Internal Reporting of Potential Compliance Matters

- Chief Compliance Officer (CO) or designee
- Ethics Action Line (EAL)
- Immediate Supervisors
- Department Directors
- Administrative Team Members

- Supervisors or Department Directors report potential compliance matter to CO
- Reported information in EAL is reviewed to identify compliance-related matters
  - Credibility of information reported by reporter is determined
  - Matter reported to the EAL is immediately reported to CO or legal counsel
    - Investigation and corrective action are initiated by CO
  - If matter is related to potential violation of federal securities laws it is reported to Chief Compliance Officer, Deputy General Counsel and the Vice President, Audit Services
- Compliance Officer (CO) designates lead investigator based on what the allegations are
  - Also regularly inquire with facility managers and other personnel to identify potential compliance matters

- Lead Investigator
  - Incident report is opened in CIMS for each reported issue
  - Potential compliance matter is investigated
  - Corrective action is assigned and taken as appropriate
  - Document investigation and resolution of matter in CIMS
- Chief Compliance Officer 
  - Potential compliance matter that may be a Reportable Event is reported
  - Determination of escalation of potential compliance matters
- Tenet Senior Management/Board of Directors Quality, Compliance and Ethics Committee
  - Escalated matters are evaluated for further actions
- Auditors
  - Any reports received by Audit are forwarded to the Ethics and Compliance Department

- EAL General Information
  - (l-800-8-ETHICS or 1-800-838-4427) toll free telephone line available 24 hours a day
  - Callers may be anonymous (where allowed by law)
  - Matters discussed are confidential
  - Employees are encouraged to also talk to other resources (e.g., CO, manager)
- CIMS Tracking and Documentation
  - Matter Tracking
    - Identification numbers are automatically assigned when any of the investigated areas relates to the eight areas in the Compliance Program Charter
  - Required CIMS Documentation
    - Evidence of refunds
    - Corrective action plans
    - Legal counsel review
    - Other evidence that matter has been fully investigated and resolved
- Timeline Guidelines
  - Investigations
    - Complete within 120 days for investigations led by the Compliance
    - Complete within 180 days for investigations led by in-house or outside counsel 
  - Extensions
    - 60-day extension requests can be made for legitimate investigative need to the Chief Compliance Officer
    - Timeline guidelines do not apply for ongoing litigation and government investigations

- Inappropriate coding
- Inappropriate claims submission
- False or fraudulent documentation matters
- Inappropriate charging/billing
- Inappropriate charge code selection/charge master
- Concerns raised by Medicare Administrative Contractor
- Accreditation matters
- Provider based status
- HIPAA or patient privacy matters
- EMTALA matters
- Overpayments
- Cost reporting matters
- Physician Arrangement matters (e.g., violations of the Stark law or Anti-kickback statute (
- Failure to meet Business Operations standards (Accounting, Sarbanes-Oxley, etc.)
- Patient inducement
- Medical necessity matters
- Correct level of care
- Failure to use Tenet-required compliance software (e.g., CARDS, Order Checker, MASS, INTERQUAL)
- Medical staff credentialing and privileging
- Appropriate licensed staff
- Quality of care matters
- Drug diversion