance Officer also
has the authority to order interim measures, such as a suspension of billing, while a
recommendation of corrective action is pending.
Corrective actions are designed to correct underlying problems leading to program
violations and prevent future noncompliance. Corrective action plans are implemented for both
internal initiatives, as well as when necessary for actions of FDRs. Corrective actions plans are
documented in a format determined by the Compliance Officer and include specific
implementation tasks, the names of individuals accountable for implementation, required time
frames for implementation, and ramifications for failing to implement. ICS conducts
independent audits of FDRs, or reviews FDR audit reports, to ensure FDRs have implemented a
corrective action plan.
Corrective Action may include, but not be limited to, any of the following steps:
Modifying existing policies, procedures or business practices;
Providing additional training or other guidance to employees or contractors;
Seeking interpretive guidance of applicable laws and regulations from government
agencies;
Disciplining employees (see Section VII or terminating contractors;
Notifying law enforcement authorities of criminal activity by employees, contractors
or others;
Returning overpayments or other funds to which ICS is not entitled to the appropriate
government agency or program in accordance with ICS’s Overpayments Policy
(Exhibit 9);
Making reports to government authorities including CMS or its designees (e.g.
MEDIC); and
Self-disclosing fraud or other illegality through established state and federal self-
disclosure protocols.
The Compliance Officer or a delegated member of his/her staff maintains a log to track
the status of corrective actions and routinely reports on the status of corrective actions to the
Compliance Committee and senior leadership on at least a quarterly basis.
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C. Self-Reporting to Government Authorities
The Compliance Officer directs the responsibility for any self-disclosures of non-
compliance, misconduct or FWA to government agencies, including CMS, the OIG, the
Department of Justice, or law enforcement, within 60 days after the determination a violation has
occurred.
D. Referrals to MEDICs
If after conducting a reasonable inquiry, ICS determines that potential fraud or
misconduct related to the Medicare-Medicaid plan has occurred, the conduct will be referred to
the MEDIC promptly, but no later than 60 days after the determination that a violation has
occurred. To the extent that potential fraud is discovered at a first tier, downstream and related
entities, the Compliance Officer will refer the conduct to the MEDIC sooner so that the MEDIC
can help identify and address any scams or schemes.
Once it is determined that a referral should be made to the MEDIC, the Compliance
Officer as needed, will develop a referral package that includes, to the extent available and
applicable, basic identifying information as described in § 50.7.4 of the Medicare Managed Care
Compliance Manual, that will allow an investigator to follow-up on a case.
If the MEDIC requests additional information ICS will furnish the requested information
within 30 days, unless the MEDIC otherwise specifies. ICS will also provide updates to the
MEDIC when new information regarding the matter is identified.
E. Identifying Providers with a History of Complaints
ICS maintains files for 10 years on both in and out-of-network providers who have been
the subject to complaints, investigations, violations and prosecutions, including: enrollee
complaints, MEDIC investigations, OIG and/or DOJ investigations, US Attorney prosecution,
and any other civil, criminal or administration action for violations of federal or state health care
program requirements. ICS also maintains files with documented warnings and educational
contacts, results or previous investigations and copies of complaints resulting in investigations.
ICS complies with requests from CMS, its designees and law enforcement regarding monitoring
of network providers that CMS has identified as potentially fraudulent or abusive.
* * * *
ICS has adopted the Program with the goal of carrying out all of its activities in
accordance with law and the highest ethical standards. The effectiveness of the Program hinges
on the active participation of all employees in preventing, detecting and appropriately responding
to fraud, abuse or other misconduct. Working together, we can make ICS a model of excellence
and integrity in the community.
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X. Addendum: Code of Conduct and Ethics — First Tier, Delegated and Related Entities (FDRs)
The following outlines ICS’ expectations of how our suppliers conduct business.
The Code of conduct is applicable to suppliers, vendors, contractors, consultants, agents
and other providers of goods and services who do, or seek to do, business with ICS.
People
1. Encourage a diverse workforce and provide a workplace free from discrimination,
harassment or any other form of abuse.
2. Treat employees and contractors fairly and honestly, including with respect to compensation,
working hours and benefits.
3. Respect human rights, consistent with local cultural norms, and prohibit all forms of forced
or compulsory labor.
4. Establish an appropriate management process and cooperate with reasonable assessment
processes requested by ICS.
5. Provide safe and humane working conditions for all employees and contractors.
Performance
1. Comply with all applicable state and federal (and foreign, where applicable) laws, rules, and
regulations, including all applicable state and federal privacy laws, including HIPAA and
HECH Act, and CMS guidance, where applicable.
2. Consistent with ICS policy as outlined in the Compliance Program section entitled Avoiding
Conflicts of Interest, pursue the ethical handling of actual or apparent conflicts of interest
when conflicts or appearance of conflicts are unavoidable including through full disclosure to
ICS, any transaction or relationship that reasonably could be expected to give rise to a
conflict.
3. Observe ICS policies regarding gifts and entertainment and conflicts of interest when dealing
with ICS associates and Medicare/Medicaid beneficiaries on ICS’s behalf.
4. Ensure no OIG or GSA excluded individuals or legal entities perform any functions for ICS.
5. Notify ICS of any employee or contractor disciplinary actions taken as a result of a
compliance infraction.
6. Compete fairly for our business, without paying bribes, kickbacks or giving anything of
value to secure an improper advantage.
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7. Keep financial books and records in accordance with all applicable legal, regulatory and
fiscal requirements and accepted accounting practices. 8. Promote, utilize and measure engagement of small and diverse suppliers without limiting the
generality of the foregoing, comply with the following Sections of this Code of Conduct:
A. Insider Trading and Fair Disclosure; and
B. Political Contributions and Activities.
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Exhibit 1 – ANTI-KICKBACK POLICY
Purpose of Policy
The purpose of this policy is to ensure compliance by Independence Care System (“ICS”)
with the federal and state anti-kickback statutes.
Applicable Law
The federal anti-kickback statute prohibits any person from knowingly and willfully
soliciting, receiving, offering or paying anything of value to another person in return for the
referral of a patient, or in return for the purchasing, leasing, ordering, or arranging for any item or
service, reimbursed by a federal health care program such as Medicare or Medicaid (42 U.S.C.
§ 1320a-7b). Penalties for violating the statute include imprisonment, criminal fines, exclusion
from government health care programs and civil monetary penalties. A similar New York law
prohibits the exchange of remuneration for referrals for items or services covered by the state’s
Medicaid program (N.Y. Social Services Law § 366-d).
Statement of Policy
Prohibition on Exchange of Remuneration for Member Referrals
Employees are prohibited from offering or paying anything of value, whether in cash or
in kind, to another party in return for the referral of a member to ICS. Likewise, employees are
prohibited from soliciting or receiving anything of value, whether in cash or in kind, from
another party in return for the referral of a member by ICS to another health care provider.
Acceptance of Gifts from Vendors
The acceptance of gifts from current or prospective vendors of ICS may also constitute an
improper kickback under state and federal law. Accordingly, employees may not solicit or
receive any such gifts.
Examples of Potential Kickbacks
Examples of conduct that violates this policy include, but are not limited to, the
following:
• An employee accepts free meals or tickets to a cultural event from a vendor in
return for entering into a contract with the vendor.
• An employee conditions a participating provider’s contract and reimbursement
rate on the referral of patients by the provider to ICS or the performance of other
marketing activities on ICS’s behalf.
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• An employee accepts something of value from a provider in exchange for being
granted a contract.
• An employee provides free space, free services or other items of value to a
community-based organization in return for the referral of potential members to
ICS.
Structuring Business Arrangements to Comply with Safe Harbors
Certain common business arrangements between parties exchanging referrals may be
structured to fit within “safe harbors” to the anti-kickback statute. Complying with a safe harbor
ensures that no portion of the compensation flowing under the arrangement may be characterized
as an improper inducement for referrals. Although compliance with a safe harbor is not legally
required, ICS seeks to fit business arrangements with vendors and member referral sources into a
safe harbor whenever feasible.
In particular, ICS generally requires that any financial concessions offered by vendors or
providers in return for business be in the form of discounted prices or rebates rather than separate
remuneration paid to ICS outside the negotiating pricing. In addition, any lease with a source or
recipient of member referrals should be reflected in a written agreement that provides for
aggregate rent that is fixed in advance for a period of at least one year and is consistent with fair
market value. Service agreements should be structured in a similar manner.
ICS may enter into a financial arrangement with a vendor or a source or recipient of
member referrals that does not satisfy a safe harbor only with the approval of the Compliance
Officer, who shall consult with counsel as necessary. Oral agreements with vendors or sources
or recipients of member referrals for space or services, including oral supplements to or
amendments of existing written agreements, are strictly prohibited. Whenever feasible, ICS will
seek to verify the fair market value of space or services through a third party expert or data
source. This process may include a review of comparable real estate listings in the community,
the purchase of proprietary databases or the retention of an independent valuation expert.
Handling Questions and Concerns
The anti-kickback statute is complex and ICS expects that, from time to time, employees
may have questions as to whether a particular activity or arrangement is consistent with this
policy. Employees are encouraged to ask their supervisors for guidance in this area. In addition,
employees may directly contact the Compliance Officer for assistance in interpreting this policy.
Enforcement
Employees who do not comply with this policy will be subject to disciplinary action by
ICS. Depending on the facts and circumstances of each case, ICS may reprimand, suspend or
dismiss any employee who fails to comply with this policy.
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Exhibit 2 – EMPLOYEE CONFLICTS OF INTEREST POLICY
Purpose of Policy
The purpose of this policy is to protect the interests of Independence Care System
(“ICS”) when it is contemplating entering into a Transaction (as defined below) that might,
directly or indirectly, benefit the private or outside interests of one of ICS’s employees. This
policy is also designed to ensure that any outside activities of employees do not conflict with
their duty of loyalty to ICS.
ICS makes business decisions impartially, fairly and without favoritism, for the purpose
of advancing ICS’s mission and interests. All employees must conduct themselves in a way that
avoids conflicts of interest and protects ICS’s resources as well as its reputation for fair and
ethical business conduct. No Transaction between ICS and any vendor or other outside party
shall be influenced, or appear to be influenced, by an employee’s personal interest or
relationships. Any personal or outside investments, relationships, transactions or interest,
whether direct or indirect, that would or could have an adverse effect on ICS’s or an employee’s
prudent, objective and independent business judgment constitute an unacceptable conflict of
interest and are prohibited.
Definitions
Family. The “Family” of an individual includes (i) such individual’s parents, spouse,
children, brothers and sisters, (ii) the parents, brothers and sisters of the individual’s spouse and
(iii) the spouses of the individual’s parents, children, brothers and sisters.
Substantial Financial Interest. A person has a “Substantial Financial Interest” in any
corporation, firm, association or other entity if such person receives compensation (i.e., wages,
fees, other direct or indirect remuneration, gifts or favors that are substantial in nature, etc.) from
or has, directly or indirectly, through business, investment or Family, an aggregate beneficial
equity interest of 10 percent or more in such corporation, firm, association or other entity.
Transaction. The term “Transaction” means any contract, investment, loan, lease, joint
venture or other business or financial arrangement, whether direct or indirect.
Statement of Policy
Prohibited Activities Representing a Conflict of Interest
Employees are prohibited from engaging in any of the following activities:
Using their position with ICS to profit, directly or indirectly, in any Transaction to which ICS
is a party. This prohibition includes any involvement by an employee in negotiating,
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recommending, approving or otherwise influencing the terms of a Transaction between
ICS and an entity in which the employee has a Substantial Financial Interest. Engaging in outside employment, self-employment or volunteer work that interferes with the
performance of their duties for ICS, impairs their prudent and independent business
judgment as an ICS employee or otherwise conflicts with their obligations to ICS. Using or disclosing to a third party any non-public information obtained as a result of
their employment for purposes unrelated to the performance of their duties as an ICS
employee. Using any property, including but not limited to, intellectual property belonging to ICS
for any purpose unrelated to the performance of their duties as an ICS employee. Taking advantage of or otherwise acting upon, for their own personal benefit or the benefit
or another party, any business, financial or other opportunity discovered in the course of
their employment with ICS that is within the scope of ICS’s existing or contemplated
operations unless (i) the opportunity is disclosed fully in writing to ICS’s Board of Directors,
(ii) the Board of Directors declines to pursue such opportunity within a reasonable time
period and
(iii) such opportunity does not otherwise result in a conflict of interest or otherwise violate
ICS’s policies.
Potential Conflicts of Interest Requiring Prior Approval
Employees are prohibited from engaging in any of the following activities without full
disclosure to and the prior written consent of the Chief Executive Officer: Obtaining a Substantial Financial Interest in, or serving as a director or officer of, any
entity with which ICS has conducted, or is contemplating the implementation of, a
Transaction. Obtaining a Substantial Financial Interest in, or serving as a director or officer of, any
competitor of ICS. The Compliance Officer shall provide guidance to employees
regarding the types of entities that are deemed competitors of ICS. Conducting business on behalf of ICS with a former Board member, officer or employee
of ICS, or an entity in which a former Board member, officer or employee has a
Substantial Financial Interest. Working as an employee or contractor of any entity other than ICS, including their
own business, for more than 16 hours per month.
Reporting and Disclosure Requirements
In order for ICS to monitor potential conflicts of interest, all employees shall promptly
report to the Compliance Officer any existing, proposed or potential Transaction of which
they are aware that could represent a conflict of interest under this policy.
Employees required to complete the Disclosure Statement must do so in a truthful, complete and
timely manner.
Referral to Compliance Officer
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Questions regarding interpretation or application of this policy should be referred to
ICS’s Compliance Officer.
Enforcement of Policy
Employees who do not comply with this policy will be subject to disciplinary action by
ICS. Depending on the facts and circumstances of each case, ICS may reprimand, suspend or
dismiss any employee who fails to comply with this policy.
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EXHIBIT 3 – DIRECTORS AND OFFICERS CONFLICTS OF INTEREST
POLICY
Purpose of Policy
The purpose of this policy is to protect the interests of Independence Care System
(“ICS”) when it is contemplating entering into a transaction or other business relationship that
might, directly or indirectly, benefit the private or outside interests of one of ICS’s directors or
officers.
Conflicts of interest potentially place personal or outside interests at odds with the
fundamental duty of loyalty owed by ICS’s officers and directors as fiduciaries of ICS. The
appearance of a conflict of interest can also damage ICS’s institutional credibility and ICS’s
ability to fulfill its mission and programmatic goals. The Board of Directors expects that
directors and officers will respect their obligations to act in the best interests of ICS in fulfilling
its non-profit mission.
Definitions
Conflict of Interest. “Conflict of Interest” means any Transaction involving ICS and an
Interested Person.
Interested Person. “Interested Person" means, with respect to any Transaction to which
ICS is a party, any of ICS’s directors or officers if such person:
• Is a party to the Transaction;
• Is a director or officer of any other corporation, firm, association or other entity that is a
party to the Transaction (or holds a position in such corporation, firm, association or
other entity with responsibilities or powers similar to those of a director or officer); or
• Has a direct or indirect Substantial Financial Interest in such Transaction.
Substantial Financial Interest. A person has a “Substantial Financial Interest” in any
corporation, firm, association or other entity if such person receives compensation (i.e., wages,
fees, other direct or indirect remuneration, gifts or favors that are substantial in nature, etc.) from
or has, directly or indirectly, through business, investment or Family, an aggregate beneficial
equity interest of 10 percent or more in such corporation, firm, association or other entity.
Family. The “Family” of an individual shall include (i) such individual’s parents, spouse,
children, brothers and sisters, (ii) the parents, brothers and sisters of the individual’s spouse and
(iii) the spouses of the individual’s parents, children, brothers and sisters.
Transaction. The term “Transaction” means any contract, investment, loan, lease, joint
venture, or other business or financial arrangement, whether direct or indirect.
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Statement of Policy
Per Se Conflicts of Interest
ICS shall not make a loan to (i) any of ICS’s current directors or officers; (ii) any
corporation, firm, association or other entity in which any current director or officer is a director,
officer or employee (or holds a position in such corporation, firm, association or other entity with
the responsibilities or powers similar to those of a director or officer); or (iii) any corporation,
firm, association or other entity in which any director or officer has a direct or indirect
Substantial Financial Interest.
The ordinary deposit of funds in a bank or the purchase by ICS of bonds, debentures, or
similar obligations of a type customarily sold in public offerings shall not be considered loans for
purposes of this policy. In addition, notwithstanding the above prohibition, ICS may make a loan
to another not-for-profit corporation that is a “Type B” corporation under applicable New York
State law, subject to the disclosure and approval requirements of this policy if such loan
represents a Conflict of Interest.
Compensation Decisions
No director who receives compensation from ICS for services shall vote on matters
pertaining to such director’s compensation; provided, however, this prohibition shall not include
determinations regarding the fee schedule established by ICS for all participating physicians,
even if the director is paid under such fee schedule. Compensation to officers shall require the
affirmative vote of a majority of the Board of Directors, unless a higher proportion is set in the
Certificate of Incorporation or By-laws.
Procedures in Other Conflict of Interest Cases
If any director or officer is an Interested Person in connection with any Transaction to
which ICS is a party, the director or officer must disclose in good faith to the Board or the Board
Committee that is considering the Transaction any material facts relevant to why such
Transaction may present a Conflict of Interest.
If the Board or Committee that is considering a Transaction has been informed or is
otherwise aware of a potential Conflict of Interest:
• Any Interested Person may make a presentation to the Board or Committee regarding the
Transaction, but after making such presentation he or she shall leave the Board or
Committee meeting while the remaining Board or Committee members discuss the
Transaction and the possible existence of a Conflict of Interest; and
• The remaining Board or Committee members shall decide if the Transaction presents a
Conflict of Interest.
If the Interested Person is a director, such person may not be counted in determining the
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presence of a quorum for any vote concerning the existence of a Conflict of Interest. No
Interested Person shall participate in, or use personal influence with regard to, the deliberations
concerning the existence of a Conflict of Interest.
Following due deliberation pursuant to this policy, the Board or Committee may
determine that a Transaction does not present a Conflict of Interest. In such cases the Board or
Committee need take no further action prior to approving the Transaction, other than its usual
procedures for approving Transactions.
If the Board or Committee determines that a Conflict of Interest exists, the Transaction
may be authorized (a) by the Board of Directors, but only by a vote sufficient to approve the
Transaction without including the vote of any director that is an Interested Person; or (b) by the
members of ICS that are entitled to vote thereon, if any, by a vote sufficient to approve the
Transaction.
Additional Guidelines for Officers, Directors and Committee Members
Officers and directors shall not use their position with ICS to benefit the interests of a
particular organization, constituency, or special interest group by any means, including but not
limited to, providing information not available to potential transaction partners or grantees,
lobbying on behalf of or serving as spokesperson to ICS for an organization or interest group
with which he or she is affiliated, or attempting to effect a positive decision for such organization
or interest group through his or her position within ICS.
Officers and directors will maintain the confidentiality of all non-public information
about ICS of which they become aware. Officers and directors shall not use confidential
information for any purpose other than as required to carry out their duties on behalf of ICS.
Records of Proceedings
The minutes of the Board and all Committee meetings shall contain:
• The names and positions of directors and officers who disclosed that they were Interested
Persons or otherwise were found to be Interested Persons, a description of the nature of
the relationship and/or Substantial Financial Interest which gave rise to such disclosure or
identification, and a description of the Transaction at issue;
• The names of the directors who were present during the taking of the action to determine
whether a Conflict of Interest was present, and the basis for there being a quorum for the
taking of such action;
• The steps taken by the Board or Committee to determine whether a Conflict of Interest
was present;
• The Board's or Committee's decision as to whether a Conflict of Interest was present and
the basis for such decision; and
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• The Board’s or Committee’s decision as to whether to proceed with the Transaction
and the names of the persons who voted to approve the Transaction.
Referral to Compliance Officer
Questions regarding interpretation or application of this policy should be referred to
ICS’s Compliance Officer.
Enforcement of Policy
If the Board or a Committee has reasonable cause to believe that a director or officer has
failed to make disclosure when there was a Conflict of Interest and such director or officer knew
or should have known that there was a Conflict of Interest, the Board or Committee shall inform
such director or officer of the basis for such belief and afford such director or officer an
opportunity to explain the alleged failure to disclose. If, after receiving the response of such
director or officer and making such further investigation as may be warranted in the
circumstances, the Board or Committee determines that such director or officer has in fact failed
to disclose a Conflict of Interest, it shall take appropriate disciplinary and corrective action.
Failure to disclose a Conflict of Interest may constitute grounds for the director or officer’s
removal from his or her position for cause.
EXHIBIT 4 – EMPLOYEE TRAINING POLICY
Purpose of Policy
The purpose of this policy is to promote Independence Care System’s (“ICS’s)
compliance with applicable laws and regulations by ensuring that all ICS employees receive
appropriate training regarding ICS’s Compliance Program and the prevention, detection and
reporting of fraud and abuse.
Applicability of Policy
This policy is applicable to all ICS employees, officers and directors. First tier,
downstream and related entities (FDRs) are required to provide their employees with
compliance and fraud, waste and abuse training.
Statement of Policy
Basic Compliance Training
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All newly hired employees, officer and directors must receive basic compliance training
within 30 days of the initial date of employment. Training will be documented by the Director
of Human Resources or a delegated member of his/her staff as part of his or her responsibility to
oversee general orientation for new employees. Basic compliance training will be no less than
one hour.
The curriculum for basic compliance training will be developed and updated as necessary
by the Compliance Officer. The curriculum will be designed to provide employees with an
overview of key compliance issues faced by ICS. The topics covered by basic compliance
training will include guidance on preventing and detecting, among other things, fraudulent or
improper billing by providers, under-utilization of health care services, inaccurate cost reporting,
kickbacks, and misuse of ICS funds. Employees will also be advised of their obligation to report
suspected fraud or abuse, the opportunity for anonymous reporting and the prohibition against
retaliating against employees for making reports in good faith.
As part of basic compliance training, each employee will receive a copy of ICS’s Code of
Conduct and Ethics. The Compliance Officer will determine the format of basic compliance
training (e.g., in-person, on-line, video, etc.), including how best to incorporate testing to assess
compliance training effectiveness, and is authorized to retain outside vendors to provide training
components. The Compliance Officer will keep records for ten (10) years of all basic
compliance training programs, including course descriptions, frequency of training and hours of
each training session.
All employees will be required to sign a written form acknowledging the receipt of basic
compliance training and the Code of Conduct and Ethics. Such forms will be retained in
employee
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personnel files for no less than ten years.
Fraud, Waste and Abuse Training
The curriculum for FWA training will be developed and updated as necessary by the
Compliance Officer. The Compliance Officer will determine the format of training (e.g., in-
person, on-line, video, etc.), including how best to incorporate testing to assess FWA training
effectiveness, and is authorized to retain outside vendors to provide training components.
Advanced Compliance Training
As necessary, Department Directors, in consultation with the Compliance Officer, will
develop a curriculum of advanced compliance training for employees in his or her Department.
Advanced compliance training will consist of in-depth guidance on the fraud prevention and
other compliance issues arising in connection with the operation of the Department. Employees
will also be provided with all policies and procedures relevant to the performance of their duties.
All advanced compliance training curricula must be approved by the Compliance Officer. In
addition, the compliance officer will work with the departments to identify an audit and FWA
deputy who will meet regularly with the compliance team to discuss training needs and/or
potential FWA or non-compliance issues identified by the team.
Compliance Officer Training
ICS will ensure that the Compliance Officer has sufficient opportunities to receive
training on compliance issues through attendance at outside conferences, subscription to trade
periodicals and other means.
Annual Refresher Training
The Compliance Officer will prepare an annual refresher compliance training program,
which will reinforce the key principles covered by basic compliance training and summarize any
changes in ICS’s Code of Conduct and Ethics or fraud and abuse prevention program during the
prior year. All employees will be required to attend an annual refresher training session. The
Director of Human Resources will be responsible for tracking refresher training sessions in
consultation with the Compliance Officer.
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Bulletins and Updates
The Compliance Officer will be responsible, on a regular basis, for preparing and
distributing to relevant employees bulletins and updates addressing new fraud and abuse or other
compliance issues of which the Compliance Officer becomes aware. These bulletins and updates
will cover, among other things, changes in government contracts, new interpretations of existing
laws or rules, revisions to ICS policies or procedures, and industry trends or developments.
Department Heads will notify the Compliance Officer of any significant matters they deem
appropriate for inclusion in such bulletins and updates. In 2015, ICS launched an intra-agency
website where staff can view regular updates from the Compliance department including but not
limited to: policy and programmatic changes, FWA issues that impact the organization, FAQs,
and a calendar to compliance trainings and meetings. In addition, the Compliance Department
also conducts department-specific trainings for staff via an in-person meeting.
Enforcement of Policy
Employees who do not comply with this policy will be subject to disciplinary action by
ICS. Depending on the facts and circumstances of each case, ICS may reprimand, suspend or
dismiss any employee who fails to comply with this policy.
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EXHIBIT 5 – WHISTLEBLOWER POLICY
Purpose of Policy
The purpose of this policy is to promote Independence Care System’s (“ICS’s”)
compliance with applicable laws and government standards by requiring all ICS employees to
report suspected compliance or fraud, waste or abuse, and ensuring that all reports are handled
appropriately and employees filing such reports in good faith are not subject to retaliation.
Applicability of Policy
This policy is applicable to all ICS employees.
Statement of Policy
Reporting Responsibilities
It is the responsibility of all employees to report observed or suspected fraud, waste,
abuse or other improper activity relating to the operation of ICS. For purposes of this policy,
fraud means any type of intentional deception or misrepresentation made by a person with the
knowledge that the deception could result in some unauthorized benefit to himself or herself, or
to ICS or another person. Waste means the overutilization of services or other practices that
result in unnecessary cost to the state or federal government or ICS. Abuse means practices that
are inconsistent with sound fiscal, business or medical practices and result in an unnecessary cost
to the state or federal government or ICS, or in reimbursement of services that are not medically
necessary or fail to meet professionally recognized standards for health care. Fraud, waste, and
abuse may be committed by ICS employees, contractors, patients or others.
Examples of the types of activities that must be reported by employees include, but are
not limited to, the following:
Billing the government for individuals who are not members. Duplicate billing.
Failing to provide all medically necessary services for which ICS receives reimbursement.
Inflating or otherwise misrepresenting ICS’s costs on cost reports filed with government
agencies or private funders. Billing the government for a member if the employee is aware that the member or his or her
family has obtained coverage fraudulently. Submitting inaccurate or misleading data or reports to government agencies.
Theft or other misuse of ICS’s funds or property by employees or contractors.
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Violations of ICS’s compliance policies or other guidance. Violations of laws, regulations or government contracts.
Reporting Mechanisms
Employees have several options for reporting fraudulent, abusive or other improper
conduct. Employees may file reports with their supervisor or department director, the
Compliance Officer or any other member of the Compliance Committee with whom the
employee feels comfortable.
ICS has also established a toll-free telephone hotline that employees may call to file
reports anonymously. The hotline may accessed by calling 1-855-427-8477 (1-855-ICS-TIPS).
The Compliance Officer will be responsible for overseeing the operation of the hotline,
responding to complaints filed through the hotline and ensuring that all employees are aware of
the hotline number and understand that reports may be filed through the hotline on an
anonymous basis. The Compliance Officer will also publicize the availability of the hotline
through regular reminders, posters and organized compliance awareness events. Staff may also
use the [email protected] e-mail to report possible FWA.
Investigations
All reports of fraudulent, abusive or other improper conduct, if not made to the
Compliance Officer or through the hotline or e-mail, will be promptly forwarded to the
Compliance Officer for review. The Compliance Officer, in consultation with other ICS staff
and counsel as appropriate, will determine whether the report warrants an investigation. If the
Compliance Officer determines an investigation is warranted, he or she will promptly
coordinate an investigation in accordance with counsel as may be necessary.
Non-Retaliation and Non-Intimidation
No individual who files a report under this policy in good faith may be subject to
retaliation or intimidation in any form. Retaliation is also prohibited against an employee for
refusing to carry out any activity that is the subject of a report made under this policy in good
faith. No employee may intimidate or threaten to retaliate against another employee for filing a
report.
Prohibited retaliation or intimidation includes, but is not limited to, the threat or act of:
terminating, suspending, demoting, failing to consider for promotion, harassing or reducing the
compensation of an employee due to the employee’s intended or actual filing of a report under
this policy. Retaliation is prohibited even if it is determined that the allegedly improper conduct
was proper or did not occur, provided that the report was made in good faith. ICS reserves the
right to take disciplinary action against any employee who maliciously files a report he or she
knows to be untrue.
Any actual or threatened retaliation should be reported by the affected employee or any
other employee to the Compliance Officer. The Compliance Officer will investigate such
allegations in the same manner as other investigations carried out under this policy.
Enforcement of Policy
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Employees who do not comply with this policy will be subject to disciplinary action by
ICS. Depending on the facts and circumstances of each case, ICS may reprimand, suspend or
dismiss any employee who fails to comply with this policy.
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EXHIBIT 6 – EMPLOYEE DISCIPLINE POLICY
Purpose of Policy
The purpose of this policy is to promote compliance with applicable legal requirements
by ensuring that Independence Care System (“ICS”) employees are appropriately disciplined if
they engage in fraudulent behavior, fail to comply with applicable law or do not adhere to ICS’s
compliance program or policies governing the prevention, detection and reporting of fraud and
abuse.
Applicability of Policy
This policy is applicable to all ICS employees.
Statement of Policy
Conduct Subject to this Policy
Employees will be subject to discipline under this policy in the event of any violation of
(i) applicable law, (ii) government standards relating to ICS’s operations or (iii) ICS’s policies
governing compliance and the prevention, detection or reporting of fraud and abuse. As more
fully described in other ICS policies, including Whistleblower and Employee Training policies,
employees have obligations to report suspected FWA and to participate in compliance and FWA
training. Nothing in this policy will restrict ICS from disciplining employees for offenses not
referenced above under other ICS policies.
Administration of Disciplinary Measures
The Compliance Officer will promptly notify the Director of Human Resources of any
improper conduct by an employee that may warrant discipline under this policy. The Director of
Human Resources will be responsible for determining the appropriate sanction, if any, in
accordance with ICS’s standard employment policies, taking into account the special
considerations set forth in this policy. The Director of Human Resources will consult with the
Compliance Officer and the General Counsel as necessary throughout the disciplinary process.
Types of Discipline
Any conduct punishable under this policy will be subject to the following disciplinary
actions, which are based on the nature of the violation:
Unintentional Violations. Unintentional violations of ICS policies or legal requirements
may occur if an employee is unaware of the relevant standards of conduct or
inadvertently fails to adhere to such standards. Although unintentional violations do
not generally constitute fraud or abuse, depending on the circumstances, they may be
grounds for discipline. The key factors to be considered in determining the
appropriate type of discipline, if any, for such violations include (i) the degree of the
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employee’s carelessness, (ii) the extent to which the conduct involved an isolated
incident or an ongoing pattern of activity, (iii) a history of any prior violations by the
employee, (iv) the effect of the conduct on ICS enrollees, (v) whether the conduct
resulted in improper billing by ICS to government agencies and (vi) the extent to
which the conduct exposed ICS to regulatory sanctions, other liabilities or adverse
publicity. Disciplinary action will typically involve counseling, an oral warning, a
written warning or modification of duties, but in certain circumstances (especially in
the case of repeat offenses) may also include suspension or termination.
Intentional Misconduct that Does Not Constitute a Crime. An employee engages in
intentional misconduct if the employee knows his or her conduct violates ICS policies
or legal requirements, or acts with reckless disregard of applicable standards of
conduct. “Reckless disregard” may occur, for example, if an employee knows there
is a relevant standard of conduct and fails to seek appropriate guidance as to the
nature of that standard. If an employee’s intentional misconduct is a first offense and
does not constitute a crime, depending on the circumstances, disciplinary action may
involve counseling, an oral or written warning, modification of duties, suspension or
termination. Second offenses will be punishable by termination.
Criminal Activity. Any employee who engages in criminal activity in the course of his or
her employment will be subject to immediate termination by ICS. A finding of
criminal activity may be based on a conviction, a plea bargain or a determination by
the General Counsel, in consultation with outside counsel as necessary, that a crime
has been committed. Being charged with a crime is not automatic grounds for
termination absent a conviction or plea bargain. The Human Resources Director will
determine, on a case-by-case basis, whether an employee should be suspended or
terminated while criminal proceedings are pending. The Compliance Officer will
determine, in consultation with legal counsel, whether it is appropriate to refer the
matter to law enforcement authorities for prosecution.
Disciplinary measures will be imposed within 30 days of the receipt of all relevant
information unless the Director of Human Resources determines there are unusual circumstances
warranting a greater review period. Except in cases of termination, employees subject to
discipline will also be required to undergo specialized retraining relevant to the violation.
Employee Evaluations
The Human Resources Director will include in all standard employee evaluation forms
one or more questions relating to ethics and compliance with applicable ICS policies and legal
requirements. ICS supervisors and managerial staff will provide accurate and complete
information in response to such question(s) when preparing employee evaluations.
Record Retention
All records regarding the imposition of disciplinary measures under this policy will be
retained by the Director of Human Resources for a period of ten (10) years.
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EXHIBIT 7 – INTERNAL AUDITING POLICY
Purpose of Policy
The purpose of this policy is to prevent fraud, waste, abuse and other illegal activity by
establishing a framework for regular internal audits of Independence Care System’s operations.
Applicability of Policy
This policy is applicable to all ICS employees.
Statement of Policy
Oversight of Internal Auditing Process
The Compliance Officer will be responsible for overseeing ICS’s internal auditing
system. The Compliance Officer is authorized to delegate auditing duties to other ICS personnel
as well as outside attorneys, accountants and vendors as necessary and appropriate.
Subjects for Auditing
• Internal audits may cover the following subjects:
• Provision of accurate and complete information by member services staff to
individuals contacting ICS’s member services call center.
• Compliance by ICS’s member services call center with waiting time and
abandonment rate goals, and staffing of the call center with sufficient
personnel to satisfy ICS’s contractual obligations.
• The processing and reporting of enrollee complaints in accordance with
applicable contractual and legal requirements.
• The proper credentialing and re-credentialing of providers, and the adherence
to credentialing standards by entities to which credentialing has been
delegated by ICS.
• The accuracy and completeness of ICS’s provider directory.
• Compliance with utilization review time frames and notice requirements set
forth in ICS’s contracts and applicable law.
• Appropriate utilization of health care services and the approval of all
medically necessary covered services.
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• Risks identified through ICS’s annual compliance risk assessment.
Audit Procedures
The Compliance Officer will develop audit tools and procedures for carrying out the
audits required by this policy. The Compliance Officer, with the approval of the Chief Operating
Officer, may contract with outside companies to conduct audits as appropriate. The Compliance
Officer will oversee the services provided by any outside vendors.
The Compliance Officer will, whenever feasible, utilize separate audit staff to carry out
internal audits. It is understood, however, that it may be appropriate or necessary for staff to
perform audits of their own department’s activities. If a department audits its own activities, the
Compliance Officer will design audit procedures that minimize auditing by employees of their
own work.
In the event the Compliance Officer determines it is in the best interests of ICS to keep
the contents and/or findings of any audit confidential, the Compliance Officer will arrange for
counsel to conduct the audit. In such event, employees will be advised that the audit is being
conducted under the attorney-client privilege and the audit report will indicate that such privilege
is applicable.
Audit Deputies
Each Department Head shall appoint an Audit Deputy who will act as a point of contract
for that department during internal audits. The Audit Deputy is responsible for completing or
obtaining audit deliverables and ensuring that audit timeframes are met.
Audit Schedule
On an annual basis, the Compliance Officer will develop a schedule for internal audits for
the upcoming year, which will be approved by the Compliance Committee. The schedule will
specify the subject of each audit, the audit methodology, the time period during which the audit
will be carried out and the personnel or contractors to be used to perform the audit. Audit
subjects may be selected from among the topics specified in this policy and will include any
other topics deemed appropriate by the Compliance Officer, based on an annual risk assessment.
The Compliance Officer will select audit subjects based on the level of risk associated with the
subject, any prior history of violations, and the length of time that has passed since the most
recent audit on the same subject. The Compliance Officer will ensure that any internal audits
mandated by law or contract be carried out on a schedule consistent with such requirements.
Nothing in this policy is intended to require internal auditing on all of the matters specified
herein each year or on any other specific schedule. The Compliance Officer will use best efforts
to minimize any disruption of ICS’s business activities caused by internal audits.
Audit Reports
Upon completion of an audit, the Compliance Officer will arrange for the preparation of
an audit report. The report will set forth the subject of the audit, the audit methodology, the audit
findings and any recommended corrective action. The report will be provided to the Compliance
Committee, the Chief Operating Officer and any appropriate Audit Deputies and Department
Heads. The Compliance Committee will work with the relevant Audit Deputy to ensure that all
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recommended corrective action is taken and will require the Audit Deputy to report to the
Compliance Officer when implementation is completed. All audit reports will be maintained by
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ICS for ten (10) years.
Enforcement of Policy
Employees who do not comply with this policy will be subject to disciplinary action by
ICS. Depending on the facts and circumstances of each case, ICS may reprimand, suspend or
dismiss any employee who fails to comply with this policy.
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EXHIBT 8 – GOVERNMENT INVESTIGATIONS POLICY
Purpose of Policy
The purpose of this policy is to establish a mechanism for the orderly response to
government investigations of Independence Care System (“ICS”) or its employees, and to ensure
that all ICS personnel and contractors cooperate appropriately with such investigations.
Applicability of Policy
This policy is applicable to all ICS employees and contractors.
Statement of Policy
Types of Government Agencies that May Investigate ICS
A variety of federal, state and local government agencies may be involved in
investigating ICS. These agencies include, but are not limited to, the U.S. Department of Health
and Human Services Office of Inspector General, the New York Office of Medicaid Inspector
General (“OMIG”), the Centers for Medicare and Medicaid Services, the Federal Bureau of
Investigation, the United States Attorney’s Office, the New York State Attorney General’s
Medicaid Fraud Control Unit (“MFCU”), the New York State Department of Health (“DOH”),
the New York State Insurance Department and District Attorneys’ offices.
General Guidelines for Responding to Government Investigators
ICS employees will be expected to be polite and to request the following information: (1)
the name, agency affiliation, business telephone number and address of all investigators; (2) the
reason for the contact; and (3) if the investigator visits in person, the investigator’s identification
and business card. Except as specified otherwise in this policy, employees will direct
investigators to the Compliance Officer who will collaborate with ICS’s counsel. The
Compliance Officer along with ICS counsel will be exclusively responsible for responding to any
requests for information or documents. If an employee is not contacted by an investigator but
learns of a government investigation through other means, the employee will immediately notify
the Compliance Officer.
Subpoenas and Other Requests for Documents
If an employee receives a subpoena or any other written request for documents from a
government agency, the employee will immediately inform the Compliance Officer and forward
the request to counsel. Counsel will be responsible for reviewing the request, verifying its
authenticity and confirming that the production of documents or witnesses is not restricted by
any applicable laws, including HIPAA or other confidentiality statutes. If there is no such
restriction, counsel will coordinate the production of documents with the investigating agency. It
is ICS’s policy to fully cooperate with all appropriate requests for documents issued by
government agencies. All documents will be provided by ICS without charge.
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Government investigators may seek documents by contacting employees by telephone or
in person at ICS’s offices. It is ICS’s policy to cooperate with these requests in an orderly
manner. Any employee who is contacted by a government investigator to provide documents
will immediately notify the Compliance Officer and ICS counsel, who will coordinate the
provision of any requested information. It is ICS’s general policy to provide documents to
government investigators only in response to a written request. However, counsel, after
verifying the authority of the requesting official, has the authority to waive this requirement on a
case-by-case basis as appropriate and permitted by law.
Requests for Interviews and Other Testimony
ICS will cooperate fully with government investigators, including OMIG and MCFU
staff, in making its employees available in person for private interviews, consultations, grand
jury proceedings, pre-trial conferences, hearings and trials. ICS’s contractors will be required to
cooperate in the same manner by making their own employees available.
All employees are required to make themselves available for interviews requested by
government investigators. Although individuals have a constitutional right not to incriminate
themselves, any failure by an employee to provide an interview, testify or otherwise cooperate in
a government investigation will constitute a violation of the employee’s employment obligations
and be grounds for termination.
All requests by government agencies to interview employees, whether by a subpoena or
in any other written or oral form, will be directed to the Compliance Officer and ICS counsel.
Counsel will be responsible for scheduling all such interviews at appropriate times and
locations.
In some cases, investigators may contact employees at their homes or other locations off
ICS’s premises, in person or by telephone, to request an interview. Employees are encouraged in
such circumstances to advise the investigator of their willingness to cooperate in an interview
scheduled by counsel during normal business hours at ICS’s offices or another appropriate
location. Employees should request the investigator’s business card and promptly report the
contact to their supervisor and the Compliance Officer, who will inform counsel. Counsel will
be responsible for coordinating the scheduling of interviews with investigators.
ICS will generally seek to have counsel attend an employee’s interview to the extent
permitted by the investigating agency. ICS’s counsel will represent the interests of ICS and not
the individual employee. Any privilege attaching to information provided to ICS’s counsel
belongs to ICS and not to the employee. An employee may consult with an attorney of his or her
own choosing to represent his or her individual interests. Employees may request reimbursement
of attorneys’ fees by ICS. Counsel will evaluate such requests for reimbursement on case-by-
case basis in accordance with the indemnification provisions of ICS’s Bylaws.
During the interview, employees will be expected to adhere to the following guidelines:
• Always tell the truth. It is a crime to lie under oath or obstruct a government criminal
investigation.
• In talking with the government investigator, employees should be very careful to
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answer questions completely, accurately and concisely so that there will be no
misunderstanding as to what is said.
• It is important for employees to make clear to the government representative whether
the information he or she is providing is first-hand knowledge, or information that the
employee has heard or otherwise obtained from another individual.
• Do not speculate. If employees do not recall something or have no knowledge or
insufficient knowledge about the topic, they should say so.
If, during the course of the interview, the investigator requests copies of any ICS
documents, the employee will forward the request to counsel, who will handle all requests for
documentation. It is essential that counsel review all documents prior to submission to
government investigators to ensure that they are fully responsive to the investigator’s request and
that they are not protected by the attorney-client or any other legal privilege.
If ICS counsel is not present during the interview, the employee should contact counsel
promptly after the interview to conduct a debriefing. Employees are encouraged to make
detailed notes during the interview.
Searches of ICS’s Premises
If OMIG, the MFCU or other government agencies appear at ICS’s offices and request to
search the premises, the employee receiving the request will immediately contact counsel and
request that the investigator wait in the reception area for counsel to appear. Counsel or his or
her designee will immediately appear in person or direct other staff on the premises as to how to
handle the request. If the investigator refuses to wait for counsel, the employee will not deny
admission to the premises.
Counsel or his or her designee will accompany the investigator on the search. Counsel or
his or her designee will keep a record of the search, including, but not limited to: (1) the date and
time period of the search; (2) the names and positions of all the investigators; (3) the areas and
files searched; (4) which files were seized; (5) the names of any employees questioned by the
investigators and (6) the subjects covered by any questioning.
If permitted by the investigator, a copy will be made of all documents that are seized. If
this is not permitted, an inventory of the seized documents will be requested from the
investigator. Any requests during the search to speak with employees will be handled in
accordance with the provisions of this policy governing employee interviews.
If any government investigators other than those representing OMIG or the MCFU
request to search ICS’s offices, the same policy as referenced above will be followed, except that
counsel or his or her designee will not be required to permit the search unless a duly authorized
search warrant is presented. Counsel will request to see a copy of the warrant and any
supporting affidavit, and confirm that the search and any documents seized are within the scope
of the warrant. If no search warrant is presented, counsel may determine, in his or her discretion,
whether to permit the search.
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Record Retention
Once counsel becomes aware of a government investigation, he or she will ensure that all
relevant ICS employees are promptly notified, and that, until further notice is issued, they are
prohibited from altering, removing or destroying any paper or electronic documents or records of
ICS relating to the subject matter of the investigation. Counsel will define with sufficient
specificity the range of documents subject to the notice. The provision of notice by counsel will
supersede any record destruction that would otherwise be carried out under ICS’s ordinary
record retention policies. Counsel will ensure notification of all relevant employees upon
completion of the investigation and direct how records relating to the investigation should be
handled.
Enforcement of Policy
Employees who do not comply with this policy will be subject to disciplinary action by
ICS. Depending on the facts and circumstances of each case, ICS may reprimand, suspend or
dismiss any employee who fails to comply with this policy.
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EXHIBIT 9 – OVERPAYMENT POLICY
Purpose of Policy
The purpose of this policy is to ensure compliance by Independence Care System (“ICS”)
with federal law requiring the return of identified overpayments received from federal health care
programs such as Medicaid and Medicare.
Applicable Law
Under the False Claims Act, as amended by the Fraud Enforcement and Recovery Act of
2009, it is unlawful for a person to knowingly avoid an obligation to pay or transmit money to
the Government. The Affordable Care Act of 2010 clarifies that a provider is liable under the
False Claims Act if it fails to return an overpayment received from Medicaid or Medicare within
sixty days of discovering the overpayment or by the date any applicable cost report is due,
whichever is later. Violations of the False Claims Act may be punished by civil fines of up to
$10,000 per claim, treble damages, and exclusion from federal health programs.
Statement of Policy
Overpayments may be discovered in many different ways, including through internal
audits, claims reconciliations, and employee complaints. Any employee of ICS who becomes
aware of an actual or suspected overpayment is required to notify his or her supervisor or the
Compliance Officer within two business days of the discovery of the actual or suspected
overpayment. Supervisors should forward all such reports to the Compliance Officer.
Upon receiving a report of a potential overpayment, the Compliance Officer or a
delegated member of his/her staff shall conduct an investigation. The Compliance Officer may
consult other ICS personnel and ICS’s legal counsel to the extent necessary to carry out the
investigation. The Compliance Officer shall attempt to complete the investigation within 30 days
of receipt of the report. The Compliance Officer may suspend billing while the investigation is
pending if necessary to prevent the receipt of additional overpayments.
If the Compliance Officer determines that ICS received an overpayment, the Compliance
Officer shall report the overpayment to ICS’s Chief Operating Officer (“COO”) and Chief
Financial Officer (“CFO”), and request approval to return the overpayment to the appropriate
Government payer. If the COO and CFO fail to approve such a request and the Compliance
Officer continues to believe that ICS received an overpayment, the Compliance Officer shall
present the matter to ICS’s Board of Directors for a final determination. The Compliance Officer
shall use best efforts to complete this process within 30 days.
All overpayments shall be returned to the appropriate Government payer within 60 days
of discovery or, if applicable, 60 days from the date any cost report is due.
The Compliance Officer shall maintain records pertaining to the reporting, investigation
and repayment of overpayments under this policy. The Compliance Officer will submit a report
annually to the New York State Department of Health and the New York State Office of the
Medicaid Inspector General detailing any overpayments made throughout the year and the actions
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Addressing Questions and Concerns
Because the rules governing government health care program reimbursement are
complex, ICS expects that, from time to time, employees may have questions as to whether a
particular payment received constitutes an overpayment. Employees are encouraged to contact
the Compliance Officer to seek guidance on these matters and to ask any questions they may
have regarding this policy.
Enforcement of Policy
Employees who do not comply with this policy will be subject to disciplinary action by
ICS. Depending on the facts and circumstance of each case, ICS may reprimand, suspend, or
dismiss any employee who fails to comply with this policy.
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