Principles of Business Ethics For Health Care Providers and Business Partners

Transcription

1 Principles of Business Ethics For Health Care Providers and Business Partners You are the key to integrity GHHH7HAHH 1212

2 Humana maintains ultimate responsibility for compliance, including compliance of its health care providers and business partners. As a result, we have developed the Principles of Business Ethics for Health Care Providers and Business Partners (PBE). It is important that you read this and, if you re an administrator, provide this information or a substantially similar document to all employees and downstream entities who support Humana. In addition, Humana s associate PBE can be accessed online from the Corporate Governance section of the Investor Relations page on Humana.com. You will see the terms below throughout this document, which are defined as follows: Associate Refers to a Humana employee Employees and Downstream Entities Individuals employed or contracted by a health care provider or business partner of Humana who are acting on behalf of Humana, either directly or indirectly. It is inclusive of employees, employed and contracted health care providers, pharmacists, and sales agents, board members, pharmacy and therapeutic committee members, volunteers, consultants, and any contracted individuals. Health Care Providers and Business Partners An organization, individual, or other entity contracted or subcontracted to provide a service or product for/to Humana, a Humana-owned or -operated facility/enterprise, a Humana affiliate, and/or to perform a function that Humana is responsible for performing. These may also be referred to as first tier, downstream, and related entities (FDRs). The definition is inclusive of health care providers, pharmacies, sales agents, sales agencies, delegates, vendors, suppliers, contractors, and related entities acting on behalf of Humana, either directly or indirectly, and continues down to the level of the ultimate provider of the service or product. It generally excludes wholly-owned subsidiaries of Humana and their employees, as well as employees of Humana. Important Resource Use the toll-free, Humana Ethics Help Line, THE-KEY ( ) to: Get answers about ethical situations not covered in this document Report instances in which you believe Humana s PBE is not being upheld Have a sounding board when you aren t comfortable taking your concerns to your manager The Ethics Help Line is staffed by non-humana associates and all calls it receives are confidential. i 2013 Principles of Business Ethics Health Care Providers and Business Partners

3 You are the Key to Integrity Dear Valued Health Care Providers and Business Partners: We appreciate all you do to maintain the highest ethical standards in your business interactions. By upholding these standards, you help enable us to do the same, while also contributing meaningfully to our success. We value our mutually beneficial relationship and are grateful for your partnership. In this spirit, we have developed the Principles of Business Ethics for Health Care Providers and Business Partners (PBE) to help you fully understand Humana s commitment to standards for integrity and our expectations for your ethical conduct. It is an important part of Humana s Corporate Compliance Program, which has a goal to facilitate a workplace climate in which ethics is so integral to day-to-day operations that ethical behavior is virtually self-enforcing. Humana believes in promoting open communication about these matters, so this guide s easy-to-follow format highlights ways you can contribute to success by doing the right thing in the right way for the right reasons. While the provisions set forth in this document don t cover every possible situation that may arise, you must comply with the letter and spirit of these principles. All health care providers and business partners should confirm that they and their employees and downstream entities comply with the required standards of conduct. After review of this document, you will be asked to confirm your commitment to business ethics as a Humana health care provider or business partner through your signature or an online attestation process. Thank you for your continued participation as a valued health care provider or business partner. With your help, Humana will continue to show that maintaining high ethical standards isn t simply the right thing to do, but that it s also good business. Sincerely, Bruce Broussard President and Chief Executive Officer Michael B. McCallister Chairman of the Board J. Gregory Catron Vice President Associate General Counsel and Chief Compliance Officer THE-KEY ii

4 Table of Contents You are the Key to Integrity Humana s Ethical Principles Integrity Judgment Test Higher Responsibilities for Humana Leaders Waivers Getting Answers to Business Ethics Questions 4 Multiple Communications Options for You Ethics Help Line Chief Compliance Officer and Corporate Compliance Programs Reporting and Investigation of Violations 6 Reporting Methods No Intimidation and/or Retaliation Investigation of Ethics and Compliance Issues Disciplinary Standards Conflicts of Interest 8 Examples Conflict of Interest Statement Gifts, Favors, Job Opportunities, and Entertainment 9 Fraud, Waste, and Abuse 10 Definitions Responsibility for, and Resources to Assist with, Proactively Addressing Fraud, Waste, and Abuse Applicable Laws and Regulations 11 Anti-kickback Laws w Antitrust Laws Health Insurance Portability and Accountability Act of 1996 (HIPAA) False Claims Act Anti-money Laundering and Office of Foreign Assets Control Program Integrity of Company Information 13 Accuracy of Information Confidential Information Assets Safeguarding Confidential Assets Privacy and Security Obligations Doing Business with the Government 15 Contracting with the Government Procurement Integrity Act Hiring Former and Current Government Employees or Elected Officials Dealing with Government Agencies Doing Business with Accrediting Agencies Doing Business with Foreign Governments, Contractors, or Consultants Ineligible Health Care Providers, Vendors, and Related Entities 17 Workplace Conduct 18 Environmental Responsibility 18 Contacts 19 Index 19 In this document, the terms Humana or the Company refer to Humana Inc. and its subsidiaries and affiliated entities. iii 2013 Principles of Business Ethics Health Care Providers and Business Partners

5 You are the Key to Integrity The principles in this document are intended to reflect the collective good judgment and common sense of all Humana s Ethical Principles Humana s PBE reaffirms Humana s commitment to integrity as the cornerstone of behavior for anyone who acts on the company s behalf. This means everyone from the board of directors and CEO to the part-time temporary worker, regardless of whether the person is a Humana associate. Therefore, it s important that Humana health care providers and business partners conduct themselves in an ethical, legal, and above-board manner. The quality of our health care providers and business partners products and services affects the quality of Humana s products and services. Your understanding of this commitment and willingness to raise ethical concerns are essential to the well-being of Humana s customers, members, patients, and clients, as well as the success of both your organization and Humana. health care providers, business partners, and their employees and downstream entities. Q. What should I do if my supervisor or manager asks me to do something I think violates Humana s PBE, related policies, or is illegal? A: You should immediately report the request to a level of management above your supervisor or manager, Humana s Ethics Office at ethics@humana.com, or the Ethics Help Line. The matter will be investigated promptly so that you can be given proper guidance THE-KEY 1

6 Some basic guidelines to follow include: Honesty and Respect: Act fairly and honestly with those who are affected by your actions. Respect and value everyone you serve by treating all the way they and you would want to be treated. Compliance with Laws and Focus on Quality: Comply not only with the letter of all applicable laws and regulations but also with the spirit of the law or regulation. Act in such a manner that the full disclosure of all facts related to any activity would reflect favorably upon your organization, you, or Humana. Strive to perform each transaction the right way the first and every time. Business Responsibility and You: Adhere to the highest ethical standards of conduct in all business activities. Act in a manner that enhances the standing of your organization, Humana s corporate citizens, and ethical competitors within the business community. Pursue no business opportunity that requires violation of these principles. Communicate openly, place customers needs first, and act appropriately, according to Humana s values. Responsibility for Reporting Suspected and Detected Violations: You are responsible for reporting suspected and detected ethical violations in your dealings with other entities and Humana. Humana promotes relationships based on mutual trust and respect and provides an environment in which health care providers and business partners may question a company practice without fear of adverse consequences. Ethical violations include, but are not limited to: violations of laws or policies, dishonest or unethical behavior, conflicts of interest, fraud, questionable accounting and internal controls, criminal misconduct, or any suspicious activity. Humana s PBE is intended to be a guide to ethical behavior and not a comprehensive set of rules. Humana also provides its Compliance Policy for Health Care Providers and Business Partners for your review and fraud, waste, and abuse training. While your organization should have its own set of business ethics requirements related to the type of business it performs, including a formal program for ethics, compliance, and ongoing training, it may also adopt Humana s PBE, Compliance Policy, and/or fraud, waste, and abuse training. Certain health care providers and business partners that support U.S. government contracts are required to have such programs in place in accordance with federal laws and regulations, such as the Federal Acquisition Regulations. Humana s PBE is not intended to constitute legal advice and should not be relied upon or used as a substitute for consultation with your own legal advisors. Integrity Judgment Test The guidelines in this document are meant to help all of us better understand what we believe to be in the best interest of our constituencies, including customers, members, patients, clients, associates, shareholders, those with whom we do business, and the public at large. In addition, we will provide value, service, and guidance to become the role model for the health care industry. If you re confronted with a situation that you re unsure how to handle, examine your options with this Integrity Judgment Test: Will my actions follow approved company practices? Will my actions give the appearance of being unethical or illegal? Will my actions bring discredit to any associate or the company if disclosed to the public? Will my actions, or the actions I m aware of, cause harm to individuals? Can I defend my actions to my supervisor or manager, other associates, and to the public? Am I appropriately protecting information about the company from disclosure to external or internal parties? Am I appropriately protecting the information of our customers, members, patients, clients, associates, and shareholders? Will my actions meet my personal code of behavior? Any of the following phrases you hear, read, or think may signal a warning that the situation may be an ethical concern: Well, maybe just this once Nobody will ever know. It doesn t matter how it gets done as long as it gets done. Everyone does it. What s in it for me? Don t call the Ethics Help Line. Remember, we didn t have this conversation Principles of Business Ethics Health Care Providers and Business Partners

7 Higher Responsibilities for Leaders While all Humana associates, senior management, and members of our Board of Directors are obligated to follow Humana s PBE, we expect our leaders to set the example. They must provide associates and contracted entities they oversee with sufficient information to comply with laws, regulations, and policies, as well as the necessary resources to resolve ethical dilemmas. Leaders must help maintain a culture within the company that promotes the highest standards of ethics and compliance. This culture must encourage all associates in the organization and those who work for or represent our health care providers and business partners to communicate concerns when they arise. Leaders are responsible for understanding and communicating the principles set forth in this document. We must never sacrifice ethical and compliant behavior in the pursuit of business objectives. All officers, members of the Board of Directors, associates, and contracted entities including contracted sales agents or agencies, health care providers, pharmacies, and other vendors are required to report information when there is an ethical concern. They should also assist in any investigation by any regulatory or law enforcement agency, elected officials, or others responsible for such matters. These matters include, but are not limited to, bank or securities fraud, any fraud against shareholders, or questionable accounting or internal controls, as well as violations of principles set forth in this document. Waivers The Board of Directors will consider whether any waiver is needed or conflict of interest exists involving members of the Board of Directors or executive officer and recommend appropriate action. A waiver is the approval of an exception to the provisions of this PBE document. Such waivers will be disclosed promptly on the Humana website at Humana.com THE-KEY 3

8 You have several options if you need to ask questions about business ethics concerns or to report a suspected or detected violation. Q: Is the Help Line staffed by Humana associates? A: No. The Ethics Help Line is staffed by specially trained, external representatives who aren t Humana associates. These representatives are obligated to keep all Humana information confidential. They won t share information outside of Humana. Getting Answers to Business Ethics Questions Multiple Communications Options for You If you become aware of a situation that you find questionable and/or suspect could be in violation of Humana s Ethical Principles, you can address it in several ways. Choose the option you feel most comfortable following: Discuss the issue with your supervisor or manager Speak to your supervisor s immediate manager or the next level of management Report your concern to the Ethics Help Line toll-free number or website Bring the issue to the attention of Humana s Ethics Office via at ethics@humana.com Ethics Help Line ( THE-KEY and You should call the Ethics Help Line at THE-KEY ( ) for each of the following reasons: Help with ethical questions Raising an issue you feel uncomfortable addressing within your own organization, and/or believe can t be addressed within your organization to your satisfaction Clarification about, or to report any suspected or detected violation of, a Humana policy or federal, state, or local law or regulation The confidential Ethics Help Line and the Ethics Help Line Web reporting site ( are available to you 24 hours a day, seven days a week Principles of Business Ethics Health Care Providers and Business Partners

9 Calls can be made anonymously and cannot be traced or otherwise identified. If you choose to remain anonymous, you are encouraged to provide enough information regarding the questionable activity or suspected or identified violation to allow Humana to review the situation and respond appropriately. Regardless of the reporting method used, you will receive a confidential identification number that will allow you to follow up on the status of the report. The Ethics Help Line Web reporting site also provides a recommended follow-up date. Ethics Help Line staff take your calls very seriously. Calls to the Ethics Help Line are documented and the information you provide is forwarded to Humana s Ethics Office for review and determination of action. Many calls are referred to internal Humana departments for investigation. Please note, however, that the Ethics Help Line staff cannot provide you with an opinion regarding your or Humana s compliance with any federal, state, or local law or regulation. You are advised to seek counsel from your own legal advisors regarding these matters. Chief Compliance Officer and Corporate Compliance Program Humana s chief compliance officer is responsible for Humana s Corporate Compliance Program. This program is supported by the Executive Management Group within Humana. Humana relies on members of its Board of Directors, senior leadership, associates, and corporate advisors in fulfilling its duty to carry out the elements of the Corporate Compliance Program. Humana s Corporate Compliance Plan and Ethics Help Line are part of the Corporate Compliance Program. The Ethics Office is accountable for the Ethics Help Line and Humana s Corporate Compliance Plan. An assessment and evaluation of the overall Corporate Compliance Program effectiveness is performed annually, and modifications to the program are made as necessary or appropriate. For more information about Humana s Compliance function, Humana also provides your organization with a copy of Humana s Compliance Policy for Health Care Providers and Business Partners. Additionally, Humana s chief compliance officer can be contacted at compliance@humana.com by any associate or external party with suggestions or comments on maintaining ethical behavior, or identifying and preventing fraudulent or criminal misconduct. Anyone supporting Humana s business also can call the Help Line at THE-KEY ( ), or access the Ethics Help Line Web reporting site at For Humana Government Business, the Ethics and Compliance Program is overseen by the Humana Government Business Compliance Official and the Humana Government Business Contract Compliance and Subcontract Management Department. Humana Government Business associates can them at HMHSCompliance@humana.com THE-KEY 5

10 Health care providers and business partners are expected to report to Humana upon discovery any suspected violation(s) of Humana s PBE, policies, or procedures. You must do what is permissible, acceptable, and expected. That means using common sense, good judgment, and proper behavior. Reporting and Investigation of Violations Reporting Methods If you become aware of a suspected or detected violation of Humana s PBE or any related law or policy, you should immediately report it by calling the Ethics Help Line at THE-KEY ( ) or using the Ethics Help Line Web reporting site at Humana assumes the responsibility to report Medicare program noncompliance, violations of law, criminal misconduct, and fraud, waste, and abuse to the Centers for Medicare & Medicaid Services (CMS), CMS designees, other regulatory agencies, and/or law enforcement, as applicable, for any violations related to Humana. No Intimidation and/or Retaliation Humana strictly prohibits intimidation and/or retaliation against any health care provider or business partner who, in good faith, reports an actual or suspected violation of ethical standards or who participation the investigation of a suspected violation. Your call to the Ethics Help Line or online report to Ethics Help Line Web reporting site can be made anonymously. Investigation of Ethics and Compliance Issues Humana has a system in place to promptly investigate any reported issues suspected of being violations of its PBE, Humana policies, or procedures. While all reported issues are treated confidentially, you are expected to cooperate fully in any investigation of an alleged violation. If you want to remain anonymous, please provide enough information to allow Humana to investigate the issue Principles of Business Ethics Health Care Providers and Business Partners

11 The following are examples of conduct that may result in disciplinary action: Disciplinary Standards Health care providers and business partners should do what is permissible, acceptable and expected. That means using common sense, good judgment and proper behavior. Violation of Humana s PBE and other policies and procedures could compromise Humana s integrity and reputation, cause Humana to be subject to criminal and monetary penalties, and may result in disciplinary action. This could include, but is not limited to, retraining, issuance of a corrective action plan, or termination of your contract, and, based on the violation, the matter being reported to the appropriate authorities. Health care providers and business partners should promptly take appropriate disciplinary actions for those employees and downstream entities found to be in violation, up to and including termination of contract or employment and report such action to Humana. Humana may take additional action if deemed necessary. Authorization or participation in actions that violate Humana s PBE or Humana policies Failure to report a violation of the PBE or Humana policies Refusal to report a violation of the PBE or Humana policies Refusal to cooperate in an investigation of an alleged violation of the PBE or Humana policies Failure to detect and report a violation of the PBE or Humana policies, if such failure reflects inadequate supervision or lack of oversight Intimidation of, or retaliation against, an individual for reporting or participating in the investigation of a violation or suspected violation of the PBE or Humana policies Q: What happens if someone deliberately makes a false report to get me into trouble? A: All investigations are handled professionally and objectively. Intentionally making a false accusation is a serious violation and may lead to disciplinary action, up to and including termination of employment THE-KEY 7

12 Conflicts of Interest Business decisions and actions must be based wholly on the best interests of Humana All health care providers and business partners and their employees and downstream entities supporting Humana business are required to avoid conflicts of interest. In addition, Humana associates must not engage in activities that compete with any of Humana s lines of business, nor invest in entities they select, manage, or evaluate as a vendor for Humana. Health care providers and business partners must be sensitive to these relationships and avoid creating situations that encourage a Humana associate to violate these policies. and must not be motivated by personal considerations or relationships. A good general rule is to avoid any action or association that would be embarrassing to you or Humana if it were disclosed to the public, or that would be perceived as a potential conflict of interest. Examples of a Conflict of Interest Conflicts of interest are personal, familial, or business relationships that could amount to, but are not limited to: Competing with any of Humana s lines of business Providing services to a competitor Interfering with the performance of your work duties Improper information processing: e.g., processing correspondence or enrollment data for family members or friends Undisclosed information: e.g., not sharing names of any relative who engages in competing activities or receives compensation from a competitor Bribes, kickbacks, or favoritism Improper use of information: using Humana, sales, or enrollee customer lists, databases, data, procedures, formulas, or any other Humana proprietary and/or confidential information for anything other than Humana business purposes Outside employment: taking on so many clients or so much work in your own consulting business that you don t have the necessary time or energy to devote to your organization s designated role Sharing a sales lead (obtained through your employment) externally with a relative at a competitor so the relative can benefit from the sales lead instead of Humana Conflict of Interest Statement Humana health care providers and business partners are required to obtain a conflict of interest statement within 90 days of hire or contract and annually thereafter from all employees and downstream entities. This statement certifies that the individual is free from any conflict of interest in performing their job function. If any disclosures on the Conflict of Interest Information Disclosure and Agreement form on file for your employees and downstream entities become inaccurate or incomplete because of a change in circumstances, a new form to reflect any current and/or potential conflicts must immediately be completed and submitted. This is an ongoing duty. Failure to disclose reportable activities, interests, or relationships may result in disciplinary action, up to and including termination of contract and/or employment, and appropriate legal action may be taken Principles of Business Ethics Health Care Providers and Business Partners

13 Gifts, Favors, Job Opportunities, and Entertainment Health care providers and business partners should never offer or provide, directly or indirectly, anything of value including cash, bribes or kickbacks to any Humana associate, representative, customer, or government official. Such prohibition includes, but is not limited to, a health care provider or business partner offering or providing consulting, employment, or a similar position to any Humana associate or the associate s family members or significant other. It is Humana s policy that associates cannot give to or accept from health care providers and business partners gifts with a value greater than $50 USD. Any nominal gifts or courtesies must be lawful, unsolicited, and infrequent. Gifts of money or cash equivalents are never permissible. The health care provider or business partner should not present gifts to associates of Humana. Humana health care providers and business partners are expected to understand the business entertainment policies of Humana before offering or providing any Humana associate or representative any business entertainment. Business entertainment should never be offered by a health care provider or business partner to a Humana associate or representative under circumstances that create an appearance of impropriety. Accepting or giving gifts, favors, travel, and entertainment may create a conflict of interest with your obligations to Humana and may constitute a violation of law THE-KEY 9

14 Fraud, Waste, and Abuse Humana has zero tolerance for any activity that constitutes fraud, waste, or abuse. The detection, correction, and prevention of fraud, waste, and abuse is essential to maintaining a health care system that is affordable for everyone. Both state and federal law enforcement agencies are increasingly focused on investigating health care fraud, waste, and abuse. Definitions Fraud means knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program to obtain (by means of false or fraudulent pretenses, representations, or promises) any of the money or property owned by, or under the custody or control of, any health care benefit program. 18 U.S.C * All health care providers and business partners and their employees and downstream entities are expected to report suspected fraud, waste, and abuse to Humana s Special Investigations Referral department at or siureferrals@humana.com, to the Ethics Help Line at THE-KEY ( ), or by ing ethics@humana.com. For example: Billing of false or fictitious claims or providing inaccurate information to enroll an ineligible person in a Medicare plan Waste means the overutilization of services or other practices that, directly or indirectly, result in unnecessary costs to the Medicare program. Waste is generally not considered to be caused by criminally negligent actions but, rather, the misuse of resources. * In other words, waste is using health care benefits or spending health care dollars without real need. An example is prescribing a medication for 30 days with a refill when it is not known if the medication will be needed for 30 days or more. Abuse includes actions that may directly or indirectly result in unnecessary costs to the Medicare Program, improper payment, payment for services that fail to meet professionally recognized standards of care, or services that are medically unnecessary. Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly, and/or intentionally, misrepresented facts to obtain payment. Abuse cannot be differentiated categorically from fraud, because the distinction between fraud and abuse depends on specific facts and circumstances, intent and prior knowledge, and available evidence, among other factors. * Examples of abuse may include: Charging in excess for services or supplies * Source: Prescription Drug Benefit Manual, Chapter 9/Medicare Managed Care Manual, Chapter 21 Providing medically unnecessary services Billing for items or services that should not be paid for by Medicare Principles of Business Ethics Health Care Providers and Business Partners

15 Applicable Laws and Regulations Please refer to Humana s Compliance Policy for Health Care Providers and Business Partners for other applicable Of the laws and regulations that impact Humana s operations, there are several in particular with which you and your organization should be familiar to sufficiently fulfill contractual obligations to Humana. They include: Anti-kickback Laws Medicare- and Medicaid-specific laws prohibit knowingly offering, paying, soliciting, or receiving monetary payment, goods, services, or benefits of any kind to induce the referral of business under a federal program. Federal acquisition regulations state that no gratuities, in the form of entertainment, gifts or otherwise, or kickbacks shall be offered or given by a health care provider or business partner or their employees and downstream entities to any employee of the government or prime contractor of the health care provider or business partner with a view toward securing favorable treatment. The U.S. Foreign Corrupt Practices Act prohibits U.S. citizens and organizations including foreign companies of U.S. organizations from paying foreign officials for the purposes of gaining a business advantage. In addition, most states have laws that prohibit kickbacks and rebates. Health plans are specifically prohibited from providing any kind of remuneration to entice Medicare/Medicaid beneficiaries to join their plans, although the government recognizes that providing very nominal items for free valued at only $15 or less retail, per item, or aggregate items throughout the year worth $50 retail or less in the course of marketing activities is acceptable. Providers of health care services to Medicare/Medicaid beneficiaries are limited to providing for free only nominal items or services valued at $10 or less retail, or aggregate items throughout the year worth $50 retail or less, per item, per beneficiary. Violators of any of these laws or regulations are subject to imprisonment, high fines, and/ or exclusion from Medicare and Medicaid and government contracts, as well as costly civil penalties and possible prosecution under many similar state laws. laws and regulations that impact you and your organization s partnership with Humana THE-KEY 11

16 Antitrust Laws State and federal antitrust laws prohibit monopolistic conduct and agreements that restrain trade. Humana is committed to competition and consumer choice in the marketplace. All health care providers and business partners must adhere to the antitrust laws and must avoid any agreements or understandings with competitors on price, customers, markets, or other terms of dealing. Trade practices that unfairly or unreasonably restrain competition in dealings with customers must also be avoided. Health Insurance Portability and Accountability Act of 1996 (HIPAA) Humana, as a covered entity, complies with HIPAA Administrative Simplification Statute and rules, and privacy, security and breach notification rules. Any health care provider or business partner considered a covered entity or business associate has the responsibility to comply with all HIPAA rules. False Claims Act The False Claims Act is a federal statute that deals with any federally funded contract or program, including Medicare or Medicaid, regarding fraudulent activities. The False Claims Act prohibits any person or company from knowingly submitting or causing to be submitted a false or fraudulent claim (any request or demand for money) to the U.S. government. Whistleblower Protection Whistleblower provisions protect employees who assist the federal government in investigation and prosecution of violations of the False Claims Act. Whistleblower protections apply only to actions taken in furtherance of a viable False Claims Act case which has been, or is about to be, filed. The provisions prevent retaliation against the employee, such as firing him/her for assisting in the investigation and prosecution. If any retaliation does occur, the employee has a right to obtain legal counsel to defend his/her actions. Note: A whistleblower is someone, such as an employee, who reports suspected misconduct that would be considered an action against company policy or federal laws or regulations. Anti-money Laundering and Office of Foreign Assets Control (OFAC) Compliance Program Humana has an anti-money laundering program and Office of Foreign Assets Control (OFAC) Compliance Program that is based on assessed risks associated with Humana s covered products, including those with cash value features, such as whole life products. The program is designed to reasonably prevent Humana from being used by others to facilitate money laundering and the financing of terrorist activities involving any covered product, and to report suspicious transactions involving any covered product to the Financial Crimes Enforcement Network (FinCEN). Health care providers and business partners may not engage in money laundering or finance terrorist activities, and are expected to have their own programs to prevent and detect such activities. Failure to comply with applicable law, Humana s Bank Secrecy Act, Anti-money Laundering, Office of Foreign Assets Control Compliance Program, or Kanawha s Anti-money Laundering Program could result in: Disciplinary action, including termination of contract or employment Civil and criminal sanctions and a ban from future employment in the insurance industry Q: A friend who works for a competitor is negotiating rates with a provider. The provider claims that Humana pays him more than her health plan does. Your friend calls you to verify how much Humana pays that provider. Is it okay for you to tell her how much Humana pays that provider? A: No. This might create the impression that Humana and the competitor were fixing reimbursement rates Principles of Business Ethics Health Care Providers and Business Partners

17 Integrity of Company Information Health care providers and business partners must safeguard Humana information. Accuracy of Information Humana is committed to providing accurate and truthful information in any transaction. This commitment is reinforced by internal controls and procedures developed so that any report and record of any type is accurate and reliable. This includes a system of internal accounting controls designed to maintain the integrity and reliability of our financial reporting to the Securities and Exchange Commission, departments of insurance, and other regulatory agencies. The internal controls are also designed to detect and prevent illegal activities, in compliance with the Foreign Corrupt Practices Act. Humana s financial reporting system also provides assurance to these regulatory agencies, stockholders, the Board of Directors, and management that our assets are safeguarded and transactions are executed and recorded properly in accordance with appropriate authorization. Humana s Board of Directors has an audit committee composed solely of independent, outside directors. The audit committee meets periodically with management and the internal and external auditors to oversee the company s financial reporting processes. Health care providers and business partners are expected to have policies and procedures in place to affirm the integrity of their organizations information. If asked, health care providers and business partners have an obligation to provide accurate and complete information to auditors about the status of financial, operational, and compliance risks and controls related to their business with Humana. Health care providers and business partners who believe they have been asked to withhold information from auditors should immediately call the Ethics Help Line at THE-KEY or report their concern at Furthermore, health care providers are responsible for submitting truthful, complete, and accurate risk adjustment data, and are required to appropriately document diagnoses in the medical record THE-KEY 13

18 Confidential Information Assets Humana creates and has access to highly confidential information. It must be safeguarded to prevent inappropriate disclosure and unwarranted invasion of the rights to privacy of our members and contracted entities. Humana s confidential information includes, among other things: Internal business practices and records Network, electronic, and media software and hardware Inventions and patent applications Information concerning members, providers, products, and pricing Marketing and sales information Humana customers and health information Financial information about Humana contracts Information assets include content that is stored, accessed, or transmitted through the following exchange methods: Physical (paper, copier, or facsimile) Electronic ( , facsimile, or data files) Oral communication that may or may not be recorded Safeguarding Confidential Assets Humana follows the privacy and security rules of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and the more recent Health Information Technology for Economics and Clinical Health Act (HITECH), as should Humana health care providers and business partners. All information belonging to Humana must be retained in strictest confidence and not be disclosed to a third party, other than its employees having a need to know, without the explicit written permission of Humana. Unauthorized Disclosure Unauthorized disclosure of, or access to, confidential or proprietary information may result in termination of contract, and also may result in civil and criminal penalties. Business partners may be required to sign a business associate agreement, depending on the services performed on Humana s behalf and the type of Humana information being accessed by the business partner. Privacy and Security Obligations It is very important that you understand your obligations and what impact privacy and security have on your organization. Foremost, your organization should have a process in place for its employees and downstream entities to identify and report a suspected privacy or security breach or violation. While your organization should contact legal counsel to determine all required actions to be compliant with privacy and security laws, rules, and regulations, there are some basic elements that are required to be compliant with privacy and security elements of HIPAA and HITECH: Privacy and security policies that clearly describe the protection of personal health information Safeguards in place to ensure that information is protected and not inappropriately used or disclosed Privacy and security training program for your employees and downstream entities Required confidentiality agreements A privacy and security breach process that includes reporting, investigating, and tracking of incidents A procedure for the required return/destruction of protected health information (PHI) if agreement is terminated with Humana A procedure for restricting the marketing of PHI In addition, Humana business partners with a signed Business Associate Agreement should review the applicable guidance document located on for additional information on developing or revising policies and procedures regarding the federal and state privacy and security laws and regulations. This information is intended to assist your organization in meeting the requirements contained within a Business Associate Agreement. Reporting a Privacy or Security Breach* If you are a Humana business partner with a signed Business Associate Agreement with Humana, any identified breach by your organization should be reported to Humana within five days of discovery. * Due to the nature of these issues, there is not an option to report them anonymously. The report should include: The information breached Individuals affected by the breach Steps being taken to investigate the breach Date of the breach Date of discovery of the breach Humana offers a variety of reporting methods, so if an issue arises, then you can choose the option that suits your communication preference: By Mail Humana Inc. Privacy Office 500 West Main Street Louisville, Kentucky By Fax By privacyoffice@humana.com Principles of Business Ethics Health Care Providers and Business Partners

19 Doing Business with the Government As a government contractor, Humana complies with various federal and state laws, Contracting with the Government It is essential that there be strict compliance with all laws and regulations in transacting business with the government. The terms of contracts with the government require explicit compliance. The U.S. Foreign Corrupt Practices Act prohibits U.S. citizens and organizations including foreign companies of U.S. organizations from paying foreign officials for the purposes of gaining a business advantage. In addition, most states have laws that prohibit kickbacks and rebates. Health care providers and business partners who communicate with government officials and work with contracts are responsible for knowing and complying with applicable laws and regulations. which impose stringent requirements. Procurement Integrity Act The Procurement Integrity Act (the Act) prohibits Humana, as a federal contractor, from: Receiving contractor bid or proposal information that would give Humana an unfair competitive advantage; Giving anything of value to a procurement official; or Giving, discussing, or making an offer of employment to a federal government or military procurement official, or certain family members. Some procurement officials have a twoyear ban, and some have a lifetime ban, on employment discussions with Humana. Violations of the Act committed by health care providers, vendors, or related entities or their employees and downstream entities are punishable by fines and imprisonment, loss of government contracts, and/or suspension or exclusion from participating in federal procurement opportunities. Humana s policy is to avoid even the appearance of impropriety. We comply with the Act in all respects. For more information about the Act, contact the Humana government chief of human resources and training, the Humana government business compliance official, or the Humana law department. compliance@humana.com to be connected to these areas THE-KEY 15

20 Dealing with Government Agencies Humana s law department should be informed of all notifications of a violation or citations alleging a violation from a governmental regulatory agency. The person receiving the notification should direct the request to Humana s law department. This requirement also applies to health care providers and business partners if a violation occurs that involves Humana business. compliance@humana.com to be connected to the law department. Health care providers and business partners and their employees and downstream entities must never: Destroy or alter any document or record in anticipation of a request for the document or record by a government agency or court; Lie or make false or misleading statements to any government investigator; or Persuade any employee or any other person to provide false or misleading information to a government investigator. Doing Business with Accrediting Agencies Certain health care providers and business partners are responsible for abiding by the standards of those outside agencies that accredit Humana plans and providing accurate information in a timely manner. If your organization is such a health care provider or business partner, you must deal with all accrediting agencies in a direct, open, and honest manner. No action should ever be taken in relationships with accrediting agencies that would directly or indirectly mislead the agency. The following agencies accredit Humana plans: National Committee for Quality Assurance URAC Accreditation Association for Ambulatory Health Care Doing Business with Foreign Governments, Contractors, or Consultants U.S. laws regarding business dealings with foreign entities, such as the Foreign Corrupt Practices Act (FCPA), can be very complex, as are international regulations of the host country or regional government, such as the European Union. Also, federal laws and regulations prohibit giving any type of gift, gratuity, or anything of value to any of the following for the purpose of obtaining or retaining business, or directing business to any person for the purpose of influencing an official act or decision or securing an improper advantage: Foreign official Political candidate Political party Party official Public international organization, its officers, employees, and downstream entities These guidelines apply to contacts with the aforementioned, or entities working with such persons, or entities at the national or local levels (e.g., vendors, consultants, agents, quasi-governmental bodies, etc.). The FCPA has specific criminal and civil penalties for violations involving what may be considered bribery of any of the aforementioned. These penalties include, but are not limited to: Fines for Humana Suspension or permanent exclusion from participation in federal programs Fines and imprisonment for individuals convicted of such conduct Accordingly, no gifts, gratuities, or anything of value, in order to obtain or retain business or secure an improper advantage, can be made to such persons or entities without clearance in writing from Humana s law department and Ethics Office. Humana health care providers and business partners who intend to interact or conduct business transactions with foreign entities on Humana s behalf must never do so without obtaining authorization to do so from Humana s senior management and instruction from Humana s law department regarding the FCPA Principles of Business Ethics Health Care Providers and Business Partners

21 Ineligible Health Care Providers, Vendors, or Related Entities As a health care company, Humana is subject to strict governmental regulation and oversight. The government requires us to refrain from contracting with those who have engaged in certain types of activities. Such parties include health care providers and business partners and their employees and downstream entities. They will be ineligible for any contractual relationship if they have been or are: Convicted of a criminal offense related to health care Listed as excluded or otherwise ineligible for participation in federal health care programs Identified and listed on the Executive Order Blocking Property and Prohibiting Transactions with Persons Who Commit, Threaten to Commit, or Support Terrorism Listed on either exclusion list of the Department of Health and Human Services Office of Inspector General and the General Services Administration The exclusion lists are checked upon initial engagement and their update lists are reviewed monthly thereafter. In addition, Humana is subject to the Violent Crime Control and Law Enforcement Act of 1994, which makes it a felony for Humana to contract with an individual who has ever been convicted of a felony involving dishonesty or a breach of trust. These individuals and their employees and downstream entities will be ineligible for any contractual relationship with Humana THE-KEY 17

22 Workplace Conduct Humana is proactive in its commitment to maintain a workplace that is free of harassment and violence, as well as compliant with applicable environmental, health, and safety laws and regulations. Humana does not tolerate any type of harassment of its associates. Harassment by or of another associate, a contractor, vendor, or anyone else on Humana premises or in the course of Humana business is absolutely prohibited. Violation of the Humana harassment policy may result in termination of contract, and also may result in civil and criminal penalties. Environmental Responsibility Humana is committed to conducting its business operations in an environmentally responsible manner and in compliance with all applicable laws and regulations. Health care providers and business partners are expected to support this commitment by: Operating in full compliance with both the letter and spirit of environmental, health, and safety laws and regulations applicable to their business, including the integration of sound environmental, health, and safety practices into their everyday activities Reporting any environmental, health, and safety concerns in connection with their Humana business dealings Identifying opportunities to improve their environmental, health, and safety programs Implementing emergency preparedness plans, if necessary Principles of Business Ethics Health Care Providers and Business Partners

23 Index and Contacts A Accuracy of information Anti-kickback Laws Anti-money Laundering Antitrust Laws B Breach , 14, 17 C Chief compliance officer CMS Confidential, reporting of ethics violations Confidentiality agreement Conflict of interest , 8 Corporate compliance program ii, 5 D Disciplinary , 8, 12 Disclosure , 8, 14 E Entertainment Environmental responsibility Ethical principles Ethics Help Line , 6, 13, 20 Ethics Office , 4, 5, 16, 20 Ethics violations failure to report investigation of , 7 reporting of , 6 F False Claims Act False reports Favors Foreign Corrupt Practices Act , 13, 15, 16 Foreign governments, contractors, or consultants Fraud, waste, and abuse , 10 G Gifts, favors, job opportunities, and entertainment Government, contracting with , 16 Government agencies, dealing with H Harassment Humana information, safeguarding Humana s ethical principles Humana s leaders, responsibilities , 5 I Information accuracy of protection safeguarding Integrity judgment test Investigation of violations M Medicare , 10, 11, 12 O Office of Foreign Assets Control P Political Privacy or security violations , 14 Procurement Integrity Act Prohibition on retaliation , 12 R Reporting ethics violations , 6, 7, 12, 20 Responsibilities for Humana leaders Retaliation , 7, 12 S Safeguarding information assets Safety Security or privacy violations T Travel and entertainment V Violations , 12, 15, 16 W Waivers Whistleblower Contacts Chief Compliance Officer compliance@humana.com Ethics Help Line THE-KEY or Ethics Office ethics@humana.com or Privacy Office PrivacyOffice@humana.com or via fax: Special Investigations Unit or siureferrals@humana.com The telephone numbers listed above may be subject to change THE-KEY 19

24 Thank you for your continued support of Humana s Principles of Business Ethics. If you have ethical questions or concerns, please contact one of the following: The Ethics Office (ethics@humana.com) The Ethics Help Line ( THE-KEY) The Ethics Help Line Web reporting site at Remember You are the key to integrity! THE-KEY Toll-free, 24/7 The information disclosed in this document, including all designs and related materials, is the valuable property of Humana Inc. and its affiliates. Humana reserves all copyright, patent, and other proprietary rights to this document, including all design, manufacturing, reproduction, use, and sales rights thereto, except to the extent such rights are expressly granted to others. Except for your internal use, reproduction of this document or portions thereof without prior written approval of Humana is prohibited. Humana.com GHHH7HAHH 1212

25 Fraud, Waste, and Abuse Detection, Correction, and Prevention Training for Health Care Providers and Business Partners 2013 The detection, correction, and prevention of fraud, waste, and abuse (FWA) is essential to maintaining a health care system that is affordable to everyone - Jean Sexton, Humana s Area Director of Special Investigations

26 What is Required of Humana Humana must meet FWA detection, correction, and prevention training (FWA training) and monitoring requirements outlined by the Centers for Medicare & Medicaid Services (CMS), Office of Civil Rights, and other regulatory bodies: Maintain policies and procedures to address suspected and detected FWA, including its reporting (internal and external), tracking, and disciplinary standards Widely-publicize disciplinary standards to its employees, first tier, and its downstream and related entities (FDRs) Provide FWA training to its employees and FDRs within 90 days* of hire or contract and annually thereafter Document that training requirements have been met System in place to collect and maintain 10 years of records of FWA training administered to employees and FDRs Humana has a compliance program with measures in place to address these requirements. * Humana s timeframes for its employees, contingent labor, and employees of acquisitions are more stringent. 1

27 Why You are Receiving this Training - Does it Apply to You? As a person or entity who provides health care services or administrative services to a Humana member, you are considered one of the following: First Tier Entity (contracted with Humana directly) Examples: Claims delegate, credentialing delegate, field marketing organization, contracted sales agent, health care provider group, pharmacy Downstream Entity (contracted with Humana indirectly, through a first tier or related entity, or another downstream relationship) Examples: Pharmacist(s), health care providers contracted through a group contract Related Entity (entity having ownership or control in common with Humana ) Example: Humana subsidiary Is your organization or any of Humana s downstream entities exempt? Humana recognizes that certain health care providers are deemed to have met FWA education and training requirements through: Enrollment into the Medicare program OR Accreditation as a supplier of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) In the case of organizations with multiple locations, such as chain pharmacies, each individual location must be enrolled into Medicare Part A or B to be deemed Note: The deeming only applies to FWA training and does not include (Humana) general compliance training or distribution of Humana policies and standards. Your organization must verify and document as deemed, or remove and replace, any employees and downstream entities who do not receive FWA training within 90 days of hire or contract 2

28 Training Objectives To meet Humana s FWA training requirements, your organization may use this training, your own similar training, or the CMS FWA training. Should the CMS training be used, Humana s FWA reporting methods and its disciplinary standards must be widely publicized to your employees and downstream entities. Such information is outlined in this training as well as Humana s Principles of Business Ethics For Health Care Providers and Business Partners. After completion of this training, you should: Understand that everyone is obligated to detect, prevent, and correct instances of FWA Be able to recognize and know how to report instances of suspected or detected FWA Be aware that Humana has resources to conduct investigations of misconduct Understand the kinds of disciplinary actions that can result from FWA concerns Understand that documentation of training provided is important and must be maintained by your organization Be informed of laws pertaining to FWA Know where to access additional resources for questions or clarifications 3

29 Cost Impact of FWA Increase in total, U.S. health care spending in 2011: 3.9% to $2.7 trillion (1) Amount lost in the U.S. each year to health care fraud: $80 billion (2) Therefore, this impacts: Employees and Members of Medicare health and/or prescription drug plans Higher premiums and out-of-pocket costs Reduced benefits Humana and Employer Groups Higher cost of providing benefits Everyone More rapid depletion of money from the Medicare Trust Fund Increased taxes for all (1) Per CMS: Reports/NationalHealthExpendData/Downloads/Proj2011PDF.pdf (2) Per FBI estimates: 4

30 Efforts Your Organization and Downstream Entities Must Make to Address FWA Your organization and downstream entities must implement and maintain policies and procedures to prevent FWA that address the following: Safeguarding Humana s confidential and propriety information Humana s Compliance Policy for Health Care Providers and Business Partners provides additional guidance on this matter Verifying information received to complete contracted services (by not making presumptions) i.e. Reviewing information to see that it truly corresponds with what is on file, such as: Is the name on a member on a claim, Bill Smith on 100 truly the same as William L. Smith? OR The same kind of check required for a member should be applied to the submitting provider Providing accurate and timely information/data in the course of business Conducting timely FWA training Widely publicizing to employees and downstream entities methods for reporting suspected and detected FWA Instituting disciplinary standards and taking appropriate action upon discovery of FWA or practices that do or could lead to FWA 5

31 Humana s Efforts to Address FWA Humana s Special Investigations Department is responsible for a variety of focused activities to detect, correct, and prevent FWA Data Analytics staff performs risk assessments and data analysis to identify trends and potentially fraudulent activity by providers, pharmacies, or members Investigative staff conducts thorough investigations of suspected FWA Humana collaborates with law enforcement on investigations at the local, state, and federal level Humana takes disciplinary and/or corrective action when appropriate 6

32 Government Efforts to Address FWA The government has initiatives in place to combat FWA schemes. As a result, government agencies recovered nearly $4.1 billion in taxpayer dollars in Fiscal Year 2011 This would not have been possible without the Health Care Fraud Prevention & Enforcement Action Team (HEAT), created in 2009 through a joint effort by the Department of Justice and the Department of Health and Human Services to fight health care fraud in the Medicare and Medicaid programs The Affordable Care Act passed in 2010 includes provisions for tougher sentences for those convicted of health care fraud, suspension of payments to those who engage in suspected fraudulent activity, and enhanced screenings of Medicare and Medicaid providers to keep them out of these programs In 2012, a voluntary, collaborative arrangement uniting public and private organizations was launched to share information to prevent health care fraud. The FBI, Humana and other Part C and D sponsors and insurers and health plans were among the first to join HEAT is multi-agency teams of federal, state and local investigators who combat fraud through data analysis and an increased focus on community policing. 7

33 What is Fraud? Fraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain (by means of false or fraudulent pretenses, representations, or promises) any of the money or property owned by, or under the custody or control of, any health care benefit program. 18 U.S.C. 1347: What does this mean? Fraud is an intentional act of misrepresentation, deception, or concealment, or an attempt to do so, to gain something of value 8

34 What are Abuse and Waste? Abuse involves payment for items or services when there is no legal entitlement to that payment and the health care provider has not knowingly and/or intentionally misrepresented facts to obtain payment. Abuse includes any action(s) that may, directly or indirectly, result in one or more of the following: Unnecessary costs to the health care system, including the Medicare program Improper payment for services Payment for services that fail to meet professionally recognized standards of care Services that are medically unnecessary Waste is the overutilization of services or other practices that, directly or indirectly, result in unnecessary costs to the health care system, including the Medicare program. It is not generally considered to be caused by criminally negligent actions, but by the misuse of resources. Abuse cannot be differentiated categorically from fraud, because the distinction between fraud and abuse depends on specific facts and circumstances, intent and prior knowledge, and available evidence, among other factors. Source of definitions: CMS Manuals (Prescription Drug Benefit - Chapter 9 and Medicare Managed Care - Chapter 21) 9

35 Examples of FWA Patterns of practices or specific activities are red flags that indicate the possible existence of FWA and can include: Provider and/or Pharmacy Submitting claims for services/items that should not be paid for by Medicare Billing fictitious or submitting false claims, including excessive amounts Pass through billing (ordering physician requests and bills for a service (i.e. lab or X-ray work) he/she did not perform) Gang visits (physician visits a nursing home and bills as if he/she rendered services for all residents, even if services were rendered for less than all; or provides and bills for unnecessary services) Upcoding and/or adding unnecessary or inaccurate modifiers Agent Enrolling someone in a plan without his/her knowledge Offering cash payments to enroll Accepting payments from providers for steering enrollees to them Unsolicited marketing Misrepresenting plans Providing an unnecessary service or writing a prescription for a quantity exceeding medically necessary amount Submitting untruthful, incomplete, or inaccurate risk adjustment data Inappropriately/incorrectly documenting diagnoses in the medical record Member Misrepresentation: Misrepresenting personal information to enroll in a Medicare plan or altering a prescription Doctor Shopping: Visiting multiple doctors or emergency rooms for narcotics Employer Enrolling ineligible individuals Providing inaccurate dates of termination or hire Providing false information While FWA can impact these categories in specific ways, an overlap can cross multiple segments. Identity theft is a common example not listed above and involves stealing another person s identity or a physician s prescription pads or ID numbers. Suppliers of Services/Non-Drugs Billing for products not delivered, services not provided, or that are unnecessary Improper access or use of Humana information (i.e. member-identifying information) and/or sharing or selling it 10

36 Correction and Disciplinary Action FWA violations could compromise Humana s integrity and reputation. Confirmed FWA violations could result in any or all of the following for your organization and/or Humana s downstream entities: Oral or written warnings or reprimands Suspensions or termination(s) of employment or contract Other measures which may be outlined in the contract Mandatory retraining Corrective action plan(s) Reporting of the conduct to the appropriate external entity(s), such as CMS, CMS designee, and law enforcement agencies 11

37 Reporting FWA Concerns Anyone within your organization or part of a Humana downstream entity who suspects or detects an FWA violation is required to report it either to Humana or within his/her respective organization, which then must report it to Humana: Telephonic SIU Direct Line: , ext (M to F: 8 a.m. to 5:30 p.m. EST) SIU Hotline: (24/7 access) Ethics Help Line: THE-KEY ( ) Humana strictly prohibits intimidation and/or retaliation against any FDR who, in good faith, reports suspected or detected violation of ethical standards. siureferrals@humana.com or ethics@humana.com Web: Key Features of Methods for Direct Reporting to Humana Anonymity: If the person making the report chooses to remain anonymous, he/she is encouraged to provide enough information on the suspected violation (i.e. date(s) and person(s), system(s), and type(s) of information involved) to allow Humana to review the situation and respond appropriately Confidential Follow-up to check on the status of an investigation In addition to these protections, any FDR offering a reporting option to its employees and downstream entities must offer 24/7 access and the same key features as outlined here. Feedback/suggestions may be directed to Humana s chief compliance officer through the Ethics Help Line or ing the Ethics Office 12