MDA Compliance Plan

It is MDA's policy to operate as a good corporate citizen and comply with all the laws and regulations applicable to its business at all governmental levels. This policy applies to Metro Denver Anesthesia, P.C. and to all employees and agents.

To this end, MDA has developed a comprehensive Compliance Plan.

Compliance Plan

I. SCOPE AND IMPLEMENTATION

This Corporate Compliance Program (the "Compliance Program") applies to Metro Denver Anesthesia, P.C. (the "Corporation") and to all employees and agents of the Corporation. It is the policy of the Corporation to operate as a good corporate citizen and comply with all the laws and regulations applicable to its business at all governmental levels. Compliance with all applicable federal state and local laws will be monitored under this Compliance Program. In implementing this Compliance Program, particular attention and, as necessary, resources shall be given to insure compliance with the laws and regulations administered by the Health Care Financing Administration and Office of Inspector General of the Department of Health and Human Services ("HHS OIG"), and the ethical standards applicable to the practice of medicine.

II. STANDARDS OF CONDUCT

The medical welfare and treatment of a patient is always the first priority of the Corporation.

A. Medicare and Medicaid Billing. The Corporation shall comply with all laws, regulations and policies of the Health Care Financing Administration and the Medicare Carrier that govern billing Medicare for services. The Corporation shall also comply with all state laws and regulations applicable to Medicaid billing. Federal law imposes a civil monetary penalty on anyone for knowingly presenting to any federal health care program a claim for an item or service that a person knows or should know was not provided as claimed, uses an inappropriate billing code resulting in a greater payment than the proper code, is false or fraudulent, or is for items or services that are not medically necessary. It is the policy of this Corporation that all claims for medical services submitted for payment to Medicare or Medicaid shall accurately and correctly identify the services performed, including the use of appropriate ICD-9-CM codes for patient diagnosis and appropriate CPT (emphasizing CPT-4 Codes commonly referred to as ASA Codes) or HCPCS codes for the procedures, services or supplies provided. The employees of the Corporation responsible for Medicare and Medicaid billing shall comply with all requirements for billing and shall report to the Corporation's Compliance Coordinator any failure to follow such requirements as soon as possible after discovering the failure.

B. Anesthesia Policies and Procedures. The Corporation shall establish policies and procedures for: pre- and post-anesthesia evaluation; monitoring of patients, patient and employee safety, care of equipment, storage of anesthesia agents and administration of anesthesia unless such care and storage is the responsibility of a third party (i.e. hospital, ambulatory surgery center). Policies and procedures shall conform to governmental or hospital requirements or guidelines, as applicable. The corporation does not employ CRNAs on the date of the adoption of this Compliance Plan. However, it is contemplated that the Corporation may retain CRNAs in the future. This Compliance Plan and Program is intended to guide the Corporation both before and after the Corporation retains CRNAs. For each patient for whom a physician shall bill Medicare of Medicaid, the physician shall:

1. Perform a preanesthetic examination and evaluation. As always, all patients will be evaluated by an anesthesiologist before surgery. In the event the Corporation employs or retains a CRNA or RN to perform the initial exam and evaluation, a MD will re-evaluate the patient and cosign the pre-op interview. The anesthesiologist or CRNA providing the anesthesia will continue to time, sign and date the box in the lower right corner of the anesthesia interview form to verify review of all information immediately before induction of anesthesia or take such other action as is appropriate as billing requirements change. The CRNA and anesthesiologist will also verify that the interview and all pertinent information, including vital signs, lab, CXR, and EKG have been seen.

2. Prescribe the anesthetic plan. The anesthetic plan, as discussed with the patient and/or the patient's family, will be recorded on the anesthetic interview form. As above, when performed by other than a MD, the anesthesiologist will prescribe the anesthesia plan and sign the interview form. The plan will include type of anesthetic and any other special consideration such as special monitoring and post-op pain relief choices.

3. Personally participates in the most demanding procedures in the anesthesia plan, including induction and emergence. In the event a CRNA is responsible for a Medicare patient, the CRNA will page or otherwise attempt to contact the MD responsible for supervision of that patient, before induction of an anesthetic. This will be done well enough in advance that the anesthesiologist can always be present. The CRNA will document that the anesthesiologist was present and the anesthesiologist will cosign or initial the induction note as well as sign the anesthesia record to document that presence. The anesthesiologist will again be voice paged on emergence so that he/she may be present. Again, this will be done well enough in advance that the anesthesiologist can always be present. This presence will be documented by both CRNA and MD as for the induction. This is a change in documentation procedures only, not a change in our medical practice or management of the patient.

4. Ensures that any procedure in the anesthesia plan that he or she does not perform, is performed by a qualified individual. If the Corporation does retain the services of one or more CRNAs, a file of all CRNA licenses, certification and hospital privileges shall be maintained in the Corporation's business office. The anesthesiologist supervising a given case will determine which procedures will be performed by the assigned CRNA.

5. Monitors the course of anesthesia administration at frequent intervals. The anesthesiologist will be responsible to maintain a presence in the operating room for a particular case based on an individual determination of that patient's needs. The time spent in direct contact will, of course, vary based on type of surgical procedure, patient stability, underlying medical condition. The CRNA is responsible for paging the anesthesiologist responsible at any time and for any reason he/she feels the anesthesiologist's presence is necessary.

6. Remains physically present and available for immediate diagnosis and treatment of emergencies. This statement is clear and obvious. Medicare does provide some guidance as to what an anesthesiologist may do while supervising anesthesia services in the operating room. This "guidance" is explained below in the paragraphs that follow item 7.

7. Provides post-anesthetic care. An anesthesiologist shall always be available for PACU care - usually the anesthesiologist on call. In PACU, as well as for all medically directed procedures, the Corporation's practice allows considerable back-up coverage. As the above paragraphs note, another anesthesiologist employed by the Corporation can provide parts of the coverage to an individual patient. When this occurs, the anesthesiologist providing that service should always be clearly documented.

"If anesthesiologists are in a group practice, one physician member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria. Similarly, one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service. However, the medical record must indicate that the services were furnished by physicians and identify the physicians who rendered them.

The direction of not more than four concurrent anesthesia procedures may be a physician service reimbursable if the physician does not perform any other services during the same period of time. (See exception noted below.) In all cases in which medical direction is furnished, the physician must be physically present in the operating suite.

EXCEPTION: Addressing an emergency of short duration in the immediate area, or administering an epidural or caudal anesthetic to ease labor pain, or periodic, rather than continuous monitoring of an obstetrical patient, does not substantially diminish the scope of control exercised by the physician in directing the administration of anesthesia to the surgical patients. It does not constitute a separate service for the purpose of determining whether the medical direction criteria are met. Further, a physician may receive patients entering the operating suite for the next surgery while directing concurrent anesthesia procedures or checking or discharging patients in the recovery room and handling scheduling matters without affecting reasonable charge reimbursement. However, if the physician leaves the immediate area of the operating suite for other than short durations, devotes extensive time to an emergency case or is otherwise not available to respond to the immediate needs of the surgical patients, the physician's services to the surgical patients are supervisory in nature."

The physician shall perform the procedure personally or direct no more than four anesthesia procedures concurrently and shall not perform other services while he or she is directing the concurrent procedures. Further, Physician shall not bill Medicare, Medicaid, or any other federally financed health care programs for services that are not medically necessary. The physician shall personally record billing information regarding each patient under the care of physician in accordance with the prescribed practices of the Corporation.

Risk Areas: There are many categories and forms of non- compliant behavior which could put the group at risk and physicians should be vigilant in avoiding all of them. Based on the group's specialty however, the following areas should be of particular concern to group members:

8. The Reporting of Anesthesia Times: For purposes for billing, physicians will report the actual time spent face-to face with patients. They will be careful not to round times to the nearest five-minute increment. The anesthesia start time for surgical cases will reflect the time they began induction of anesthesia, whether in the operating room or an equivalent holding area, and the anesthesia end time will correspond to the time responsibility for the patient was transferred to the PACU or ICU staff such that the total anesthesia time will represent the total time the anesthesiologist had the patient under his or her direct care.

For obstetric anesthesia cases involving the management of an epidural catheter, the physicians will be careful to document actual time spent face-to-face with the patient. Physicians should note the actual number of minutes spent inserting an epidural, if applicable, the actual times spent following up on patients with in situ epidurals and the actual time spent with the patient during delivery.

9. The Medical Appropriateness of Invasive Monitoring: Physicians understand that it is inappropriate to submit a charge for the monitoring or use of an arterial line, a Central Venous Pressure line or a Swan-Ganz catheter inserted by a physician who is not a member of MDA. To ensure compliance with this policy all physicians who work with invasive monitoring will confirm, in writing, on the anesthesia record, that any catheters indicated were inserted by them.

10. Unbundling of Independent Procedures: Medicare intermediaries have been instructed by HCFA to screen claims involving multiple types of service, e.g. a claim involving both an anesthesia charge and a charge for invasive monitoring or a charge for an acute pain management service such as an epidural narcotic injection. Many combinations of specific charges are considered inappropriate because they represent "unbundling." The following are specifically to be avoided by MDA physicians:

• Epidural narcotic injections are not considered billable if they involve the injection of narcotics into a catheter which was used as the primary mode of anesthesia for the management of the case;
• CVPs are not considered billable if they are used as the introducer for Swan-Ganz catheters;
• Naso-gastric tubes are not considered billable.

11. The Use of Evaluation and Management Codes: Physicians should recognize that the use of Evaluation and Management codes (E/M codes) represents a special point of compliance vulnerability for the group. Physicians agree not to exercise "default coding," a practice whereby a specific E/M code is always selected to describe the evaluation of a patient for a block procedure. Instead they agree to consider the following six criteria in their selection of an appropriate code for each patient:

• Whether the patient is a new or established patient;
• Whether the services are performed on an in- or out patient basis;
• Whether the evaluation meets the criteria for a consult;
• The nature and extent of the history performed;
• The nature and extent of the physician examination; and
• The level of medical decision-making.

12. Pain Management Billing: In addition to the careful selection of E/M codes, physicians who perform pain management services should make a concerted and ongoing effort to ensure that the codes they report for billing reasonably and accurately describe the services rendered. They should seek out periodic validation that the primary payors in the area recognize and reimburse the codes submitted.

13. Appropriateness of Service and Billing: Physicians should avoid default billing patterns, i.e. any assumptive billing which does not correspond to actual services rendered. An example of this would be the physician who routinely billed for follow-up visits for patients with epidural catheters whether or not he or she had had a chance to see and evaluate the patients and write a note in the chart.

14. Documentation of Services Rendered: Physicians should understand that if their charges were audited there would be a careful review of the documentation for each charge. The auditor will, most likely, take the position that if the service was not documented it did not take place. This is especially true of the use of E/M codes, where the chart must demonstrate the basic requirements for the selection of the code submitted. This is equally true of anesthesia times, however, where the notes section should support the anesthesia start and end time.

15. The Waiving of Co-Payments and Deductibles: The Health Care Insurance Portability and Accountability Act of 1996 specifically prohibits the routine waiver of co-payments and deductibles by physicians. The intent of the law is to prohibit physicians from giving patients a greater financial discount than their insurance companies. This effectively precludes the use of "professional courtesy" or "insurance only" in these cases. Financial hardship is an acceptable reason for waiving a patient balance, but professional courtesy is not.

16. Billing Service Compliance: The group agrees to only do business with billing services which maintain an effective internal compliance plan and which can provide the group periodic feedback concerning compliance matters.

17. Compliance with Credentialling Requirements: Physicians agree to make every effort to work with the billing office staff to ensure that they are appropriately credentialled with all payors with which the group has contracts. They understand that this involves both the prompt processing of credentialling paperwork as well as the furnishing of copies of all critical documents such as medical licenses, diplomas and Board Certification certificates. In addition they, also should understand that credentialling is ultimately a physician responsibility.

C. Medicare and Medicaid Fraud. Federal law prohibits knowingly and willfully soliciting payment or offering to make payment of anything of value for the purpose of inducing a referral of any form of care reimbursable under Medicare, Medicaid or any other Federally financed health care program. All employees shall strictly comply with this prohibition. Any employee who becomes aware that an employee of the Corporation has solicited payment or offered to make any type of payment for the referral of work reimbursable under Medicare, Medicaid or any other Federally financed health care program shall report such conduct to the Corporation's Compliance Coordinator as soon as possible.

D. Health Care Fraud. Federal law also prohibits knowingly and willfully defrauding any health care benefit program, knowingly and willfully obtaining money from a health care benefit program by means of false pretenses or knowingly and willfully making a false statement in providing or billing health care services. A health care benefit program means any public or private plan which pays medical benefits, therefore, it includes Medicare, Medicaid, CHAMPUS, and other Federally financed health care programs, state employees health care programs and all forms of private health insurance. All employees shall strictly comply with this prohibition. Any employee who becomes aware of conduct by any employee of the Corporation, which he or she believes violates this prohibition, shall immediately report such conduct to the Corporation's Compliance Coordinator.

E. Patient Care. Patient care is of primary importance to the Corporation and it is the policy of the Corporation to provide appropriate care for each of its patients in accordance with applicable laws and the ethical standards applicable to the practice of medicine. Employees shall maintain confidential the records of patients and shall only disclose patient records as authorized pursuant to the Corporation's policies regarding patient records and confidentiality. If an employee believes any conduct violates these policies, he or she should immediately report such conduct to the Corporation's Coordinator.

F. Contracts and Business Relationships. As a business entity, MDA, has negotiated and will continue to negotiate numerous contracts and agreements on behalf of all member physicians. Such agreements may include professional service agreements, reimbursement arrangements with payors and benefits arrangements. While individual physicians may not agree with all provisions of every agreement they must understand that they are, nevertheless, obligated to know about, understand and be bound by such agreements.

1. Self-referrals and kickbacks: Federal law specifically prohibits the acceptance of kickbacks or financial inducements to provide services. An anesthesiologist who routinely waives the co-payment or deductible liability of a specific surgeon or a member of that surgeon's family could be construed as just such an inducement.

2. Anti-trust: Physicians should understand that it is a violation of federal law to discuss their fees with members of other groups in the area. They must be careful not to engage in any discussions, meetings or actions which could be construed as collusive or which might be construed as anti-competitive or price-fixing.

The Corporation may from time to time adopt additional, specific Standards of Conduct under this program which it will circulate to employees of the Corporation. In addition, the Corporation has established and maintained policies and procedures not set forth in this Compliance Program. The additional practices, procedures and policies of the Corporation are an integral part of the Compliance Program of the Corporation and employees are expected to comply with all such practices, procedures and policies. All employees are expected to act in accordance with the law and seek guidance from a Compliance Coordinator or officer of the Corporation if in doubt as to the legality of any conduct.

III. COMPLIANCE COORDINATOR

A. One or more Compliance Coordinators shall be appointed by the Board of Directors of the Corporation. All employees shall be notified of such appointment and of any change in the Compliance Coordinator appointed by the Corporation. The Compliance Coordinator, on behalf of the Corporation, shall have overall responsibility to oversee compliance with the standards of conduct established for the Corporation and to oversee the proper functioning of the compliance procedures established under this Compliance Program.

B. The Compliance Coordinator shall oversee the communications of this Compliance Program and the standards of conduct to all employees of the Corporation on at least an annual basis. The Compliance Coordinator shall coordinate with appropriate management personnel training for staff regarding appropriate issues in the Corporation's Standards of Conduct.

C. The Compliance Coordinator shall establish and publicize a system permitting employees to submit anonymous reports of suspected misconduct, as well as publicizing that an employee can communicate suspected problems directly to the Compliance Coordinator.

D. The Compliance Coordinator and the Corporation shall periodically review the Corporation's Medicare, Medicaid and other health care services billing procedures, its procedures for obtaining opinions of counsel on proposed transactions or activities that may raise questions under the Medicare and Medicaid laws, health care fraud laws, anti-trust laws, or other laws, and its procedures for entering into agreements with other providers that may raise legal issues. The Corporation shall periodically review the HHS OIG Fraud Alerts with the Compliance Coordinator and its legal counsel; the Corporation shall take reasonable action to correct conduct criticized in such Fraud Alerts, if applicable, and to prevent such conduct from recurring in the future.

The Compliance Coordinator shall coordinate appropriate periodic review and audit to ensure the Corporation and its employees are complying with its standards of conduct, and applicable laws and regulations. Billing practices shall be a specific focus of periodic audits. The Compliance Coordinator shall report the results of the review and audits to the Board of Directors and recommend, if necessary, appropriate changes in such procedures to the Board of Directors or any committee designated by it for said purposes.

E. The Compliance Coordinator shall see to it that reports of suspected misconduct or impropriety relating to the Corporation's operations or practices are promptly and thoroughly investigated in accordance with this Compliance Program and procedures approved by the Corporation's Board of Directors. Where appropriate, disciplinary sanctions will be imposed in accordance with this Compliance Program.

F. The Compliance Coordinator shall maintain appropriate records of actions taken in connection with this Compliance Program, including appropriate records of audit or investigation results, to establish the Corporation's efforts to comply with the law. All of such records shall be reviewed by the Corporation's legal counsel prior to disclosure to any third-party for any reason to ensure no disclosure will violate any confidentiality requirement.

G. The Compliance Coordinator shall have the authority to take such other actions as are necessary and appropriate to implement and improve the Compliance Program on behalf of the Corporation.

IV. DELEGATIONS OF AUTHORITY

It is the policy of the Corporation that it will not employ or delegate authority to individuals the Corporation knows do not meet its standards for honesty and integrity. The Compliance Coordinator shall periodically review the delegations of discretionary authority within the Corporation to determine whether any current delegation violates corporate policy. In conducting such review, the Compliance Coordinator may rely on information in personnel files, on the opinions of managers and other personnel of the Corporation, and on other available information.

V. COMMUNICATION OF STANDARDS AND PROCEDURES TO EMPLOYEES

Employees and agents of the Corporation shall be provided with a copy of this Compliance Program. At least annually, the Corporation shall review this Compliance Program with its employees, emphasizing the importance of complying with Medicare, Medicaid and other federal statutes affecting the Corporation. This educational program shall reinforce the Corporation's policy that strict compliance with the law and this Corporate Compliance Program is a condition of employment. The Compliance Coordinator will emphasize to employees that employees will not be penalized for reporting in good faith improper conduct to the Compliance Coordinator, either directly or anonymously.

Records of the education programs shall be maintained by the Compliance Coordinator.

VI. RESPONSE TO VIOLATIONS

A. If any employee of the Corporation becomes aware of any practice (or omission) that involves a violation or potential violation of a federal, state or local law, or other violation or potential violation of this Compliance Program, then the employee must report such practice or omission as soon as possible to the Compliance Coordinator.

B. No employee will suffer any penalty or retribution for good faith reporting of any suspected misconduct or impropriety.

C. Any report of misconduct or impropriety may be made directly or anonymously to the Compliance Coordinator

D. Strict compliance with this Compliance Program and the Standards of Conduct set out in this Program is a condition of employment by the Corporation.

E. It is the policy of the Corporation that the Standards of Conduct set forth in this Compliance Program shall be consistently enforced through prompt, appropriate disciplinary mechanisms. Disciplinary actions may be up to and including dismissal. Disciplinary action may be imposed on employees who violate the law and may also extend, as appropriate, to individuals responsible for the failure to detect or report an offense.

F. The Compliance Coordinator is available for any questions an employee of the Corporation may have concerning the application of any law, regulation, or standard of conduct to the Corporation's operations and practices.

G. Any employee who learns of a violation of any law, regulation or standards of conduct shall report the violation to the Compliance Coordinator. Whenever the Compliance Coordinator receives information regarding a possible violation of any applicable law or regulation, the Compliance Coordinator shall report such information to the Corporation's legal counsel, then the Compliance Coordinator shall take appropriate steps to examine information and conduct the investigation necessary to determine whether an actual violation has occurred. The Compliance Coordinator shall recommend to the Corporation an appropriate course of action, and the Corporation shall render a timely decision with respect to such recommendation. The Corporation shall, as appropriate, request the assistance of its legal counsel in conducting such investigation or in taking the necessary follow-up action.

H. It is the policy of the Corporation, that, if a violation of any applicable law, regulation or standard of conduct relating to the business of the Corporation is detected, the Corporation shall take all reasonable steps to respond appropriately to the violation and to prevent further similar violations. The action taken may consist of revising this Plan to prevent the occurrence of future violations, revising or increasing the Corporation's auditing procedures, removing or reassigning personnel, modifying employee training, or reporting conduct to the appropriate governmental agency. If, after investigation and consultation with the Corporation's advisors, the Corporation determines that it has received an overpayment from a federally funded health care program, the Corporation shall make prompt restitution of the overpayment to the appropriate program.