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1. Compliance standards and procedures

2. Oversight responsibility

3. Effective education and training

4. Monitoring and auditing system

5. Effective lines of communication

6. Enforcement and discipline

7. Response and direction

Program Goals:

The following are the program goals for the compliance program:

1. Maintain zero tolerance of fraud.

2. Prevent, detect and respond to unacceptable legal risk and its financial implications.

3. Route non-compliance issues to appropriate areas.

Code of Conduct:

As an Organizational employee, you are expected to abide by a high standard of ethical behavior at all times. You must obey the laws and rules that apply to health system operations and to your particular duties. We urge you to make sure you know and understand all the rules and policies that apply to your work. If you are not familiar with them, you might make mistakes that could be costly to the health system and to you. If you do not know what rules apply to you, talk to your supervisor or call the Chief Audit/Compliance Officer at (252) 847-0125. You must also be careful to understand and obey applicable laws including antitrust laws as well as the conflict of interest policy and the ethical behavior policy in the Administrative Policy Manual. You should be particularly careful not to inadvertently do anything that amounts to fixing prices, limiting competition or dividing up customers or markets. You should also be careful not to engage in any of the following illegal activities:

1. Kickbacks- you may not ask for, give or receive any kind of direct or indirect payment or reward for Medicare or Medicaid referrals.

2. False Claims- you may not make false or misleading claims for services given or received or about people who gave or received services.

3. Mail and Wire Fraud- you must not send false claims or statements through the US Postal Service or electronically.

It is your duty to report any transaction or conduct that you think may be a violation of federal, state or local law. You can do that by:

1. Notifying your immediate supervisor (Alyson Riddick in the GME Office, 847-4268)

2. Contacting the Chief Audit/Compliance Officer by telephone or email.

3. Making a toll-free, anonymous call to the compliance hotline at 1-888-777-2617.

4. Should employees or agents feel that the health system has not taken appropriate action to address a potential violation, they can also lodge a complaint concerning waste, fraud and abuse directly to the federal government to the Health and Human Service’s Office of

March 17, 2009

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