Noyes Health

Health Care Compliance Code of Conduct

Introduction:

UR Medicine Noyes Health is committed to providing quality service to our patients. UR Medicine Noyes Health's reputation for quality care is founded on the honesty, integrity, and commitment of its employees to observe all applicable laws, rules, regulations, and standards of ethical conduct. This Code of Conduct (“the Code”) outlines the standards of behavior expected from all individuals working for, or on behalf of Noyes Health.

The Code is not intended to cover all possible situations, but rather it is intended to help all Affected Individuals know and understand the ethical, legal standards, and company policies applicable in performing their daily tasks. The Code provides general guidance regarding appropriate behavior. For more specific information and guidance, please refer to the specific policies and procedures as appropriate. The Code and associated policies also apply to all employees, volunteers and relationships with providers, subcontractors, independent contractors, vendors, consultants, and other relevant third parties (“Affected Individuals”). Affected Individuals are responsible for upholding these values and contributing to a positive experience for all.

The Code of Ethical Conduct is distributed to all Affected Individuals within 30 days of hire or appointment and annually thereafter.

Code of Ethical Conduct General Standards:

Our success in achieving our mission and vision is dependent upon maintaining our commitment to honesty, integrity, quality service, and excellent care. UR Medicine Noyes Health is committed to an ethical environment founded on these principles of conduct:

• Treat patients, employees, and customers with dignity and respect.
• Abide by applicable laws, rules, and regulations.
• Behave honestly and fairly.
• Use good judgment and high ethical standards in business dealings.
• Do not use confidential information for personal gain.
• Protect trade secrets and competitive information.
• Keep accurate and timely records.
• Maintain confidentiality of patient information.
• Strive for mutual respect and trust in relationships.
• Ensure a safe and healthy work environment.
• Do not seek gifts, favors, or entertainment.
• Avoid personal conflicts of interest.
• Guard against theft and misuse of UR Medicine Noyes Health's property.
• When in doubt about a situation, ask before acting.
• Do the right thing!

Patient Care:

Patient Relations: Patient care administered by UR Medicine Noyes Health will be in accordance with the Patients' Bill of Rights in New York State.

Patient Care: UR Medicine Noyes Health's main concern is for the well-being, comfort, and dignity of their patients. All patients are provided with service and care that is medically necessary and appropriate in a respectful and dignified manner, without regard to race, color, creed, sex, national origin, sexual orientation, marital status, age, veteran status, disability, source of payment, or ability to pay. All clinical decisions will be based upon identified health care needs regardless of how UR Medicine Noyes Health compensates or shares financial risk with any individual or entity.

Emergency Treatment: UR Medicine Noyes Health will offer emergency medical care, as indicated by a patient's medical condition. An appropriate medical screening examination will be provided to all patients presenting to the Emergency Department. If the examination reveals an emergency medical condition, the patient will be given treatment to stabilize the condition. If admission is necessary, the patient will be admitted unless the treatment required by the patient is outside of the scope of services, the patient refuses admission, or the patient requests a transfer to another facility. In such instances, patients will either be discharged or transferred, as appropriate, after they have been stabilized. For patients in life-threatening situations, financial, and demographic information will be obtained only after patients are stabilized or as appropriate to the situation.

Patient Choice, Informed Consent, and Advance Directives: UR Medicine Noyes Health will listen to and follow the choices made by their patients with respect to their clinical care. Upon admission, patients are provided with a written statement of their rights. Patients and, as appropriate, their families or representatives, will be given the information necessary to enable them to give informed consent prior to the start of any non-emergency procedure or treatment. It is the responsibility of the providers to inform patients about their proposed plan of care, including the risks, benefits, and alternatives available to them. UR Medicine Noyes Health respects patients' rights to make informed decisions about treatment as well as to establish advance directives. UR Medicine Noyes Health honors patients' advance directives as well as their freedom of choice in selecting service providers including, but not limited to, physicians and ancillary service providers such as home health, home infusion, and durable medical equipment suppliers.

Patient Confidentiality: During the course of their work, employees may become aware of information about patients and their medical conditions. All patient information is confidential. Accordingly, it is inappropriate to discuss patients or their cases in a public area where other people may overhear the conversation, and it is inappropriate to permit access to a patient's record by individuals who are not involved in legitimate activities relating to the patient. Information about a patient may be disclosed only as authorized by the patient or as otherwise permitted by law.

Prohibited Gifts to Patients:

Federal law prohibits offering anything of value to a Medicare of Medicare beneficiary when that person knows or should know that it is likely to influence the beneficiary’s decision regarding their chose of health care provider.

UR Medicine Noyes Health has a strict policy against providing any gifts or items less than fair market value to any patient. Items of nominal value are not considered a gift or inducement and may be provided when appropriate. Nominal value means anything with a retail value no more than $15 per item or $75 per patient per year. Any questions regarding gifts or provision of free items or services to patients shall be directed to the Corporate Compliance Department.

Physician and Provider Relationships:

The federal Physician Self-Referral (Stark) Law prohibits a physician or their immediate family member from making referrals for certain designated health services (DHS) payable by Medicare to an entity with the physician (or their immediate family member) has a financial relationship (ownership, investment, or compensation), unless an exception applies. It also prohibits the entity from presenting or causing to be presented claims to Medicare (or billing another individual, entity, or third-party payer) for those referred services.

The federal Anti-Kickback Statute (AKS) and Civil Monetary Penalties Law (CMPL) prohibit any individual or company from offering, soliciting, paying, or receiving any kind of reward (cash, gifts) to induce or reward patient referrals. AKS violations are felonies and may result in criminal and/or civil penalties.

Violations of laws may also result in exclusion from federal health care programs and False Claims Act liability.

Referral of Patients to UR Medicine Noyes Health: UR Medicine Noyes Health accepts referrals of patients based on the patient's needs and the provider's ability to render the services for which the referral is made. Under no circumstance will UR Medicine Noyes Health or its affiliates pay or offer any type of compensation for referrals of patients. Employees are not permitted to enter into such agreements.

Employees or any other person acting on behalf of UR Medicine Noyes Health are not permitted to knowingly offer, pay, solicit, or receive anything of value, directly, or indirectly, in exchange for the referral of patients. Examples include gifts, entertainment, or other benefits to physicians or other providers including discounted or free medical care.

Referral of Patients by UR Medicine Noyes Health: UR Medicine Noyes Health will refer patients to other providers based solely on the patient's clinical needs, the ability of the referred provider to render the services for which the referral is made, and the patient's choice. Employees may not refer patients to other health care providers in which they or their family members have financial interests unless compliance with Stark Self-Referral Law Safe Harbor is documented with the legal department and the Corporate Compliance Officer before such referral occurs. Also, when making patient referrals to another provider, employees will not take into account the volume or value of referrals that the provider has made (or may make).

If you are aware of any situation involving kickbacks or inappropriate referrals you are required to report this to the Corporate Compliance Officer or the Integrity Help Line.

Confidential Information and Recordkeeping:

Confidential Information: Information created in the conduct of business, such as patient information, employee data, patient lists, financial data, research data, strategic plans, or statistical information, is confidential and will not be shared unless that information is necessary in order to perform job functions or responsibilities. During their work, employees may also learn confidential information about a vendor, supplier, business partner, or how planned transactions between UR Medicine Noyes Health and a third party could positively or negatively impact the third party. Employees may not use UR Medicine Noyes Health, business partner, or competitor confidential information for their own purpose or benefit. This includes buying or selling investments in a company based on such inside information.

Records Accuracy: Accurate and complete records are crucial for continuity of patient care and treatment, accurate and proper billing, and compliance with regulatory, tax, and financial reporting requirements.

Employees who enter information into a medical record, business record, regulatory, or financial report, have a responsibility to do so in a truthful, accurate, legible, and timely manner.

Records Retention: UR Medicine Noyes Health maintains record retention schedules to assure all patient and business records are maintained in accordance with legal and business requirements. Records include paper copies, electronic files, microfiche, and microfilm. Employees must not tamper with records, remove them from the property, or destroy them prior to the date specified in the relevant retention schedule.

Billing for Services:

Basis for Coding and Billing: UR Medicine Noyes Health will make every attempt to code medical records completely and accurately using the proper ICD-10-CM, CPT-4, HCPCS coding, or any other required coding system. If a diagnosis is unclear or has not been provided, Coders, in accordance with established procedures, must review the medical documentation or contact the appropriate clinical practitioner or local intermediary to obtain the necessary information. In all cases, the documentation must support codes that are submitted on a patient's bill.

Employees with responsibility to keep records for goods or services for which a bill will be sent to a patient or third party payer have responsibility to ensure an accurate bill that includes charges only for those goods and services actually provided. UR Medicine Noyes Health will bill accurately for services rendered in accordance with the law and with its agreements with third party payers.

Collections will be pursued by UR Medicine Noyes Health and its agents in accordance with all applicable laws and without harassment.

UR Medicine Noyes Health will:

• bill only for documented items and services rendered;
• bill only for the items and services that are medically necessary and were ordered by a Physician or other appropriately licensed individual;
• correctly represent the type or level of service rendered; and
• represent diagnoses correctly to obtain payment.

Billing Questions or Conflicts: When employees receive a question from a patient or third party payer about an invoice or charge, they will promptly review and address the question, if authorized to do so, or will refer the matter to an individual who is so authorized. If employees are unable to resolve a dispute regarding a patient's bill, they will refer the issue to their Supervisor or Corporate Compliance Officer for resolution.

Billing Companies: Any billing companies engaged to perform billing and coding services must comply with both legal and UR Medicine Noyes Health's requirements to generate accurate billing documentation.

Cost Reports: UR Medicine Noyes Health receives reimbursement under government programs requiring the submission of complete and accurate reports of its cost of operation and other information. UR Medicine Noyes Health will comply with all applicable legal, regulatory, and program requirements in the preparation of its cost reports. These laws and regulations define what costs are allowable and outline appropriate methodologies to claim reimbursement for the cost of services provided to program beneficiaries.

A Nondiscriminatory Environment:

UR Medicine Noyes Health is an equal opportunity employer and does not discriminate against employees or potential employees on the basis of race, color, creed, religion, sex, national origin, sexual orientation, veteran status, marital status, age, or disability. UR Medicine Noyes Health will make reasonable accommodations for its disabled employees. UR Medicine Noyes Health will not tolerate discrimination, verbal, physical harassment, or abuse (whether or not sexually related) by employees, supervisors, vendors, subcontractors, or visitors. UR Medicine Noyes Health is committed to actions and policies to assure fair employment, including equal treatment in hiring, promotion, training, compensation, termination, and disciplinary action.

Government Transactions:

UR Medicine Noyes Health's business transactions sometimes involve national, state, and local governments. The laws and regulations governing transactions with government entities impose special rules that are more stringent and that have requirements not usually found in standard transactions with private parties. This is particularly true in dealing with the federal government where, for example, it is a crime to knowingly make a false statement or false representation to a federal government official or to submit such false information in an application or statement given to a federal agency.

All employees involved in government business activities must adhere to the ethical standards of the Code as well as government rules and regulations.

If an employee's job involves business with any government entity, the employee must know the rules applicable to their specific job. If there is any doubt, employees should not interpret the rules. When questions arise, employees should discuss the matter with the appropriate Supervisor, Manager, or the Corporate Compliance Officer.

Health and Safety:

UR Medicine Noyes Health is committed to providing its employees with a healthy, smoke free, and safe workplace in compliance with all applicable laws, rules and regulations, including those laws issued by the United States Occupational Safety and Health Administration. Employees are expected to be aware of the safety issues and policies which affect their job including, as applicable, the proper handling and disposal of medical waste and other contaminated media, including linens and equipment. It is important for all employees to advise their Supervisor of any workplace injury or any circumstance presenting a dangerous situation so that timely corrective action can be taken to resolve the issue.

Employees may not carry weapons on UR Medicine Noyes Health's property. Episodes of abuse or violence on UR Medicine Noyes Health's property will not be tolerated and will result in immediate disciplinary action up to and including termination.

Impairment and Substance Abuse:

All UR Medicine Noyes Health's facilities are alcohol and drug-free work environments. Only properly authorized individuals, during the course of their job responsibilities, may handle pharmaceuticals. Under no circumstance will pharmaceuticals be diverted for personal use. Employees are expected to perform their responsibilities in a professional manner, free from the effects of alcohol, drugs, or other substances which may hinder job performance or judgment. Employees suspected of being under the influence of drugs or alcohol must submit to appropriate drug or alcohol tests. Employees who perform an activity for UR Medicine Noyes Health while impaired or otherwise under the influence of alcohol or illicit drugs will be subject to Human Resources Substance Abuse Policy.

Gifts, Entertainment, Discounted, or Free Medical Care:

Employees or their immediate family may not solicit or accept any cash, gifts, or services from any patient, visitor, vendor, provider, or contractor. A department or group may accept perishable or consumable gifts. Payments, gifts, or entertaining government officials are strictly prohibited.

Current or potential business associates may occasionally invite employees or their immediate family to attend a social or entertainment event in the ordinary course of business. Discounted or free medical care to clinical practitioners, employees, clergy, trustees, volunteers, or their family members is strictly prohibited.

Conflicts of Interest:

This organization reviews its relationships and its staffs' relationships with other care providers, educational institutions, and payers to continuously ensure that those relationships are within law and regulation and determine if conflicts of interest exist.

Employees have a duty in conducting business to place the interests of UR Medicine Noyes Health ahead of their personal interests. Employees must avoid conduct that could have the appearance of a conflict between their personal interests and those of UR Medicine Noyes Health or any relationship that might appear to influence decisions or actions. Employees must not use their positions or confidential information gained during job functions to their personal advantage. Employees must disclose possible conflicts of interest.

Some examples of potential conflict situations:

1. Acting as a director, partner, consultant, or employee of a firm which either provides services, supplies, or equipment, or is a competitor.
2. Ownership by employees or members of their family of a material financial interest in a firm that is either a competitor of or vendor.
3. Purchase or lease of real estate that my increase in value because it is known that UR Medicine Noyes Health may have an interest in the property.
4. Hiring by employees or their subordinates of UR Medicine Noyes Health's vendors to perform personal work for themselves or their families without appropriate administrative approval.
5. Having an employee's research funded by a company in which the employee's family member has a material ownership interest.

Supplier, Vendor, and Subcontractor Relationships:

UR Medicine| Noyes Health selects its suppliers, vendors, and subcontractors based upon the quality, price, service, delivery, and supply of their goods and services. Personal relationships, gratuities, or contributions to UR Medicine Noyes Health's facilities may not influence the selection process.

Political Activity:

UR Medicine Noyes Health's political participation is limited by law. Funds or resources are not to be used to contribute to political campaigns or for gifts or payments to any political party or organization, unless it is expressly permitted by state and federal law and approved by the Corporate Compliance Officer. It is important to separate personal and company political activities in order to comply with the appropriate rules and regulations relating to lobbying or attempting to influence government officials. As private citizens, employees may participate in the political process if so desired. At times, UR Medicine |Noyes Health may ask employees to make personal contact with members of government or write letters to present our position on specific issues or periodically use professional lobbyists to promote our interests. If you are making these communications on behalf of UR Medicine Noyes Health, you may be engaging in regulated lobbying activities, and you must receive authorization from the Corporate Compliance Officer. Lobbyists are required by law to register and disclose their activities with government bodies as to time and money spent.

UR Medicine Noyes Health may speak out on issues which impact our business. Senior Management is responsible for developing our position on legislative and regulatory matters. If you have any questions or concerns, or if you are contacted by legislators, the press, regulators, or third parties regarding our position on public issues, please refer them to the Corporate Compliance Officer.

Hiring Former and Current Government Employees:

The recruitment and employment of former or current United States Government employees is subject to complex rules which change frequently and vary by employee. In some cases, these rules may also apply to the immediate family of the government employee. Similar rules may also apply to current or former state or local government employees or legislators and members of their immediate family.

If a former government employee or consultant becomes an employee or consultant to UR Medicine Noyes Health, care should be exercised to insure that the requirements of the United States Government conflict of interest laws are not violated. Each situation should be considered on an individual basis, and you should consult the Corporate Compliance Officer or legal department on issues related to recruitment and hiring of former or current government employees.

Antitrust:

It is our policy to fully comply with antitrust laws. Antitrust laws are designed to create a level playing field in the marketplace and to promote fair competition. Our competitors are other hospital facilities and health care entities in markets where we operate. Antitrust laws, as well as other regulations, could be violated by discussing business with a competitor such as how our rates are set, disclosing the terms of supplier relationships, allocating markets amongst competitors, or agreeing with a competitor to refuse to deal with a supplier.

Relationships with patients and suppliers can also raise antitrust issues, particularly in geographic areas where UR Medicine Noyes Health occupies a significant market position. The Corporate Compliance Officer should be consulted before (1) conditioning the sale of one product on the requirement that the customer also buy another product or service or our full line of products or services; (2) refusing to deal with suppliers (including physicians) who sell to, or otherwise benefit, competitors; and (3) refusing to do business or deal with or to attempt to create or maintain a monopoly (e.g., a refusal to deal with suppliers who sell to competitors who are price cutters).

At trade association meetings, be alert to potential situations where it may not be appropriate for you to participate in discussions. If a competitor raises a prohibited subject, end the conversation immediately. Document your refusal to participate in the conversation by request that your objection be reflected in the minutes, or drafting a memo to the file, or to the legal department. Prohibited subjects include any aspects of pricing, our services in the market, key costs such as labor costs, and marketing plans. This includes arrangements between competitors which may stabilize prices, alter production levels of a product, allocate or divide markets, territories, or customers, or refusing to deal with third parties. An unlawful arrangement may result not only from a written document or oral arrangement, but also from any kind of mutual understanding which gives the parties a basis for expecting that a business practice or decision made by one will be honored by another.

For these reasons, you should avoid discussing sensitive topics with competitors or suppliers, unless you are proceeding with the advice of the Corporate Compliance Officer. You should also not provide any information in response to oral or written inquiry concerning an antitrust matter without first consulting the general counsel office.

Environmental Compliance:

It is our policy to comply with all environmental laws and regulations as they relate to our business. It is the responsibility of all employees to understand how their job responsibilities may impact the environment and insure adherence to local, state, and federal environmental laws and regulations as well as UR Medicine Noyes Health's policies and procedures. If questions arise about environmental regulations or the proper handling of hazardous materials, a Supervisor should be contacted for assistance.

It is also the responsibility of all employee to report any potential or actual violation of environmental laws and policies and procedures. This includes advising UR Medicine Noyes Health or the national response center immediately should you see discharge of what may be hazardous substances or potential danger of discharge. Employee protective planning enables us to respond quickly and effectively to any environmental incidents involving UR Medicine Noyes Health. If you have any questions or comments, please do not hesitate to call the Environmental Services Department.

Financial Reporting and Records:

UR Medicine Noyes Health has established and maintains a high standard of accurate and completeness in our financial records. These records serve as a basis for managing our business and are important in meeting our obligations to patients, employees, and others; as well as for compliance with tax and financial reporting requirements. It is our policy to comply with the reporting requirements of applicable laws and established financial standards and generally accepted accounting principles.

Communication Systems:

All communications, electronic mail, intranet, internet access, voice mail, or paper is the property of UR Medicine Noyes Health and is to be primarily used for business purposes. Reasonable personal use of the communication systems is permitted; however, employees should assume that these communications are not private. Generally, confidential information should not be sent through intranet or the internet since its confidentiality cannot be guaranteed.

UR Medicine Noyes Health may review intranet and voice messages periodically for business reasons or conducting reviews for quality control purposes. If an employee abuses the communication system or uses them excessively for non-business purposes, the employee may lose these privileges and/or be subject to disciplinary action.

Communication may not be used to:

• send harassing, threatening, or obscene messages;
• send chain letters;
• access non-business information on the internet;
• send copyrighted documents that are not authorized for reproduction;
• conduct a job search; or
• open misaddressed mail.

Employment Practices:

UR Medicine Noyes Health is committed to providing a fair and equal opportunity work environment where employees, subcontractors, vendors, and visitors are treated with respect and courtesy. We will not tolerate any unlawful harassment or discrimination for any reason. We expect the same from all of our contractors, vendors, and visitors. This means that UR Medicine Noyes Health will:

1. Provide equal opportunity for employment, advancement, and compensate according to performance.
2. Provide equitable benefits to all employees.
3. Have zero tolerance for harassment of any type.
4. Not discriminate against any individual with a disability with respect to any offer, term, or condition of employment. Reasonable accommodations will be made for the known physical and mental limitations of otherwise qualified individuals with disabilities.

Use of UR Medicine Noyes Health's Resources:

Employees may not use UR Medicine Noyes Health's resources for non-UR Medicine Noyes Health purposes. Resources include information, technology, intellectual property (for example, copyrights, patents, and trademarks), buildings, land, equipment, machines, telephones, voice mail, and/or email, copiers, computers, software, supplies, cash, and the time and skills of employees.

Examples of misuse are:

1. unauthorized possession or personal use of company resources;
2. permitting or directing others to misuse company resources; and
3. soliciting for personal use on voice mail or email such advertisements for the sale of a house or car.

Media Inquiries:

The Administrative Staff is responsible for all contact with the media. Unless specifically authorized to represent UR Medicine Noyes Health to the media, employees should not respond to inquiries or requests for information. This includes newspapers, magazines, trade publications, radio, television, as well as any other external source that is looking for information. If an employee has questions or concerns, or if the media contacts an employee about any topic, they should contact their Manager.

Securities:

Directors, officers, and employees can expect that in the course of performing their duties they will come into possession of material non-public information about UR Medicine Noyes Health or other companies with whom we do business. Material non-public information is defined as any information that would affect securities prices, either positively or negatively that is not generally available to the investigating public. This information is generally referred to as insider information. Buying or selling stocks using inside information is referred to as insider trading, an illegal activity.

It is illegal for directors, officers, and employees to buy or sell our stocks or bonds or the stocks or bonds of another company based on insider information or to discuss such information with others who might buy or sell such securities. Such activity is deemed to be insider trading.

For example, if in the course of your work and prior to public announcement, you become aware of a new and efficient process or equipment that would materially affect UR Medicine Noyes Health's productivity, you would be guilty of insider trading if you bought or sold securities or passed information to a friend or relative who bought or sold the securities.

Marketing and Advertising:

UR Medicine Noyes Health markets its services in a fair, truthful, and ethical manner. Marketing materials are designed to reflect only the services available and the level of the provider's licensure and accreditation. UR Medicine Noyes Health uses marketing and advertising to educate the public, report to its communities, increase awareness of its services, and recruit employees.

Sexual Harassment:

Sexual harassment is illegal and is defined by law as unwelcome sexual advances, requests for sexual favors, or other verbal or physical conduct of a sexual nature that creates a hostile work environment. Various subtle verbal and non-verbal communications should constitute sexual harassment.

UR Medicine Noyes Health Compliance with Fraud, Waste, and Abuse Laws:

UR Medicine Noyes Health employees shall conduct all activities in compliance with applicable laws and regulations, including fraud and abuse laws, self-referral and anti-kickback prohibitions.

• Affected individuals shall maintain impartial relationships with actual and potential vendors and contractors. We will avoid exerting or appearing to exert influences on behalf of those with whom UR Medicine Noyes Health does business or may do business because of friendship or any other relationship.
• All vendors and contractors who have or desire business relationships with UR Medicine Noyes Health are mandated to abide by our organizational ethics and Compliance Program. Affected Individuals who have knowledge of vendors or contractors who violate these ethics in their relationship with UR Medicine Noyes Health should report these to their supervisor or appropriate Human Resources personnel.
• UR Medicine Noyes Health employees should avoid selling merchandise or requesting donations for any purpose from employees or patients on UR Medicine Noyes Health premise’s without specific prior approval by the senior leadership of the facility.
• Employees shall not condition any charitable gift or contribution made by UR Medicine Noyes Health on an actual or potential business relationship with UR Medicine Noyes Health.
• Donations offered to UR Medicine Noyes Health on or behalf of employees must be referred to the Foundation or senior leadership.
• Staff may not endorse any private product or private services on behalf of UR Medicine Noyes Health.

UR Medicine Noyes Health Policy for Detection and Prevention of Fraud, Waste and Abuse

In compliance with the Deficit Reduction Act of 2005, UR Medicine Noyes Health provides detailed information to Affected Individuals on the federal and state False Claims Acts, federal administrative remedies for false claims, New York laws pertaining to civil and criminal penalties for false claims, and whistleblower protections contained in such statutes.

A summary is attached to this policy, which provides an overview of the False Claims Act, federal administrative remedies for false claims, New York laws pertaining to civil and criminal penalties for false claims, and whistleblower protections contained in such statutes.

UR Medicine Noyes Health requires Affected Individuals to report suspicions of fraud, waste, or abuse and educates all of its employees and agents to enable them to detect, prevent, and report suspected incidents of fraud, waste, and abuse.

UR Medicine Noyes Health prohibits Affected Individuals from intentionally or recklessly submitting a claim which includes fraudulent information or is based on fraudulent documentation to any federally funded or state-funded program for payment approval.

Any UR Medicine Noyes Health employee or agency who violates, or encourages, directs, facilitates, or permits violations of applicable laws, regulations, UR Medicine Noyes Health Code of Conduct or its policies and procedures will risk individual indictment, criminal prosecution and penalties, and civil actions for damages and penalties. Moreover, that individual also subjects UR Medicine Noyes Health to the same risks and penalties UR Medicine Noyes Health employee or agent who violates any of these requirements may be subject to discipline, up to and including immediate termination.

Please refer to UR Medicine Noyes Health Deficit Reduction Act Policy: Fraud, Waste, and Abuse.

Reporting Violations of the Code of Conduct

It is the duty of all UR Medicine Noyes Health employees or those working on behalf of UR Medicine Noyes Health to comply with applicable federal health care program requirements, laws, rules, regulations, and with all policies and procedures developed by UR Medicine Noyes Health. A failure to do so may subject an employee to disciplinary action. Appropriate action will be taken for violations by relevant third parties.

Affected Individuals must report actual or suspected violations of applicable law, rules, regulations, or the Code. Employees have the same reporting obligations for actual or suspected violations committed by subcontractors, vendors, or other relevant third parties. UR Medicine Noyes Health provides multiple reporting options to ensure that employees are comfortable with whom they communicate corporate compliance issues.

Actual or suspected violation(s) of the Code should be reported immediately to your supervisor or the Director of Human Resources. If you would like to remain anonymous in your reporting of actual or potential violations of the Code, you can utilize the Integrity Helpline, which is available 24 hours a day, seven days a week. The Integrity Helpline number is (585) 756-8888.

Corporate Compliance will facilitate an investigation into the concern and follow-up with you, if requested. We will make every effort to keep the identity of anyone reporting a suspected violation confidential to the extent permitted by law, unless doing so prevents us from fully and effectively investigating the suspected violation. Retaliation or Intimidation of any kind in response to reporting a concern is strictly prohibited. Any retaliatory or intimidating behavior must be reported to the Corporate Compliance Officer or to the Integrity Helpline.