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POLICY and PROCEDURE

TITLE: Compliance: Issue Reporting Policy

Number: 6013 Version: 6013.4

Type: Administrative Author: Ethics & Compliance Department

Effective Date: 8/14/2012 Original Date: 1/21/2007 Approval Date: 8/6/2012 Deactivation Date:

Facility: System

Population (Define): All Employees

Replaces:

Approved by: Administrative Policy Committee, Senior Management Team, Board of Directors

May not be current policy once printed 1

Print Date: 8/14/2012

TITLE: Compliance Issue Reporting Policy

I. Purpose/Expected Outcome: A. To ensure that Banner Health provides adequate avenues for employees, medical staff members,

patients, and vendors to report compliance issues or good faith concerns without fear of retaliation and

to further ensure that employees are aware of the federal and state laws and regulations that govern

false claims and statements and the role these laws play in preventing and detecting fraud, waste, and

abuse.

II. Definitions: A. N/A

III. Policy: A. Each employee of Banner Health is obligated to report to the Ethics & Compliance Department, Banner

management, or any other appropriate representative any issue or practice which he or she believes in

good faith may constitute a violation of the law, a regulation or Banner Health’s policies. Any

employee who is aware of, or reasonably suspects, any violation of an applicable law, regulation or

Banner Health policy and fails to report it may be subject to disciplinary action.

B. Banner Health fosters an environment where employees, medical staff members, patients, vendors, and others affiliated with Banner feel free to bring forward any good faith question or concern and they feel

free to report suspected policy violations, illegal or unethical conduct without fear of retaliation.

Employees should also feel free to report any questionable business practices that may or may not be a

violation of law or policy. The procedure below is primarily applicable to Banner employees. There

are other procedures and avenues for medical staff members, patients, and vendors to raise their

compliance-related questions and concerns, although all should feel free to use the Banner

ComplyLine.

1. Banner Health has approved the Policy, Compliance: Prohibition Against Retaliation for Reporting

Suspected Non-Compliance, to ensure that employees and others feel free to bring forward their

compliance questions and concerns without fear of retaliation.

2. Banner Health has the Four-Step Communication Process described below to assist its employees

in reporting compliance issues or concerns.

3. Banner Health maintains an ethics and compliance hotline known as the ComplyLine that

employees may use if they feel the need or if they wish to remain anonymous.

4. Banner Health provides its employees with detailed information about the Federal False Claims

Act and any Federal or State administrative remedies for false claims and statements, including

reporting protections and how these laws help prevent fraud, waste, and abuse. Detailed

Policy Title: Compliance: Issue Reporting Policy

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information shall be available on the Ethics & Compliance intranet web site and in the

Department’s compliance training materials.

IV. Procedure/Interventions: A. To assist employees in reporting any compliance issues or concerns, Banner Health has implemented

the Four-Step Communication Process. Generally, compliance issues or concerns should be reported

and resolved promptly, constructively, and at the lowest level possible by following these four steps:

1. Discuss the issue with your supervisor. Supervisors are familiar with the particular workplace

environment and its issues. Therefore, they should be given the first opportunity to resolve the

matter.

2. Speak to your Department Manager or Director. If you and your supervisor cannot resolve the

matter, or you feel that your concern is not getting the proper attention, or your supervisor is the

issue then you should request a meeting with your Department Manager or Director to discuss the

matter further.

3. Speak to your Compliance Officer, People Resources Department, and/or your CEO. If your

Department Manager or Director is unable to resolve the matter to your satisfaction, you should

contact your Compliance Officer or People Resources Department, or, alternatively, you may elect

to bring the matter directly to your CEO or Senior Executive.

4. Bring the matter to the attention of the Ethics & Compliance Department or the Legal

Department. Matters that are not resolved at the facility level should be brought to the attention of

the Ethics & Compliance Department or the Legal Department.

B. If an employee has exhausted the above avenues, or if the employee feels uncomfortable reporting a compliance issue or concern to his or her supervisor or other Banner executive, he or she should call or

email the ComplyLine. The number is 888-747-7989, and the email address is

https://bannerhealthcomplyline.alertline.com. The ComplyLine should also be used if the employee

wishes to remain anonymous. To the extent allowed by law, ComplyLine users may remain

anonymous.

C. Issues or concerns that are reported into the ComplyLine or come to the attention of the Legal Department, the Ethics & Compliance Department, or the Internal Audit Department and that involve

or relate to executive management or a Board member, regardless of how the matter is brought forth,

shall be handled in the following way:

1. The Chair of the Audit Committee of the Banner Health Board shall be notified immediately of any

allegations concerning Banner Board members, the President of Banner, the Regional Presidents,

Executive or Senior Vice Presidents, and any other officer of Banner involved in the areas of

financial reporting, compliance, internal controls, and treasury.

2. Allegations concerning the above-referenced individuals shall be brought to the Audit Committee

Chair by either the Vice President of Ethics & Compliance, the General Counsel, or the Director of

Audit Services. If the allegations concern one of these three officers, the others will be responsible

for presenting it to the Chair. The Audit Committee of the board may oversee any investigation,

using internal and/or external resources as it sees fit.

3. Allegations concerning other Banner employees shall be investigated by the Vice President of

Ethics & Compliance or the Director of Audit Services, in consultation with appropriate Banner

executives and Board members.

V. Procedural Documentation: A. Any disciplinary action given under this Policy must be documented in accordance with Banner

Health’s Performance Recognition Policy.

Policy Title: Compliance: Issue Reporting Policy

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VI. Additional Information: A. N/A

VII. References: A. N/A

VIII. Other Related Policies/Procedures: A. Patient Complaint, Discrimination and Grievance Policy (#2865) B. Compliance: Prohibition Against Retaliation for Reporting Suspected Non-Compliance (#2749)

IX. Keywords and Keyword Phrases: A. Reporting B. Retaliation C. False Claims D. Fraud E. Waste F. Abuse G. Ethics

X. Appendix: A. N/A