Document:

Plea Agreement

 EXHIBIT 10.18 
 CIVIL AND ADMINISTRATIVE SETTLEMENT AGREEMENT 
 I. PARTIES 
 This Civil and Administrative Settlement Agreement (Agreement) is entered into between the following (hereinafter “the Parties”) through their
authorized representatives: the United States of America, acting through the United States Department of Justice and on behalf of the Office of Inspector General (OIG-HHS) of the Department of Health and Human Services (HHS); the TRICARE Management
Activity (TMA) (formerly the Office of Civilian Health and Medical Program of the Uniformed Services (OCHAMPUS), through its General Counsel; the Office of Personnel Management (OPM), which administers the Federal Employees Health Benefits Program
(FEHBP), through the United States Attorney’s Office for the District of Columbia; (collectively the “United States”); and HCA - The Healthcare Company, formerly known as Columbia/HCA Healthcare Corporation, on behalf of its
predecessors and current and former affiliates, divisions and subsidiaries (collectively “HCA”). 
 II. PREAMBLE 
 As a preamble to this Agreement, the Parties agree to the following: 
 A. HCA is a Delaware corporation that through its predecessors and/or its subsidiaries and affiliates operates or has operated over 400 hospitals, over 500 home health agencies, 

 
and numerous ancillary health care facilities in at least thirty states. 
 B. Dennis J. Wyman, M.D., Robert K. Rothfeder, M.D., Health Outcomes Technologies, Donald S. McLendon, Tonya M. Atchison, Randal T. Boston, Sharon Christian, Martha Long, Kristen Kuhn, Pamela Cianci, Mary R. Hampton,
Sara Ortega, John W. Schilling, Madelyn Rappaport, J. Watson Maxwell, Francis M. Patton, and Francesco Lanni (the “relators”) filed qui tam actions in various United States District Courts that are now pending before the District Court for
the District of Columbia captioned as follows: 
 (1) U.S. ex rel. Wyman and Rothfeder v. HealthTrust, Columbia/HCA, et al.,
No. 99 - 3310 (D.D.C.)(formerly D.Utah); 
 (2) U.S. ex rel. Health Outcomes Technologies v. Columbia Medical
Center-East, et al., No. 99 - 3297 (D.D.C.)(formerly E.D.Pa.); 
 (3) U.S. ex rel. McLendon v. Columbia Healthcare Corp.,
et al., No. 99-3295 (D.D.C.)(formerly N.D.Ga.); 
 (4) U.S. ex rel. Cianci v. Columbia/HCA Healthcare Corp., et al.,
No. 99-2761-CIV-T-23E (formerly M.D. Fla.); 
 (5) U.S. ex rel. Atchison v. Columbia/HCA Healthcare, Inc.,
No. 99-2399 (D.D.C.)(formerly M.D. Tenn.); 
  
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 (6) U.S. ex rel. Atchison v. Columbia/HCA Healthcare, Inc., No. 99-3307
(D.D.C.)(formerly W.D.Tex.); 
 (7) U.S. ex rel. Boston v. Columbia/HCA Healthcare Corp., No. 99-3301 (D.D.C.)(formerly
N.D. Tex.); 
 (8) U.S. ex rel. Christian, Long and Kuhn v. Columbia/HCA Healthcare Corp., et al., No. 99-3303
(D.D.C.)(formerly S.D. Tex.); 
 (9) U.S. ex rel. Hampton v. Columbia/HCA Healthcare Corp., et al., No. 99-3294
(D.D.C.)(formerly M.D.Ga.); 
 (10) U.S. ex rel. Ortega v. Columbia/HCA Healthcare Corp., et al., No. 99-3305
(D.D.C.)(formerly W.D.Tex.); 
 (11) U.S. ex rel. Schilling v. Columbia/HCA Healthcare Corp., et al., Civ.
No. 96-1264-CIV-T-23B (formerly M.D.Fla.); 
 (12) U.S. ex rel. Rappaport v. Hospital Corporation of America et al., Civ.
No. 99-3228 (formerly N.D. Ala.); 
 (13) U.S. ex rel. Lanni v. Curative Health Services, Inc. et al., No. 00-2584
(D.D.C.)(formerly S.D.N.Y.). 
 C. HCA submitted or caused to be submitted claims for payment to the Medicare Program (Medicare), Title XVIII
of the Social Security Act, 42 U.S.C. ss.ss.1395-1395ggg, the Medicaid Program, 42 U.S.C. ss.ss.1396-1396v; the TRICARE Program 
  
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(hereinafter referred to as TRICARE), 10 U.S.C. ss.1071 - 1107, and the FEHBP, 5 U.S.C.ss.ss.8901 et seq. (collectively “the government health care
programs”). 
 D. The United States contends that it has certain civil claims under the False Claims Act, 31 U.S.C. ss.3729-33, and
other federal statutes and/or common law doctrines, as specified in Paragraph 2 below, against HCA, for engaging in the following conduct (hereinafter referred to as the “Covered Conduct”). 
  

	 	(1)	OUTPATIENT LABORATORY BILLING 

 From January 1, 1989
through December 31, 1997, HCA hospitals identified in Attachment 1 to this Agreement billed the government health care programs for outpatient laboratory tests designated by the CPT Codes in the 80000-89999 range, and by CPT Codes G0058, G0059
and G0060, without regard for whether they were medically necessary, had been properly ordered by physicians or were being billed appropriately. 
  

	 	(2)	DRG UPCODING 

 From January 1, 1990 through
December 31, 1997, HCA hospitals identified in Attachment 2 to this Agreement “upcoded” claims to the government health care programs for inpatient hospital admissions by assigning diagnosis codes that were not supported by physician
documentation in the patients’ medical records for the purpose of improperly increasing reimbursement on inpatient claims submitted for the following Diagnosis Related 
  
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Groups (DRGs): 076, 079, 087, 121, 124, 132, 138, 316, 416, and 475; and the complication and comorbidity DRGs (“cc” DRGs) identified in Attachment
3 to this Agreement. 
  

	 	(3)	HOME HEALTH COMMUNITY EDUCATION 

 For cost report years
1994 through 1997, HCA submitted claims to Medicare for reimbursement of costs, including administrative and general costs, that it had allocated to community education activities. In fact, some of these costs were attributable to nonreimbursable
advertising and marketing functions performed by home health community educators, including, but not limited to, patient care coordinators, home care coordinators, community liaisons and community liaison nurses. The conduct described in this
Paragraph does not include claims, if any, submitted to Medicaid, TRICARE or FEHBP. 
  

	 	(4)	HOME HEALTH BILLING ISSUES 

 Between January 1, 1995
and December 31, 1998, the HCA-owned home health agencies listed in Attachment 4 to this Agreement submitted claims to Medicare, Medicaid, and TRICARE (a) for visits to patients who did not qualify for home health services because
(i) the patients were not homebound, (ii) there was no medical need for such services, or (iii) there was no medical need for skilled services; (b) for visits that were not provided; (c) for visits to deliver services that
were in fact or should 
  
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have been provided by an assisted living facility; (d) for visits that lacked proper physician authorization because (i) the home health agency had
not received physician orders prior to billing for services, (ii) the home health agency had not properly obtained the physician signature, (iii) the home health agency provided the services after expiration of the written order from the
physician; and (e) for visits billed but not documented. The conduct described in this Paragraph does not include claims, if any, submitted to FEHBP. 
  

	 	(5)	HOME HEALTH MANAGEMENT FEES 

 For cost report years 1993
through 1998, HCA improperly included in Medicare cost reports the management fee costs related to the acquisition of the Olsten, ResCare, AbleCare, CareOne and Central (a/k/a Simeone Central) home health agencies in Florida, Georgia and Alabama.
The costs referred to in this Paragraph include all kickback, related party, undisclosed rebate and cost report claims relating to these acquisitions, but do not include duplicative services or non-allowable costs included in administrative and
general costs not otherwise covered in this release allocated to the acquired agencies. The conduct described in this Paragraph does not include claims, if any, submitted to Medicaid, TRICARE or FEHBP. 
 E. The United States also contends that it has certain administrative claims against HCA under the provisions 
  
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for permissive exclusion from the Medicare, Medicaid, and other Federal health care programs, 42 U.S.C. ss.1320a-7(b), the provisions for civil monetary
penalties, 42 U.S.C. ss.1320a-7a, permissive exclusion from TRICARE, 32 C.F.R. ss.199.9, and permissive exclusion from FEHBP, 5 U.S.C. ss.8902a and 5 C.F.R. Part 970, for the Covered Conduct. 
 F. The following States (“the States”) contend that they have certain civil claims against HCA for the conduct specified in Paragraphs D
(1)(outpatient laboratory), (2)(DRG upcoding) and (4)(home health billing) above: Alaska, Alabama, Arizona, Arkansas, California, Colorado, Florida, Georgia, Idaho, Illinois, Indiana, Kansas, Kentucky, Louisiana, Maine, Massachusetts, Mississippi,
Missouri, Nevada, New Hampshire, New Mexico, North Carolina, Ohio, Oklahoma, Oregon, South Carolina, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wyoming. HCA and the States will execute separate settlement agreements regarding these
claims in exchange for the payment specified in Paragraph 1(b) below. 
 G. The relators identified in Paragraph B above are among those who
claim entitlement under 31 U.S.C. ss.3730(d) to a share of the proceeds of this Agreement, but the relators and the United States have not agreed on the entitlement or amount of that award, if any. This Agreement does not cover the claims of

  
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any relator to payment of attorney’s fees under 31 U.S.C. ss.3730(d). 
 H. This Settlement Agreement does not constitute evidence or an admission by any party of any liability or wrongful conduct. 
 I. HCA has executed letters of credit in favor of the United States in the total amount of one billion dollars ($1,000,000,000) pursuant to a February 1999 Letter of Credit Agreement (LOC Agreement). The LOC Agreement
is incorporated herein by reference. 
 J. HCA and OIG-HHS have executed a separate Corporate Integrity Agreement (CIA), which is
incorporated herein by reference. 
 K. To avoid the delay, uncertainty, inconvenience, and expense of protracted litigation of the claims
set forth above, the Parties hereby reach a full and final settlement of the claims against HCA pursuant to the Terms and Conditions set forth below. 
 III. TERMS AND CONDITIONS 
 NOW, THEREFORE, in reliance upon the representations contained herein, in
consideration of the mutual promises, covenants, and obligations set forth below, and for good and valuable consideration as stated herein, the Parties agree as follows: 
  

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& HCA 

 1. HCA agrees to pay to the United States and the States $745,000,000.00, plus interest accruing at a
simple rate of 6.5% per annum from May 18, 2000 through and including the Payment Date (the Settlement Amount). The “Payment Date” shall be within five (5) days of approval of this Agreement by the United States District
Court for the District of Columbia. HCA agrees to pay the Settlement Amount as follows: 
 (a) HCA agrees to pay
$731,367,246.23 plus interest accruing at a simple rate of 6.5% per annum from May 18, 2000 through and including the Payment Date to the United States by electronic funds transfer pursuant to written instructions to be provided by Michael
F. Hertz, Director, Commercial Litigation Branch, Civil Division, United States Department of Justice. The $731,367,246.23 represents the total of the following settlement amounts: $90,016,350 (outpatient laboratories); $395,567,650 (DRG upcoding);
$50,000,000 (home health community education); $90,000,000 (home health management fees); $105,783,246.23 (home health billing). 
 (b) HCA also agrees to pay the States $13,632,753.77, plus interest accruing at a simple rate of 6.5% per annum from May 18, 2000 through and including the Payment Date in a separate escrow, as designated by the States, for
distribution to the individual States upon completion of the separate State settlement agreements. 
  
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 2. Subject to the exceptions in Paragraph 10 below, in consideration of the obligations of HCA set forth
in this Agreement, conditioned upon HCA’s payment in full of the Settlement Amount, the United States (on behalf of itself, its officers, agents, agencies, and departments) agrees to release HCA together with its current and former parent
corporations, each of its direct and indirect subsidiaries, brother or sister corporations, divisions, current or former owners and affiliates, and the successors and assigns of any of them from any civil or administrative monetary claim the United
States has or may have under the False Claims Act, 31 U.S.C. ss.ss.3729-3733; the Civil Monetary Penalties Law, 42 U.S.C. ss.1320a-7a; the Program Fraud Civil Remedies Act, 31 U.S.C. ss.ss.3801-3812; or the common law theories of payment by mistake,
unjust enrichment, breach of contract, and fraud, for the Covered Conduct. 
 3. On the Payment Date, conditioned upon receipt of the
Settlement Amount, the LOC Agreement is hereby amended as follows: 
 (a) The unconditional guarantee by the Company (as
defined in the LOC Agreement) of the Obligations (as defined in the LOC Agreement) in the form of the Letters of Credit (as defined in the LOC Agreement), and the aggregate amount which may be drawn under the Letters of Credit by the United States,
shall be two hundred fifty million dollars ($250,000,000) rather than one billion dollars ($1,000,000,000). 
  
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 (b) Upon receipt by the United States of any payment made in satisfaction of any of the
Obligations following the Payment Date, whether pursuant to an Actionable Order or Settlement Agreement (as such terms are defined in the LOC Agreement) and including any payment made through a drawing under any Letter of Credit, the unconditional
guarantee by the Company of the Obligations in the form of the Letters of Credit, and the aggregate amount which may be drawn under the Letters of Credit by the United States, shall immediately be reduced dollar-for-dollar by the amount of such
payment. Reductions pursuant to this clause (b) shall be cumulative and in addition to the reduction described in clause (a) above. For purposes of this clause (b), a payment shall be deemed made in satisfaction of an obligation only if
acknowledged in writing as such by the United States or if made through a drawing under a Letter of Credit. 
 (c) In
connection with any reduction of the Company’s guarantee of the Obligations described in clause (a) or (b) above, the Company may elect to replace the then outstanding Letter(s) of Credit with one or more new Letter(s) of Credit in an
amount at least equal to the reduced amount of the Company’s guarantee set forth in clause (a) or (b) (as applicable), so long as the new Letter(s) of Credit are issued by a Letter of Credit issuer acceptable under Paragraph 2 of the
LOC Agreement. The replaced Letter(s) of Credit shall be returned for cancellation 
  
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to the Company in exchange for the replacement Letter(s) of Credit. 
 HCA and the United States acknowledge that the foregoing agreement to replace the Company’s unconditional guaranty of the Obligations in the form of the Letters of Credit on the Payment Date with two hundred
fifty million dollars ($250,000,000) rather than one billion dollars ($1,000,000,000) is not based on the amount or expected amount of HCA’s remaining liability for conduct not addressed by this Agreement. 
 4. This Agreement is expressly conditioned upon resolution, through execution of plea agreement(s) or otherwise, of the Company’s corporate criminal
liability, with the Department of Justice (the Criminal Condition) as set forth in the Plea Agreement executed on December 14, 2000. As used in this Paragraph, the term “resolution” includes, where appropriate, acceptance by the
appropriate court(s) of any plea agreement(s) and imposition of any sentence(s) necessary to effectuate the Criminal Condition. 
 5. After
the execution of this Agreement, the United States and HCA will move the United States District Court for the District of Columbia for (1) dismissal with prejudice of the claims against HCA in the Civil Actions identified in Paragraph B (1) -
(4) above; and (2) dismissal with prejudice of those claims against HCA in the Civil Actions identified in Paragraph B (5) - (13) above that are co-extensive with the Covered Conduct. 
  
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 The motions to dismiss will be conditioned upon receipt by the United States of the Settlement Amount. The claims that
the United States and HCA agree are co-extensive with the Covered Conduct are identified in Attachment 5 to this Agreement, incorporated by reference herein. The parties agree that they reserve the right to seek to dismiss any claim of any relator
other than those identified on the grounds they are coextensive with the Covered Conduct or are otherwise barred. The United States also agrees to use reasonable good faith efforts to cause the dismissal or release of any claims filed by relators
(with prejudice to relators but without prejudice to the United States) in the Civil Actions identified in Paragraph B (5) - (13) above that: 1) relate to home health community education claims (as described in Paragraph D (3) above)
submitted to Medicaid, TRICARE or FEHBP; 2) relate to home health billing claims (as described in Paragraph D (4) above) submitted to FEHBP; and 3) relate to home health management fees claims (as described in Paragraph D (5) above)
submitted to Medicaid, TRICARE or FEHBP. 
 6. Should this Agreement be challenged by any relator as not fair, adequate or reasonable
pursuant to 31 U.S.C. ss.3730(c)(2)(B), the United States and HCA agree that they will take all reasonable and necessary steps to defend this Agreement. 
 7. In consideration of the obligations of HCA set forth in this Agreement and the CIA, conditioned upon HCA’s payment in full of the Settlement Amount, the OIG-HHS agrees to 
  
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release and refrain from instituting, directing or maintaining any administrative action seeking exclusion from the Medicare, Medicaid, or other Federal
health care programs (as defined in 42 U.S.C. ss.1320a-7b(f)) against HCA under 42 U.S.C. ss.1320a-7a (Civil Monetary Penalties Law), or 42 U.S.C. ss.1320a-7(b)(7) (permissive exclusion for fraud, kickbacks, and other prohibited activities), for the
Covered Conduct, except as reserved in Paragraph 10, below, and as reserved in this Paragraph. The OIG-HHS expressly reserves all rights to comply with any statutory obligations to exclude HCA together with its current and former parent
corporations, each of its direct and indirect subsidiaries, brother or sister corporations, divisions, current or former owners, affiliates, and the successors and assigns of any of them from the Medicare, Medicaid, or other Federal health care
program under 42 U.S.C. ss.1320a-7(a)(mandatory exclusion) based upon the Covered Conduct. 
 8. In consideration of the obligations of HCA
set forth in this Agreement, conditioned upon HCA’s payment in full of the Settlement Amount, TMA agrees to release and refrain from instituting, directing, or maintaining any administrative action seeking exclusion from the TRICARE/CHAMPUS
Program against HCA under 32 C.F.R. ss.199.9 for the Covered Conduct, except as reserved in Paragraph 10, below, and as reserved in this Paragraph. TMA expressly reserves authority to exclude HCA together with its current and former parent
corporations, each of 
  
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its direct and indirect subsidiaries, brother or sister corporations, divisions, current or former owners, affiliates, and the successors and assigns of any
of them, from the TRICARE/CHAMPUS program under 32 C.F.R. ss.ss.199.9 (f)(1)(i)(A), (f)(1)(i)(B), and (f)(1)(iii), based upon the Covered Conduct. 
 9. In consideration of the obligations of HCA set forth in this Agreement, conditioned upon HCA’s payment in full of the Settlement Amount, OPM agrees to release and refrain from instituting, directing, or maintaining any
administrative action seeking exclusion from the FEHBP program against HCA under 5 U.S.C. ss.8902a or 5 C.F.R. Part 970 for the Covered Conduct, except as reserved in Paragraph 10, below and except if excluded by the OIG-HHS pursuant to 42 U.S.C.
ss.1320a-7(a). 
 10. Notwithstanding any term of this Agreement, specifically reserved and excluded from the scope and terms of this
Agreement as to any entity or person (including HCA and Relators) are any and all of the following claims of the United States: 
 a. Any civil, criminal or administrative liability to the United States arising under Title 26, U.S. Code (Internal Revenue Code); 
 b. Any criminal liability; 
 c. Except as explicitly stated in this Agreement, any
administrative liability, including mandatory exclusion from Federal health care programs; 
  
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 d. Any liability to the United States (or its agencies) for any conduct other than the
Covered Conduct; 
 e. Any claims of the United States based upon such obligations as are created by this Agreement;

 f. Any claims by FEHBP for the Covered Conduct identified in Paragraph D(3) (home health community education),
(4) (home health billing), and (5) (home health management fees) above. 
 g. Any claims by TRICARE/CHAMPUS for the
Covered Conduct identified in Paragraph D(3) (home health community education) and (5) (home health management fees) above. 
 h. Any claims by the United States or the States relating to the Medicaid Program for the Covered Conduct identified in Paragraph D(3) (home health community education) and (5) (home health management fees) above. 
 i. Any express or implied warranty claims or other claims for defective or deficient products or services, including quality of goods and
services, provided by HCA; 
 j. Any claims for personal injury or property damage or for other similar consequential damages
arising from the Covered Conduct; 
 k. Any claims of the United States based on a failure to deliver items or services due
(with the exception of home health services that the United States alleges were not provided, as described in Paragraph D(4)); 
  
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 l. Any civil or administrative claims of the United States against individuals (including
current or former directors, officers, employees, agents, or shareholders of HCA). 
 11. HCA has entered into a Corporate Integrity
Agreement (CIA) with HHS, attached as Attachment 6, which is incorporated into this Agreement by reference. HCA will implement its obligations under the CIA immediately upon the execution of this Agreement. 
 12. HCA waives and will not assert any defenses HCA may have to any criminal prosecution or administrative action relating to the Covered Conduct, which
defenses may be based in whole or in part on a contention that, under the Double Jeopardy Clause in the Fifth Amendment of the Constitution, or under the Excessive Fines Clause in the Eighth Amendment of the Constitution, this Settlement bars a
remedy sought in such criminal prosecution or administrative action. HCA agrees that this settlement is not punitive in purpose or effect. Nothing in this Paragraph or any other provision of this Agreement constitutes an agreement by the United
States concerning the characterization of the Settlement Amount for purposes of the Internal Revenue Laws, Title 26 of the United States Code. 
 13. HCA fully and finally releases the United States, its agencies, employees, servants, and agents from any claims (including attorney’s fees, costs, and expenses of every kind and however denominated) which HCA has asserted, could
have asserted, 
  
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or may assert in the future against the United States, its agencies, employees, servants, and agents, related to the Covered Conduct and the United
States’ investigation and prosecution thereof. 
 14. The Settlement Amount will not be decreased as a result of the denial of claims
for payment now being withheld from payment by any Medicare carrier or intermediary or by FEHBP or TRICARE or any State payer, related to the Covered Conduct; and HCA agrees not to resubmit to any Medicare carrier or intermediary or to FEHBP or
TRICARE or any State payer any previously denied claims related to the Covered Conduct, and agrees not to appeal any such denials of claims. 
 15. HCA agrees to the following: 
 (a) Unallowable Costs Defined: HCA agrees that all costs (as defined in the
Federal Acquisition Regulations (FAR) 48 C.F.R. ss.31.205-47 and in Titles XVIII and XIX of the Social Security Act, 42 U.S.C. ss.ss.1395-1395ggg and 1396-1396v, and the regulations promulgated thereunder) incurred by or on behalf of HCA, its
present or former officers, directors, employees, shareholders, and agents in connection with: 
 (1) the matters covered by
this Agreement and any related plea agreement, 
  
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 (2) the Government’s audit(s) and civil and any criminal investigation(s) of the
matters covered by this Agreement, 
 (3) HCA’s investigation, defense, and corrective actions undertaken in response to
the Government’s audit(s) and civil and any criminal investigation(s) in connection with the matters covered by this Agreement (including attorney’s fees and the obligations undertaken pursuant to the CIA incorporated in this Agreement),

 (4) the negotiation and performance of this Agreement and any Plea Agreement, and 
 (5) the payment HCA makes to the United States pursuant to this Agreement and any payments that HCA may make to relators, are unallowable
costs on Government contracts and under the Medicare Program, Medicaid Program, TRICARE Program, and Federal Employees Health Benefits Program (FEHBP). 
 (All costs described or set forth in this Paragraph 15(a) are hereafter, “unallowable costs”). 
 (b)
Future Treatment of Unallowable Costs: These unallowable costs will be separately estimated and accounted for by HCA, and HCA will not charge such unallowable costs directly or indirectly to any contracts with the United States or any State Medicaid
Program, or seek payment for such unallowable 
  
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costs through any cost report, cost statement, information statement, or payment request submitted by HCA or any of its subsidiaries to the Medicare,
Medicaid, TRICARE, or FEHBP Programs. 
 (c) Treatment of Unallowable Costs Previously Sought: HCA further agrees that within
60 days of the effective date of this Agreement it will identify to applicable Medicare and TRICARE fiscal intermediaries, carriers, and/or contractors, and Medicaid, VA and FEHBP fiscal agents, any unallowable costs (as defined in this Paragraph)
included in payments previously sought from the United States, or any State Medicaid Program, including, but not limited to, payments sought in any cost reports, cost statements, information reports, or payment requests already submitted by HCA or
any of its subsidiaries, and will request, and agree, that such cost reports, cost statements, information reports, or payment requests, even if already settled, be adjusted to account for the effect of the inclusion of the unallowable costs. HCA
agrees that the United States will be entitled to recoup from HCA any overpayment as a result of the inclusion of such unallowable costs on previously-submitted cost reports, information reports, cost statements, or requests for payment. Any
payments due after the adjustments have been made shall be paid to the United States pursuant to the direction of the Department of Justice, and/or the affected agencies. The 
  
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United States reserves its rights to disagree with any calculations submitted by HCA or any of its subsidiaries on the effect of inclusion of unallowable
costs (as defined in this Paragraph) on HCA or any of its subsidiaries’ cost reports, cost statements, or information reports. Nothing in this Agreement shall constitute a waiver of the rights of the United States to examine or reexamine the
unallowable costs described in this Paragraph. 
 16. HCA agrees to cooperate fully and completely with the United States in any criminal,
civil and/or administrative investigations and proceedings of any present and former officers, directors, employees and agents, and of any parties with whom it had or has a business or professional relationship with respect to the Covered Conduct.
HCA will itself provide information through testimony and/or oral briefings by competent corporate representatives upon request of the United States. HCA will furnish to the United States, upon reasonable request, complete and un-redacted copies of
all non-privileged documents, reports, memoranda of interviews, and records in its possession, custody, or control concerning any investigation of the Covered Conduct which it has undertaken, or which has been performed by others on its behalf, and
agrees that it will not assert any claim of privilege with respect to information requested by the United States to establish the authenticity or evidentiary 
  
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foundation for the non-privileged information it has provided. HCA agrees not to impair, and, upon reasonable notice, will encourage, the cooperation of its
directors, officers, employees and agents in any investigation of the Covered Conduct. HCA also agrees to use its best efforts to make available, and encourage the cooperation of, former directors, officers and employees for interviews and
testimony, consistent with the rights and privileges of such individuals in any investigation of the Covered Conduct. The obligations referred to in this Paragraph shall in no way limit HCA’s obligations under any other agreement with the
United States or the States, including, but not limited to, the Plea Agreement that HCA is entering with the United States. 
 17. This
Agreement is intended to be for the benefit of the Parties and the States only, and by this instrument the Parties and the States do not release any claims against any other person or entity, except to the extent specifically provided for in this
Agreement. 
 18. HCA agrees that it will not seek payment for any of the health care billings covered by this Agreement from any health care
beneficiaries or their parents or sponsors. HCA waives any causes of action against these beneficiaries or their sponsors or responsible parties based upon the claims for payment covered by this Agreement. 
  
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 19. Except as may be expressly provided to the contrary in this Agreement, each party to this Agreement
will bear its own legal and other costs incurred in connection with this matter, including the preparation and performance of this Agreement. 
 20. This Agreement is governed by the laws of the United States. The Parties agree that the exclusive jurisdiction and venue for any dispute arising between and among the Parties under this Agreement will be the United States District Court
for the District of Columbia, except that disputes arising under the Corporate Integrity Agreement shall be resolved exclusively under the dispute resolution provisions in the Corporate Integrity Agreement and disputes arising under the separate
agreements with the States shall be governed by the relevant provisions of those agreements. 
 21. This Agreement may not be amended except
by written consent of the Parties, except that only HCA and OIG-HHS must agree in writing to modification of the Corporate Integrity Agreement. 
 22. The undersigned individuals signing this Agreement on behalf of HCA represent and warrant that they are authorized by HCA to execute this Agreement. The undersigned United States signatories represent that they are signing this
Agreement in 
 their official capacities and that they are authorized to execute this Agreement. 
 23. This Agreement may be executed in counterparts, each of which constitutes an original and all of which constitute one and the same agreement.

 24. This Agreement is binding on HCA’s successors, transferees, heirs, and assigns. 
 25. This Agreement is effective on the date of signature of the last signatory to the Agreement. Facsimiles of signatures shall constitute acceptable,
binding signatures for purposes of this Settlement Agreement. 
  
 CIVIL AND
ADMINISTRATIVE SETTLEMENT AGREEMENT 
 BETWEEN U.S. & HCA 

 THE UNITED STATES OF AMERICA 
  

									
				
	DATED: December 14, 2000	 		 	BY:	 	/s/ Joyce R. Branda
		 		 		 		 	JOYCE R. BRANDA
		 		 		 		 	DEPUTY DIRECTOR
		 		 		 		 	COMMERCIAL LITIGATION BRANCH
		 		 		 		 	CIVIL DIVISION
		 		 		 		 	U.S. DEPARTMENT OF JUSTICE

  
 CIVIL AND ADMINISTRATIVE SETTLEMENT
AGREEMENT 
 BETWEEN U.S. & HCA 

									
				
	DATED: 12/13/00	 		 	BY:	 	/s/ LEWIS MORRIS
		 		 		 		 	LEWIS MORRIS
		 		 		 		 	ASSISTANT INSPECTOR GENERAL
		 		 		 		 	OFFICE OF COUNSEL TO THE
		 		 		 		 	INSPECTOR GENERAL
		 		 		 		 	OFFICE OF INSPECTOR GENERAL
		 		 		 		 	UNITED STATES DEPARTMENT OF
		 		 		 		 	HEALTH AND HUMAN SERVICES

  
 CIVIL AND ADMINISTRATIVE SETTLEMENT
AGREEMENT 
 BETWEEN U.S. & HCA 

									
				
	DATED: 12/12/00	 		 	BY:	 	/s/ ROBERT L. SHEPHERD
		 		 		 		 	ROBERT L. SHEPHERD
		 		 		 		 	DEPUTY GENERAL COUNSEL
		 		 		 		 	TRICARE MANAGEMENT ACTIVITY
		 		 		 		 	UNITED STATES DEPARTMENT
		 		 		 		 	OF DEFENSE

  
 CIVIL AND ADMINISTRATIVE SETTLEMENT
AGREEMENT 
 BETWEEN U.S. & HCA 

									
				
	DATED: 12-13-00	 		 	BY:	 	/s/ William E. Flynn III
		 		 		 		 	WILLIAM E. FLYNN III
		 		 		 		 	ASSOCIATE DIRECTOR FOR
		 		 		 		 	RETIREMENT AND INSURANCE SERVICE
		 		 		 		 	UNITED STATES OFFICE OF
		 		 		 		 	PERSONNEL MANAGEMENT

  
 CIVIL AND ADMINISTRATIVE SETTLEMENT
AGREEMENT 
 BETWEEN U.S. & HCA 

									
				
	DATED: 12-14-01	 		 	BY:	 	/s/ E. Jeremy Hutton
		 		 		 		 	E. JEREMY HUTTON
		 		 		 		 	ASSISTANT INSPECTOR GENERAL
		 		 		 		 	FOR LEGAL AFFAIRS
		 		 		 		 	UNITED STATES OFFICE OF
		 		 		 		 	PERSONNEL MANAGEMENT

  
 CIVIL AND ADMINISTRATIVE SETTLEMENT
AGREEMENT 
 BETWEEN U.S. & HCA 

 HCA - The Healthcare Company 
  

									
				
	DATED: 12/14/00	 		 	BY:	 	/s/ Robert A. Waterman
		 		 		 		 	ROBERT A. WATERMAN
		 		 		 		 	GENERAL COUNSEL
		 		 		 		 	HCA
				
	DATED: 12/14/00	 		 	BY:	 	/s/ Cathryn L. Sowers
		 		 		 		 	CATHRYN L. SOWERS
		 		 		 		 	VICE PRESIDENT
		 		 		 		 	LITIGATION
		 		 		 		 	HCA
				
	DATED: 12/14/00	 		 	BY:	 	/s/ Roger S. Goldman
		 		 		 		 	ROGER S. GOLDMAN
		 		 		 		 	LATHAM & WATKINS
		 		 		 		 	COUNSEL FOR HCA
				
	DATED: 12/14/00	 		 	BY:	 	/s/ Craig Holden
		 		 		 		 	S. CRAIG HOLDEN
		 		 		 		 	OBER, KALER, GRIMES & SHRIVER
		 		 		 		 	COUNSEL FOR HCA

  
 CIVIL AND ADMINISTRATIVE SETTLEMENT
AGREEMENT 
 BETWEEN U.S. & HCACorporate Integrity Agreement

 Exhibit 10.19 
 CORPORATE INTEGRITY AGREEMENT 
 BETWEEN THE 
 OFFICE OF INSPECTOR GENERAL 
 OF THE

 DEPARTMENT OF HEALTH AND HUMAN SERVICES 
 AND 
 HCA-THE HEALTHCARE COMPANY 
 I. PREAMBLE 
 HCA—The Healthcare Company (“HCA”) hereby enters into this Corporate Integrity Agreement
(“CIA”) with the Office of Inspector General (“OIG”) of the United States Department of Health and Human Services (“HHS”) to promote compliance by itself, its subsidiaries, and their employees, contractors, agents, and
physicians with the requirements of Medicare, Medicaid and all other Federal health care programs (as defined in 42 U.S.C. ss. 1320a-7b(f))(hereinafter collectively referred to as the “Federal health care programs.”) This CIA shall be
applicable only to those operations of HCA that are subject to United States law and regulations. HCA’s compliance with the terms and conditions in this CIA shall constitute an element of HCA’s present responsibility with regard to
participation in the Federal health care programs. Whenever the term “HCA” is used in this CIA, it includes all of HCA’s subsidiaries, as defined in this agreement. Contemporaneously with this CIA, HCA is entering into a Settlement

  

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Agreement with the United States, and this CIA is incorporated by reference into the Settlement Agreement. HCA currently operates an Ethics and Compliance
Program, which HCA agrees to operate in a manner consistent with the terms of this CIA. 
 II. TERM OF THE CIA AND DEFINITIONS 
 A. Term. The period of the compliance obligations assumed by HCA under this CIA shall be eight years from the effective date of this CIA (unless otherwise specified). The
effective date of this CIA shall be the date that the court(s) accept the plea(s) and impose a sentence in the criminal proceedings related to the plea agreement entered into between HCA and the United States on or about the date of the signing of
this CIA. Sections VII, VIII, IX, X and XI of this CIA shall remain in effect until OIG has completed its review of the final annual report and any additional materials submitted by HCA pursuant to OIG’s request. The compliance obligations of
the Corporate Integrity Agreement in place for Lanier Park Hospital in Gainesville, Georgia, shall not apply to the time period beginning on the effective date of this CIA (sections II.D, II.E, III, V, and VI of the Lanier Park CIA shall remain in
effect until OIG has completed its review of the most recent annual report and any additional materials submitted by HCA pursuant to OIG’s request), and upon the effective date of this CIA Lanier Park Hospital shall be subject to the provisions
of this CIA to the same extent as other HCA facilities. 
  

 2 

 B. Definitions. For the purposes of this CIA, the following terms have the following meanings. 
 1. Covered Person: (a) any officer, director, or employee of HCA or any of its subsidiaries; or (b) any agent or other individual who furnishes health care
items or services to any Federal health care program beneficiary at a facility owned or operated by HCA or any of its subsidiaries for which HCA or any of its subsidiaries claims reimbursement from any Federal health care program. Notwithstanding
the above, this term does not include part-time or per diem employees, agents or other individuals who are not reasonably expected to work more than 160 hours per year, except that any such individuals shall become “Covered Persons” at the
point when they work more than 160 hours during the calendar year. 
 2. Subsidiary: any corporation or other entity that provides items or services for
which payment may be made by any Federal health care program, or prepares or submits requests for such payment, and in which HCA (i) has at least a 50% ownership interest, or (ii) has at least a 5% ownership interest and either manages or
controls. 
 3. Covered Contractor: any agent or other individual (who is not a covered person) who prepares claims, cost reports, or other requests for
reimbursement from any Federal health care program on behalf of HCA or any of its subsidiaries on a regular basis (i.e., for more than 80 hours within the calendar year). 
  

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 III. CORPORATE INTEGRITY OBLIGATIONS 
 HCA shall ensure that its Ethics and Compliance Program includes the following elements during the term of this CIA. 
 A. Compliance Officers and
Committees. 
 1. Ethics, Compliance and Corporate Responsibility Committee of the Board of Directors. HCA currently has an Ethics, Compliance and Corporate
Responsibility Committee of the Board of Directors (“Board Committee”) comprised of five outside directors of HCA. The Board Committee is responsible for the review of matters related to the Ethics and Compliance Program, this CIA, and
compliance with requirements of Federal health care programs. The Board Committee shall meet at least quarterly. When new members of the Board Committee are appointed or the responsibilities or authorities of the Board Committee are substantially
changed, HCA shall notify the OIG, in writing, within 15 days of such a change. 
 2. Senior Vice President for Compliance. HCA currently has a Senior Vice
President for Ethics, Compliance, and Corporate Responsibility (“SVP- Compliance”). The SVP-Compliance is and shall be responsible for developing and implementing policies, procedures, and practices designed to ensure compliance with the
requirements set forth in this CIA and with the requirements of the Federal health care programs. The SVP-Compliance is and shall be a member of senior management of HCA, shall make 

  

 4 

 
regular (at least quarterly) reports regarding compliance matters directly to the CEO and/or to the Board of Directors (including the Board Committee) of
HCA, and shall be authorized to report to the Board of Directors (including the Board Committee) at any time. The SVP-Compliance shall be responsible for monitoring the day-to-day activities engaged in by HCA to further its compliance objectives as
well as for any reporting obligations created under this CIA. In the event a new SVP- Compliance is appointed or the responsibilities or authorities of the SVP-Compliance are substantially changed, HCA shall notify the OIG, in writing, within 15
days of such a change. 
 3. Ethics, Compliance and Corporate Responsibility Department. HCA currently has an Ethics, Compliance and Corporate Responsibility
Department (“EC Department”). The EC Department is managed by the SVP-Compliance and is responsible for the operation of the Ethics and Compliance Program and for compliance with the requirements of this CIA and of the Federal health care
programs. In the event the responsibilities or authorities of the EC Department are substantially changed, HCA shall notify the OIG, in writing, within 15 days of such a change. 
 4. Local Ethics and Compliance Officers. HCA currently has a Local Ethics and Compliance Officer (“ECO”) at each of its facilities (for the purpose of this CIA, a “facility” is any hospital,
ambulatory surgery center, clinic or group of clinics, or other location where health care items or services are provided by HCA or one of its 

  

 5 

 
subsidiaries). Each ECO shall have sufficient management responsibility so as permit the effective performance of his or her duties. Each ECO is responsible
for implementation and oversight of the Ethics and Compliance Program at the facility and for the facility’s compliance with the requirements of this CIA and of the Federal health care programs. HCA shall make proper execution of ECO duties a
major component of the performance evaluations of ECOs. HCA shall continually assess the effectiveness of ECOs and the methods and findings of any such assessments shall be made available to the OIG upon request. HCA shall not implement any
substantial change in the responsibilities or authorities of the ECOs relating to HCA’s Ethics and Compliance Program without prior written approval from the OIG. 
 5. Corporate Ethics and Compliance Committees. HCA currently has a Corporate Ethics and Compliance Steering Committee (“Compliance Steering Committee”). The Compliance Steering Committee is chaired by the
SVP-Compliance and includes the Corporate CEO, COO, the two group presidents, and certain senior vice presidents. The Compliance Steering Committee oversees the effectiveness of the Ethics and Compliance Program and makes decisions on investments in
the Program. The Compliance Steering Committee shall be responsible for overseeing the implementation of the requirements of this CIA. HCA also currently has a Corporate Ethics and Compliance Policy Committee (“Compliance Policy
Committee”). The Compliance 

  

 6 

 
Policy Committee is chaired by the SVP-Compliance and includes the group CFOs, three hospital presidents, a number of senior vice presidents, e.g., Internal
Audit, General Counsel, Quality, Information Systems, Human Resources, Government Programs, and executives representing major compliance areas, such as coding, billing, physician relationships, and cost reports. The Compliance Policy Committee
reviews and approves all compliance-related policies. The two committees shall conduct at least 12 meetings per year in aggregate. The committees shall keep a record of their proceedings that shall be available to the OIG upon request. 

6. Hospital Compliance Committees. Each Hospital shall have a Hospital Ethics and Compliance Committee (“Hospital Committee”). The Hospital Committee shall
be chaired by the ECO of the facility and include the heads of each of the facility’s major compliance-related departments. The Hospital Committee shall be responsible for assisting the ECO in implementing the Ethics and Compliance Program, and
ensuring compliance by the facility with this CIA and the requirements of Federal health care programs. The Hospital Committee shall also be responsible for reporting on compliance issues to the ECO. 
 7. Responsible Executives. HCA has designated certain individuals (“Responsible Executives”) to be responsible for development and implementation of a portion
of the Ethics and Compliance Program related to a specific compliance risk area. 
  

 7 

 For example, the Vice President, Health Information Management Services, is the Responsible Executive for coding
compliance. The Responsible Executives work with the SVP-Compliance, EC Department, Compliance Policy Committee, and others to develop, oversee, monitor, and implement compliance policies within their designated areas of responsibility. HCA shall
not discontinue or materially alter its current Responsible Executive structure without written approval from the OIG. 
 B. Written Standards. 

1. Code of Conduct. HCA currently has a Code of Conduct. HCA has implemented a program to distribute the Code of Conduct to covered persons. HCA shall make the
promotion of, and adherence to, the Code of Conduct an element in evaluating the performance of managers, supervisors, and all other employees. HCA has implemented a program to obtain an acknowledgment from each covered person that he or she has
received HCA’s Code of Conduct and understands that it represents the mandatory policies of the organization. Within 90 days of the effective date of this CIA, HCA shall obtain a certification from each of its facilities and corporate
departments that, based on information and belief, this distribution and acknowledgment process is complete. New covered persons shall receive the Code of Conduct and shall complete the required acknowledgment within 30 days after becoming a covered
person. HCA shall annually review the Code of Conduct and shall make any necessary revisions. These 

  

 8 

 
revisions shall be distributed as expeditiously as possible after initiating such a change and no later than 30 days after the effective date of the revised
Code of Conduct. HCA shall implement a program to obtain an acknowledgment from each covered person that he or she has received the revised Code of Conduct, understands that it represents the mandatory policies of the organization, and agrees to
abide by it. Within 90 days of the effective date of the revised Code of Conduct, HCA shall obtain a certification from each of its facilities and corporate departments that, based on information and belief, this distribution and acknowledgment
process is complete. HCA shall obtain the acknowledgments and certifications described in the preceding two sentences every time that a revised Code of Conduct is distributed (but in any event no less frequently than every three years). 

2. Covered Contractor Requirements. HCA shall require a Covered Contractor to: (a) agree to abide by HCA’s Code of Conduct or adopt its own Code of Conduct
substantially similar to HCA’s Code of Conduct; (b) distribute either (i) HCA’s Code of Conduct or (ii) its Code of Conduct and information about HCA’s Confidential Disclosure Program (including the Ethics Line number) to
employees working on HCA matters; and, (c) certify to HCA that employees working on HCA matters have received a copy of (i) HCA’s Code of Conduct or (ii) its Code of Conduct and information about HCA’s Confidential
Disclosure Program (including the Ethics Line number). Where the Covered Contractor is a solo practitioner, the Covered Contractor must be provided with HCA’s Code of Conduct and certify that he or she will abide by it. 
  

 9 

 3. Policies and Procedures. HCA is developing written compliance Policies and Procedures. Prior to the effective date of
this CIA, HCA has implemented many such Policies and Procedures and provided them to the OIG. HCA shall assess and update as necessary the Policies and Procedures at least annually and more frequently, as appropriate. HCA shall provide a summary of
changes to its Policies and Procedures in its Annual Reports under this CIA and the current Policies and Procedures shall continue to be available to OIG upon request. HCA represents that it has distributed its Policies and Procedures to its
facilities. Compliance staff at both the facilities and the corporate headquarters, including the Responsible Executives, shall be available to explain any and all Policies and Procedures. 
 C. Training and Education. HCA shall meet the following training requirements. The training requirements are cumulative (not exclusive) so that one person may be
required to attend training in several substantive areas in addition to the general training. All training requirements set forth below in paragraphs 1 to 5 shall be implemented as specified below. With respect to the initial training required to be
provided within a certain time period after the effective date of this CIA, HCA need not provide such training to persons who have received training in the six-month period prior to the effective date of this CIA, if the training provided meets all
the subject matter and duration requirements that would apply to the initial training under the CIA. 
  

 10 

 1. General Training. HCA shall provide at least two hours of training initially (within 90 days of the effective date of
this CIA) to each covered person, and one hour of refresher training annually thereafter. The training shall cover HCA’s Ethics and Compliance Program, its Code of Conduct, and the requirements of this CIA. The training conducted by HCA when it
issued its Code of Conduct, One Clear Voice, and its ethics and compliance refresher training, Commitments We Share, and/or its revised Code of Conduct, A Tradition of Caring, (all of which explained HCA’s Ethics and Compliance Program and its
Code of Conduct) regardless of the date the training occurred will satisfy this requirement for training within 90 days notwithstanding the fact that such training did not cover the CIA. Covered persons who have received prior training described in
the previous sentence must receive at least one hour of refresher training (including discussion of the CIA) during the first year covered by the CIA and annually thereafter. Within 90 days after the effective date of this CIA, HCA shall notify all
covered persons of the execution of the CIA and provide a summary of the key provisions of this CIA through electronic mail, its internet and/or intranet sites, newsletters, and other appropriate means. All general training conducted after the
effective date of this CIA shall include training on the CIA. 
  

 11 

 2. Coding Training. HCA shall continue to have in place an introductory training course for each hospital inpatient
coder, as well as an intermediate coding course. HCA shall provide at least eight hours of coding training to inpatient hospital coders and supervisors within 180 days of the effective date of this CIA. HCA shall maintain its DRG coding course for
hospital inpatient coders accessible through its intranet. HCA shall maintain and enforce its current policy requiring 30 hours of continuing education annually for hospital inpatient coders. 
 3. Billing Training. HCA shall provide training to all individuals (including Laboratory and Business Office Directors and other billing personnel) responsible for
Federal health care program billing in their facilities. HCA shall provide at least eight hours of such training within 180 days of the effective date of this CIA and during each subsequent year. The training shall include the following subject
matters: 
 a. the submission of accurate bills for services rendered to Federal health care program beneficiaries; 
 b. policies, procedures and other requirements applicable to the documentation of medical records; 
 c. the personal obligation of each individual involved in the billing process to ensure that such billings are accurate; 
  

 12 

 d. applicable reimbursement statutes, regulations, and program requirements and directives; 
 e. the legal sanctions for improper billings; and 
 f. examples of proper
and improper billing practices. 
 4. Cost Report Training. HCA shall ensure that covered persons who prepare cost reports receive at least eight hours of
training on preparation of cost reports for Federal health care programs within 180 days of the effective date of this CIA. HCA shall maintain and enforce its current practice requiring 40 hours of continuing education annually to include Federal
and/or state statutes, regulations, and guidelines, compliance, and Corporate policies for covered persons who prepare cost reports. 
 5. Physician
Relations Training. Within 90 days of the effective date of this CIA and annually thereafter, HCA shall provide at least one hour of training to its Hospital CEOs, CFOs, and all other personnel substantially involved in negotiating or monitoring
physician relationships on the statutes and regulations related to hospital/physician relationships (including but not limited to 42 U.S.C. ss.ss. 1320a-7b(b) and 1395nn). HCA shall annually distribute its physician relationship policy checklist to
such personnel. 
 6. Overall Compliance Training. HCA shall continue its process of establishing individual training profiles for its employees. HCA shall
pursue the implementation of these training profiles in order to ensure that all covered persons are familiar with areas of compliance risk relevant to their positions. 
  

 13 

 7. New Persons. Affected new covered persons shall receive the General Training described in section III.C.1 above by the
end of the first 30 days after the person begins work. The orientation training (which is defined as all other training required, under section III.C, to be accomplished within 180 days or less after the effective date of this CIA) required by this
CIA shall also be promptly provided to appropriate new covered persons (but in no event later than 90 days after the person begins work on the matter for which they must be trained) so that the persons are fully qualified by virtue of such training
to perform whatever responsibilities may be assigned to them. In any situation where training requirements have not been completed, a fully trained HCA employee shall carefully monitor the work of the untrained person. 
 8. Covered Contractor Requirements. HCA must document completion of the applicable coding, billing, cost report, or physician relationships training to employees of
Covered Contractors working on HCA matters if: (i) the Covered Contractor is a solo-practitioner; (ii) the Covered Contractor was not retained because of its professional expertise in the area for which training is necessary; or
(iii) the Covered Contractor has not complied with the requirements of section III.B.2. HCA is responsible for ensuring the expertise and compliance of Covered Contractors. 
  

 14 

 9. Certifications and Retention. HCA shall maintain sufficient records to demonstrate that the required training has
occurred. These records shall include certifications from covered persons that they have attended the required training. The certifications may be acquired through: attendance/sign-in sheets for in-person group training sessions; computer
attestations for computer-based training; or similar mechanisms for other forms of training. Facility ECOs and/or Responsible Executives shall retain training records and certifications in a manner that permits reporting to the SVP-Compliance to
enable the SVP-Compliance to report on the training, and provide the specific course materials and certifications, to the OIG upon request. 
 D. Review
Procedures. 
 1. Retention of Independent Review Organization. HCA shall retain an entity (or entities), such as an accounting, auditing or consulting firm
(hereinafter “Independent Review Organization” or “IRO”), to perform review procedures to assist HCA in assessing the adequacy of its Policies and Procedures, Ethics and Compliance Program, its compliance with this CIA, and its
compliance with the requirements of Federal health care programs. The reviews shall be performed annually during the term of the CIA in accordance with the attached workplans. These reviews shall cover the calendar years 2001 through 2008, unless
otherwise specified in a workplan. The Independent Review Organization used for each review must have expertise in the 

  

 15 

 
matters to be reviewed and particularly with the requirements of the Federal health care programs relevant to that area of review. The Independent Review
Organization must be retained to conduct the reviews for the first year within 90 days of the effective date of this CIA. An IRO may engage qualified sub-IROs (including, as appropriate, law firms), as necessary and HCA shall have the right to
designate a different IRO for any particular area of compliance concern if it believes that such different IRO would be better qualified to undertake a particular focused review. HCA shall have the right to designate a new IRO at any time it
chooses. If HCA designates a new IRO, it shall provide written notice to the OIG within 15 days of designating the new IRO. This written notice will include the following: (a) the name, address, and primary contact person at the new IRO;
(b) a brief description of the qualifications of the new IRO; and (c) a brief description of the reasons that a new IRO was designated. 
 2. Types of
Reviews. The IRO(s) and HCA appropriate internal resources or directed external resources shall annually perform the reviews described in the audit work plans (“workplans”) attached to, and incorporated by reference into, this CIA. The
workplans address the following areas: (1) Diagnosis Related Groups (DRGs); (2) Laboratory Billing; (3) Outpatient Prospective Payment; and (4) Physician Relationships. The workplans require reviews of systems and processes in
place at HCA and its facilities, and of claims submitted by HCA and paid by Federal health care programs (the 

  

 16 

 
physician relationship workplan includes review of physician relationships rather than claims). The reviews of claims more specifically described in the
workplans fall into two general categories: (1) probe samples of a set number of claims (with no pre-determined statistical confidence or precision parameters); and (2) full samples of claims from which an overpayment amount can be
projected to the total population of claims in question within pre-determined statistical confidence and precision parameters. HCA and the IRO will evaluate the IRO work plans annually based upon prior year results. If appropriate, HCA will submit
revised IRO work plan(s) to the OIG for its review and action. 
 3. Statistical Sampling and Appraisal Methodologies for Reviews. All matters related to
this CIA and the workplans that involve statistical sampling or appraisal, or the review of claims, including probe samples and full samples, shall be conducted in accordance with the provisions of Appendix A to this CIA. 
 4. Ethics and Compliance Program Review. The IRO shall conduct a compliance review providing findings regarding whether HCA’s Ethics & Compliance Program,
Policies and Procedures, and operations comply with the terms of this CIA. This review shall include section by section findings regarding the requirements of this CIA. In addition, the IRO shall provide findings regarding whether HCA has complied
with its obligation under the Settlement Agreement: (a) not to resubmit to any Federal health care program payors any previously denied claims related to the conduct addressed 

  

 17 

 
in the Settlement Agreement, and its obligation not to appeal any such denials of claims; and (b) not to charge to, or otherwise seek payment from,
federal or state payors for unallowable costs (as defined in the Settlement Agreement) and its obligation to identify and adjust any past charges of unallowable costs. 
 5. Review Reports. HCA and the IRO(s) shall annually produce reports corresponding to all of the required reviews and including all of the information required by this section of the CIA, workplans, and the Claims
Review Reports described in Appendix A. A complete copy of all of the reports for the reporting year shall be included in each of HCA’s Annual Reports to OIG. 
 6. Verification/Validation. In the event that the OIG has reason to believe that any of HCA’s reviews fail to conform to its obligations under the CIA or indicates improper billings not otherwise adequately addressed in the audit
report, and thus determines that it is necessary to conduct an independent review to determine whether or the extent to which HCA is complying with its obligations under this CIA, HCA agrees to pay for the reasonable cost of any such review by the
OIG or any of its designated agents. Prior to proceeding with such an independent review, the OIG shall notify HCA of its intent to do so and its reasons for believing such a review is necessary, and shall attempt to resolve any issues without
proceeding with an independent review. This attempt to resolve issues may include permitting HCA to recommend further work it or the IRO may undertake to address the OIG’s concerns. However, it shall remain in the sole discretion of the OIG to
proceed with an independent review as described above. 
  

 18 

 E. Confidential Disclosure Program. HCA has established a Confidential Disclosure Program. HCA provides a toll free
“Ethics Line” to enable employees, contractors, agents or other individuals to disclose, to the EC Department or some other person who is not in the disclosing individual’s chain of command, any identified issues or questions
associated with HCA’s Policies and Procedures, practices, or operations with respect to any Federal health care program, believed by the individual to be inappropriate. HCA shall continue to publicize the existence of the Ethics Line to all
covered persons. HCA has established a Policy governing its handling of disclosures made through the Ethics Line. HCA shall continue to operate the Ethics Line through such Policy. HCA shall continue to forbid retribution or retaliation for
disclosures and allow for anonymous, confidential disclosures. The EC Department shall maintain a confidential disclosure log, which shall include a record and summary of each allegation received, the status of the respective investigations, and any
corrective action taken in response to the investigation. 
 F. Ineligible Persons. 
 1. Definition. For purposes of this CIA, an “Ineligible Person” shall be any individual or entity who: (i) is currently excluded, debarred, or otherwise ineligible to participate in the Federal health
care programs; or (ii) has been convicted of a criminal offense related to the provision of health care items or services but has not yet been excluded, debarred, or otherwise declared ineligible. 
  

 19 

 2. Screening Requirements. HCA shall not hire or engage as contractors, or grant staff privileges to, any Ineligible
Person. To prevent hiring or contracting with, or granting staff privileges to, any Ineligible Person, HCA shall screen all prospective employees and prospective contractors prior to engaging their services and screen physicians prior to granting
staff privileges by (i) requiring applicants to disclose whether they are Ineligible Persons, and (ii) reviewing the General Services Administration’s List of Parties Excluded from Federal Programs (available through the Internet at
http://epls.arnet.gov) and the HHS/OIG List of Excluded Individuals/Entities (available through the Internet at http://www.hhs.gov/oig) (these lists will hereinafter be referred to as the “Exclusion Lists”). 
 3. Review and Removal Requirement. HCA has reviewed its list of current employees and contractors paid through automated means against the Exclusion Lists. Within 180
days of the effective date of this CIA, HCA shall review its list of current physicians with staff privileges against the Exclusion Lists. HCA shall review the lists of employees, contractors, and physicians with staff privileges against the
Exclusion Lists at least semi-annually during the duration of this CIA. In addition, HCA shall require employees, contractors and physicians with staff privileges to disclose immediately any 

  

 20 

 
debarment, exclusion or other event that makes the person an Ineligible Person. If HCA has notice that an employee, agent, or physician has become an
Ineligible Person, HCA shall remove such person from responsibility for, or involvement with, HCA’s business operations related to the Federal health care programs and shall remove such person from any position for which the person’s
salary or the items or services rendered, ordered, or prescribed by the person are paid in whole or part, directly or indirectly, by Federal health care programs or otherwise with Federal funds at least until such time as the person is reinstated
into participation in the Federal health care programs. 
 4. Pending Charges and Proposed Exclusions. If HCA has notice that an employee or contractor is
charged with a criminal offense related to any Federal health care program, or is proposed for exclusion during his or her employment or contract, HCA shall take all appropriate actions to ensure that the responsibilities of that employee or
contractor have not and shall not adversely affect the quality of care rendered to any beneficiary, patient or resident, or the accuracy of any claims submitted to any Federal health care program. 
 G. Notification of Proceedings. Within 30 days of discovery by HCA, HCA shall notify OIG, in writing, of any ongoing investigation or legal proceeding conducted or
brought by a governmental entity or its agents involving an allegation that HCA has committed a crime or has engaged in fraudulent activities. This notification shall include 

  

 21 

 
a description of the allegation, the identity of the investigating or prosecuting agency, and the status of such investigation or legal proceeding. HCA shall
also provide written notice to OIG within 30 days of the resolution of the matter, and shall provide OIG with a description of the findings and/or results of the proceedings, if any. 
 H. Reporting. 
 1. Overpayments 
 a. Definition of Overpayments. For purposes of this CIA, an “overpayment” shall mean the amount of money HCA has received in excess of the amount due and payable under any Federal health care program requirements. HCA may not
subtract any underpayments for purposes of determining the amount of relevant “overpayments.” 
 b. Reporting of Overpayments. If, at any time, HCA
identifies or learns of any overpayments, HCA shall notify the payor (e.g., Medicare fiscal intermediary or carrier) and repay any identified overpayments within 30 days of identification and take remedial steps within 60 days of identification (or
such additional time as may be agreed to by the payor) to correct the problem, including preventing the underlying problem and the overpayments from 

  

 22 

 
recurring. Also, within 30 days of identification of the overpayment, HCA shall repay the overpayment to the appropriate payor to the extent such overpayment
has been quantified (submission of corrected bills in conformance with payor policy within 30 days fulfills this requirement). If not yet quantified, within 30 days of identification, HCA shall notify the payor of its efforts to quantify the
overpayment amount along with a schedule of when such work is expected to be completed. Notification and repayment to the contractor should be done in accordance with the contractor policies. For Medicare overpayments identified through HCA’s
Ethics and Compliance Program and/or the processes required under this CIA, (including internal and IRO audits, Ethics Line cases, or other corporate-level monitoring or review), the notice to the contractor must include the information contained on
the Overpayment Refund Form, attached to this as Appendix B to this CIA (unless the contractor has authorized the form not to be submitted for this particular type of claim correction). 
  

 23 

 2. Reportable Events. 
 a.
Definition of Reportable Event. For purposes of this CIA, a “Reportable Event” means anything that involves: 
 (i) a substantial overpayment; or

 (ii) a matter that a reasonable person would consider a potential violation of any criminal, civil, or administrative statute or regulation applicable to
any Federal health care program for which criminal penalties, civil monetary penalties, or exclusion may be authorized. 
 A Reportable Event may be the
result of an isolated event or a series of occurrences. 
 b. Reporting of Reportable Events. If HCA determines that there is a Reportable Event, HCA shall
notify OIG, in writing, within 30 days of making the determination that the Reportable Event exists. The report to the OIG shall include the following information: 
 (i) If the Reportable Event results in an overpayment, the report to the OIG shall be made at the same time as the notification to the payor required in section III.H.1, and shall include all of the information on the Overpayment Refund
Form, as well as: 
  

 24 

 (A) the payor’s name, address, and contact person to whom the overpayment was sent; and 
 (B) the date of the check and identification number (or electronic transaction number) on which the overpayment was repaid/refunded; 
 (ii) a complete description of the Reportable Event, including the relevant facts, persons involved, and legal and Federal health care program authorities implicated;

 (iii) a description of HCA’s actions taken to correct the Reportable Event; and 
 (iv) any further steps HCA plans to take to address the Reportable Event and prevent it from recurring. 
 I. Corrective
Actions Related to Investigation of Physician Relationships. In the context of the investigation, self-audit, and settlement discussions related to the issue of physician relationships, certain such relationships have been identified as anomalies.
HCA shall take appropriate measures to review these anomalous relationships. Those relationships that are determined by HCA to be non-compliant shall be terminated or amended to conform to HCA’s Ethics and Compliance Program and the
requirements of the Federal health care programs. HCA shall report on these measures as required in section V and all supporting documents shall be available to the OIG upon request. 
  

 25 

 IV. NEW AND DIVESTED LOCATIONS 
 In the event that HCA: (1) purchases or establishes a new hospital, freestanding ambulatory surgery center, home health agency, or another line of business that provides services that are billed to Federal health care programs; or
(2) sells or divests an existing hospital, freestanding ambulatory surgery center, or home health agency, HCA shall notify OIG of this fact within 30 days of the date of purchase, establishment, sale, or divestiture. This notification shall
include the location of the operation(s), telephone number, fax number, Federal health care program provider number(s) (if any), and the corresponding payor(s) (contractor specific). All covered persons at new locations shall be subject to the
requirements in this CIA that apply to new covered persons (e.g., completing certifications and undergoing training). If HCA sells all of the assets or its ownership interest related to a location, then that location shall no longer be considered
part of HCA for the purposes of this CIA. If the location is still owned or operated in whole or in part by HCA or any of its subsidiaries or their successors, then the location shall continue to be considered part of HCA for the purposes of this
CIA. If a hospital or ambulatory surgery center shall no longer be subject to the CIA due to a sale or transfer from HCA, HCA shall require as a condition of the sale that buyer or transferee 

  

 26 

 
represents and agrees that it has or shall implement and maintain with respect to its operations of the facility an effective program to prevent and detect
violations of the legal requirements applicable to the delivery of goods and services in connection with any health care benefits and that such a program will comply with the provisions of the U.S. Sentencing Guidelines relating to corporate
compliance programs and will be mindful of any applicable guidance issued by the OIG or other components of HHS; and that the buyer or transferee agrees that it will maintain such program for no less than five years from the date of sale or
transfer. 
 V. IMPLEMENTATION AND ANNUAL REPORTS 
 A.
Implementation Report. Within 120 days after the effective date of this CIA, HCA shall submit a written report to OIG summarizing the status of its implementation of the requirements of this CIA. This Implementation Report shall include: 

1. the name, title, address, facility name (if applicable), and telephone number of all of the individuals who are in positions, or on committees, described in section
III.A (except that with respect to section III.A.6 only, the SVP-Compliance shall certify that the Hospital Committees are in place as required and the information otherwise required by this section shall be available to the OIG upon request);

  

 27 

 2. the copy of all Policies and Procedures required by section III.B.2 that have not been previously provided to the OIG;

 3. a description of the training required by section III.C, including a description of the targeted audiences and a schedule of when the training sessions
were held; 
 4. a certification by the SVP-Compliance that: 
 a.
the Policies and Procedures required by section III.B have been developed and implemented, and have been distributed to all pertinent covered persons; 
 b.
all covered persons have completed the Code of Conduct certification required by section III.B.1; and 
 c. all covered persons have completed the training
and executed the certification required by section III.C. 
 5. the identity of the Independent Review Organization(s) and the proposed start and completion
date of the first set of reviews by the Independent Review Organization(s) and appropriate HCA internal resources or directed external resources; 
 6. a
summary of personnel actions taken pursuant to section III.F (other than hiring or granting of staff privileges); 
  

 28 

 7. a summary of the actions taken to ensure that the anomalous physician relationships identified in the investigation,
self-audit, and settlement discussions have been reviewed, and terminated or amended, as appropriate, in conformance with section III.I.; 
 8. a list of all
of HCA’s locations (including physical locations and mailing addresses), the corresponding name under which each location is doing business, the corresponding phone numbers and fax numbers, each location’s Medicare provider identification
number(s), and the contractor’s name and address; and 
 9. To the extent not already furnished to OIG, or if modified, a description of HCA’s
corporate structure, including identification of any parent, sister, and other related companies, subsidiaries and their respective lines of business. 
 B.
Annual Reports. HCA shall submit to OIG Annual Reports with respect to the status and findings of HCA’s compliance activities. The first Annual Report shall cover the time period from the effective date of this CIA through December 31,
2001 and shall be received by the OIG no later than April 30, 2002. Subsequent Annual Reports shall cover each of the calendar years 2002 through 2008 and shall be received by the OIG no later than April 30 of the year following the year
covered in the report. Each Annual Report shall include: 
  

 29 

 1. any change in the identity, title, address, facility name (if applicable), telephone number, and position description
of all of the individuals who are in positions, or on committees, described in section III.A (except that with respect to section III.A.6 only, the SVP-Compliance shall certify that the Hospital Committees are in place as required and the
information otherwise required by this section shall be available to the OIG upon request); 
 2. a certification by the SVP-Compliance that: 
 a. all covered persons have completed the annual Code of Conduct certification required by section III.B.1; 
 b. all covered persons have completed the training and executed the certification required by section III.C; and 
 c. HCA
has complied with the following specified obligations under the Settlement Agreement: (i) not to resubmit to any Federal health care program payors any previously denied claims related to the conduct addressed in the Settlement Agreement, and
its obligation not to appeal any such denials of claims; and (ii) not to charge to or otherwise seek payment from federal or state payors for unallowable costs (as defined in the Settlement Agreement) and its obligation to identify and adjust
any past charges of unallowable costs. 
  

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 3. notification of any changes or amendments to the Policies and Procedures referenced in section III.B and the reasons
for such changes (e.g., change in contractor policy); 
 4. a complete copy of the reports prepared pursuant to the reviews required in section III.D,
including a copy of the methodologies used, along with a copy of the IRO’s engagement letter; 
 5. HCA’s response/corrective action plan to any
issues raised in the reviews conducted under section III.D; 
 6. a summary of Reportable Events required to be identified and reported by section III.H and
an update on corrective actions taken in response to such Reportable Events; 
 7. a report of the aggregate overpayments identified through HCA’s
Ethics and Compliance Program and/or the processes required under this CIA, (including internal and IRO audits, Ethics Line cases, or other corporate-level monitoring or review) that have been returned to the Federal health care programs.
Overpayment amounts shall be broken down into the following categories: inpatient Medicare; outpatient Medicare; Medicaid (report each applicable state separately); and other Federal health care programs; 
  

 31 

 8. a copy of the confidential disclosure log required by section III.E and a description of any changes to the
Confidential Disclosure Program or Ethics Line referenced in that section; 
 9. a description of any personnel actions (other than hiring or granting staff
privileges) taken by HCA as a result of the obligations in section III.F; and, with respect to any person that falls within the ambit of section III.F.4, the name, title, and responsibilities of the person, and the actions taken by HCA in response
to the obligations set forth in that section; 
 10. a summary describing any ongoing investigation or legal proceeding conducted or brought by a
governmental entity involving an allegation that HCA has committed a crime or has engaged in fraudulent activities, which is required to be reported by section III.G. The statement shall include a description of the allegation, the identity of the
investigating or prosecuting agency, and the status of such investigation, legal proceeding or requests for information; 
 11. to the extent that such
relationships still exist and have not been appropriately altered and reported in an earlier report to the OIG, a 

  

 32 

 
summary of the actions taken to ensure that the anomalous physician relationships identified in the investigation, self-audit, and settlement discussions
have been reviewed, and terminated or amended, as appropriate, in conformance with section III.I; and 
 12. a description of all changes to the most
recently provided list (as updated) of HCA’s locations (including physical locations and mailing addresses) as required by section V.A.7, the corresponding name under which each location is doing business, the corresponding phone numbers and
fax numbers, each location’s Federal health care program provider identification number(s), and the contractor name and address that issued each provider identification number. 
 C. Certifications. The Implementation Report and Annual Reports shall include a certification by the SVP-Compliance that: (1) except as otherwise explicitly described in the applicable report, HCA is in
compliance with all of the requirements of this CIA, to the best of his or her knowledge; and (2) the SVP-Compliance has reviewed the report and has made reasonable inquiry regarding its content and believes that the information is accurate and
truthful. 
  

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 VI. NOTIFICATIONS AND SUBMISSION OF REPORTS 
 Unless otherwise stated in writing subsequent to the effective date of this CIA, all notifications and reports required under this CIA shall be submitted to the entities listed below: 
 OIG: 
 Civil Recoveries Branch - Compliance Unit Office of Counsel to
the Inspector General Office of Inspector General U.S. Department of Health and Human Services Cohen Building, Room 5527 330 Independence Avenue, SW Washington, DC 20201 Phone 202.619.2078 Fax 202.205.0604 
 HCA: 
 Alan Yuspeh 
 Senior Vice President 
 Ethics, Compliance, and
Corporate Responsibility 
 HCA-The Healthcare Company 
 One Park Plaza 
 Nashville, TN 37203 
 Phone 615.344.1005 
 Fax 615.344.1045 
 Unless otherwise specified, all notifications and reports required by this CIA may be made by certified mail, overnight mail, hand delivery or other means, provided that
there is proof that such notification was received. For purposes of this requirement, internal facsimile confirmation sheets do not constitute proof of receipt. 
  

 34 

 VII. OIG INSPECTION, AUDIT AND REVIEW RIGHTS 
 In addition to any other rights OIG may have by statute, regulation, or contract, OIG or its duly authorized representative(s) may examine HCA’s books, records, and other documents and supporting materials and/or
conduct an on-site review for the purpose of verifying and evaluating: (a) HCA’s compliance with the terms of this CIA; and (b) HCA’s compliance with the requirements of the Federal health care programs in which it participates.
The documentation described above shall be made available by HCA to OIG or its duly authorized representative(s) at all reasonable times for inspection, audit or reproduction. Furthermore, for purposes of this provision, OIG or its duly authorized
representative(s) may interview any of HCA’s employees, contractors, or agents who consent to be interviewed at the individual’s place of business during normal business hours or at such other place and time as may be mutually agreed upon
between the individual and OIG. HCA agrees to assist OIG in contacting and arranging interviews with such individuals upon OIG’s request. HCA’s employees may elect to be interviewed with or without a representative of HCA present.

 VIII. DOCUMENT AND RECORD RETENTION 
 In addition to any other
requirements for record retention, HCA shall maintain for inspection all documents and records: (1) related to reimbursement from the Federal health care programs for at least five years after the submission of the request for 

  

 35 

 
reimbursement (or longer if otherwise required); and (2) necessary to establishing HCA’s compliance with this CIA for at least three years
following the submission of the Annual Report covering the relevant year. Imaged copies of documents shall satisfy this requirement. 
 IX. DISCLOSURES

 Consistent with HHS’s Freedom of Information Act (“FOIA”) procedures, set forth in 45 C.F.R. Part 5, the OIG shall make a reasonable effort
to notify HCA prior to any release by OIG of information submitted by HCA pursuant to its obligations under this CIA and identified upon submission by HCA as trade secrets, commercial or financial information and privileged and confidential under
the FOIA rules. With respect to such releases, HCA shall have the rights set forth at 45 C.F.R. ss. 5.65(d). HCA shall refrain from identifying any information as trade secrets, commercial or financial information and privileged and confidential
that does not meet the criteria for exemption from disclosure under FOIA. 
 X. BREACH AND DEFAULT PROVISIONS 
 HCA is expected to fully and timely comply with all of its CIA obligations. 
 A. Stipulated Penalties for Failure to Comply with Certain Obligations. As a contractual remedy, HCA and OIG hereby agree that failure to comply with certain obligations set forth in this CIA may lead to the imposition of the following
monetary penalties (hereinafter referred to as “Stipulated Penalties”) in accordance with the following provisions. 
  

 36 

 1. A Stipulated Penalty of $2,500.00 (which shall begin to accrue on the day after the date the obligation became due)
for each day, beginning 90 days after the effective date of this CIA and concluding at the end of the term of this CIA, HCA fails to have in place any of the following: 
 a. all of the personnel and committees required in section III.A; 
 b. a written Code of Conduct as required in section
III.B.1; 
 c. written Policies and Procedures as required in section III.B.2; 
 d. a training program as required in section III.C; and 
 e. a Confidential Disclosure Program as required in section III.E;

 2. A Stipulated Penalty of $2,500.00 (which shall begin to accrue on the day after the date the obligation became due) for each day HCA fails meet any of
the deadlines to submit the Implementation Report or the Annual Reports to the OIG. 
 3. A Stipulated Penalty of $2,500.00 (which shall begin to accrue on
the date the failure to comply began) for each day HCA employs, contracts with, or grants staff privileges to an Ineligible Person and that person: (i) has responsibility for, or involvement with, HCA’s business operations related to the
Federal health care programs; 

  

 37 

 
or (ii) is in a position for which the person’s salary or the items or services rendered, ordered, or prescribed by the person are paid in whole or
part, directly or indirectly, by Federal health care programs or otherwise with Federal funds (the Stipulated Penalty described in this paragraph shall not be demanded for any time period during which HCA can demonstrate that it did not discover the
person’s exclusion or other ineligibility after making a reasonable inquiry (as described in section III.F) as to the status of the person). 
 4. A
Stipulated Penalty of $2,500.00 (which shall begin to accrue on the date the HCA fails to grant access) for each day HCA fails to grant access to the information or documentation as required in section VII of this CIA. 
 5. A Stipulated Penalty of $2,500.00 (which shall begin to accrue on the date the failure began) for a failure by HCA to report a Reportable Event, take corrective
action, and pay the appropriate refunds, as provided in section III.H; 
 6. A Stipulated Penalty of $2,000.00 (which shall begin to accrue 10 days after the
date that OIG provides notice to HCA of the failure to comply) for each day HCA fails to comply fully and adequately with any obligation of this CIA and such failure is not already subject to a penalty in section X.A.1 through 5 above. In its notice
to HCA, the OIG shall state the specific grounds for its determination that the HCA has failed to comply fully and adequately with the CIA obligation(s) at issue. 
  

 38 

 B. Payment of Stipulated Penalties. 
 1. Demand Letter. Upon a finding that HCA has failed to comply with any of the obligations described in section X.A and determining that Stipulated Penalties are appropriate, OIG shall notify HCA of: (a) HCA’s failure to comply;
and (b) the OIG’s exercise of its contractual right to demand payment of the Stipulated Penalties (this notification is hereinafter referred to as the “Demand Letter”). Within 10 days after receiving the Demand Letter, HCA shall
either: (a) cure the breach to the OIG’s satisfaction and pay the applicable stipulated penalties; or (b) request a hearing before an HHS administrative law judge (“ALJ”) to dispute the OIG’s determination of
noncompliance, pursuant to the agreed-upon provisions set forth below in section X.D. In the event HCA elects to request an ALJ hearing, the Stipulated Penalties shall continue to accrue until HCA cures, to the OIG’s satisfaction, the alleged
breach in dispute. Failure to respond to the Demand Letter in one of these two manners within the allowed time period shall be considered a material breach of this CIA and shall be grounds for exclusion under section X.C. 
 2. Timely Written Requests for Extensions. HCA may submit a timely written request for an extension of time to perform any act or file any notification or report
required by this CIA. Notwithstanding any other provision in this section, if OIG grants the timely written request with respect to an act, notification, or report, Stipulated 

  

 39 

 
Penalties for failure to perform the act or file the notification or report shall not begin to accrue until one day after HCA fails to meet the revised
deadline set by the OIG. Notwithstanding any other provision in this section, if OIG denies such a timely written request, Stipulated Penalties for failure to perform the act or file the notification or report shall not begin to accrue until two
business days after HCA receives OIG’s written denial of such request. A “timely written request” is defined as a request in writing received by OIG at least five business days prior to the date by which any act is due to be performed
or any notification or report is due to be filed. 
 3. Form of Payment. Payment of the Stipulated Penalties shall be made by certified or cashier’s
check, payable to “Secretary of the Department of Health and Human Services,” and submitted to OIG at the address set forth in section VI. 
 4.
Independence from Material Breach Determination. Except as otherwise noted, these provisions for payment of Stipulated Penalties shall not affect or otherwise set a standard for the OIG’s determination that HCA has materially breached this CIA,
which decision shall be made at the OIG’s discretion and governed by the provisions in section X.C, below. 
  

 40 

 C. Exclusion for Material Breach of this CIA 
 1. Notice of Material Breach and Intent to Exclude. The parties agree that a material breach of this CIA by HCA constitutes an independent basis for OIG to exclude HCA and/or any of its subsidiaries from participation
in the Federal health care programs (as defined in 42 U.S.C. ss. 1320a-7b(f)). Upon a determination by OIG that HCA has materially breached this CIA and that exclusion should be imposed, the OIG shall notify HCA by certified mail of:
(a) HCA’s material breach; and (b) OIG’s intent to exercise its contractual right to impose exclusion (this notification is hereinafter referred to as the “Notice of Material Breach Letter”). 
 2. Opportunity to Cure. HCA shall have 30 days after receiving the Notice of Material Breach Letter to demonstrate to the OIG’s satisfaction that: 
 a. HCA is in full compliance with this CIA; 
 b. the alleged material breach
has been cured; or 
 c. the alleged material breach cannot be cured within the 30-day period, but that: (i) HCA has begun to take action to cure the
material breach; (ii) HCA is pursuing such action with due diligence; and (iii) HCA has provided to OIG a reasonable timetable for curing the material breach. 
  

 41 

 3. Exclusion Letter. If at the conclusion of the 30-day period, HCA fails to satisfy the requirements of section X.C.2,
OIG may exclude HCA and/or any of its subsidiaries from participation in the Federal health care programs. OIG shall notify HCA in writing of its determination to exclude HCA and/or any of its subsidiaries (this letter shall be referred to
hereinafter as the “Exclusion Letter”). Subject to the Dispute Resolution provisions in section X.D, below, the exclusion shall go into effect 30 days after the date of the Exclusion Letter. The exclusion shall have national effect and
shall also apply to all other federal procurement and non-procurement programs. If HCA and/or any of its subsidiaries is excluded under the provisions of this CIA, HCA may seek reinstatement pursuant to the provisions at 42 C.F.R. ss.ss.
1001.3001-.3004. 
 4. Material Breach. A material breach of this CIA means: 
 a. a failure by HCA to report a Reportable Event, take corrective action and pay the appropriate refunds, as provided in section III.H, provided that any of the following individuals at HCA had notice of the
Reportable Event: an officer; a director; a Responsible Executive; an ECO; a member of the EC Department; or an attorney in the Legal Department; 
  

 42 

 b. repeated or flagrant violations of the obligations under this CIA, including, but not limited to, the obligations
addressed in section X.A of this CIA; 
 c. a failure to respond to a Demand Letter concerning the payment of Stipulated Penalties in accordance with section
X.B above; or 
 d. a failure to retain and use an Independent Review Organization for review purposes in accordance with section III.D. 
 D. Dispute Resolution 
 1. Review Rights. Upon the OIG’s delivery to
HCA of its Demand Letter or of its Exclusion Letter, and as an agreed-upon contractual remedy for the resolution of disputes arising under the obligation of this CIA, HCA shall be afforded certain review rights comparable to the ones that are
provided in 42 U.S.C. ss. 1320a-7(f) and 42 C.F.R. Part 1005 as if they applied to the Stipulated Penalties or exclusion sought pursuant to this CIA. Specifically, the OIG’s determination to demand payment of Stipulated Penalties or to seek
exclusion shall be subject to review by an ALJ and, in the event of an appeal, the Departmental Appeals Board (“DAB”), in a manner consistent with the provisions in 42 C.F.R. ss.ss. 1005.2-1005.21. Notwithstanding the language in 42 C.F.R.
ss. 1005.2(c), the request for a hearing involving stipulated penalties shall be made within 10 days of HCA receiving the Demand Letter and the request for a hearing involving exclusion shall be made within 20 days of HCA receiving the Exclusion
Letter. 
  

 43 

 2. Stipulated Penalties Review. Notwithstanding any provision of Title 42 of the United States Code or Chapter 42 of the
Code of Federal Regulations, the only issues in a proceeding for stipulated penalties under this CIA shall be: (a) whether HCA was in full and timely compliance with the obligations of this CIA for which the OIG demands payment; and
(b) the period of noncompliance. HCA shall have the burden of proving its full and timely compliance and the steps taken to cure the noncompliance, if any. If the ALJ finds for the OIG with regard to a finding of a breach of this CIA and orders
HCA to pay Stipulated Penalties, such Stipulated Penalties shall become due and payable 20 days after the ALJ issues such a decision notwithstanding that HCA may request review of the ALJ decision by the DAB. 
 3. Exclusion Review. Notwithstanding any provision of Title 42 of the United States Code or Chapter 42 of the Code of Federal Regulations, the only issues in a
proceeding for exclusion based on a material breach of this CIA shall be: (a) whether HCA was in material breach of this CIA; (b) whether such breach was continuing on the date of the Exclusion Letter; and (c) whether the alleged
material breach could not have been cured within the 30-day period, but that (i) HCA had begun to take action to cure the material breach within that period, (ii) HCA has pursued and is pursuing such action with 

  

 44 

 
due diligence, and (iii) HCA provided to OIG within that period a reasonable timetable for curing the material breach. For purposes of the exclusion
herein, exclusion shall take effect only after an ALJ decision that is favorable to the OIG. HCA’s election of its contractual right to appeal to the DAB shall not abrogate the OIG’s authority to exclude HCA and/or any of its subsidiaries
upon the issuance of the ALJ’s decision. If the ALJ sustains the determination of the OIG and determines that exclusion is authorized, such exclusion shall take effect 20 days after the ALJ issues such a decision, notwithstanding that HCA may
request review of the ALJ decision by the DAB. 
 XI. EFFECTIVE AND BINDING AGREEMENT 
 Consistent with the provisions in the Settlement Agreement pursuant to which this CIA is entered, and into which this CIA is incorporated, HCA and OIG agree as follows: 
 A. This CIA shall be binding on the successors, assigns, and transferees of HCA, consistent with the terms of Section IV; 
 B. This CIA shall become final and binding on the date that the court(s) accept the plea(s) and impose a sentence in the criminal proceedings related to the plea
agreement entered into between HCA and the United States on or about the date of the signing of this CIA; 
 C. Any modifications to this CIA shall be made
with the prior written consent of the parties to this CIA; and 
  

 45 

 D. The undersigned HCA signatories represent and warrant that they are authorized to execute this CIA. The undersigned
OIG signatory represents that he is signing this CIA in his official capacity and that he is authorized to execute this CIA. 
  

 46 

 ON BEHALF OF HCA 
  

					
	 /s/ Thomas F. Frist, Jr.
	 		 	12/12/00
	Thomas F. Frist, Jr., M.D	 		 	DATE
	Chairman and Chief Executive Officer	 		 	
	HCA-The Healthcare Company	 		 	
			
	 /s/ Alan Yuspeh
	 		 	12/12/00
	Alan Yuspeh	 		 	DATE
	Senior Vice President	 		 	
	Ethics, Compliance, and Corporate Responsibility	 		 	
	HCA-The Healthcare Company	 		 	

 ON BEHALF OF THE OFFICE OF INSPECTOR GENERAL 
 OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES 
  

					
	 /s/ Lewis Morris
	 		 	12/14/00
	Lewis Morris	 		 	DATE
	Assistant Inspector General for Legal Affairs	 		 	
	Office of Inspector General	 		 	
	U.S. Department of Health and Human Services  	 		 	

  

 47

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