DEPARTMENT: Legal / POLICY DESCRIPTION: Physician Relations Training
PAGE: 1 of 2 / REPLACES POLICY DATED:
APPROVED: December 18, 2000 / REVISED:
EFFECTIVE DATE: January 1, 2001 / REFERENCE NUMBER: LL.020
SCOPE: All Chief Executive Officers (CEOs) and Chief Financial Officers (CFOs) of Company-affiliated hospitals, all Practice Managers and Administrators of other Company-affiliated facilities, and all other personnel substantially involved in negotiating or monitoring physician relationships.
PURPOSE: To ensure that all personnel substantially involved in negotiating or monitoring of physician relationships are aware of current rules and regulations related to hospital/physician relationships, including but not limited to 42 U.S.C. §§ 1320a-7b(b) and 1395nn.
POLICY:
  1. Each person substantially involved in negotiating or monitoring physician relationships must complete one hour of Physician Relations training prior to negotiating or contracting with physicians, or monitoring such relationships.
  1. After initial Physician Relations training, one hour of Physician Relations training must be completed annually.
  1. Each person required to receive Physician Relations training will receive a copy of the physician relationship policy checklist annually.
  1. The purpose of training shall include the following:
  1. the development of permissible contractual/financial relationships with physicians;
  2. the personal obligation of each individual involved in physician relationships to ensure all aspects of each relationship is permissible;
  3. an understanding of the applicable laws, regulations, and statutes;
  4. the legal sanctions for engaging in improper financial relationships; and
  5. examples of proper and improper relationships.

PROCEDURE:
  1. The facility Ethics and Compliance Officer (ECO), or designee, must ensure that each person substantially involved in negotiating or monitoring physician relationships receives the required one hour of Physician Relations training prior to negotiating or contracting with physicians, or monitoring such relationships, and annually thereafter.
  1. The ECO, or designee, will also be responsible for ensuring that each person required to receive training receives a copy of the physician relationship policy checklist on an annual basis.
  2. Completion of the Physician Relations training (e.g., certificate of completion) must be maintained in the Company’s Learning Management System (LMS).
  1. Until the LMS is in operation at the facility, the ECO or designee must use the tracking method located on the Company’s intranet at the Ethics and Compliance website (which has been developed for the express purpose of interfacing with the LMS).
  1. The ECO will be responsible for reporting on the Physician Relations training in the ECO Quarterly Report.
  1. It is the responsibility of the facility ECO to ensure appropriate processes are in place for compliance with this policy.

REFERENCES:
General Statement on Agreements with Referral Sources; Approval Process Policy, LL.001

12/2000