Corporate Compliance Program
Code of Ethics &
Triboro Administrative Services, LLC (the “Management Company”) and Chinatown True Care Medical, PLLC (the “Practice”) and their affiliated companies (collectively, “Rendr Care Physicians”) are committed to complying with all applicable laws, rules and regulations that govern or affect their businesses, and to conducting their businesses in accordance with the highest ethical business standards. To that end, Rendr Care Physicians has implemented this Corporate Compliance Program/Code of Ethics & Business Conduct that includes measures designed to prevent, detect, and correct non-compliance as well as fraud, waste, and abuse.
This Corporate Compliance Program/Code of Ethics & Business Conduct (“Compliance Program” or the “Code”) is designed to be a guide and resource for everyone both at the corporate offices and at the clinical practice that comprise Rendr Care Physicians. The Code is reviewed and approved by the Rendr Care Physicians’ Executive Compliance Committee (“Executive Compliance Committee”) and the Board. The Code describes the procedures that will be followed in enforcing our standards and sets forth responsibilities for each one of us regarding the Compliance Program.
Mission and Values Rendr Care Physicians supports its medical practices so as to enable them to offer the highest quality medical care to their patients. The high standards of ethics and conduct embodied in this Code apply to all of our interactions with our health care provider; companies that we do business with; government entities to whom we report; and the public and private entities that we seek reimbursement from.
Rendr Care Physicians will not tolerate unlawful or unethical behavior by anyone associated with our organization, and each one of us is expected to be law-abiding, honest, trustworthy, and fair in all of our business dealings.
Everyone associated with Rendr Care Physicians– Board Members, officers, employed staff, consultants and contractors– is expected to follow the ethical standards set out in this Code. No one at Rendr Care Physicians should take an action that is believed to be in violation of any law or the Code. If you are unsure whether an action is lawful you should check with your supervisor or the Compliance Officer. When in doubt, you should ask before taking action.
While management and the Board is primarily responsible and accountable for ensuring that the requirements of the Compliance Program are implemented, Rendr Care Physicians requires everyone to cooperate with inquiries concerning possible improper business activities; documentation problems; coding or billing practices and actively work to correct improper practices that are identified.
II. ELEMENTS OF RENDR CARE PHYSICIANS’ COMPLIANCE PROGRAM
Rendr Care Physicians, through its compliance efforts, seeks to:
Create a culture that promotes prevention, detection and resolution of instances of conduct that do not conform to applicable laws, regulations, or any other health care compliance requirements.
Ensure internal controls in the reimbursement and payment areas are firmly in place, as claims and billing operations are often the source of fraud and abuse concerns.
Our Compliance Program includes the eight (8) core elements below that are based on the expectations of the federal and state government.
Element 1 Written Policies & Procedures
Our Compliance Program is, in part, a statement of Rendr Care Physicians’ overarching principles and values and defines the framework for compliance policies and procedures. It describes expectations that all employees conduct themselves in an ethical manner; that issues of noncompliance and potential illegal conduct are reported through appropriate mechanisms; and that reported issues are addressed and corrected. At Rendr Care Physicians compliance is everyone’s responsibility.
The Code is regularly reviewed and updated to incorporate changes in applicable laws and other compliance program requirements. It is approved by the Executive Compliance Committee of the Practice and the Management Company. Together with our policies and procedures, the Compliance Program serves as a reference guide that describes Rendr Care Physicians’ standards of conduct, including our core values and cultural attributes.
Policies & Procedures
Our policies and procedures (“P&Ps”) are detailed and specific and describe the operation of the Compliance Program. They address issues such as how to report compliance concerns; training requirements; the operation of our Compliance Hotline; and how suspected, detected or reported issues are investigated and addressed. Compliance P&Ps are reviewed and approved by the Executive Compliance Committee.
Upon hire, employees are required to acknowledge receipt of the Compliance Program/Code of Ethics & Business Conduct and to agree to abide by its standards.
Updates and Revisions
The compliance P&Ps are reviewed and updated as necessary to incorporate any relevant changes in applicable laws, regulations and other requirements. Proposed revisions are developed under the direction of the Compliance Officer and presented to the Executive Compliance Committee for review and approval.
Element 2 High-Level Oversight, Including a Compliance Officer and Compliance Committee
Board of Managers (“Board”) & Practice Owners
The Board of the Practice is ultimately accountable for oversight of the Compliance Program and conducts that oversight through the Board’s Compliance Committee.
Board Compliance Committee
The Board Compliance Committee is composed of members of the Board with senior management as invited guests. The Board’s Compliance Committee receives training and education on the structure and operation of the Compliance Program, and its members are expected to be knowledgeable about compliance risks and strategies.
The Board’s Compliance Committee, among other things, monitors the effectiveness of the Compliance Program; recommends improvements as necessary or appropriate; reviews and oversees compliance with federal, state and other applicable healthcare program requirements; and reviews significant compliance risk areas and the steps management has taken to monitor, control, and report such compliance risk exposure.
The Rendr Care Physicians Compliance Officer has the responsibility to implement the required elements of the Compliance Program and oversee the day-to-day operations of the program. The Compliance Officer is responsible for ensuring that processes are in place to monitor and oversee activities by key business units; compliance issues are properly addressed as they arise; and that appropriate compliance assurance reviews and inquiries are conducted.
The Compliance Officer makes reports directly to the Board’s Compliance Committee regarding significant operational compliance issues and updates on the implementation of the elements of the Compliance Program.
Executive Compliance Committee
Rendr Care Physicians also has in place an Executive Compliance Committee comprised primarily of senior management. This committee meets on at least a quarterly basis and has overall responsibility for the continued improvement of the performance of the Compliance Program. The Executive Compliance Committee, among other things, ensures that necessary policies and procedures and compliance education are in place.
Element 3 Training and Education
The Compliance Officer, working with the Human Resources Department, develops and oversees compliance training and education for all stakeholders of Rendr Care Physicians. Managers at practice sites are responsible for ensuring that assigned compliance education is completed by their teams.
On an annual basis, all employees are required to complete online modules on Corporate Compliance and HIPAA Privacy and Security.
Employees also receive compliance education specific to their functions and as well as warranted by the implementation of new operational processes or corrective actions.
Additionally, employees in identified risk areas may be provided education in person, through audio/web conferences, or in writing on various topics. Similarly, the Compliance Officer can provide issue- or area-specific education.
Human Resources maintains the content and employee attendance records of the required training.
Element 4 Effective Lines of Communication
If you have a compliance issue or questions you are encouraged to raise the issue or question with your supervisor or another management staff member. If you are uncomfortable raising the issue with a supervisor or management, or the issue is not resolved, you should contact the Compliance Officer. Your failure to report a compliance issue may result in disciplinary action against you for failing to report.
We also have set up an email Compliance Hotline that you can use to report compliance issues, concerns or questions. Upon receiving a report of possible unethical or illegal conduct, the Compliance Officer will conduct an investigation. All employees are expected to cooperate in compliance investigations. The Compliance Officer will bring the report, as appropriate, to the attention of senior management so that any issue of noncompliance is addressed as soon as possible.
How to Report a Compliance Concern
Anyone may report instances of perceived non-compliant conduct through any of the following:
Email Compliance Hotline
The electronic Compliance Hotline (“Hotline”) is a resource available to employees and other interested individuals to report compliance violations, concerns, or questions. You can email your concern at any time and it will be reviewed and investigated.
All employee concerns are handled and investigated in a confidential manner, and confidentiality will be preserved to the extent circumstances and the law allow.
Non-Retaliation and Anonymous Reporting
Reports can be made in good faith without fear of retribution or adverse consequences. As detailed in the Rendr Care Physicians’ Non Retaliation Policy, any form of retaliation against any employee who makes a report in good faith or otherwise participates in the Compliance Program is strictly prohibited. Retaliation of any sort will result in disciplinary action up to and including termination of employment for the individual who engages in retaliation.
Element 5 Well-Publicized Disciplinary Standards
Rendr Care Physicians’ P&Ps include guidance regarding disciplinary action for those who have failed to comply with our policies and procedures, the Code or federal and state laws. Any individual who fails to participate in the Compliance Program as required, including engaging in or failing to report noncompliance or violations of the Code or policies and procedures, is subject to disciplinary action, up to and including termination of employment.
Rendr Care Physicians encourages the highest standards of ethical conduct. When suspected non-compliance is determined to exist, the Compliance Officer is required to ensure an investigation is performed and determine whether a violation of law or policy has occurred. If an investigation reveals that a violation has occurred, the Compliance Officer will provide management with recommendations to correct the violation, and may recommend disciplinary action and education/training to prevent recurrence of the issue. It is the responsibility of management to implement corrective actions for any identified noncompliance.
If disciplinary action is initiated, management works with Human Resources to make sure that the disciplinary action is reflected in the employee’s personnel file. Documentation of disciplinary action serves as proof of the effectiveness of the Compliance Program by demonstrating that compliance is taken seriously within the organization.
Element 6 Effective System for Routine Monitoring, Auditing and Identification of Compliance Risks
Auditing and monitoring and self-assessments assist organizations in identifying and acting on real or potential issues before they become liabilities. To prevent and detect non-compliance, Rendr Care Physicians conducts monitoring of key systems and processes.
Monitoring involves daily, weekly, or other periodic spot checks to verify that essential functions are being adequately performed and that processes are working effectively. Departments may be required to report the results of their monitoring effort to the Compliance Officer and/or the Executive Compliance Committee.
Compliance audits are conducted in a systematic and structured approach. The process involves identifying a risk area; researching applicable regulatory guidelines; determining the key objectives; detailing the scope and methodology to be utilized; selecting a sample; and producing a written report of findings, recommendations and management responses to those findings and recommendations.
Compliance Work Plan
The Compliance Officer, in conjunction with members of management, assesses the risks of the business on a continuous basis. Annually, the Compliance Officer compiles a Compliance Work Plan that is reviewed and signed off on by the Executive Compliance Committee. The Compliance Work Plan identifies specific risk areas that are to be reviewed during the upcoming year. Throughout the year, the Compliance Officer reports progress on these reviews to the Executive Compliance Committee and to the Board Compliance Committee.
Rendr Care Physicians will not hire, contract or retain any employee or company to perform services if that employee or company is excluded from participation in any federal or state-funded healthcare program. To that end, in accordance with the Rendr Care Physicians Exclusion Check Policy, all employees and vendors are checked on a monthly basis against applicable exclusion lists. If it is confirmed that any employee or vendor is excluded from participation in federal or state-funded healthcare programs, Rendr Care Physicians will ensure that that employee or vendor does not provide services related to such programs.
Element 7 Procedures and System for Prompt Response to Noncompliance
Any noncompliance threatens our reputation as reliable, honest, and trustworthy. Rendr Care Physicians is therefore committed to correcting any identified noncompliance and implementing necessary steps to prevent its recurrence.
Investigating Compliance Issues
Upon notice of possible noncompliance, the Compliance Officer will promptly initiate an investigation into the issue to determine whether a compliance issue exists, or if there has been a violation of the Code, P&Ps or applicable laws. If a compliance issue or violation does exist, then the investigation will attempt to determine its cause so that appropriate and effective corrective action can be implemented.
Corrective Action Plans
In the event that noncompliance is identified, the non-compliant activity will be stopped as soon as feasible. An investigation into the extent and root cause of the noncompliance will be conducted to examine, among other issues:
existing workflows and processes;
relevant policies and procedures;
training and education of staff involved; and
the effectiveness of monitoring systems, if any.
When all the relevant facts have been determined, a corrective action plan (“CAP”) to correct and prevent the recurrence of the noncompliance will be developed and implemented. The CAP will include detailed steps to be taken and a timeline for implementation of those steps.
The Compliance Officer will collaborate with operational leaders in the investigation of any issue and the creation of the CAP, and will ensure that other appropriate steps, such as disciplinary action and the identification and correction of any internal control that contributed to the noncompliance, are taken.
Element 8 Policy of Non-Intimidation and Non-Retaliation
Rendr Care Physicians’ non-intimidation and Non Retaliation Policy provides that anyone who makes a report, complaint, or inquiry in good faith, will be protected from retaliatory action. We have a no-tolerance policy for intimidation of, or retaliation taken against, individuals making such good faith reports, complaints or inquiries, and will take disciplinary action against individuals who have intimidated or retaliated against such individuals.
III. COMPLIANCE EXPECTATONS
Rendr Care Physicians expects all employees to ensure compliance in all areas of our work, including:
Claims Development and Submission
Rendr Care Physicians has an obligation to third-party payors, and the federal and state governments to exercise diligence, care and integrity when submitting claims for payment for services rendered. To uphold this obligation, Rendr Care Physicians shall maintain honest, fair, and accurate billing practices. All individuals involved in the billing functions, shall have experience and knowledge, and billing personnel shall be appropriately trained to perform all billing functions in accordance with federal, state and local law.
Financial Accounting Records: Integrity and Accuracy
All financial reports, accounting records, expense accounts, and other financial documents shall accurately represent the performance of operations.
Compliance with Licensure and Competency Requirements
All physicians and other providers of Rendr Care Physicians represents must be properly licensed pursuant to applicable state requirements. We will not knowingly submit any bill to a third-party payor for services provided by a physician or other provider who is not properly licensed.
Gifts, Payments, Loans and Entertainment
It is the policy of Rendr Care Physicians to maintain the highest standards of ethical conduct in its relationships with clients, suppliers and others. The solicitation of gifts, gratuities, favors or kickbacks by an employee is strictly prohibited. No employee will make or offer to make any payment or provide any other thing of value to another person with the understanding or intention that such payment is to be used to influence the referral of patients.
Gifts cannot be given or received for the purpose of influencing the business behavior of the recipient. Cash or cash-equivalent gifts are strictly prohibited. Non-cash gifts made to Rendr Care Physicians staff members from individuals who seek to patient referrals are also strictly prohibited. Gifts of even nominal value may not be offered to any governmental official. Such gifts can be misinterpreted as an attempt to improperly influence the official and are to be avoided. Any questions regarding whether or not an item or situation falls within the scope of this section must be raised immediately with the Compliance Officer.
Billing & Coding
To reduce fraud, waste and abuse in the billing of claims, Rendr Care Physicians has identified the following potential risk areas:
Billing and Coding
Billing for items or services not rendered or not provided as claimed;
Submitting claims for supplies and services that are not reasonably necessary;
Billing for non-covered services as if such services are covered;
Knowing misuse of provider identification numbers, which results in improper billing;
Unbundling (billing for each component of the service instead of billing or using an all- inclusive code);
Failure to properly use coding modifiers;
Failure to correctly identify services ordered;
Upcoding the level of service provided.
Medical Necessity and Quality of Care
Rendr Care Physicians will not knowingly submit claims to a payor for services that are not medically necessary or that were ordered by a physician or other individual who was not properly credentialed.
Overpayments or Underpayments
In connection with Rendr Care Physicians’ review of coding and billing, Rendr Care Physicians reviews payment remitted to ensure compensation reflects services rendered and, will work with the client medical practice to timely refunds to payors as appropriate.
Billing procedures must always be based on adequate documentation of the medical justification for the services rendered or test conducted and for the bill submitted, and this medical documentation must comport with all applicable regulations.
All billing must be accurate and truthful. No personnel should ever misrepresent charges to, or on behalf of, a patient or third-party payor. Rendr Care Physicians bills only for those services that were actually and appropriately rendered. We will not tolerate false statements by any personnel to a government agency or other payor. Deliberate misstatements to government agencies or other payors will expose the personnel involved to criminal penalties and termination of employment.
General Business Practices
Rendr Care Physicians will not make any unethical or illegal payments to anyone to induce the use of our services. In addition, management must ensure that all of Rendr Care Physicians’ business records are accurate and truthful, with no material omissions; that the assets and liabilities of the Practice and the management company are accounted for properly in compliance with all tax and financial reporting requirements, and that no false records are made. Similarly, all reports submitted to governmental agencies, insurance carries, or other entities must be accurately and honestly made.
If you become aware of any improper use of, or accounting practice concerning Rendr Care Physicians’ resources, you should report the matter immediately to the Compliance Officer.
All purchasing decisions must be made with the purpose of obtaining the highest quality product or service at the most reasonable price. No purchasing decision may be made based on any consideration that any employee, officer or partner – or any family member or friend of any of them – will benefit by the transaction. Rather, the sole criteria behind all purchasing decisions must be only the best interests of the Practice. Nor can any service or item be purchased in return for a referral of patients from another or with a view towards inducing another to refer patients.
Antitrust laws are designed to preserve and foster fair and honest competition for businesses. To accomplish this goal, the language of these laws is deliberately broad, prohibiting such activities as “unfair methods of competition” and agreements “in restraint of trade.” This type of language gives enforcement agencies the right to examine many different business activities to judge the effect on competition.
Rendr Care Physicians’ policy requires full compliance with all antitrust laws. The greatest danger for violations of antitrust laws rests in contacts with competitors. Antitrust laws make illegal any agreement that restricts competition or interferes with the ability of the free market system to function properly. You should not have any discussions, conversations or other communications with competitors about the division of geographic areas, or services; the circumstances under which business will be conducted with suppliers, insurance companies, patients or customers; or marketing efforts. Further, you should avoid discussions with competitors regarding the future business plans of Rendr Care Physicians or any competitors. Finally, you should not have any discussions with competitors regarding prices or reimbursement or salary levels.
Compliance with Anti-Kickback Laws
Both federal and state laws specifically prohibit any form of kickback, bribe or rebate made directly or indirectly, overtly or covertly, in cash or in kind to induce the purchase, recommendation to purchase or referral of any kind of healthcare goods, services or items paid for by Medicare or the Medicaid program. The term “kickback” means the giving of anything of value in exchange for patient referrals. Any question concerning these laws or any business arrangement subject to anti-kickback or anti-referral laws should be directed to the Compliance Officer.
To list everything that may constitute an improper inducement under the anti-kickback laws would not be possible. However, Rendr Care Physicians must scrupulously avoid being either the offeror or the recipient of an improper inducement. Care must be taken in structuring relationships with persons not employed by the Practice or Management Company so as not to create a situation where Rendr Care Physicians appears to be offering an improper inducement to those who may be in a position to refer or influence the referral of patients to the Practice. For example, the offering of free goods or services, or those priced below market value, to physicians for the purpose of influencing them to refer patients to, or utilize the professional services offered by, Rendr Care Physicians would be improper.
Rendr Care Physicians also should not receive any improper inducement from its vendors to influence it in making decisions regarding the use of particular products or the referral or recommendation of patients to other providers of goods and services. For example, free or at below-market value goods or services from vendors, awards, discounts, prizes or other forms of remuneration may be treated as a “kickback” even if given as part of a promotional program of a vendor or provider, e.g., pharmaceutical company, medical equipment supplier, etc.
Likewise, it is a violation of Rendr Care Physicians’ policy for any officer, employee or any other person acting on behalf of or in the name of Rendr Care Physicians to make or authorize the paying of any bribe, any payment for an illegal act or any other use of a Rendr Care Physicians resource which, although arguably not illegal, could be interpreted as improper or unwarranted. In general, any money, property or favor offered or given to induce someone to forego normal business or professional considerations in making decisions that affect Rendr Care Physicians constitutes improper use of a resource.
Marketing Activities and Patient Referrals
We are committed to the delivery of high-quality medical care and relies on the quality of that care in marketing its services to attorneys, patients, physicians, and others. All marketing activities and advertising by personnel must be truthful and not misleading and must be consistent with regulations on physician practice advertising.
Rendr Care Physicians does not pay physicians, or anyone else, either directly or indirectly, for patient referrals. This includes the giving of any form of remuneration, including virtually anything of value, in return for a referral. Also, we do not accept any form of remuneration in return for referring patients to other healthcare providers.
Environment, Health and Safety
In the course of medical practice operations, hazardous materials and infectious wastes may be used or generated. Rendr Care Physicians must ensure the proper handling and disposal of these materials.
Pharmaceuticals, Prescription Drugs, Controlled Substances
Many of Rendr Care Physicians employees have access to prescription drugs, controlled substances, hypodermic needles, drug samples and other regulated pharmaceuticals. It is Rendr Care Physicians’ policy that all employees be both diligent and vigilant in carrying out their obligations to handle and dispense drugs and related medical supplies and in preventing unauthorized access to them.
HIPAA and Other Confidential or Protected Information
The Health Insurance Portability and Accountability Act (“HIPAA”) provides federal protections for protected health information (“PHI”) held by Rendr Care Physicians and provides patients an array of rights with respect to that information. At the same time, the law is balanced so that it permits the disclosure of protected health information needed for patient care and other important purposes. The HIPAA Security Rule specifies a series of administrative, physical, and technical safeguards for Rendr Care Physicians to assure the confidentiality, integrity, and availability of electronic protected health information.
Individuals are expected to treat confidential information obtained through their employment or service to Rendr Care Physicians with the utmost confidentiality. Information learned about a patient’s medical treatment or condition is considered confidential as a matter of law and should be treated with particular care. It is essential, therefore, that everyone adhere to all applicable laws regarding the confidential and privileged status of medical records and communications. This information should be shared within Rendr Care Physicians only as appropriate to ensure the optimum patient care and as provided in established policies regarding matters such as medical records, quality assurance, risk management, and administration.
Confidential information acquired by personnel about the business of Rendr Care Physicians must be held in confidence and may not be used as a basis for personal gain by the personnel, their families, or others. Information relating to transactions pending with Rendr Care Physicians is not to be released to any person unless this information has been published or otherwise made generally available to the public.
Information Owned by Others
Like Rendr Care Physicians, other organizations have intellectual property they want to protect. So do individuals. These other parties are sometimes willing to disclose their confidential information for a particular purpose. If you receive another party’s confidential information, you must proceed with caution to prevent any accusations that you or Rendr Care Physicians misappropriated or misused the information.
Special care should be taken in acquiring software from others. As intellectual property, software is protected by copyright laws and may also be protected by patent, trade secret laws or as confidential information. Such software includes computer programs, databases and related documentation owned by the party with whom you are dealing or by another party. Before you accept software or sign a license agreement, you must follow established procedures.
The Practice and the Management Company are required by law to maintain certain types of medical and business records, usually for a specified period of time. Failure to retain such documents for such minimum period could subject our businesses to penalties and fines.
All dealings with governmental agencies must be truthful and accurate.
Having a government agent come to a practice site or business location can be intimidating. Below are some steps you should follow:
If a governmental agent comes to a site or the corporate offices and seeks information, you should contact your supervisor immediately.
Do not consent to a search or review. Unless the governmental agent has a Warrant, that agent may not enter the site or review documentation.
Do not provide statements to the agent.
Make photo copies of the agent’s business cards and send to the Compliance Officer.
Any staff member who receives an official governmental request for information must notify their supervisor and the Compliance Officer immediately.
It is Rendr Physicians’ policy to comply with the law and to cooperate with reasonable demands made during the course of a governmental investigation or inquiry.
Rendr Care Physicians recognizes that its greatest strength lies in the talent and ability of its employees. Accordingly, Rendr Care Physicians has developed and implemented numerous human resources policies and has published for staff members.
IV CONFLICTS OF INTEREST
Rendr Care Physicians recognizes that employees and others associated with our organization have varied professional, financial and personal interests. We expect that these interests and commitments will be managed in a manner that does not harm Rendr Care Physicians’ operations or reputation, in accordance with the Conflicts of Interest Policy.
A conflict of interest may exist in a variety of situations, including whenever an individual has an opportunity to use his or her position for personal gain or the gain of a family member or a friend; or when a person or group not associated with Rendr Care Physicians might influence the work decisions of employees. A conflict of commitment exists when outside consulting or other relationships keep an individual from devoting appropriate amounts of time, energy, creativity or other personal resources to his or her Rendr Care Physicians responsibilities.