DEPARTMENT: Ethics and Compliance POLICY DESCRIPTION: Internal Handling of 

Reports to the Ethics Line 

PAGE: 1 of 5 REPLACES POLICY DATED: 1/21/98, 7/8/98, 

11/9/99, 1/1/06, 3/1/14 

EFFECTIVE DATE: October 1, 2020 REFERENCE NUMBER: EC.002 

APPROVED BY: Ethics and Compliance Policy Committee 

SCOPE: This policy and procedure applies to HCA Healthcare Ethics Line. 

PURPOSE: To establish protocols for the manner in which HCA Healthcare Ethics Line manages 

reports and investigations of ethics or compliance concerns.

POLICY: 

1. Reports made to the Ethics Line will be managed in a manner that preserves the confidentiality of 

the reporter and individuals involved in the investigation. 

2. Reports made to the Ethics Line will be investigated and closed within 30 days of receipt, under

most circumstances.

3. Reports made to the Ethics Line will be investigated by persons having a sufficient level of 

expertise or knowledge with regard to the issue(s) presented by the reporter.

4. Disciplinary or corrective action in response to substantiated allegations will be an integral part of 

the Ethics Line program. 

PROCEDURE: 

A. Scope of the Ethics Line 

The Ethics Line manages ethics or compliance related concerns that may be reported verbally or 

in writing through: 

1. The “Call Center,” a toll-free phone number (1-800-455-1996), which is managed by a third

party administrator;

2. The HCA Healthcare Corporate Ethics and Compliance department;

3. The HCA Healthcare Ethics Line online portal (https://hcahealthcareethicsline.ethix360.com/); 

4. The HCA Healthcare external website; and/or 

5. Other HCA Healthcare corporate departments.

B. Intake of Reports to the Ethics Line

1. Telephone calls to the Ethics Line will be received by the Call Center, when made to the tollfree number or a representative of the Ethics Line when made to Corporate Ethics and 

Compliance. For each call, the following information must be obtained from the reporter: 

a. Name or location of the Facility or business unit involved;

b. Date of the report;

c. Any relevant information concerning the allegations;

d. Name of reporter (unless the reporter has requested anonymity); and 

e. Contact phone number or email for the reporter.

7/2020 

Case 9:22-cv-81733-DMM Document 7-2 Entered on FLSD Docket 11/16/2022 Page 1 of 5
DEPARTMENT: Ethics and Compliance POLICY DESCRIPTION: Internal Handling of 

Reports to the Ethics Line 

PAGE: 2 of 5 REPLACES POLICY DATED: 1/21/98, 7/8/98, 

11/9/99, 1/1/06, 3/1/14 

EFFECTIVE DATE: October 1, 2020 REFERENCE NUMBER: EC.002 

APPROVED BY: Ethics and Compliance Policy Committee 

2. Written submissions to the HCA Healthcare Ethics Line online portal or the HCA Healthcare 

external website or other correspondence sent to the corporate office will be reviewed for 

sufficiency upon receipt. If contact information is made available, an Ethics Line representative 

will contact the reporter within two (2) business days of receipt to obtain additional information 

regarding the submission. 

3. Each case will be assigned a case number generated by the Ethics Line case management 

system and assigned to the appropriate Case Manager, if applicable. 

C. Anonymous or Confidential Reports to the Ethics Line 

1. If an anonymous report is made to the Call Center or through the HCA Healthcare online 

portal, the reporter will be provided a unique case number, generated by the Ethics Line case 

management system with instructions for obtaining information regarding the disposition of the 

case. For all other anonymous reports to the Ethics Line, to the extent contact information has 

been provided by the reporter, efforts will be made to obtain additional information to conduct 

an investigation, as needed. 

2. If the reporter’s identity is disclosed to the Ethics Line, but the reporter desires anonymity 

throughout the investigation, then efforts will be made to preserve the confidentiality of the 

reporter. Some cases will be difficult to investigate without disclosing the identity of the 

reporter. In such situations, the reporter will be asked whether their identity may be disclosed 

in connection with the investigation. If the reporter is unwilling to allow their identity to be 

disclosed in connection with the investigation, the difficulties of conducting an investigation 

without disclosing their identity should be explained to the reporter. However, in such 

circumstances, the wishes of the reporter must be respected. 

D. Ethics Line Case Management

1. All information received from the reporter will be documented and entered into the Ethics Line 

case management system.

2. After receipt of a report, the Ethics Line Coordinator will identify the management team for the 

Facility or business unit named in the report and prepare an Ethics Line case file, incorporating 

the appropriate data. If the report relates to a general request for information (e.g., policy 

interpretation), the request for information will be referred to the appropriate Facility or

business unit, if necessary, and an appropriate annotation reflecting this referral will be made 

in the case file, if applicable. 

3. The case file will be assigned to the appropriate Case Manager. Case Managers will be 

assigned by Facility and business units and responsible for all cases arising out of their 

respective facilities or business units. Under certain circumstances, an alternate Case 

Manager or Investigator may be assigned to a case (e.g., staffing prioritization, subject matter 

expertise). 

4. For cases with identified reporters, the Case Manager or designee, will contact the reporter 

within two (2) business days of receipt of the case. The reporter will be provided with the 

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Case 9:22-cv-81733-DMM Document 7-2 Entered on FLSD Docket 11/16/2022 Page 2 of 5
DEPARTMENT: Ethics and Compliance POLICY DESCRIPTION: Internal Handling of 

Reports to the Ethics Line 

PAGE: 3 of 5 REPLACES POLICY DATED: 1/21/98, 7/8/98, 

11/9/99, 1/1/06, 3/1/14 

EFFECTIVE DATE: October 1, 2020 REFERENCE NUMBER: EC.002 

APPROVED BY: Ethics and Compliance Policy Committee 

contact information for the Ethics Line representative whom the reporter may contact for future 

inquires. 

5. The Case Manager will review reports submitted to the Ethics Line and determine if additional 

information is necessary to develop an investigative plan. If additional information is required, 

the Case Manager will request additional information from the reporter. If the reporter is

anonymous, the Case Manager will evaluate the report to determine if the case can be 

investigated without obtaining additional information from the reporter. If an anonymous report 

was initiated via the Call Center, the Case Manager will inform the Call Center of nature and 

scope of the additional information required. If an anonymous report was initiated via the 

Ethics Line online portal, the Case Manager will post a response in the portal to solicit 

additional information from the reporter. Unless sufficient information is provided to conduct an 

investigation, the case may be closed without investigation, due to insufficient information.

6. The Case Manager will examine all of the information obtained in connection with the case and

determine what questions or concerns must be answered to resolve the case. In determining 

the questions that must be answered or concerns, which must be addressed, the Case 

Manager may consult with Responsible Executives or other internal or external resources, as 

appropriate. If there is any doubt as to the appropriate questions to be answered or if the case 

raises unusual or especially troubling issues, the Case Manager will consult with the Vice 

President Ethics and Compliance, responsible for administration and oversight of the Ethics 

Line.

E. Investigations 

1. The Case Manager will determine the appropriate personnel to investigate a particular matter 

(e.g., ECO, VPHR, VPQ) and provide the preliminary instructions for conducting the 

investigation, using the standard Instructions to Investigator form.

a. The Case Manager will consider the breadth of resources available to Corporate, Group, 

Divisions, Markets, facilities and business units. On occasion, a multi-disciplinary team of

investigators may be appropriate for an investigation. Prior to tasking more than one 

investigator to conduct an investigation, the Case Manager will consult with the Vice 

President Ethics and Compliance, responsible for the administration and oversight of the 

Ethics Line.

b. Certain concerns reported to the Ethics Line may be referred to another Corporate 

Department for investigation, including, but not limited to: (1) matters that appear to involve 

criminal liability to the corporation or substantial civil liability (substantial civil liability 

determinations will be made by the Vice President, Ethics and Compliance), will be

referred to the Vice President, Litigation Counsel; (2) matters involving quality of care 

concerns will be referred to Clinical Services Group; (3) matters involving medical coding 

should be referred to Vice President, Regulatory Compliance Support, and Vice President, 

Internal Audit; and (4) matters implicating The Sarbanes-Oxley Act or impacting company 

finances should be referred to Vice President, Internal Audit.

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Case 9:22-cv-81733-DMM Document 7-2 Entered on FLSD Docket 11/16/2022 Page 3 of 5
DEPARTMENT: Ethics and Compliance POLICY DESCRIPTION: Internal Handling of 

Reports to the Ethics Line 

PAGE: 4 of 5 REPLACES POLICY DATED: 1/21/98, 7/8/98, 

11/9/99, 1/1/06, 3/1/14 

EFFECTIVE DATE: October 1, 2020 REFERENCE NUMBER: EC.002 

APPROVED BY: Ethics and Compliance Policy Committee 

c. Cases may be referred to the Facility or business unit CEO or ECO, Division or Market 

officers, or Group officers or the Ethics Line Investigator for investigation, as appropriate. 

d. Other company resources at the Corporate, Group, Division, Market, Facility or business 

unit level may be utilized in an investigation, as appropriate. 

e. External investigators will only be used or assigned with the express approval of the Vice 

President with concurrence from the Senior Vice President and Chief Ethics and 

Compliance Officer. 

2. The Case Manager will determine the appropriate amount of time, which ordinarily will not 

exceed 21 days, to allow for the investigation. Shorter periods may be necessary to ensure,

management’s ability to consider the results of the investigation. If a shorter investigative 

period is necessary, the Case Manager will negotiate the appropriate amount of time to allow 

for the investigation. Once the amount of time to accomplish the investigation is established, 

the investigator must complete the investigation within the agreed upon time frame or obtain 

an extension from the Case Manager. 

3. The Case Manager will decide who should be notified of the existence of an investigation. 

Under ordinary circumstances, the Facility, business unit, Division, Market or Group 

management will be informed of the existence of the investigation. However, if it appears that 

a member of management at such level may be implicated in the investigation, the Vice 

President, Ethics and Compliance, will be consulted prior to notification to management. 

4. Upon receipt of an Ethics Line case, the investigator should develop a detailed investigative 

plan, interview appropriate personnel, and review documents and other evidence. The findings 

of the investigation should be documented in detail and forwarded to the Case Manager. The 

investigator’s report will include the plan for and status of disciplinary or corrective action, if 

applicable.

5. The Case Manager will determine if the initial allegation(s) and any subsequent allegations 

were sufficiently investigated. If there are deficiencies in the investigation, the Case Manager 

will immediately contact the investigator and apprise the investigator of the deficiencies. The

Case Manager will document in the case file all contacts made related to the investigation. 

6. If the investigation sufficiently resolves all of the allegations, the Case Manager will evaluate 

the reasonableness of the disposition (e.g., substantiated, unsubstantiated, etc.) and 

disciplinary or corrective action, if warranted.

7. If there is disagreement between leadership within Ethics and Compliance and other 

Corporate Departments, Group, Division, Market, Facility or business unit concerning 

appropriateness of disciplinary or corrective action, the parties will attempt to reach an agreed 

upon resolution. If the parties are unsuccessful in reaching agreement on the appropriate 

disciplinary or corrective action, the matter will be referred to the Company’s Chief Executive 

Officer. 

7/2020 

Case 9:22-cv-81733-DMM Document 7-2 Entered on FLSD Docket 11/16/2022 Page 4 of 5
DEPARTMENT: Ethics and Compliance POLICY DESCRIPTION: Internal Handling of 

Reports to the Ethics Line 

PAGE: 5 of 5 REPLACES POLICY DATED: 1/21/98, 7/8/98, 

11/9/99, 1/1/06, 3/1/14 

EFFECTIVE DATE: October 1, 2020 REFERENCE NUMBER: EC.002 

APPROVED BY: Ethics and Compliance Policy Committee 

8. For each investigation, the Case Manager will prepare a Close-Out Memorandum. The CloseOut Memorandum will summarize the allegations and facts of the case, investigative actions 

and findings, conclusions, and disciplinary or corrective action, as appropriate. The resolution 

of the case must be approved by the Senior Vice President and Chief Ethics and Compliance 

Officer or the Vice President, Ethics and Compliance, responsible for administration and 

oversight of the Ethics Line, or a designee, based upon criteria to be established from time to 

time by the Senior Vice President and Chief Ethics and Compliance Officer. Once approval is 

obtained, the case may be closed. The Close-Out Memorandum will be maintained in the case 

file and case management system.

9. The Case Manager will inform the reporter of the results of the investigation and the 

disposition of the case, if possible. 

10. The Case Manager will notify the investigator of the final disposition of the case. 

REFERENCES: N/A 

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Case 9:22-cv-81733-DMM Document 7-2 Entered on FLSD Docket 11/16/2022 Page 5 of 5