Document:

Exhibit 4.3

The Depository Trust Company

A
subsidiary of The Depository Trust & Clearing Corporation

Book-Entry-Only Medium-Term Notes
(MTNs)/Medium-Term Bank Notes/ 

and Deposit Notes (Master Note and/or Global Certificates) Program

Letter of Representations

[To
be Completed by Issuer, Issuing Agent, and Paying Agent]

	
  

  	
  PACCAR, Financial
  Corp.

  
	
  [Name of Issuer]

  
	
   

  
	
   

  	
  Citibank, N.A.
  #2790

  
	
  [Name and DTC
  Participant Number of Issuing Agent and Paying Agent]

  
	
   

  
	
   

  
	
   

  	
  November 6, 2006

  
	
   

  	
  [Date]

  
				

 

Attention: Underwriting
Department

The Depository Trust Company

55 Water Street, 25th Floor

New York, NY 10041-0099

	
  Re:

  	
  PACCAR Financial Corp.

  	
   

  
	
   

  	
  Medium Term Notes

  	
   

  
	
   

  	
  Series L

  	
   

  
	
   

  	
  [Description of Note Program, including, as applicable,
  (a) series designator, (b) rank of indebtedness: and (c) reference to
  the provision of the Securities Act of 1933, as amended, pursuant to which Note Program is exempt from registration.]

  

 

Ladies and Gentlemen:

This
letter sets forth our understanding with respect to certain matters relating to
the issuance by Issuer from time to time of notes under its note program
described above (the “Securities”). Issuing Agent shall act as issuing agent
with respect to the Securities. Paying Agent shall act as paying agent or other
such agent of Issuer with respect to the Securities. Issuance of the Securities
has been authorized pursuant to a prospectus supplement, private placement
memorandum, or other such document authorizing the issuance of the Securities, dated
as of November 6, 2006.

Paying Agent has entered into a Money Market Instrument Master Note
and/or Global Certificates Certificate Agreement, or a Medium-Term Note
Certificate Agreement, with The Depository Trust Company (“DTC”) dated as of
October 31, 1988, pursuant to which

DTCC.

The Depository Trust &

Clearing Corporation

Paying
Agent shall act as custodian of a Master Note Certificate and/or Global
Certificates evidencing the Securities, when issued. Paying Agent shall amend
Exhibit A to such Certificate Agreement to include the note program described
above, prior to issuance of the Securities.

To induce DTC to accept the Securities as eligible for deposit at DTC
and to act in accordance with its Rules with respect to the Securities, Issuer,
Issuing Agent, and Paying Agent make the following representations to DTC:

1.             All
or certain issues of the Securities shall be evidenced by one Master
NoteCertificate, or by one or more Global Certificates for each issue, in
registered form registered in the name of DTC’s nominee, Cede & Co., and
such Certificate or Certificates shall represent 100% of the principal amount
of the Securities issued through DTC. The Master Note Certificate, if any, shall
include the substance of all material provisions set forth in the appropriate
DTC model Master Note for the note program described above, a copy of which
previously has been furnished to Issuing Agent and Paying Agent, and may
include additional provisions as long as they do not conflict with the material
provisions set forth in the DTC model. If the principal amount of an issue of
the Securities to be evidenced by one or more Global Certificates, if any,
exceeds $500 million, one Global Certificate shall be issued with respect to
each $500 million of principal amount and an additional Global Certificate
shall be issued with respect to any remaining principal amount. Paying Agent
shall cause each Global Certificate to be stamped with the following legend:

Unless this certificate is presented by an
authorized representative of The Depository Trust Company, a New York
corporation (“DTC”), to Issuer or its agent for registration of transfer,
exchange, or payment, and any certificate issued is registered in the name of
Cede & Co. or in such other name as is requested by an authorized
representative of DTC (and any payment is made to Cede & Co. or to such
other entity as is requested by an authorized representative of DTC), ANY
TRANSFER, PLEDGE, OR OTHER USE HEREOF FOR VALUE OR OTHERWISE BY OR TO ANY
PERSON IS WRONGFUL inasmuch as the registered owner hereof, Cede & Co., has
an interest herein.

2.            Issuer: (a) understands that DTC has no
obligation to, and will not, communicate to its participants (“Participants”)
or to any person having an interest in the Securities any information contained
in the Master Note Certificate, if any, or the Global Certificates, if any; and
(b) acknowledges that neither DTC’s Participants nor any person having an
interest in the Securities shall be deemed to have notice of the provisions of
such Certificate or Certificates by virtue of submission of such Certificate or
Certificates to DTC.

3.                   Issuer or Issuing Agent has obtained from the
CUSIP Service Bureau a written list of approximately 50 or fewer nine-character
numbers (the basic first six characters of which are the same and uniquely
identify Issuer and the Securities to be issued under its note program
described above). The CUSIP numbers on such list have been reserved for future
assignment to issues of the Securities. At any time when fewer than 25 of the
CUSIP numbers on such list remain unassigned, Issuer or Issuing Agent shall
promptly obtain from the CUSIP Service Bureau an additional written list of
approximately 50 or fewer such numbers.

 2
 

4.            When Securities are to be issued through DTC,
Issuing Agent shall notify Paying Agent and shall give issuance instructions to
DTC in accordance with DTC’s Procedures, including DTC’s Final Plan for DTC
Money Market Programs, and DTC’s Issuing/Paying Agent General Operating
Procedures and Participant Terminal System Procedures for Medium-Term Notes
(MTNs) Including Deposit Notes and Medium-Term Bank Notes (the “MMI Procedures”),
a copy of which previously has been furnished to Issuing Agent and Paying
Agent. The giving of such issuance instructions, which include delivery
instructions, to DTC shall constitute: (a) a representation that the Securities
are issued in accordance with applicable law; and (b) a confirmation that a
Master Note Certificate, or a Global Certificate (or Certificates), evidencing
such Securities, in the form described in paragraph 1, has been issued and
authenticated.

5.                   All notices and payment advises sent to DTC
shall contain the CUSIP number of the Securities.

6.            Issuer recognizes that DTC does not in any
way undertake to, and shall not have any responsibility to, monitor or
ascertain the compliance of any transactions in the Securities with the
following, as amended from time to time: (a) any exemptions from registration
under the Securities Act of 1933; (b) the Investment Company Act of 1940; (c)
the Employee Retirement Income Security Act of 1974; (d) the Internal Revenue
Code of 1986; (e) any rules of any self-regulatory organizations (as defined
under the Securities Exchange Act of 1934); or (f) any other local, state, federal,
or foreign laws or regulations thereunder.

7.            If issuance of Securities through DTC is
scheduled to take place one or more days after Issuing Agent has given issuance
instructions to DTC, Issuing Agent may cancel such issuance by giving a
cancellation instruction to DTC in accordance with the MMI Procedures.

8.                   At any time that Paying Agent has Securities
in its DTC accounts, it may request withdrawal of such Securities from DTC by
giving a withdrawal instruction to DTC in accordance with the MMI Procedures.
Upon DTC’s acceptance of such withdrawal instruction, Paying Agent shall reduce
the principal amount of the Securities evidenced, as the case may be, by the
Master Note Certificate, or by one or more Global Certificates, accordingly.

9.                   In the event of any solicitation of consents
from or voting by holders of the Securities, Issuer, Issuing Agent, or Paying
Agent shall establish a record date for such purposes (with no provision for
revocation of consents or votes by subsequent holders) and shall send notice of
such record date to DTC’s Reorganization Department, Proxy Unit no fewer than
15 calendar days in advance of such record date. If sent by telecopy, such
notice shall be directed to (212) 855-5181 or (212) 855-5182. If the party
sending the notice does not receive a telecopy receipt from DTC such party
shall confirm DTC’s receipt of such telecopy by telephoning (212) 855-5187. For
information regarding such notices, telephone The Depository Trust and Clearing
Corporation’s Proxy hotline at (212) 855-5191.

10.                 Notices of reorganization events (corporate
actions) with respect to the Securities, including full or partial redemptions
(calls), repayments (puts), extensions of maturities, resets of interest rates
or spreads, mandatory tenders, and consolidations of individual issues, shall
be given to DTC by Paying Agent in accordance with the MMI Procedures.

 3
 

11.                 Paying Agent may override DTC’s determination
of interest and principal payment dates, in accordance with the MMI Procedures.

12.                 Notice regarding the amount of variable
interest and principal payments on the Securities shall be given to DTC by
Paying Agent in accordance with the MMI Procedures.

13.                 All notices sent to DTC shall contain the
CUSIP number of the Securities.

14.                 Paying Agent shall confirm with DTC daily, by
CUSIP number, the face value of the Securities outstanding, and Paying Agent’s
corresponding interest and principal payment obligation, in accordance with the
MMI Procedures.

15.                 DTC may direct Issuer, Issuing Agent, or
Paying Agent to use any other telephone number or address as the number or
address to which notices or payments may be sent.

16.                 Payments on the Securities, including
payments in currencies other than the U.S. Dollar, shall be made by Paying
Agent in accordance with the MMI Procedures.

17.                 In the event that
Issuer determines that beneficial owners of Securities shall be able to obtain certificated Securities, Issuer,
Issuing Agent, or Paying Agent shall notify DTC of the availability of
certificates. In such event, Issuer, Issuing Agent, or Paying Agent shall
issue, transfer, and exchange certificates in appropriate amounts, as required
by DTC and others.

18.                 DTC may discontinue providing its services as
depository with respect to the Securities at any time by giving reasonable
notice to Issuer, Issuing Agent, or Paying Agent (at which time DTC will
confirm with Issuer, Issuing Agent, or Paying Agent the aggregate amount of
Securities outstanding by CUSIP number). Under such circumstances, at DTC’s
request, Issuer, Issuing Agent, and Paying Agent shall cooperate fully with DTC
by taking appropriate action to make available one or more separate
certificates evidencing Securities to any Participant having Securities
credited to its DTC accounts.

19.                 Issuer authorizes DTC to provide to Issuing
Agent and/or Paying Agent listings of DTC Participants’ holdings, known as
Security Position Reports (“SPRs”) with respect to the Assets from time to time at the request of Issuing Agent
or Paying Agent. DTC charges a fee for such SPRs. This authorization,
unless revoked by Issuer, shall continue with respect to the Assets while any
Assets are on deposit at DTC, until and unless Issuing Agent and/or Paying
Agent shall no longer be acting as Issuing and/or Paying Agent for Issuer. In
such event, Issuer shall provide DTC with similar evidence, satisfactory to
DTC, of the authorization of any successor thereto so to act. Proxy Web
Services are available at www.dtc.org. To register for or inquire about Proxy
Web Services, telephone The Depository Trust and Clearing Corporation’s Proxy
Hotline at (212) 855-5191.

20.          Nothing
herein shall be deemed to require Issuing Agent or Paying Agent to advance
funds on behalf of Issuer.

21.          This Letter of Representations may be executed in any number of
counterparts, each of which when so executed shall be deemed to be an original,
but all such counterparts together shall constitute but one and the same
instrument.

 4
 

22.           This Letter of Representations shall
be governed by, and construed in accordance with, the laws of the State of New
York, without giving effect to principals of conflicts of law.

23.          The sender of each notice delivered to DTC pursuant to this Letter of
Representations is responsible for confirming that such notice was properly
received by DTC.

24.          Issuer represents that the Securities are not securities of an issuer
that is listed on the Office of Foreign Asset Control (“OFAC”) issuer list
distributed by the U.S. Department of the Treasury, or of an issuer that is
incorporated in a country that is on the OFAC list of “pariah” countries.

25.          Issuer,
Issuing Agent and Paying Agent shall comply with the applicable requirements
stated in DTC’s MMI Procedures, as they may be amended from time to time.

26.          The following riders, attached hereto, are hereby incorporated into
this Letter of Representations:

Sample Offering
Document Language

Describing Book-Entry Only Issuance

[The remainder of this page was intentionally left blank]

 5
 

Note:

Schedule A contains statements
that DTC believes accurately describe DTC, the method

of effecting book-entry transfer of securities distributed through DTC, and
certain

related matters.

	
   

  	
  Very truly yours,

  
	
   

  	
   

  
	
   

  	
  PACCAR Financial Corp.

  
	
   

  	
  [Issuer]

  
	
   

  	
   

  
	
   

  	
  By:

  	
   

  
	
   

  	
  (Authorized
  Officer’s Signature]

  
	
   

  	
   

  
	
   

  	
  Citibank, N.A.

  
	
   

  	
  [Issuing Agent]

  
	
   

  	
   

  
	
   

  	
  By:

  	
   

  
	
   

  	
  [Authorized
  Officer’s Signature]

  
	
   

  	
   

  
	
   

  	
  Citibank, N.A.

  
	
   

  	
  [Paying Agent]

  
	
   

  	
   

  
	
   

  	
  By:

  	
   

  
	
   

  	
  [Authorized
  Officer’s Signature]

  
	
   

  	
   

  
	
  Received and Accepted:

  	
   

  
	
  THE DEPOSITORY TRUST COMPANY

  	
   

  
	
   

  	
   

  
	
   

  	
   

  
	
  cc:

  	
  Underwriter

  	
   

  
	
   

  	
  Underwriter’s Counsel

  	
   

  

 

 6

 

SCHEDULE A

SAMPLE OFFERING DOCUMENT LANGUAGE 

DESCRIBING BOOK-ENTRY-ONLY ISSUANCE

(Prepared by DTC—bracketed
material may be applicable only to certain issues)

1.              The Depository Trust Company (“DTC”), New
York, NY, will act as securities depository for the securities (the “Securities”).
The Securities will be issued as fully-registered securities registered in the
name of Cede & Co. (DTC’s partnership nominee) or such other name as may be
requested by an authorized representative of DTC. One fully-registered Security
certificate will be issued for [each issue of] the Securities, [each] in the
aggregate principal amount of such issue, and will be deposited with DTC. [If,
however, the aggregate principal amount of [any] issue exceeds $500 million,
one certificate will be issued with respect to each $500 million of principal
amount, and an additional certificate will be issued with respect to any
remaining principal amount of such issue.]

2.        DTC, the world’s largest securities
depository, is a limited-purpose trust company organized under the New
York Banking Law, a “banking organization” within the meaning of the New York
Banking Law, a member of the Federal Reserve System, a “clearing corporation”
within the meaning of the New York Uniform Commercial Code, and a “clearing
agency” registered pursuant to the provisions of Section 17A of the Securities
Exchange Act of 1934. DTC holds and provides asset servicing for over 2.2
million issues of U.S. and non-U.S. equity issues, corporate and municipal debt
issues, and money market instruments (from over 100 countries) that DTC’s
participants (“Direct Participants”) deposit with DTC. DTC also facilitates the
post-trade settlement among Direct Participants of sales and other securities
transactions in deposited securities, through electronic computerized
book-entry transfers and pledges between Direct Participants’ accounts. This
eliminates the need for physical movement of securities certificates. Direct
Participants include both U.S. and non-U.S. securities brokers and dealers,
banks, trust companies, clearing corporations, and certain other organizations.
DTC is a wholly-owned subsidiary of The Depository Trust & Clearing
Corporation (“DTCC”). DTCC, in turn, is owned by a number of Direct
Participants of DTC and Members of the National Securities Clearing
Corporation, Fixed Income Clearing Corporation, and Emerging Markets Clearing
Corporation (NSCC, FICC, and EMCC, also subsidiaries of DTCC), as well as by
the New York Stock Exchange, Inc., the American Stock Exchange LLC, and the
National Association of Securities Dealers, Inc. Access to the DTC system is
also available to others such as both U.S. and non-U.S. securities brokers and
dealers, banks, trust companies, and clearing corporations that clear through
or maintain a custodial relationship with a Direct Participant, either directly
or indirectly (“Indirect Participants”). DTC has Standard & Poor’s highest
rating: AAA. The DTC Rules applicable to its Participants are on file with the
Securities and Exchange Commission. More information about DTC can be found at www.dtcc.com
and www.dtc.org.

3.        Purchases of Securities under the DTC system
must be made by or through Direct Participants, which will receive a credit for
the Securities on DTC’s records. The ownership interest of each actual
purchaser of each Security (“Beneficial Owner”) is in turn to be recorded on
the Direct and Indirect Participants’ records. Beneficial Owners will not
receive written confirmation from DTC of their purchase. Beneficial Owners are,
however, expected to receive written confirmations providing details of the
transaction, as well as periodic statements of their holdings, from the Direct
or Indirect Participant through which the Beneficial Owner entered into the

 i
 

 

transaction. Transfers of
ownership interests in the Securities are to be accomplished by entries made on
the books of Direct and Indirect Participants acting on behalf of Beneficial
Owners. Beneficial Owners will not receive certificates representing their
ownership interests in Securities, except in the event that use of the
book-entry system for the Securities is discontinued.

4.         To facilitate subsequent transfers, all Securities deposited by Direct
Participants with DTC are registered in the name of DTC’s partnership nominee,
Cede & Co., or such other name as may be requested by an authorized
representative of DTC. The deposit of Securities with DTC and their
registration in the name of Cede & Co. or such other DTC nominee do not
effect any change in beneficial ownership. DTC has no knowledge of the actual
Beneficial Owners of the Securities; DTC’s records reflect only the identity of
the Direct Participants to whose accounts such Securities are credited, which
may or may not be the Beneficial Owners. The Direct and Indirect Participants
will remain responsible for keeping account of their holdings on behalf of
their customers.

5.              Conveyance of notices and other
communications by DTC to Direct Participants, by Direct Participants to
Indirect Participants, and by Direct Participants and Indirect Participants to
Beneficial Owners will be governed by arrangements among them, subject to any
statutory or regulatory requirements as may be in effect from time to time.
[Beneficial Owners of Securities may wish to take certain steps to augment the
transmission to them of notices of significant events with respect to the
Securities, such as redemptions, tenders, defaults, and proposed amendments to
the Security documents. For example, Beneficial Owners of Securities may wish
to ascertain that the nominee holding the Securities for their benefit has
agreed to obtain and transmit notices to Beneficial Owners. In the alternative,
Beneficial Owners may wish to provide their names and addresses to the
registrar and request that copies of notices be provided directly to them.]

[6.       Redemption notices shall be sent to DTC. If
less than all of the Securities within an issue are being redeemed, DTC’s
practice is to determine by lot the amount of the interest of each Direct
Participant in such issue to be redeemed.]

7.        Neither DTC nor Cede & Co. (nor any other DTC nominee) will consent
or vote with respect to Securities unless authorized by a Direct Participant in
accordance with DTC’s MMI Procedures. Under its usual procedures, DTC mails an
Omnibus Proxy to Issuer as soon as possible after the record date. The Omnibus
Proxy assigns Cede & Co.’s consenting or voting rights to those Direct
Participants to whose accounts Securities are credited on the record date
(identified in a listing attached to the Omnibus Proxy).

8.             Redemption proceeds, distributions, and
dividend payments on the Securities will be made to Cede & Co., or such
other nominee as may be requested by an authorized representative of DTC. DTC’s
practice is to credit Direct Participants’ accounts upon DTC’s receipt of funds
and corresponding detail information from Issuer or Agent, on payable date in
accordance with their respective holdings shown on DTC’s records. Payments by
Participants to Beneficial Owners will be governed by standing instructions and
customary practices, as is the case with securities held for the accounts of
customers in bearer form or registered in “street name,” and will be the
responsibility of such Participant and not of DTC, Agent, or Issuer, subject to
any statutory or regulatory requirements as may be in effect from time to time.
Payment of redemption proceeds, distributions, and dividend payments to Cede
& Co. (or such other nominee as may be requested by an authorized
representative of DTC) is the responsibility of Issuer or Agent, disbursement
of such payments to Direct Participants will be the responsibility of DTC, and
disbursement of such payments to the Beneficial Owners will be the
responsibility of Direct and Indirect Participants.

 ii
 

 

[9.       A Beneficial Owner shall give notice to elect to have its Securities
purchased or tendered, through its Participant, to [Tender/Remarketing] Agent,
and shall effect delivery of such Securities by causing the Direct Participant
to transfer the Participant’s interest in the Securities, on DTC’s records, to
[Tender/Remarketing] Agent. The requirement for physical delivery of Securities
in connection with an optional tender or a mandatory purchase will be deemed
satisfied when the ownership rights in the Securities are transferred by Direct
Participants on DTC’s records and followed by a book-entry credit of tendered
Securities to [Tender/Remarketing] Agent’s DTC account.]

10.           DTC may discontinue providing its services as depository with respect
to the Securities at any time by giving reasonable notice to Issuer or Agent.
Under such circumstances, in the event that a successor depository is not
obtained, Security certificates are required to be printed and delivered.

11.           Issuer may decide to discontinue use of the
system of book-entry-only transfers through DTC (or a successor securities depository). In that event, Security
certificates will be printed and delivered to DTC.

12.           The information in this section concerning DTC and DTC’s book-entry
system has been obtained from sources that Issuer believes to be reliable, but
Issuer takes no responsibility for the accuracy thereof.

 iiiEXHIBIT
10(a)

CORPORATE INTEGRITY
AGREEMENT

between the

Office of Inspector General

of the

Department of Health and Human Services

and

Tenet Healthcare Corporation

I.              INTRODUCTION
AND RELEASE

Tenet Healthcare Corporation, together with its
subsidiaries, affiliates, hospitals, and other health care facilities, 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 with the statutes, regulations, and
written directives of Medicare, Medicaid, and all other Federal health care
programs (as defined in 42 U.S.C. § 1320a-7b(f)) (Federal health care
program requirements).  For the purposes
of this CIA, “Tenet” shall mean the following: 
(1) Tenet Healthcare Corporation and its wholly-owned subsidiaries and
affiliates; (2) any other corporation, limited liability company, partnership,
or any other legal entity or organization in which Tenet Healthcare Corporation
or a wholly-owned subsidiary or affiliate owns a direct or indirect equity
interest of 50% or more; and (3) any hospital or other health care facility in
which Tenet Healthcare Corporation or a wholly-owned subsidiary or affiliate
either manages or controls the day-to-day operations of the facility.

Tenet and the United States entered into a Settlement
Agreement dated June 28, 2006 (Settlement Agreement) in which certain Tenet
Entities, as defined in the Settlement Agreement, agreed to pay the United
States $900 million, plus applicable interest, in exchange for a release from
liability under the False Claims Act, and other civil and administrative
authorities, for specified conduct detailed in Paragraph E of the Settlement
Agreement (hereinafter referred to as the “Covered Conduct”).  In the Settlement Agreement, the United
States alleged that it had certain administrative claims against the Tenet
Entities for the Covered Conduct and OIG expressly reserved all rights to
institute, direct, or to maintain any administrative action seeking exclusion
against the Tenet Entities, and/or its officers, directors, and employees from
Medicare, Medicaid, or other Federal health care programs (as defined in 42
U.S.C. § 1320a-7b(f)) under 42 U.S.C. § 1320a-7(a) (mandatory exclusion), or 42
U.S.C. § 1320a-7(b) (permissive exclusion).

In consideration of the obligations of Tenet set forth
in the Settlement Agreement and this CIA, conditioned upon the Tenet Entities’
full payment of the Settlement Amount under Paragraph III.1 of the Settlement Agreement,
and subject to Paragraph III.18 of the Settlement Agreement (concerning
bankruptcy proceedings commenced within 91 days of the Effective Date of the
Settlement Agreement or any payment under the Settlement Agreement), OIG agrees
to release and refrain from instituting, directing, or maintaining any
administrative action seeking exclusion from Medicare, Medicaid, and other
Federal health care programs (as defined in 42 U.S.C. § 1320a-7b(f)) against
the Tenet Entities under 42 U.S.C. § 1320a-7(b)(7) (permissive exclusion for
fraud, kickbacks, and other prohibited activities) for the Covered Conduct,
except as reserved in Paragraph III.11 of the Settlement Agreement and as
reserved in this Section.  OIG expressly
reserves all rights to comply with any statutory obligations to exclude the
Tenet 

 

Entities, and/or its officers, directors, and
employees from Medicare, Medicaid, or other Federal health care programs under
42 U.S.C. § 1320a-7(a) (mandatory exclusion) based upon the Covered
Conduct.  Nothing in this Section
precludes OIG from taking action against entities or persons, or for conduct
and practices, for which claims have been reserved in Paragraph III.11 of the
Settlement Agreement.

II.            TERM AND
SCOPE OF THE CIA

A.            The
period of the compliance obligations assumed by Tenet under this CIA shall be
five years from the effective date of this CIA, unless otherwise
specified.  The effective date shall be
the date on which the final signatory of this CIA executes this CIA (Effective
Date).  Each one-year period, beginning
with the one-year period following the Effective Date, shall be referred to as
a “Reporting Period.”

B.            Sections
VII, VIII, IX, X, and XI shall expire no later than 120 days after OIG’s
receipt of:  (1) Tenet’s final annual
report; or (2) any additional materials submitted by Tenet pursuant to OIG’s
request, whichever is later.

C.            The
scope of this CIA shall be governed by the following definitions:

1.             “Covered
Persons” includes:

a.             all natural persons who are owners
(other than shareholders who:  (i) have
an ownership interest of less than 5%; and (ii) acquired the ownership interest
through public trading), officers, directors, and employees of Tenet;

b.             all contractors, subcontractors,
agents, and other persons who provide patient care items or services or who
perform billing or coding functions on behalf of Tenet, excluding vendors whose
sole connection with Tenet is selling or otherwise providing medical supplies
or equipment to Tenet; and

c.             physicians with active medical
staff privileges at any Tenet hospital.

Notwithstanding the above, this term does not include
part-time or per diem employees, contractors, subcontractors, agents, and other
persons 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.                                       “Billing and
Reimbursement Covered Persons” includes all Covered Persons involved, directly
or in a supervisory role, in the preparation or submission of claims for
reimbursement from, or cost reports to, any Federal health care program.

 2
 

 

3.                                       “Arrangements
Covered Persons” includes all Covered Persons involved in the negotiation,
preparation, review, approval, maintenance, and approval for payment of all
Arrangements as defined below on behalf of Tenet.

4.                                       “Clinical
Quality Covered Persons” includes all Covered Persons involved in the delivery
of patient care items or services at Tenet hospitals or involved in the
monitoring of clinical quality at Tenet hospitals.

5.                                       “Relevant
Covered Persons” means all Billing and Reimbursement Covered Persons,
Arrangements Covered Persons, and Clinical Quality Covered Persons.

6.                                       “Excepted
Physician” means any physician who has active medical staff privileges at any
Tenet hospital but who is not (a) employed by Tenet; (b) a medical
director at a Tenet hospital or health care facility; or (c) a member of the
governing board at a Tenet hospital or health care facility.

7.             “Arrangements” shall mean every arrangement or
transaction that:

a.             involves, directly
or indirectly, the offer, payment, solicitation, or receipt of anything of
value; and is between Tenet and any actual or potential source of health care
business or referrals to Tenet or any actual or potential recipient of health
care business or referrals from Tenet. 
The term “source” shall mean any physician, contractor, vendor, or agent
and the term “health care business or referrals” shall mean referring,
recommending, arranging for, ordering, leasing, or purchasing of any good,
facility, item, or service for which payment may be made in whole or in part by
a Federal health care program; or

b.             is between Tenet
and a physician (or a physician’s immediate family member (as defined at 42
C.F.R. § 411.351)) who makes a referral (as defined at 42 U.S.C. §
1395nn(h)(5)) to Tenet for designated health services (as defined at 42 U.S.C.
§ 1395nn(h)(6)).

8.             “Focus Arrangements” means every Arrangement that:

a.             involves, directly
or indirectly, the offer or payment of anything of value and are between Tenet
and any actual source of health care business or referrals to Tenet; or

b.             is between Tenet
and a physician (or a physician’s immediate family member (as defined at 42
C.F.R. § 411.351)) who makes a referral (as defined at 42 U.S.C. §
1395nn(h)(5)) to Tenet for designated health services (as defined at 42 U.S.C.
§ 1395nn(h)(6)).

Provided, however, that any Arrangement that satisfies
the requirements of 42 C.F.R. § 411.356 (ownership of investment interests), 42
C.F.R. § 411.357(g) 

 3
 

 

(remuneration unrelated to the provision of designated
health services), 42 C.F.R. § 411.357(i) (payments by a physician for
items and services), 42 C.F.R. § 411.357 (m) (medical staff incidental
benefits), 42 C.F.R. § 411.357(o) (compliance training), 42 C.F.R. § 411.357(q)
(referral services), 42 C.F.R. § 411.357(s) (professional courtesy), 42
C.F.R. § 411.357(u) (community-wide health information systems), or any
exception to the prohibitions of 42 U.S.C. § 1395nn enacted following the
Effective Date that does not require a written agreement shall not be
considered a Focus Arrangement for the purposes of the CIA.

III.           CORPORATE
INTEGRITY OBLIGATIONS

Tenet shall establish and maintain a Compliance
Program that includes the following elements:

A.            Compliance Management and Oversight.

1.             Chief Compliance Officer.  Tenet has appointed, and shall maintain
during the term of the CIA, an individual to serve as its Chief Compliance
Officer.  The Chief Compliance Officer
has primary responsibility for ensuring the effective operation of the
Compliance Program 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 Federal health care program
requirements at Tenet.  The Chief
Compliance Officer shall be a member of senior management of Tenet, shall make
periodic (at least quarterly) reports regarding compliance matters directly to
the Board of Directors of Tenet, and shall be authorized to report on such
matters to the Board of Directors at any time. 
The Chief Compliance Officer shall be responsible for monitoring the
day-to-day compliance activities engaged in by Tenet as well as for any
reporting obligations created under this CIA. 
The Chief Compliance Officer shall not be, or be subordinate to, Tenet’s
General Counsel or Chief Financial Officer. 
Tenet shall report to OIG, in writing, any changes in the identity or
position description of the Chief Compliance Officer, or any actions or changes
that would affect the Chief Compliance Officer’s ability to perform the duties
necessary to meet the obligations in this CIA, within 15 days after such a
change.

2.             Regional and Hospital
Compliance Officers.  Tenet
has appointed, and shall maintain during the term of the CIA, individuals to
serve as Regional Compliance Officers for Tenet’s regional offices and Hospital
Compliance Officers for each Tenet hospital. 
The Regional Compliance Officer shall be responsible for implementing policies,
procedures, and practices designed to ensure compliance with the requirements
set forth in this CIA and with Federal health care program requirements for the
applicable regional office, and shall monitor the day-to-day compliance
activities of the applicable regional office. 
The Hospital Compliance Officer shall be responsible for implementing
policies, procedures, and practices designed to ensure compliance with the
requirements set forth in this CIA and with Federal health care program
requirements for the applicable hospital, and shall monitor the day-to-day
compliance activities of the applicable hospital.  The Regional Compliance Officers shall be
members of the Ethics and Compliance Department, and shall be independent from
Tenet’s Legal Department.  The Hospital
Compliance Officers shall report to the Regional Compliance Officers for ethics

 4
 

 

and compliance purposes, and shall be
independent from Tenet’s Legal Department. 
Tenet shall report to OIG, in writing, any changes in the identity or
position description of any Regional or Hospital Compliance Officers, or any
actions or changes that would affect any Regional or Hospital Compliance
Officer’s ability to perform the duties necessary to meet the obligations in
this CIA, within 15 days after such a change.

3.             Ethics and Compliance
Department.  Tenet has
created, and shall maintain during the term of the CIA, an Ethics and
Compliance Department comprised of senior officers, corporate compliance staff,
Regional Compliance Officers, and Hospital Compliance Officers.  The Ethics and Compliance Department shall be
responsible for implementing policies, procedures, and practices designed to
ensure privacy and security of protected health information, compliance audits
(including coding audits), reporting and monitoring of compliance issues on the
Compliance Issue Tracking System and the Master Action Plan, policies and
training, and the Disclosure Program described in Section III.E of the
CIA.  The Ethics and Compliance
Department shall be independent from Tenet’s Legal Department.  Tenet shall continue to provide, at a
minimum, the same level of resources currently provided to the Ethics and
Compliance Department (commensurate with the size of Tenet) throughout the term
of the CIA.  Tenet shall report to OIG,
in writing, any actions or changes that would affect the Ethics and Compliance
Department’s ability to perform the duties necessary to meet the obligations in
this CIA, within 15 days after such a change.

4.             Clinical Quality
Department.  Tenet has
established, and shall maintain during the term of the CIA, a Clinical Quality
Department comprised of a Chief Medical Officer, senior officers, and other
clinical quality staff.  The Clinical
Quality Department is responsible for monitoring clinical quality at Tenet
hospitals, including the “Commitment to Quality” Program, Comprehensive
Clinical Audits, physician credentialing, privileging, and peer review
programs, evidence-based medicine programs, standards of clinical excellence,
utilization management and review, and quality metrics on the balanced
scorecard and other performance standards. 
Tenet shall continue to provide, at a minimum, the same level of
resources currently provided to the Clinical Quality Department (commensurate
with the size of Tenet) throughout the term of the CIA.  Tenet shall report to OIG, in writing, any
actions or changes that would affect the Clinical Quality Department’s ability
to perform the duties necessary to meet the obligations of the CIA, within 15
days after such a change.

5.             Corporate Compliance
Committee.  Tenet has
established, and shall maintain during the term of the CIA, a Compliance and
Ethics Committee (Corporate Compliance Committee).  The Tenet Compliance Committee shall, at a
minimum, include the Chief Compliance Officer and other members of senior
corporate management necessary to meet the requirements of this CIA (e.g.,
senior executives of relevant departments, such as billing, clinical, human
resources, audit, and operations).  The
Chief Compliance Officer shall chair the Corporate Compliance Committee and the
Corporate Compliance Committee shall support the Chief Compliance Officer in
fulfilling his/her responsibilities (e.g., shall assist in the analysis
of the organization’s risk areas and shall oversee monitoring of internal and
external audits and investigations). 
Tenet shall report to OIG, in writing, any changes in the composition of
the Corporate Compliance Committee, or any actions or changes that would affect
the Corporate Compliance Committee’s ability to perform the duties necessary to
meet the obligations in this CIA, within 15 days after such a change.

 5
 

 

6.             Regional and Hospital
Compliance Committees.  In
addition, Tenet has established, and shall maintain during the term of the CIA,
regional compliance committees for Tenet’s regional offices (Regional
Compliance Committees) and hospital compliance committees at each Tenet
hospital (Hospital Compliance Committees). 
The Regional and Hospital Compliance Committees shall include appropriate
personnel from the Ethics and Compliance Department (e.g., applicable
Regional Compliance Officer, applicable Hospital Compliance Officer, and other
compliance personnel where appropriate) and other members of senior management
at Tenet’s regional offices and Tenet hospitals necessary to meet the
requirements of this CIA (e.g., senior executives of relevant
department, such as billing, clinical, human resources, audit, and
operations).  The Regional and Hospital
Compliance Committees shall support the Regional and Hospital Compliance
Officers in fulfilling their responsibilities (e.g., shall assist in the
analysis of the organization’s risk areas and shall oversee monitoring of
internal and external audits and investigations).  Tenet shall report to OIG, in writing, any
actions or changes that would affect any Regional or Hospital Compliance
Committee’s ability to perform the duties necessary to meet the obligations of
the CIA, within 15 days after such a change.

7.             Quality, Compliance, and
Ethics Committee of the Board of Directors.  Tenet’s Board of Directors currently has, and
shall maintain during the term of the CIA, a Quality, Compliance, and Ethics
Committee comprised of independent directors of Tenet (hereinafter “Board
Committee”).  The Board Committee is
responsible for the review and oversight of matters related to compliance with
the requirements of Federal health care programs and the obligations of this
CIA.  The Board Committee shall, at a
minimum, be responsible for the following:

a.             The Board Committee
shall meet at least quarterly and shall review and oversee Tenet’s Compliance
Program, including but not limited to the performance of the Chief Compliance
Officer, Regional and Hospital Compliance Officers, the Ethics and Compliance
Department, the Clinical Quality Department, the Corporate Compliance
Committee, and Regional and Hospital Compliance Committees.

b.             The Board Committee
shall arrange for the performance of a review on the effectiveness of Tenet’s
Compliance Program (Compliance Program Review) for each Reporting Period of the
CIA and shall review the results of the Compliance Program Review as part of
the review and assessment of Tenet’s Compliance Program.  A copy of the Compliance Program Review
Report shall be provided to OIG in each Annual Report submitted by Tenet.

c.             The Board Committee
shall retain an independent individual or entity with expertise in compliance
with the Federal health care program requirements (Compliance Expert).  The Compliance Expert shall assist the Board
Committee by creating a work plan for the Compliance Program Review, overseeing
the performance of the Compliance Program Review, and supporting the Board
Committee’s responsibilities for reviewing and assessing Tenet’s Compliance
Program.

 6
 

 

d.             For each Reporting
Period of the CIA, the Board Committee shall adopt a resolution, signed by each
individual member of the Board Committee, summarizing its review and oversight
of Tenet’s compliance with the requirements of Federal health care programs and
the obligations of this CIA.

At a minimum, the
resolution shall include the following language:

“The Quality, Compliance,
and Ethics Committee of the Board of Directors has made reasonable and due
inquiry into the operations of Tenet’s Compliance Program, including the performance
of the Chief Compliance Officer, Regional and Hospital Compliance Officers, the
Ethics and Compliance Department, the Clinical Quality Department, the
Corporate Compliance Committee, and Regional and Hospital Compliance
Committees.  In addition, the Quality,
Compliance, and Ethics Committee has retained an independent expert in
compliance with the Federal health care program requirements to support the
Committee’s responsibilities.  The
Quality, Compliance, and Ethics Committee has also arranged for the performance
and reviewed the results of the Compliance Program Review.  Based on all of these steps, the Committee
has concluded that, to the best of its knowledge, Tenet has implemented an
effective Compliance Program to meet the requirements of the Federal health
care programs and the obligations of the CIA.”

If the Board Committee is
unable to provide such a conclusion in the resolution, the Board shall include
in the resolution a written explanation of the reasons why it is unable to
provide the conclusion and the steps it is taking to implement an effective
Compliance Program at Tenet.

Tenet shall report to
OIG, in writing, any changes in the composition of the Board Committee, or any
actions or changes that would affect the Board Committee’s ability to perform
the duties necessary to meet the obligations in this CIA, within 15 days after
such a change.

B.            Written Standards.

1.             Code of Conduct.  Tenet has developed, implemented, and
distributed a written Code of Conduct to all Covered Persons.  During the term of the CIA, Tenet shall
maintain the Code of Conduct and make the promotion of, and adherence to, the
Code of Conduct an element in evaluating the performance of all employees.  The Code of Conduct shall, at a minimum, set
forth:

a.             Tenet’s commitment
to fall compliance with all Federal health care program requirements, including
its commitment to prepare and submit accurate claims consistent with such
requirements;

b.             Tenet’s requirement
that all of its Covered Persons shall be expected to comply with all Federal
health care program requirements and 

 7
 

 

with Tenet’s own Policies and Procedures as implemented pursuant to
Section III.B (including the requirements of this CIA);

c.             the requirement
that all of Tenet’s Covered Persons shall be expected to report to the Chief
Compliance Officer, or other appropriate individual designated by Tenet,
suspected violations of any Federal health care program requirements or of
Tenet’s own Policies and Procedures;

d.             the possible
consequences to both Tenet and Covered Persons of failure to comply with
Federal health care program requirements and with Tenet’s own Policies and
Procedures and the failure to report such noncompliance; and

e.             the right of all
individuals to use the Disclosure Program described in Section III.E, and Tenet’s
commitment to nonretaliation and to maintain, as appropriate, confidentiality
and anonymity with respect to such disclosures.

Within 120 days after the
Effective Date, each Covered Person shall certify, in writing, that he or she has
received, read, understood, and shall abide by Tenet’s Code of Conduct.  New Covered Persons shall receive the Code of
Conduct and shall complete the required certification within 30 days after
becoming a Covered Person or within 120 days after the Effective Date,
whichever is later.  Notwithstanding any
provision in this section, Tenet shall use best efforts to obtain written
certifications from Excepted Physicians and shall keep records of the
percentage of Excepted Physicians who have completed the certification.

Tenet shall periodically
review the Code of Conduct to determine if revisions are appropriate and shall
make any necessary revisions based on such review.  Any revised Code of Conduct shall be
distributed within 30 days after any revisions are finalized.  Each Covered Person shall certify, in
writing, that he or she has received, read, understood, and shall abide by the
revised Code of Conduct within 30 days after the distribution of the revised
Code of Conduct.

2.             Policies and Procedures.  Within 120 days after the Effective Date,
Tenet shall implement written Policies and Procedures regarding Tenet’s
operations and its compliance with Federal health care program
requirements.  At a minimum, the Policies
and Procedures shall address the following subject areas:

a.             Billing and
Reimbursement.  These policies and
procedures shall be designed to ensure that Tenet complies with the Federal
health care programs requirements on billing and reimbursement, and shall
include the following:

(i)            ensuring the proper
and accurate preparation and submission of claims to Federal health care
programs;

(ii)           ensuring the proper
and accurate documentation of medical records;

 8
 

 

(iii)          ensuring the proper
and accurate submission of cost reports submitted to the Federal health care
programs;

(iv)          conducting periodic
billing and coding reviews and audits at Tenet hospitals;

(v)           ensuring that each
Tenet hospital has an established charge structure which is applied uniformly
to each patient as services are furnished to the patient and which is
reasonably and consistently related to the cost of providing services
(consistent with the Provider Reimbursement Manual);

(vi)          monitoring all
changes to the chargemasters at Tenet hospitals to ensure review and approval
by appropriate Tenet personnel; and

(vii)         reporting and
repayment of all identified Overpayments to Federal health care programs and
other payors.

b.             Compliance with
the Anti-Kickback Statute and Stark Law. 
These policies and procedures shall be designed to ensure that each
existing and new or renewed Arrangement does not violate the Anti-Kickback
Statute, 42 U.S.C. § 1320a-7b(b), and/or the Physician Self-Referral Law (“Stark
Law”), 42 U.S.C. § 1395nn, or the regulations, directives, and guidance related
to these statutes, and shall include the following:

(i)            creating and
maintaining a database of all existing and new or renewed Focus Arrangements
that shall contain the information specified in Attachment 1 (Focus
Arrangements Database);

(ii)           tracking
remuneration to and from all parties to each Focus Arrangement;

(iii)          tracking service
and activity logs to ensure that parties to the Focus Arrangement are
performing the services required under the applicable Focus Arrangement(s);

(iv)          monitoring the use
of leased space, medical supplies, medical devices, equipment, or other patient
care items to ensure that such use is consistent with the terms of the
applicable Focus Arrangement(s);

(v)           establishing and
implementing a written review and approval process for all Arrangements,
including but not limited to a legal review of Focus Arrangements by counsel
with expertise in the Anti-Kickback Statute and Stark Law and appropriate
documentation of all internal controls, the purpose of which is to 

 9
 

 

ensure that all new and existing or renewed Arrangements do not violate
the Anti-Kickback Statute or Stark Law;

(vi)          requiring the Chief
Compliance Officer, or appropriate designee, to review the Focus Arrangements
Database, internal review and approval process, and other Arrangements Procedures
on at least a quarterly basis and to provide a report on the results of such
review to the Board Committee;

(vii)         implementing
effective responses when suspected violations of the Anti-Kickback Statute and
Stark Law are discovered, including disclosing Reportable Events and
quantifying and repaying Overpayments pursuant to Section III.H (Reporting)
when appropriate.

(viii)        ensuring that each
Focus Arrangement is set forth in writing and signed by Tenet and the other
parties to the Focus Arrangement; provided that Focus Arrangements constituting
non-contractual transactions subject to 42 C.F.R. § 411.357(k) are not required
to be in writing but are required to be tracked in the Focus Arrangements
Database.

(ix)           including in each
written agreement reflecting a Focus Arrangement a requirement that all
individuals who meet the definition of Covered Persons shall comply with Tenet’s
Compliance Program and Tenet’s policies and procedures related to the
Anti-Kickback Statute and the Stark Law; and

(x)            including in each
written agreement a certification by the parties to the Focus Arrangement that
the parties shall not violate the Anti-Kickback Statute and the Stark Law.

c.             Clinical Quality.  These policies and procedures shall be
designed to promote the delivery of patient care items or services at Tenet
hospitals that meet professionally recognized standards of health care and are
reasonable and appropriate to the needs of Federal health care program
beneficiaries.  These policies and
procedures shall include the following:

(i)            ensuring the
appropriate documentation of medical records;

(ii)           measuring,
analyzing, and tracking quality indicators, including adverse patient events,
and other aspects of performance that relate to processes of care, hospital
services, and operations;

(iii)          incorporating
quality indicator data, including patient care data and other relevant data to
monitor the effectiveness and safety of services and quality of care and to
identify opportunities for improvement and changes that will lead to
improvement;

 10

 

 

(iv)          setting priorities for performance
improvement activities that (1) focus on high risk, high-volume, or
problem-prone areas; (2) consider the incidence, prevalence, and severity of
problems in those areas; and (3) affect health outcomes, patient safety, and
quality of care;

(v)           tracking medical errors and adverse
patient events, analyzing their causes, and implementing preventive actions and
mechanism that include feedback and learning throughout Tenet;

(vi)          conducting quality assessment and
performance improvement projects, including periodic clinical quality audits of
Tenet hospitals;

(vii)         collecting and reporting quality
assessment and performance improvement data to relevant data registries;

(viii)        periodically reporting quality
assessment and performance improvement data to the Board Committee;

(ix)           collecting, verifying, and assessing
current licensure, education, relevant training, experience, ability and
current competence to perform requested privileges;

(x)            monitoring practitioners with current
privileges by the review of clinical practice patterns, ongoing case review,
proctoring, and discussion with other individuals involved in the care of
patients;

(xi)           implementing and monitoring medical
staff peer review in all Tenet hospitals;

(xii)          incorporating clinical quality metrics
on the balanced scorecard for senior management; and

(xiii)         implementing effective responses when
clinical quality problems are discovered.

d.             Performance Standards and
Incentives.  These policies and
procedures shall address performance standards for Tenet corporate
management.  These policies and
procedures shall include the following:

(i)            clinical quality measures;

(ii)           compliance program effectiveness
measures; and

 11
 

 

(iii)          compensation and incentive awards
directly linked to clinical quality measures and compliance program
effectiveness measures.

Within 120 days after the Effective Date, the relevant
portions of the Policies and Procedures shall be distributed to all Covered
Persons whose job functions relate to those Policies and Procedures.  Appropriate and knowledgeable staff shall be
available to explain the Policies and Procedures.

At least annually (and more frequently, if
appropriate), Tenet shall assess and update, as necessary, the Policies and
Procedures.  Within 30 days after the
effective date of any revisions, the relevant portions of any such revised
Policies and Procedures shall be distributed to all Covered Persons whose job
functions relate to those Policies and Procedures.

C.            Training
and Education.

1.             General Training. 
Within 120 days after the Effective Date, Tenet shall provide at least
two hours of General Training to each Covered Person.  This training, at a minimum, shall explain
Tenet’s:

a.             CIA requirements; and

b.             Tenet’s Compliance Program (including
the Code of Conduct and the Policies and Procedures as they pertain to general
compliance issues).

New Covered Persons shall receive the General Training
described above within 30 days after becoming a Covered Person or within 120
days after the Effective Date, whichever is later.  After receiving the initial General Training
described above, each Covered Person shall receive at least one hour of General
Training in each subsequent Reporting Period.

If, pursuant to Tenet’s Compliance Program, Tenet has
provided training to Covered Persons that satisfies the requirements set forth
above in Section III.C.1 within 60 days prior to the Effective Date, OIG will
credit that training for purposes of satisfying Tenet’s General Training
obligations for the first Reporting Period of this CIA.

2.             Specific Training.  Each Relevant Covered Person shall receive
Specific Training under the following training modules in addition to the
General Training required above in a manner relevant to the individual’s job
responsibilities as follows:

a.             Billing and
Reimbursement Training.  Within 120
days after the Effective Date, each Billing and Reimbursement Covered Person
shall receive at least four hours of Billing and Reimbursement Training that
covers the following topics:

(i)            the Federal health
care program requirements regarding the accurate preparation and submission of
claims and cost reports;

 12
 

 

(ii)           policies,
procedures, and other requirements applicable to the documentation of medical
records;

(iii)          the personal
obligation of each individual involved in the claims submission process and/or
preparation of cost reports to ensure that such claims and cost reports are
accurate;

(iv)          applicable
reimbursement statutes, regulations, and program requirements and directives;

(v)           the legal sanctions
for violations of the Federal health care program requirements;

(vi)          examples of proper
and improper claims submission and cost reporting practices;

(vii)         policies and
procedures for the reporting and repayment of Overpayments to Federal health
care programs and other payors; and

(viii)        policies and
procedures on setting or modifying charges on hospital chargemasters, including
the requirement that each Tenet hospital has an established charge structure
which is applied uniformly to each patient as services are furnished to the
patient and which is reasonably and consistently related to the cost of
providing services (consistent with the Provider Reimbursement Manual).

b.             Arrangements
Training.  Within 120 days after the
Effective Date, each Arrangements Covered Person shall receive at least four
hours of Arrangements Training that covers the following topics:

(i)            Anti-Kickback
Statute and Stark Law, and the regulations and other guidance documents related
to these statutes, and business or financial arrangements or contracts that may
violate the Anti-Kickback Statute or the Stark Law;

(ii)           Arrangements that
potentially implicate the Anti-Kickback Statute or the Stark Law, as well as
the regulations and other guidance documents related to these statutes;

(iii)          Tenet’s policies,
procedures, and other requirements relating to Arrangements, including but not
limited to the Focus Arrangements Database, the internal review and approval
process, and the tracking of remuneration to and from sources of health care
business or referrals required by Section III.B.2.b of the CIA;

 13
 

 

(iv)          the personal
obligation of each individual involved in the development, approval,
management, or review of Tenet’s Arrangements to know the applicable legal
requirements and Tenet’s Arrangements Policies and Procedures;

(v)           the legal sanctions
under the Anti-Kickback Statute, the Stark Law, and other applicable statutes
and regulations; and

(vi)          examples of
violations of the Anti-Kickback Statute, the Stark Law, and other applicable
statutes and regulations.

c.             Clinical Quality
Training.  Within 120 days after the
Effective Date, each Clinical Quality Covered Person shall receive at least
three hours of Clinical Quality Training that covers the following topics:

(i)            Tenet’s policies,
procedures, and other requirements relating to clinical quality, including but
not limited to the “Commitment to Quality” Program, Comprehensive Clinical
Audits, physician credentialing, privileging, and peer review programs,
evidence-based medicine programs, standards of clinical excellence, utilization
management and review, clinical quality measures, and the other requirements
under Sections III.B.2.c and III.B.2.d;

(ii)           the personal
obligation of each individual involved in the delivery of patient care items or
services at Tenet hospitals or involved in the monitoring of clinical quality
at Tenet hospitals to know the applicable legal requirements and Tenet’s
Clinical Quality Policies and Procedures;

(iii)          the legal sanctions
for violating the Federal health care program requirements; and

(iv)          examples of proper
and improper patient care at Tenet hospitals.

New Relevant Covered
Persons shall receive this training within 30 days after the beginning of their
employment or becoming Relevant Covered Persons, or within 120 days after the
Effective Date, whichever is later.  A
Tenet employee who has completed the Specific Training shall review a new
Relevant Covered Person’s work, to the extent that the work relates to the
delivery of patient care items or services and/or the preparation or submission
of claims for reimbursement from any Federal health care program, until such
time as the new Relevant Covered Person completes his or her Specific Training.

After receiving the
initial Specific Training described in this Section, each Relevant Covered
Person shall receive at least two hours of Specific Training in each subsequent
Reporting Period.

 14
 

 

If, pursuant to Tenet’s
Compliance Program, Tenet has provided training to applicable Covered Persons
that satisfies the requirements set forth above in Section III.C.2 within 60
days prior to the Effective Date, OIG will credit that training for purposes of
satisfying Tenet’s Specific Training obligations for the first Reporting Period
of this CIA.

3.             Certification.  Each individual who is required to attend
training shall certify, in writing or in electronic form, if applicable, that
he or she has received the required training. 
The certification shall specify the type of training received and the
date received.  The Compliance Officer
(or designee) shall retain the certifications, along with all course
materials.  These shall be made available
to OIG, upon request.

4.             Qualifications of Trainer.  Persons providing the training shall be
knowledgeable about the subject area.

5.             Update of Training.  Tenet shall review the training annually,
and, where appropriate, update the training to reflect changes in Federal
health care program requirements, any issues discovered during audits or
reviews, and any other relevant information.

6.             Computer-based Training.  Tenet may provide the training required under
this CIA through appropriate computer-based training approaches.  If Tenet chooses to provide computer-based
training, it shall make available appropriately qualified and knowledgeable
staff or trainers to answer questions or provide additional information to the
individuals receiving such training.

7.             Excepted Physicians.  Notwithstanding any other provision of this
Section III.C, Tenet shall:  (a) make the
General and Specific Training available to Excepted Physicians; (b) use its
best efforts to encourage the attendance and participation of Excepted
Physicians in the General and Specific Training; and (c) maintain records of
the percentage of all Excepted Physicians who attend such training.

8.             Covered Contractors.  To the extent that Tenet engages contractors
who are Covered Persons (Covered Contractors), Tenet may comply with the
Specific Training requirements under Section III.C.2 with respect to the
Covered Contractor by obtaining, and providing to OIG upon request, a
certification from each Covered Contractor that the Covered Contractor:  (a) presently has a program designed to
ensure compliance with all Federal health care program requirements; and (b)
has received training equivalent to the Specific Training required under
Section III.C and in a manner relevant to the Covered Contractor’s
responsibilities.

D.            Review Procedures.

1.             Type of Reviews.  The following reviews shall be performed by
an entity (or entities), such as an accounting, auditing, or consulting firm
(hereinafter “Independent Review Organization” or “IRO”), to be engaged by
Tenet during the term of the CIA:  (a)
Outlier Payments Review; (b) DRG Claims Review; (c) Unallowable Costs Review;
(d) Focus Arrangements Review; and (e) Clinical Quality Systems Review
(collectively the “IRO Reviews”).  The
work plans for the IRO Reviews are attached to the CIA in Appendices A-E and
are hereby incorporated by reference into the CIA.

 15
 

 

2.             Engagement of IRO(s).  Within 120 days after the Effective Date,
Tenet shall engage the IRO(s) to perform the IRO Reviews.  Tenet shall notify OIG of the identity of the
IRO in the Implementation Report required under Section V.A of the CIA.  Within 30 days after OIG receives written
notice of the identity of the selected IRO, OIG will notify Tenet if the IRO is
unacceptable.  Absent notification from
OIG that the IRO is unacceptable, Tenet may continue to engage the IRO.  If Tenet engages a new IRO during the term of
the CIA, this IRO shall also meet the requirements of this Section.  If a new IRO is engaged, Tenet shall submit
the information identified in Section V.A.10 to OIG within 30 days of
engagement of the IRO.  Within 30 days
after OIG receives written notice of the identity of the selected IRO, OIG will
notify Tenet if the IRO is unacceptable. 
Absent notification from OIG that the IRO is unacceptable, Tenet may
continue to engage the IRO.

3.             IRO Qualifications.  Each IRO engaged by Tenet shall have
expertise in the substantive matters of the IRO Reviews and in the general
requirements of the Federal health care program(s) from which Tenet seeks
reimbursement.  The IRO shall:

a.             assign individuals
to conduct the IRO Reviews who have expertise in the substantive matters of the
IRO Reviews and in the general requirements of the Federal health care
program(s) from which Tenet seeks reimbursement;

b.             for the DRG Claims
Review, assign individuals to conduct the coding review portions who have a
nationally recognized coding certification (e.g., CCA, CCS, CCS-P, CPC,
RRA, etc.) and who have maintained this certification (e.g., completed
applicable continuing education requirements);

c.             assign individuals
to design and select the samples who are knowledgeable about the appropriate statistical
sampling techniques; and

d.             have sufficient
staff and resources to conduct the IRO Reviews required by the CIA on a timely
basis.

4.             IRO Responsibilities.  The IRO shall:

a.             perform each IRO
Review in accordance with the specific requirements of the CIA;

b.             follow all
applicable Medicare, Medicaid, or other Federal health care programs rules and
reimbursement guidelines in making assessments in the IRO Review;

c.             if in doubt of the
application of a particular Medicare, Medicaid, or other Federal health care
programs policy or regulation, request clarification from the appropriate
authority (e.g., fiscal intermediary or carrier);

 16
 

 

d.             respond to all OIG
inquires in a prompt, objective, and factual manner; and

e.             prepare timely,
clear, well-written reports that include all the information required by the
CIA (hereinafter “IRO Review Reports”).

5.             IRO
Independence/Objectivity. 
Each IRO must perform each IRO Review in a professionally independent
and objective fashion, as appropriate to the nature of the engagement, taking
into account any other business relationships or engagements that may exist
between the IRO and Tenet.  Tenet and
each IRO shall assess whether the IRO can perform the IRO review in a
professionally independent and objective fashion, as appropriate to the nature
of the engagement, taking into account any other business relationships or
other engagements that may exist.  Each
IRO shall include in its report(s) to Tenet a certification or sworn affidavit
that it has evaluated its professional independence and objectivity, as
appropriate to the nature of the engagement, with regard to the IRO Reviews and
that it has concluded that it is, in fact, independent and objective.

6.             IRO Removal/Termination.  If Tenet terminates any IRO during the course
of the engagement, Tenet must submit a notice explaining its reasons to OIG no
later than 30 days after termination. 
Tenet must engage a new IRO in accordance with Section III.D of the CIA.  In the event OIG has reason to believe that
the IRO does not possess the qualifications described in Section III.D.3 of the
CIA, is not independent and objective as set forth in Section III.D.5 of the
CIA, or has failed to carry out its responsibilities as described in Section
III.D.4 of the CIA, OIG may, at its sole discretion, require Tenet to engage a
new IRO in accordance with Section III.D.2 of the CIA.  Prior to requiring Tenet to engage a new IRO,
OIG shall notify Tenet of its intent to do so and provide a written explanation
of why OIG believes such a step is necessary. 
To resolve any concerns raised by OIG, Tenet may request a meeting with
OIG to discuss any aspect of the IRO’s qualifications, independence,
objectivity, or performance of its responsibilities and to present additional
information regarding these matters. 
Tenet shall provide any additional information as may be requested by
OIG under this Paragraph in an expedited manner.  OIG will attempt in good faith to resolve any
differences regarding the IRO with Tenet prior to requiring Tenet to terminate
the IRO.  However, the final
determination as to whether or not to require Tenet to engage a new IRO shall
be made at the sole discretion of OIG.

7.             Validation Review.  In the event OIG has reason to believe that
any of the IRO Reviews fails to conform to the requirements of this Agreement;
or (b) the IRO’s findings or results are inaccurate, OIG may, at its sole
discretion, conduct its own review to determine whether the IRO Reviews
complied with the requirements of the Agreement and/or the findings or results
are inaccurate (Validation Review). 
Tenet shall pay for the reasonable cost of any such review performed by
OIG or any of its designated agents.  Any
Validation Review of Reports submitted as part of Tenet’s final Annual Report
must be initiated no later than one year after Tenet’s final submission (as
described in Section II of the CIA) is received by OIG.

Prior to
initiating a Validation Review, OIG shall notify Tenet of its intent to do so
and provide a written explanation of why OIG believes such a review is
necessary.  To resolve any concerns
raised by OIG, Tenet may request a meeting with OIG to:  (a) discuss the results of any IRO
Review submissions or findings; (b) present any additional information to
clarify the results 

 17
 

 

of the IRO Reviews
or to correct the inaccuracy of the IRO Reviews; and/or (c) propose
alternatives to the proposed Validation Review. 
Tenet agrees to provide any additional information as may be requested
by OIG under this Section in an expedited manner.  OIG will attempt in good faith to resolve any
IRO Review issues with Tenet prior to conducting a Validation Review.  However, the final determination as to
whether or not to proceed with a Validation Review shall be made at the sole
discretion of OIG.

8.             Retention of Records.  The IRO and Tenet shall retain and make
available to OIG, upon request, all work papers, supporting documentation,
correspondence, and draft reports (those exchanged between the IRO and Tenet)
related to the reviews.

E.             Disclosure Program.

Tenet has established,
and shall maintain for the term of the CIA, a Disclosure Program that includes
a mechanism (e.g., a toll-free compliance telephone line) to enable
individuals to disclose, to the Compliance Officer or some other person who is
not in the disclosing individual’s chain of command, any identified issues or
questions associated with Tenet’s policies, conduct, practices, or procedures
with respect to a Federal health care program believed by the individual to be
a potential violation of criminal, civil, or administrative law.  Tenet shall appropriately publicize the
existence of the disclosure mechanism (e.g., via periodic e-mails to
employees or by posting the information in prominent common areas).

The Disclosure Program
shall emphasize a nonretribution, nonretaliation policy, and shall include a
reporting mechanism for anonymous communications for which appropriate
confidentiality shall be maintained. 
Upon receipt of a disclosure, the Chief Compliance Officer (or designee)
shall gather all relevant information from the disclosing individual.  The Chief Compliance Officer (or designee)
shall make a preliminary, good faith inquiry into the allegations set forth in
every disclosure to ensure that he or she has obtained all of the information
necessary to determine whether a further review should be conducted.  For any disclosure that is sufficiently
specific so that it reasonably: 
(1) permits a determination of the appropriateness of the alleged
improper practice; and (2) provides an opportunity for taking corrective
action, Tenet shall conduct an internal review of the allegations set forth in
the disclosure and ensure that proper follow-up is conducted.

The Chief Compliance
Officer (or designee) shall maintain a disclosure log, which shall include a
record and summary of each disclosure received (whether anonymous or not), the
status of the respective internal reviews, and any corrective action taken in
response to the internal reviews.  The
disclosure log shall be made available to OIG upon request.

F.             Ineligible Persons.

1.             Definitions.  For purposes of this CIA:

a.             an “Ineligible
Person” shall include an individual or entity who:

i.              is currently
excluded, debarred, suspended, or otherwise ineligible to participate in the
Federal health care programs or in Federal procurement or nonprocurement
programs; or

 18
 

 

ii.             has been convicted
of a criminal offense that falls within the ambit of 42 U.S.C. § 1320a-7(a),
but has not yet been excluded, debarred, suspended, or otherwise declared
ineligible.

b.             “Exclusion Lists”
include:

i.              the HHS/OIG List
of Excluded Individuals/Entities (available through the Internet at http://www.oig.hhs.gov);
and

ii.             the General
Services Administration’s List of Parties Excluded from Federal Programs
(available through the Internet at http://www.epls.gov).

c.             “Screened Persons”
include prospective and current owners (other than shareholders who:  (1) have an ownership interest of less than
5%; and (2) acquired the ownership interest through public trading), officers,
directors, employees, contractors, and agents of Tenet.

2.             Screening Requirements.  Tenet shall ensure that all Screened Persons
are not Ineligible Persons, by implementing the following screening
requirements.

a.             Tenet shall screen
all Screened Persons against the Exclusion Lists prior to engaging their
services and, as part of the hiring or contracting process, shall require such
Screened Persons to disclose whether they are Ineligible Persons.

b.             Tenet shall screen
all Screened Persons against the Exclusion Lists within 90 days after the
Effective Date and on an annual basis thereafter.

c.             Tenet shall
implement a policy requiring all Screened Persons to disclose immediately any
debarment, exclusion, suspension, or other event that makes that person an Ineligible
Person.

Nothing in this Section
affects the responsibility of (or liability for) Tenet to refrain from billing
Federal health care programs for items or services furnished, ordered, or
prescribed by an Ineligible Person.  Tenet
understands that items or services furnished by excluded persons are not
payable by Federal health care programs and that Tenet may be liable for
overpayments and/or criminal, civil, and administrative sanctions for employing
or contracting with an excluded person regardless of whether Tenet meets the
requirements of this Section III.F.

3.             Removal Requirement. 
If Tenet has actual notice that a Screened Person has become an
Ineligible Person, Tenet shall remove such Screened Person from responsibility
for, or involvement with, Tenet’s business operations related to the Federal
health care programs and shall remove such Screened Person from any position
for which the Screened Person’s compensation or the items or services
furnished, ordered, or prescribed by the Screened Person are paid in whole or
part, directly or indirectly, by Federal health care programs or otherwise 

 19
 

 

with Federal funds at least until such time
as the Screened Person is reinstated into participation in the Federal health
care programs.

4.             Pending Charges and
Proposed Exclusions.  If Tenet
has actual notice that a Screened Person is charged with a criminal offense
that falls within the ambit of 42 U.S.C. §§ 1320a-7(a), 1320a-7(b)(l)-(3),
or is proposed for exclusion during his, her or its employment or contract term
or, in the case of a physician, during the term of the physician’s medical
staff privileges, Tenet shall take all appropriate actions to ensure that the
responsibilities of that Screened Person 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 Government Investigation or Legal
Proceedings.

Within 30 days after discovery, Tenet shall notify
OIG, in writing, of any ongoing investigation or legal proceeding known to
Tenet conducted or brought by a governmental entity or its agents involving an
allegation that Tenet has committed a crime or has engaged in fraudulent
activities.  This notification shall
include a description of the allegation, the identity of the investigating or
prosecuting agency, and the status of such investigation or legal
proceeding.  Tenet shall also provide
written notice to OIG within 30 days after the resolution of the matter, and
shall provide OIG with a description of the findings and/or results of the
investigation or proceedings, if any.

H.            Reporting.

1.             Overpayments.

a.             Definition of
Overpayments.  For purposes of this
CIA, an “Overpayment” shall mean the amount of money Tenet has received in
excess of the amount due and payable under any Federal health care program
requirements.

b.             Reporting of Overpayments.  If, at any time, Tenet identifies or learns
of any Overpayment, Tenet shall notify the payor (e.g., Medicare fiscal intermediary
or carrier) within 30 days after identification of the Overpayment and take
remedial steps within 60 days after identification (or such additional time as
may be agreed to by the payor) to correct the problem, including preventing the
underlying problem and the Overpayment from recurring.  Also, within 30 days after identification of
the Overpayment, Tenet shall repay the Overpayment to the appropriate payor to
the extent such Overpayment has been quantified.  If not yet quantified, within 30 days after
identification, Tenet 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 payor shall be done in accordance with the payor’s policies, and, for
Medicare contractors, shall include the information contained on the
Overpayment Refund Form, provided as Attachment 2 to this CIA.  Notwithstanding the above, notification and
repayment of any Overpayment amount that routinely is reconciled or adjusted
pursuant to policies and procedures established by the payor should be handled
in accordance with such policies and procedures.

 

 20

 

 

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 probable violation of criminal, civil, or administrative laws
applicable to any Federal health care program for which penalties or exclusion
may be authorized; or

iii.            a violation of the obligation to
provide items or services of a quality that meets professionally recognized
standards of health care where such violation has occurred in one or more
instances and presents an imminent danger to the health, safety, or well-being
of a Federal health care program beneficiary or places the beneficiary
unnecessarily in high-risk situations.

A Reportable Event may be the result of an isolated
event or a series of occurrences.

b.             Reporting of Reportable Events.  If Tenet determines (after a reasonable
opportunity to conduct an appropriate review or investigation of the
allegations) through any means that there is a Reportable Event, Tenet shall
notify OIG, in writing, within 30 days after making the determination that the
Reportable Event exists.  The report to
OIG shall include the following information:

i.              If the Reportable Event results in
an Overpayment, the report to 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 (see Attachment 2), as well as:

(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) by which the
Overpayment was repaid/refunded;

 21
 

 

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 Tenet’s actions
taken to correct the Reportable Event; and

iv.            any further steps Tenet plans to
take to address the Reportable Event and prevent it from recurring.

Notwithstanding any other provision in Section III.H
to the contrary, in the event that a submission by Tenet is accepted into the
OIG Provider Self-Disclosure Protocol regarding a Reportable Event that
resulted in an Overpayment, OIG may, in its sole discretion and upon request by
Tenet, waive the CIA’s requirement that Tenet repay the Overpayment within the
time otherwise required in Section III.H and permit Tenet to repay the
Overpayment within a time period agreed to by OIG.

IV.           NEW
BUSINESS UNITS OR LOCATIONS

In the event that, after the Effective Date, Tenet
changes locations or sells, closes, purchases, or establishes a new business
unit or location related to the furnishing of items or services that may be
reimbursed by Federal health care programs, Tenet shall notify OIG of this fact
as soon as possible, but no later than within 30 days after the date of change
of location, sale, closure, purchase, or establishment.  This notification shall include the address
of the new business unit or location, phone number, fax number, Medicare
Provider number, provider identification number and/or supplier number, and the
corresponding contractor’s name and address that has issued each Medicare
number.  Each new business unit or
location shall be subject to all the requirements of this CIA.

V.            IMPLEMENTATION
AND ANNUAL REPORTS

A.            Implementation
Report.  Within 150 days after the
Effective Date, Tenet shall submit a written report to OIG summarizing the status
of its implementation of the requirements of this CIA (Implementation
Report).  The Implementation Report
shall, at a minimum, include:

1.             the
names, addresses, phone numbers, and position descriptions of the Chief
Compliance Officer, Regional Compliance Officers, Hospital Compliance Officers,
and Chief Medical Officer as required by Section III.A;

2.             the
name, addresses, phone numbers, and position descriptions of the Chief
Executive Officer, Chief Financial Officer, Chief Operating Officer, General Counsel,
Vice President for Government Programs, and all Regional Senior Vice
Presidents;

3.             the
names and positions of the members of the Corporate Compliance Committee and
the Regional Compliance Committees required by Section III.A;

 22
 

 

4.             the
names of Tenet’s directors on the Quality, Compliance, and Ethics Committee of
the Board of Directors required by Section III.A.7;

5.             a
copy of Tenet’s Code of Conduct required by Section III.B.1;

6.             an
index of all Policies and Procedures required by Section III.B.2;

7.             the
number of individuals required to complete the Code of Conduct certification
required by Section III.B.1, the percentage of individuals (including Excepted
Physicians) who have completed such certification, and an explanation of any
exceptions (the documentation supporting this information shall be available to
OIG, upon request);

8.             the
following information regarding each type of training required by Section
III.C:

a.             a description of such training,
including a summary of the topics covered, the length of sessions and a
schedule of training sessions;

b.             the number of individuals required
to be trained, percentage of individuals (including Excepted Physicians)
actually trained, and an explanation of any exceptions.

A copy of all training materials and the documentation
supporting this information shall be available to OIG, upon request.

9.             a
description of the Disclosure Program required by Section III.E;

10.           the
following information regarding each of the IROs: (a) identity, address, and
phone number; (b) a copy of the engagement letter; (c) a summary and
description of any and all current and prior engagements and agreements between
Tenet and the IRO; and (d) the proposed start and completion dates of the IRO
Reviews;

11.           a
certification from each IRO regarding its professional independence and
objectivity with respect to Tenet;

12.           a
description of the process by which Tenet fulfills the requirements of Section
III.F regarding Ineligible Persons;

13.           the
name, title, and responsibilities of any person who is determined to be an
Ineligible Person under Section III.F; the actions taken in response to the
screening and removal obligations set forth in Section III.F; and the actions
taken to identify quantify, and repay any overpayments to Federal health care
programs relating to items or services furnished, ordered or prescribed by an
Ineligible Person;

14.           a
list of all of Tenet’s hospitals and other health care facilities (including
locations and mailing addresses); the corresponding name under which each
facility is doing business; the corresponding phone numbers and fax numbers;
each facility’s Medicare provider 

 23
 

 

number(s), provider identification number(s), and/or supplier
number(s); and the name and address of each Medicare contractor to which Tenet currently
submits claims;

15.           a
description of Tenet’s corporate structure, including identification of any
parent, sister, or holding companies, subsidiaries, their respective lines of
business, their locations, and mailing addresses; and

16.           the
certifications required by Section V.C.

B.            Annual Reports.  Tenet shall submit to OIG annually a report
with respect to the status of, and findings regarding, Tenet’s compliance
activities for each of the five Reporting Periods (Annual Report).

Each Annual Report shall include, at a minimum:

1.             any
change in the identity, position description, or other noncompliance job
responsibilities of the Chief Compliance Officer, Regional Compliance Officers,
Hospital Compliance Officers, Chief Medical Officer, Chief Executive Officer,
Chief Financial Officer, Chief Operating Officer, General Counsel, Vice
President for Government Programs, or Regional Senior Vice President;

2.             any
change in the membership of the Corporate Compliance Committee or the Regional
Compliance Committees described in Section III.A;

3.             any
change in the membership of the Board Committee described in Section III.A.7;

4.             a
copy of the Board Committee’s resolution required under Section III.A.7;

5.             a
copy of the Board Committee’s Compliance Program Review required under Section
III.A.7;

6.             a
summary of any significant changes or amendments to the Written Standards
required by Section III.B and the reasons for such changes;

7.             the
number of individuals required to complete the Code of Conduct certification required
by Section III.B.1, the percentage of individuals (including Excepted
Physicians) who have completed such certification, and an explanation of any
exceptions (the documentation supporting this information shall be available to
OIG, upon request);

8.             the
following information regarding each type of training required by Section
III.C:

a.             a description of such training,
including a summary of the topics covered, the length of sessions and a
schedule of training sessions;

 24
 

 

b.             the number of individuals required
to be trained, percentage of individuals (including Excepted Physicians)
actually trained, and an explanation of any exceptions;

c.             a complete list of all Billing and
Reimbursement Covered Persons, Arrangements Covered Persons, and Clinical
Quality Covered Persons; and

d.             a complete list of Covered
Contractors who did not receive Specific Training from Tenet but who completed
certifications required under Section III.C.8.

A copy of all training materials and the documentation
supporting this information shall be available to OIG, upon request.

9.             a
complete copy of all reports prepared pursuant to Section III.D and Appendices
A-E, along with a copy of each IRO’s engagement letter;

10.           Tenet’s
response and corrective action plan(s) related to any issues raised by the
reports prepared pursuant to Section III.D and Appendices A-E;

11.           a
summary and description of any and all current and prior engagements any
agreements between Tenet and each IRO, if different from what was submitted as
part of the Implementation Report;

12.           a
certification from each of the IROs regarding its professional independence and
objectivity with respect to Tenet;

13.           a
summary of Reportable Events (as defined in Section III.H) identified during
the Reporting Period and the status of any corrective and preventative action
relating to all such Reportable Events;

14.           a
report of the aggregate Overpayments that have been returned to the Federal
health care programs.  Overpayment
amounts shall be broken down by each Tenet hospital into the following
categories:  inpatient Medicare,
outpatient Medicare, Medicaid (report each applicable state separately, if
applicable), and other Federal health care programs.  Overpayment amounts that are routinely
reconciled or adjusted pursuant to policies and procedures established by the
payor do not need to be included in this aggregate Overpayment report;

15.           a
summary of the disclosures in the disclosure log required by Section III.E
that:  (a) relate to Federal health care
programs; or (b) allege abuse or neglect of patients;

16.           any
changes to the process by which Tenet fulfills the requirements of Section
III.F regarding Ineligible Persons;

17.           the
name, title, and responsibilities of any person who is determined to be an
Ineligible Person under Section III.F; the actions taken by Tenet in response
to the screening 

 25
 

 

and removal obligations set forth in Section III.F; and the actions
taken to identify, quantify, and repay any overpayments to Federal health care
programs relating to items or services furnished, ordered or prescribed by an
Ineligible Person;

18.           a
summary describing any ongoing investigation or legal proceeding required to
have been reported pursuant to Section III.G. 
The summary shall include a description of the allegation, the identity
of the investigating or prosecuting agency, and the status of such
investigation or legal proceeding;

19.           a
description of all changes to the most recently provided list of Tenet’s
locations (including addresses) as required by Section V.A.14; the corresponding
name under which each location is doing business; the corresponding phone
numbers and fax numbers; each location’s Medicare Provider number(s), provider
identification number(s), and/or supplier number(s); and the name and address
of each Medicare contractor to which Tenet currently submits claims; and

20.           the
certifications required by Section V.C.

The first Annual Report shall be received by OIG no
later than 90 days after the end of the first Reporting Period.  Subsequent Annual Reports shall be received
by OIG no later than the anniversary date of the due date of the first Annual
Report.

C.            Certifications. 
The following certifications shall be included in the Implementation
Report and Annual Reports:

1.                                       Senior
Corporate Management.  In each
Implementation Report and Annual Report, Tenet shall include the following
individual certification by the Chief Executive Officer, Chief Financial
Officer, Chief Operating Officer, Chief Compliance Officer, Chief Medical
Officer, General Counsel, Regional Senior Vice Presidents, and Regional
Compliance Officers:

To the best of my knowledge, except as otherwise
described in the applicable report, Tenet is in compliance with the
requirements of the Federal health care program requirements and the obligations
of this CIA.

2.                                       Chief
Compliance Officer and Regional Compliance Officers.  In each Implementation Report and Annual
Report, Tenet shall include the following individual certification by the Chief
Compliance Officer and each Regional Compliance Officer:

I have reviewed the Report and have made reasonable
inquiry regarding its content and, to the best of my knowledge, believe that
the information in the Report is accurate and truthful.

3.                                       Chief
Compliance Officer and Vice President for Government Programs.  In each Implementation Report and Annual
Report, Tenet shall include the 

 26
 

 

                                                following
individual certification by the Chief Compliance Officer and Vice President for
Government Programs:

To the best of my knowledge, Tenet has complied with
its obligations under the Settlement Agreement: 
(a) not to resubmit to any Federal health care program payors any
previously denied claims related to the Covered Conduct addressed in the
Settlement Agreement, and not to appeal any such denials of claims; (b) not to
charge to or otherwise seek payment from federal or state payors for
unallowable costs (as defined in the Settlement Agreement); and (c) to identify
and adjust any past charges or claims for unallowable costs.

D.            Designation of
Information.  Tenet shall clearly
identify any portions of its submissions that it believes are trade secrets, or
information that is commercial or financial and privileged or confidential, and
therefore potentially exempt from disclosure under the Freedom of Information
Act (FOIA), 5 U.S.C. § 552.  Tenet shall
refrain from identifying any information as exempt from disclosure if that
information does not meet the criteria for exemption from disclosure under
FOIA.

VI.           NOTIFICATIONS AND SUBMISSION OF REPORTS

Unless otherwise stated in writing after the Effective
Date, all notifications and reports required under this CIA shall be submitted
as follows:

A.            Tenet.  Tenet shall submit each notification or
report in writing to OIG at the following address:

Administrative and Civil Remedies Branch 

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, S.W.

Washington, DC  20201

Telephone:  (202) 619-2078

Facsimile:  (202) 205-0604

Tenet shall also provide to OIG an electronic copy of
each notification or report in single page TIF format with optical character
recognition (OCR) text files, along with the data and image load files
compatible with Concordance and Opticon respectively, on CD-ROM.

B.            OIG.  OIG shall submit each notification in writing
to Tenet at the following address:

 27
 

 

Steven W. Ortquist

Senior Vice President, Ethics and Compliance

Chief Compliance Officer

Tenet Healthcare Corporation

13737 Noel Road, Suite 100

Dallas, TX 75240

Telephone:  (469) 893-2040

Facsimile:  (469) 893-3040

with copy to:

E. Peter Urbanowicz

General Counsel

Tenet Healthcare Corporation

13737 Noel Road, Suite 100

Dallas, TX  75230

Telephone:  (469) 893-6450

Facsimile:  (469) 893-2654

C.            Proof of Submissions.  Unless otherwise specified, all written
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.

VII.         OIG
INSPECTION, AUDIT, AND REVIEW RIGHTS

A.            Inspection,
Audit, and Review.  In addition to
any other rights OIG may have by statute, regulation, or contract, OIG or its
duly authorized representative(s) may examine or request copies of Tenet’s
books, records, and other documents and supporting materials and/or conduct
on-site reviews of any of Tenet’s locations for the purpose of verifying and
evaluating:  (a) Tenet’s compliance
with the terms of this CIA; and (b) Tenet’s compliance with the requirements of
the Federal health care programs in which it participates.  The documentation described above shall be
made available by Tenet 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 Tenet’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.  Tenet shall assist OIG or its duly
authorized representative(s) in contacting and arranging interviews with such
individuals upon OIG’s request.  Tenet’s
employees may elect to be interviewed with or without a representative of Tenet
present.

B.            Assertion of
Privilege.  If Tenet believes that
any notification, report, or documentation required to be submitted under the
CIA or requested by OIG pursuant to this Section VII is a privileged
attorney-client communication and Tenet has decided to assert the privilege,
the privilege shall be asserted as follows: 
(1) Tenet’s General Counsel shall assert the privilege in a written
letter to OIG and shall include in that letter, for each applicable document,
the privilege being claimed and an explanation of the claim in sufficient
detail to allow an 

 28
 

 

assessment of its validity and a description of each such document or
part thereof, including, as applicable, the type of document (e.g.,
letter, memorandum, or handwritten notes), subject matter, date of preparation,
number of pages, name, address and title of author(s), and names, addresses and
titles of all actual and intended recipients; (2) Tenet’s General Counsel shall
report the assertion of privilege to the Corporate Compliance Committee and the
Board Committee within 30 days of the notification to OIG, and (3) if OIG (in
its sole discretion) so requests, Tenet shall engage an Unaffiliated Law Firm
to review any materials claimed as privileged to determine whether such
privilege applies (hereinafter “Privilege Review”).  For the purposes of this Section VII, an “Unaffiliated
Law Firm” shall mean a law firm with expertise in attorney-client privilege
that has no prior affiliation or engagement with Tenet or its predecessors
within the past five years from the Effective Date.  If OIG requests such Privilege Review, Tenet
shall engage the Unaffiliated Law Firm and notify OIG of the identity of the
Unaffiliated Law Firm within 30 days after OIG’s request.  Within 30 days after OIG receives written
notice of the identity of the Unaffiliated Law Firm, OIG will notify Tenet if
the Unaffiliated Law Firm is unacceptable. 
Absent notification from OIG that the Unaffiliated Law Firm is
unacceptable, Tenet may instruct the Unaffiliated Law Firm to proceed with the
Privilege Review.  The Unaffiliated Law
Firm shall review the assertion of privilege, create a privilege log, and
submit the privilege log to OIG within 60 days of OIG’s request.  Tenet agrees to abide by the determinations
of the Unaffiliated Law Firm on the assertion of attorney-client privilege.

VIII.        DOCUMENT
AND RECORD RETENTION

Tenet shall maintain for inspection all documents and
records relating to reimbursement from the Federal health care programs, or to
compliance with this CIA, for six years (or longer if otherwise required by
law) from the Effective Date.

IX.           DISCLOSURES

Consistent with HHS’s FOIA procedures, set forth in 45
C.F.R. Part 5, OIG shall make a reasonable effort to notify Tenet prior to any
release by OIG of information submitted by Tenet pursuant to its obligations
under this CIA and identified upon submission by Tenet as trade secrets, or
information that is commercial or financial and privileged or confidential,
under the FOIA rules.  With respect to
such releases, Tenet shall have the rights set forth at 45 C.F.R.
§ 5.65(d).

X.            BREACH AND
DEFAULT PROVISIONS

Tenet 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, Tenet and OIG hereby agree that failure to comply with
certain obligations as 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.

1.             A Stipulated Penalty of $2,500 (which shall begin to
accrue on the day after the date the obligation became due) for each day Tenet
fails to establish and implement any of the following obligations as described
in Section III:

 29
 

 

a.             Chief Compliance Officer;

b.             Regional Compliance Officers;

c.             Hospital Compliance Officers;

d.             Ethics and Compliance Department;

e.             Clinical Quality Department;

f.              Corporate Compliance Committee;

g.             Regional and Hospital Compliance
Committees;

h.             Quality, Compliance, and Ethics
Committee of the Board of Directors;

i.              written Policies and Procedures;

j.              training of Covered Persons,
Billing and Reimbursement Covered Persons, Arrangements Covered Persons, and
Clinical Quality Covered Persons;

k.             a Disclosure Program;

l.              Ineligible Persons screening and
removal requirements; and

m.            Notification of Government
investigations or legal proceedings.

2.             A
Stipulated Penalty of $2,500 (which shall begin to accrue on the day after the
date the obligation became due) for each day Tenet fails to engage an IRO, as
required in Section III.D and Appendices A-E.

3.             A
Stipulated Penalty of $2,500 (which shall begin to accrue on the day after the
date the obligation became due) for each day Tenet fails to submit the
Implementation Report or the Annual Reports to OIG in accordance with the
requirements of Section V by the deadlines for submission.

4.             A
Stipulated Penalty of $2,500 (which shall begin to accrue on the day after the
date the obligation became due) for each day Tenet fails to submit the IRO
Review Reports in accordance with the requirements of Section III.D and
Appendices A-E.

5.             A
Stipulated Penalty of $1,500 for each day Tenet fails to grant access to the
information or documentation as required in Section VII or any other provision
under the CIA.  (This Stipulated Penalty
shall begin to accrue on the date Tenet fails to grant access.)

6.             A
Stipulated Penalty of $50,000 for each false certification submitted by or on
behalf of Tenet as part of its Implementation Report, Annual Report, additional
documentation to a report (as requested by the OIG), or otherwise required by
this CIA.

 

 30

 

7.             A
Stipulated Penalty of $1,000 for each day Tenet fails to comply fully and
adequately with any obligation of this CIA. 
OIG shall provide notice to Tenet, stating the specific grounds for its
determination that Tenet has failed to comply fully and adequately with the CIA
obligation(s) at issue and steps Tenet shall take to comply with the CIA.  (This Stipulated Penalty shall begin to
accrue 10 days after Tenet receives this notice from OIG of the failure to
comply.)  A Stipulated Penalty as
described in this Subsection shall not be demanded for any violation for which
OIG has sought a Stipulated Penalty under Subsections 1-6 of this Section.

B.            Timely
Written Requests for Extensions. 
Tenet may, in advance of the due date, 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 Penalties for
failure to perform the act or file the notification or report shall not begin
to accrue until one day after Tenet fails to meet the revised deadline set by
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 three business days after Tenet receives OIG’s
written denial of such request or the original due date, whichever is later.  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.

C.            Payment
of Stipulated Penalties.

1.             Demand Letter.  Upon a
finding that Tenet has failed to comply with any of the obligations described
in Section X.A and after determining that Stipulated Penalties are appropriate,
OIG shall notify Tenet of:  (a) Tenet’s
failure to comply; and (b) OIG’s exercise of its contractual right to demand
payment of the Stipulated Penalties (this notification is referred to as the “Demand
Letter”).

2.             Response to Demand Letter. 
Within 10 days after the receipt of the Demand Letter, Tenet shall
either:  (a) cure the breach to OIG’s
satisfaction and pay the applicable Stipulated Penalties; or (b) request a
hearing before an HHS administrative law judge (ALJ) to dispute OIG’s
determination of noncompliance, pursuant to the agreed upon provisions set
forth below in Section X.E.  In the event
Tenet elects to request an ALJ hearing, the Stipulated Penalties shall continue
to accrue until Tenet cures, to 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.D.

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 set forth in Section X.D.1.c, these
provisions for payment of Stipulated Penalties shall not affect or otherwise
set a standard for OIG’s decision that Tenet has materially breached this CIA,
which 

 31
 

 

decision shall be made at OIG’s discretion and shall be governed by the
provisions in Section X.D, below.

D.            Exclusion
for Material Breach of this CIA.

1.             Definition of Material Breach.  A material breach of this CIA means:

a.             a failure by Tenet to report a
Reportable Event, take corrective action, and make the appropriate refunds, as
required in Section III.H;

b.             a repeated or flagrant violation of
the obligations under this CIA, including, but not limited to, the obligations
addressed in Section X.A;

c.             a failure to respond to a Demand
Letter concerning the payment of Stipulated Penalties in accordance with
Section X.C; or

d.             a failure to engage and use an IRO
in accordance with Section III.D.

2.             Notice of Material Breach and Intent to Exclude.  The parties agree that a material breach of
this CIA by Tenet constitutes an independent basis for Tenet’s exclusion from
participation in the Federal health care programs.  Upon a determination by OIG that Tenet has
materially breached this CIA and that exclusion is the appropriate remedy, OIG
shall notify Tenet of:  (a) Tenet’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 and Intent to Exclude”).

3.             Opportunity to Cure. 
Tenet shall have 30 days from the date of receipt of the Notice of
Material Breach and Intent to Exclude to demonstrate to OIG’s satisfaction
that:

a.             Tenet is in compliance with the
obligations of the CIA cited by OIG as being the basis for the material breach;

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) Tenet has begun to take action to cure the material breach; (ii)
Tenet is pursuing such action with due diligence; and (iii) Tenet has
provided to OIG a reasonable timetable for curing the material breach.

4.             Exclusion Letter.  If,
at the conclusion of the 30-day period, Tenet fails to satisfy the requirements
of Section X.D.3, OIG may exclude Tenet from participation in the Federal
health care programs.  OIG shall notify
Tenet in writing of its determination to exclude Tenet (this letter shall be
referred to hereinafter as the “Exclusion Letter”).  Subject to the Dispute Resolution provisions
in Section X.E, below, the exclusion shall go into effect 30 days after the
date of Tenet’s receipt of the Exclusion Letter.  The exclusion shall have national effect and
shall also apply to all other Federal procurement and nonprocurement
programs.  

 32
 

 

Reinstatement to program participation is not automatic.  After the end of the period of exclusion,
Tenet may apply for reinstatement by submitting a written request for
reinstatement in accordance with the provisions at 42 C.F.R. §§
1001.3001-.3004.

E.             Dispute
Resolution.

1.             Review Rights.  Upon
OIG’s delivery to Tenet of its Demand Letter or of its Exclusion Letter, and as
an agreed-upon contractual remedy for the resolution of disputes arising under
this CIA, Tenet shall be afforded certain review rights comparable to the ones
that are provided in 42 U.S.C. § 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, OIG’s determination to demand
payment of Stipulated Penalties or to seek exclusion shall be subject to review
by an HHS ALJ and, in the event of an appeal, the HHS Departmental Appeals
Board (DAB), in a manner consistent with the provisions in 42 C.F.R. § 1005.2-1005.21.  Notwithstanding the language in 42 C.F.R. § 1005.2(c),
the request for a hearing involving Stipulated Penalties shall be made within
10 days after receipt of the Demand Letter and the request for a hearing
involving exclusion shall be made within 25 days after receipt of the Exclusion
Letter.

2.             Stipulated Penalties Review. 
Notwithstanding any provision of Title 42 of the United States Code or
Title 42 of the Code of Federal Regulations, the only issues in a proceeding
for Stipulated Penalties under this CIA shall be:  (a) whether Tenet was in full and timely
compliance with the obligations of this CIA for which OIG demands payment; and
(b) the period of noncompliance.  Tenet
shall have the burden of proving its full and timely compliance and the steps
taken to cure the noncompliance, if any. 
OIG shall not have the right to appeal to the DAB an adverse ALJ
decision related to Stipulated Penalties. 
If the ALJ agrees with OIG with regard to a finding of a breach of this
CIA and orders Tenet to pay Stipulated Penalties, such Stipulated Penalties
shall become due and payable 20 days after the ALJ issues such a decision
unless Tenet requests review of the ALJ decision by the DAB.  If the ALJ decision is properly appealed to
the DAB and the DAB upholds the determination of OIG, the Stipulated Penalties
shall become due and payable 20 days after the DAB issues its decision.

3.             Exclusion Review. 
Notwithstanding any provision of Title 42 of the United States Code or
Title 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 Tenet 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) Tenet had begun to take action to cure
the material breach within that period; (ii) Tenet has pursued and is
pursuing such action with due diligence; and (iii) Tenet provided to OIG
within that period a reasonable timetable for curing the material breach and
Tenet has followed the timetable.

 33
 

 

For purposes of the exclusion herein, exclusion shall take
effect only after an ALJ decision favorable to OIG, or, if the ALJ rules for
Tenet, only after a DAB decision in favor of OIG.  Tenet’s election of its contractual right to
appeal to the DAB shall not abrogate OIG’s authority to exclude Tenet upon the
issuance of an ALJ’s decision in favor of OIG. 
If the ALJ sustains the determination of OIG and determines that
exclusion is authorized, such exclusion shall take effect 20 days after the ALJ
issues such a decision, notwithstanding that Tenet may request review of the
ALJ decision by the DAB.  If the DAB
finds in favor of OIG after an ALJ decision adverse to OIG, the exclusion shall
take effect 20 days after the DAB decision. 
Tenet shall waive its right to any notice of such an exclusion if a
decision upholding the exclusion is rendered by the ALJ or DAB.  If the DAB finds in favor of Tenet, Tenet
shall be reinstated effective on the date of the original exclusion.

4.             Finality of Decision. 
The review by an ALJ or DAB provided for above shall not be considered
to be an appeal right arising under any statutes or regulations.  Consequently, the parties to this CIA agree
that the DAB’s decision (or the ALJ’s decision if not appealed) shall be
considered final for all purposes under this CIA.

XI.           DEFAULT OF
PAYMENT OBLIGATIONS UNDER THE SETTLEMENT AGREEMENT

A.            Exclusion
in the Event of Default. 
Notwithstanding any term in this CIA, in the event of default of Tenet’s
payment obligations under Paragraph 1 of the Settlement Agreement, OIG may
exclude the Tenet Entities from participating in all Federal health care
programs until the Tenet Entities pays the Settlement Amount and reasonable
costs as set forth in Paragraph 3 of the Settlement Agreement.

B.            Effect
of Exclusion.  Such exclusion shall
have national effect and shall also apply to all other federal procurement and
nonprocurement programs.  Federal health
care programs shall not pay anyone for items or services, including
administrative and management services, furnished, ordered, or prescribed by
the Tenet Entities in any capacity while Tenet are excluded.  This payment prohibition applies to Tenet and
all other individuals and entities (including, for example, anyone who employs
or contracts with Tenet, and any hospital or other provider where Tenet provides
services).  The exclusion applies
regardless of who submits the claim or other request for payment.  Tenet shall not submit or cause to be
submitted to any Federal health care program any claim or request for payment
for items or services, including administrative and management services,
furnished, ordered, or prescribed by Tenet during the exclusion.  Violation of the conditions of the exclusion
may result in criminal prosecution, the imposition of civil monetary penalties
and assessments, and an additional period of exclusion.  Tenet further agrees to hold the Federal
health care programs, and all Federal beneficiaries and/or sponsors, harmless
from any financial responsibility for items or services furnished, ordered, or
prescribed to such beneficiaries or sponsors after the effective date of the
exclusion.

C.            Implementation
of Exclusion.  Tenet waives any
further notice of the exclusion under 42 U.S.C. § 1320a-7(b)(7), and agree not
to contest such exclusion either administratively or in any state or federal
court.  Reinstatement to program
participation is not automatic.  If at
the end of the period of exclusion Tenet wishes to apply for reinstatement,
Tenet must submit a written request for reinstatement to the OIG in accordance
with the provisions of 42 C.F.R. 

 34
 

 

§§ 1001.3001-.3005.  Tenet
will not be reinstated unless and until the OIG approves such request for
reinstatement.

XII.         EFFECTIVE
AND BINDING AGREEMENT

Tenet and OIG agree as follows:

A.            This
CIA shall be binding on the successors, assigns, and transferees of Tenet.

B.            This
CIA shall become final and binding on the date the final signature is obtained
on the CIA.

C.            Any
modifications to this CIA shall be made with the prior written consent of the
parties to this CIA.

D.            OIG
may agree to a suspension of Tenet’s obligations under the CIA in the event of
Tenet’s cessation of participation in Federal health care programs.  If Tenet withdraws from participation in
Federal health care programs and is relieved of its CIA obligations by OIG,
Tenet shall notify OIG at least 30 days in advance of Tenet’s intent to reapply
as a participating provider or supplier with any Federal health care
program.  Upon receipt of such
notification, OIG shall evaluate whether the CIA should be reactivated or
modified.

E.             The
undersigned Tenet 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.

 35
 

 

ON
BEHALF OF TENET HEALTHCARE CORPORATION

 

	
  /s/ Trevor Fetter

  	
   

  	
  9/27/06

  
	
  TREVOR FETTER 

  	
   

  	
  DATE

  
	
  Chief Executive Officer 

  	
   

  	
   

  
	
  Tenet Healthcare Corporation

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  /s/ Steven W. Ortquist

  	
   

  	
  9/27/06

  
	
  STEVEN W. ORTQUIST  
  

  	
   

  	
  DATE

  
	
  Senior Vice President, Ethics and Compliance

  	
   

  	
   

  
	
  and Chief Compliance Officer

  	
   

  	
   

  
	
  Tenet Healthcare Corporation

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  /s/ Roger S. Goldman

  	
   

  	
  9/27/06

  
	
  ROGER S. GOLDMAN 

  	
   

  	
  DATE

  
	
  Latham & Watkins LLP 

  	
   

  	
   

  
	
  Counsel for Tenet Healthcare Corporation

  	
   

  	
   

  

 

 36
 

 

ON
BEHALF OF THE OFFICE OF INSPECTOR GENERAL

OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES

 

	
  /s/ Gregory E. Demske

  	
   

  	
  9/27/06

  
	
  GREGORY E.
  DEMSKE 

  	
   

  	
  DATE

  
	
  Assistant
  Inspector General for Legal Affairs 

  	
   

  	
   

  
	
  Office of
  Inspector General 

  	
   

  	
   

  
	
  U.S. Department
  of Health and Human Services

  	
   

  	
   

  

 

 37
 

 

APPENDIX A

OUTLIER PAYMENTS REVIEWS

The IRO shall perform reviews of Medicare inpatient
operating outlier payments (as defined in 42 C.F.R. Part 412) paid to Tenet
acute care hospitals (“Outlier Payments”), as well as the processes by which
Tenet may receive such outlier payments (collectively “Outlier Payments Reviews”),
except as provided under Section 7 of this Appendix.  The reviews shall be performed as follows:

1.                                       CCR
Review.  For every Tenet hospital
whose total Outlier Payments exceed $500,000 in a cost reporting period filed
during a Reporting Period of the CIA, the IRO shall compare the hospital’s
actual operating cost-to-charge ratio (CCR) based on the hospital’s most recent
filed cost report and the CCR(s) used by the Medicare fiscal intermediary
during the corresponding time period to make Outlier Payments (hereinafter “CCR
Review”).  If the actual operating CCR(s)
are found to be plus or minus 10 percentage points or more from the CCR(s) used
by the Medicare fiscal intermediary during that time period to make Outlier
Payments, the IRO shall investigate and determine the root cause(s) of the
variance.  Such investigation may
include, but shall not be limited to, a review of the hospital’s cost
report(s), chargemaster, charge or price increases, the hospital’s costs for
items or services, length of stays, and any other potential causes for the
variance.  If applicable, the IRO shall
provide its findings and recommendations to Tenet for any such variance in the
CCR, including a recommendation that Tenet request the Centers of Medicare
& Medicaid Services (CMS) to reconcile outlier payments pursuant to 42 C.F.R.
Part 412.  Tenet shall develop and
implement a corrective action plan based on the IRO’s findings and
recommendations for each variance.  The
Chief Compliance Officer shall certify in each Annual Report that Tenet has
implemented these corrective actions.

2.                                       Outlier
Payment Percentage Review.  The IRO
shall compare each Tenet hospital’s Outlier Payment Percentage for the cost reporting
period filed during each Reporting Period of the CIA to the Outlier Payment
percentage for the prior cost reporting period (hereinafter “Outlier Payment
Percentage Review”).  “Outlier Payment
Percentage” shall be defined as (a) the total Outlier Payments received by the
hospital divided by (b) the total Outlier Payments plus Medicare operating DRG
payments.  If the Outlier Payment
Percentage for the cost reporting period is at least five percent (5%) and increased
from the prior cost reporting period to the cost reporting period under review
by more than 10%, the IRO shall investigate and determine the root cause(s) of
the variance.  The IRO shall provide
Tenet with findings and recommendations for any variance in the Outlier Payment
Percentage.  Tenet shall develop and
implement a corrective action plan based on the IRO’s findings and
recommendations for each variance.  The
Chief Compliance Officer shall certify in each Annual Report that Tenet has
implemented these corrective actions.

 38
 

 

3.                                       Chargemaster
Review.  The IRO shall randomly
select and review 250 requests to add or increase charges to Tenet hospital
chargemasters under the eCDM review process and the CDM AS/400 system
(hereinafter “Chargemaster Review”).  For
the purposes of the Chargemaster Review, “Requests” shall include any charge
additions, charge activations, charge code changes, and rate increases and
adjustments, including but not limited to annual/periodic across-the-board
prices increases implemented in Tenet hospital chargemasters.  For each Request selected to be reviewed, the
IRO shall review (1) whether the appropriate Tenet personnel, including the
applicable Tenet hospital’s chief financial officer and Tenet’s Patient
Financial Services Department, have reviewed and approved the Request; (2)
whether the Request was appropriately processed through the eCDM software
program; (3) whether the Request was correctly transmitted to the CDM AS/400
system; and (4) whether the Request was correctly incorporated on the Tenet
hospital’s chargemaster.  If the IRO
determines that there has been any variance in the process, the IRO shall
investigate and determine the root cause(s) of the variance.  If applicable, the IRO shall provide findings
and recommendations to Tenet for any variance identified during the
Chargemaster Review.  Tenet shall develop
and implement a corrective action plan based on the IRO’s findings and
recommendations for each variance.  The
Chief Compliance Officer shall certify in each Annual Report that Tenet has
implemented these corrective actions.

4.                                       Frequency
of Reviews.  The Outlier Payments
Reviews shall be performed annually beginning with the cost reporting periods
ending December 31, 2006 and shall cover each of the cost reporting periods
filed during the Reporting Periods.  The
IRO shall perform all components of the Outlier Payments Reviews unless
performed by Tenet’s Internal Audit Department as permitted in Section 7 of
this Appendix.

5.                                       IRO
Qualifications.  The IRO engaged by
Tenet shall have expertise in hospital chargemasters, outlier payments, billing
and reimbursement, and the general requirements of the Federal health care
program(s) from which Tenet seeks reimbursement.

6.                                       Outlier
Payments Review Report.  The IRO
shall prepare a report based upon the Outlier Payments Reviews performed for
each Reporting Period (Outlier Payments Review Report).  Each report shall include a narrative
description of the IRO’s findings, the total number of variances in the CCRs
and/or Outlier Percentages identified in the Outlier Payments Reviews, a
description of each identified variance, a description of the root cause(s) of
the variance, and any corrective actions recommended by the IRO.  The IRO shall provide Tenet with a copy of
the Outlier Payments Review Reports.

7.                                       Internal
Option for Outlier Payment Percentage Review.  Tenet’s Internal Audit Department (IAD) may
conduct the Outlier Payment Percentage Review in accordance with the
requirements of Section 2 of this Appendix. 
Tenet’s IAD 

 39
 

 

shall prepare an Outlier
Payments Review Report in accordance with Section 6 of this Appendix, and Tenet
shall include these reports in each Annual Report.

 

 40

 

 

APPENDIX B

DIAGNOSIS RELATED GROUPS
CLAIMS REVIEW

The IRO shall conduct claims reviews to identify any
Overpayments through an appraisal of inpatient discharges paid on the basis of
DRGs by the Medicare program (hereinafter “DRG Claims Review”), except as
provided in Section 7 of this Appendix. 
The DRG Claims Review shall be conducted at 20% of Tenet’s hospitals for
each Reporting Period.  For each
Reporting Period, 10% of Tenet’s hospitals shall be reviewed for the twelve
month period ending at the midpoint of the applicable Reporting Period (i.e.,
six months into the Reporting Period) and the remaining 10% of Tenet’s
hospitals shall be reviewed for the twelve month period ending at the close of
the Reporting Period.  Each DRG Claims
Review shall include a Discovery Sample and, if necessary, a Full Sample for
each Tenet hospital reviewed.  The review
shall be performed as follows:

1.                                       Selection
of Tenet Hospitals To Be Reviewed. 
Within 60 days after the start of each Reporting Period, Tenet shall
provide OIG with the following information for each Tenet hospital for the
prior fiscal year:  (1) total dollar
amount of Paid Claims for inpatient discharges paid on the basis of DRGs; and
(2) the percentage of Medicare and Medicaid reimbursement received by the Tenet
hospital compared to the hospital’s total revenue.  In addition, within 60 days after the start
of each Reporting Period, the IRO shall provide OIG with its recommendations of
the hospitals to be reviewed and the schedule of reviews for the Reporting Period.  Within 30 days after OIG receives the IRO’s
recommendations, OIG will notify the IRO if the recommendations are
unacceptable and provide the final list of hospitals to be reviewed and the
schedule of reviews.  Absent notification
from OIG that the recommendations are unacceptable, the IRO may proceed with
the DRG Claims Review.

2.                                       Discovery
Sample.  For each Tenet hospital
selected to be reviewed, the IRO shall randomly select and review a sample of
50 Paid Claims for inpatient discharges paid on the basis of DRGs submitted by
or on behalf of Tenet (Discovery Sample). 
The Paid Claims shall be reviewed based on the supporting documentation
available at Tenet’s office or under Tenet’s control and applicable billing and
coding regulations and guidance to determine whether the claim was correctly
coded, submitted, and reimbursed.

If the Error Rate for the Discovery Sample for any
hospital reviewed is less than 5%, no additional sampling is required nor is
the Systems Review required for the applicable hospital.  (Note: The guidelines listed above do not
imply that this is an acceptable error rate. 
Accordingly, Tenet should, as appropriate, further analyze any errors
identified in the Discovery Sample. 
Tenet recognizes that OIG or other HHS component, in its discretion and
as authorized by statute, regulation, or other appropriate authority may also
analyze or review Paid Claims included, or errors identified, in the Discovery
Sample or any other segment of the universe.)

 41
 

 

 

If the Discovery Sample for any hospital reviewed
indicates that the Error Rate is 5% or greater, the IRO shall perform a Full
Sample and a Systems Review for the applicable hospital, as described below.

3.                                       Full
Sample.  If necessary, as determined
by procedures set forth above, the IRO shall select an additional sample of
Paid Claims using commonly accepted sampling methods and in accordance with
this Appendix.  The Full Sample shall be
designed to: (i) estimate the actual Overpayment in the population with a 90%
confidence level and with a maximum relative precision of 25% of the point
estimate; and (ii) conform with CMS’s statistical sampling for overpayment
estimation guidelines.  The Paid Claims
shall be reviewed based on supporting documentation available at Tenet’s office
or under Tenet’s control and applicable billing and coding regulations and
guidance to determine whether the claim was correctly coded, submitted, and
reimbursed.  For purposes of calculating
the size of the Full Sample, the Discovery Sample may serve as the probe
sample, if statistically appropriate. 
Additionally, Tenet may use the Items sampled as part of the Discovery
Sample, and the corresponding findings for those 50 Items, as part of its Full
Sample, if:  (i) statistically
appropriate and (ii) Tenet selects the Full Sample Items using the seed number
generated by the Discovery Sample.  OIG,
in its sole discretion, may refer the findings of the Full Sample (and any
related workpapers) received from Tenet to the appropriate Federal health care
program payor, including the Medicare contractor (e.g., carrier, fiscal
intermediary, or DMERC), for appropriate follow-up by that payor.

4.                                       Systems
Review.  If the Discovery Sample for
any hospital reviewed identifies an Error Rate of 5% or greater, the IRO shall
also conduct a Systems Review for the applicable hospital.  Specifically, for each claim in the Discovery
Sample and Full Sample that resulted in an Overpayment, the IRO shall perform a
“walk through” of the system(s) and process(es), that generated the claim to identify
any problems or weaknesses that may have resulted in the identified
Overpayments.  The IRO shall provide its
observations and recommendations on suggested improvements to the system(s) and
the process(es) that generated the claim.

5.                                       Repayment
of Identified Overpayments.  In
accordance with Section III.H.1 of this Agreement, Tenet shall repay within 30
days any Overpayment(s) identified in the Discovery Sample or the Full Sample
(if applicable), regardless of the Error Rate, to the appropriate payor and in
accordance with payor refund policies. 
Tenet shall make available to OIG any and all documentation that
reflects the refund of the Overpayment(s) to the payor.

6.                                       Frequency
of DRG Claims Review.  The DRG Claims
Review shall be performed annually and shall cover full twelve month periods in
accordance with the first paragraph of this Appendix.  The IRO(s) shall perform all components of
each annual DRG Claims Review, except as provided by Section 7 of this Appendix.

7.                                       Internal
DRG Claims Review Option.  Tenet’s
Coding Compliance Department (CCD) may conduct the Discovery Samples for half
of the Tenet hospitals 

 42
 

 

                                                selected
to be reviewed, which hospitals shall be determined in accordance with Section
1 of this Appendix.  Tenet’s CCD shall
conduct the Discovery Samples in accordance with the requirements of Section 2
of this Appendix.  Tenet’s CCD shall
prepare a DRG Claims Review Report in accordance with Section 8 of this
Appendix, and Tenet shall include these reports in each Annual Report.  If the Discovery Sample Error Rate at any
Tenet hospital is 5% or greater, the IRO shall conduct a Full Sample and a
Systems Review at the applicable hospital in accordance with Sections 3 and 4
of this Appendix.  Following the OIG’s
review of Tenet’s Second Annual Report, Tenet may request the OIG to permit
Tenet’s CCD to perform a greater percentage of the Discovery Samples.  However, the decision to allow Tenet’s CCD to
perform a greater percentage of the Discovery Samples shall be within the sole
discretion of the OIG.

8.                                       DRG
Claims Review Report.  The IRO shall
prepare a report based upon the DRG Claims Review performed (DRG Claims Review
Report).  The following information shall
be included in the DRG Claims Review Report for each Discovery Sample
and Full Sample:

a.                                       DRG Claims Review Methodology.

(i)                                     Sampling Unit.  A description of the Item as that term is
utilized for the DRG Claims Review.

(ii)                                  Claims Review
Population.  A description of the
Population subject to the DRG Claims Review.

(iii)                               Claims Review Objective.  A clear statement of the objective intended
to be achieved by the DRG Claims Review.

(iv)                              Sampling Frame.  A description of the sampling frame, which is
the totality of Items from which the Discovery Sample and, if any, Full Sample
has been selected and an explanation of the methodology used to identify the
sampling frame.  In most circumstances,
the sampling frame will be identical to the Population.

(v)                                 Source of Data.  A description of the specific documentation
relied upon by the IRO when performing the DRG Claims Review (e.g.,
medical records, physician orders, certificates of medical necessity,
requisition forms, local medical review policies (including title and policy
number), CMS program memoranda (including title and issuance number), Medicare
carrier or intermediary manual or bulletins (including issue and date), other
policies, regulations, or directives).

(vi)                              Review Protocol.  A narrative description of how the Claims
Review was conducted and what was evaluated.

 43
 

 

 

b.                                      Statistical Sampling Documentation.

(i)                                     The number of
Items appraised in the Discovery Sample and, if applicable, in the Full Sample.

(ii)                                  A copy of the
printout of the random numbers generated by the “Random Numbers” function of
the statistical sampling software used by the IRO.

(iii)                               A copy of the
statistical software printout(s) estimating how many Items are to be included
in the Full Sample, if applicable.

(iv)                              A description or
identification of the statistical sampling software package used to select the
sample and determine the Full Sample size, if applicable.

c.                                       DRG Claims Review Findings.

(i)                                     Narrative
Results.

(a)                                  A
description of Tenet’s billing and coding system(s), including the
identification, by position description, of the personnel involved in coding
and billing.

(b)                                 A
narrative explanation of the IRO’s findings and supporting rationale (including
reasons for errors, patterns noted, etc.) regarding the DRG Claims Review,
including the results of the Discovery Sample, and the results of the Full
Sample (if any).

(ii)                                  Quantitative
Results.

(a)                                  Total
number and percentage of instances in which the IRO determined that the Paid
Claims submitted by Tenet (Claim Submitted) differed from what should have been
the correct claim (Correct Claim), regardless of the effect on the payment.

(b)                                 Total
number and percentage of instances in which the Claim Submitted differed from
the Correct Claim and in which such difference resulted in an Overpayment to
Tenet.

(c)                                  Total
dollar amount of all Overpayments in the sample.

(d)                                 Total
dollar amount of paid Items included in the sample and the net Overpayment
associated with the sample.

(e)                                  Error
Rate in the sample.

 44
 

 

 

(f)                                    A
spreadsheet of the DRG Claims Review results that includes the following
information for each Paid Claim appraised: Federal health care program billed,
beneficiary health insurance claim number, date of service, procedure code
submitted, procedure code reimbursed, allowed amount reimbursed by payor,
correct procedure code (as determined by the IRO), correct allowed amount (as
determined by the IRO), dollar difference between allowed amount reimbursed by
payor and the correct allowed amount. 
(See Appendix B-l of the CIA)

d.                                      Systems Review.  Observations, findings, and recommendations
on possible improvements to the system(s) and process(es) that generated the
Overpayment(s).

e.                                       Credentials.  The names and credentials of the individuals
who: (1) designed the statistical sampling procedures and the review
methodology utilized for the DRG Claims Review; and (2) performed the DRG
Claims Review.

9.                                       Definitions
and Other Requirements.  For the
purposes of the DRG Claims Review, the following definitions shall be used:

a.                                       Overpayment:  The amount of money Tenet has received in
excess of the amount due and payable under any Federal health care program
requirements.

b.                                      Item: 
Any discrete unit that can be sampled (e.g., code, line item,
beneficiary, patient encounter, etc.).

c.                                       Paid Claim:  A code or line item submitted by Tenet and
for which Tenet has received reimbursement on the basis of DRGs from the
Medicare program.

d.                                      Population:  For the first Reporting Period, the
Population shall be defined as all Items for which a code or line item has been
submitted by or on behalf of Tenet and for which Tenet has received
reimbursement from Medicare (i.e., Paid Claim) during the 12-month
period covered by the first DRG Claims Review. 
For the remaining Reporting Periods, the Population shall be defined as
all Items for which Tenet has received reimbursement from Medicare (i.e.,
Paid Claim) during the 12-month period covered by the DRG Claims Review.  To be included in the Population, an Item
must have resulted in at least one Paid Claim.

e.                                       Error Rate:  The Error Rate shall be the percentage of net
Overpayments identified in the sample. 
The net Overpayments shall be calculated by subtracting all
underpayments identified in the sample from all gross Overpayments identified
in the sample.  (Note: Any potential cost

 45
 

 

                                                settlements
or other supplemental payments should not be included in the net Overpayment
calculation.  Rather, only underpayments
identified as part of the Discovery Sample shall be included as part of the net
Overpayment calculation.)  The Error Rate
is calculated by dividing the net Overpayment identified in the sample by the
total dollar amount associated with the Items in the sample.

f.                                         Paid Claims without Supporting Documentation.  For the purpose of appraising Items included
in the DRG Claims Review, any Paid Claim for which Tenet cannot produce
documentation sufficient to support the Paid Claim shall be considered an error
and the total reimbursement received by Tenet for such Paid Claim shall be
deemed an Overpayment.  Replacement
sampling for Paid Claims with missing documentation is not permitted.

g.                                      Replacement Sampling.  Considering the Population shall consist only
of Paid Claims and that Items with missing documentation cannot be replaced,
there is no need to utilize alternate or replacement sampling units.

h.                                      Use of First Samples Drawn.  For the purposes of all samples (Discovery
Samples and Full Samples) discussed in this Appendix, the Paid Claims
associated with the Items selected in each first sample (or first sample for
each strata, if applicable) shall be used (i.e., it is not permissible
to generate more than one list of random samples and then select one for use
with the Discovery Sample or Full Sample).

 46

 

APPENDIX B-1

CLAIM
REVIEW RESULTS

 

	
  Federal

  Health Care

  Program

  Billed

  	
   

  	
  Bene 

  HIC #

  	
   

  	
  Date of

  Service

  	
   

  	
  DRG 

  Code

  Submitted

  	
   

  	
  DRG 

  Code

  Reimbursed

  	
   

  	
  Allowed

  Amount

  Reimbursed

  	
   

  	
  Correct DRG

  Code (IRO

  determined)

  	
   

  	
  Correct

  Allowed Amt

  Reimbursed

  (IRO

  determined)

  	
   

  	
  Dollar

  Difference

  between Amt

  Reimbursed

  and Correct

  Allowed Amt

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  

 

 

 47

 

 

APPENDIX C

UNALLOWABLE COST REVIEW

The IRO shall conduct a review of Tenet’s compliance
with the unallowable cost provisions of the Settlement Agreement (hereinafter “Unallowable
Cost Review”) as follows:

1.                                       Unallowable
Cost Review.  The IRO shall determine
whether Tenet has complied with its obligations 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 to applicable federal
or state payors any unallowable costs included in payments previously sought
from the United States, or any state Medicaid program.  This unallowable cost analysis shall include,
but not be limited to, payments sought in any cost reports, cost statements,
information reports, or payment requests already submitted by Tenet or any
affiliates.  To the extent that such cost
reports, cost statements, information reports, or payment requests, even if
already settled, have been adjusted to account for the effect of the inclusion
of the unallowable costs, the IRO shall determine if such adjustments were
proper.  In making this determination,
the IRO may need to review cost reports and/or financial statements from the
year in which the Settlement Agreement was executed, as well as from previous
years.

2.                                       Frequency
of Unallowable Cost Review.  The IRO
shall perform the Unallowable Cost Review for the first Reporting Period.  The IRO shall perform all components of the
Unallowable Cost Review.

3.                                       IRO
Qualifications.  The IRO engaged by
Tenet shall have expertise in billing and reimbursement and in the general
requirements of the Federal health care program(s) from which Tenet seeks
reimbursement.

4.                                       Unallowable
Cost Review Report.  The IRO shall
prepare a report based upon the Unallowable Cost Review performed.  The Unallowable Cost Review Report shall
include the IRO’s findings and supporting rationale regarding the Unallowable
Costs Review and whether Tenet has complied with its obligation 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
to applicable federal or state payors any unallowable costs included in
payments previously sought from such payor.

 48
 

 

 

APPENDIX D

FOCUS ARRANGEMENTS REVIEWS

The IRO shall perform reviews to assess Tenet’s
compliance with the Arrangements Policies and Procedures required by Section
III.B.2.b of this CIA (hereinafter “Focus Arrangements Reviews”).  The IRO shall conduct this review at 20% of
Tenet’s hospitals for each Reporting Period. 
For each Reporting Period, 10% of Tenet’s hospitals shall be reviewed
for the twelve month period ending at the midpoint of the applicable Reporting
Period (i.e., six months into the Reporting Period) and the remaining 10% of
Tenet’s hospitals shall be reviewed for the twelve month period ending at the
close of the Reporting Period.  The
review shall be performed as follows:

1.                                       Selection
of Tenet Hospitals To Be Reviewed. 
Within 60 days after the start of each Reporting Period, the IRO shall
provide OIG with its recommendations of the hospitals to be reviewed and the
schedule of reviews for the Reporting Period. 
Within 30 days after OIG receives the IRO’s recommendations, OIG will
notify the IRO if the recommendations are unacceptable and provide the final
list of hospitals to be reviewed and the schedule of reviews.  Absent notification from OIG that the
recommendations are unacceptable, the IRO may proceed with the Focus
Arrangements Review.

2.                                       Focus
Arrangements Review.  The IRO
shall randomly select a sample of 40 Focus Arrangements at each Tenet hospital
to be reviewed.  The IRO shall assess
whether Tenet has implemented the Arrangements Policies and Procedures and, for
each selected Focus Arrangement, the IRO shall assess whether Tenet has
complied with the Arrangements Policies and Procedures with respect to that
Focus Arrangement.  The IRO’s assessment
shall include, but is not limited to (a) verifying that the Focus
Arrangement is listed in the Focus Arrangements Database; (b) verifying that
the Focus Arrangement was subject to the internal review and approval process
(including both a legal and business review) and obtained the necessary
approvals and that such review and approval is appropriately documented; (c)
verifying that the remuneration related to the Focus Arrangement is properly
tracked; (d) verifying that any required service and activity logs are properly
completed and reviewed; (e) verifying that leased space, medical supplies,
medical devices, and equipment, and other patient care items, if provided to a
physician, are monitored; (f) verifying that the Hospital Compliance Officer is
reviewing the Focus Arrangements Database, internal review and approval
process, and other Arrangements Policies and Procedures on a quarterly basis
and reporting the results of such review to the Hospital Compliance Committee,
the Regional Compliance Officer, and the Chief Compliance Officer (if
necessary); (g) verifying that corrective action is being implemented when
violations of the Anti-Kickback Statute and Stark Law are discovered; and
(h) verifying that Tenet’s agreements include incorporate the requirements
of Section III.B.2.b of the CIA.

 49
 

 

 

3.                                       Frequency
of Focus Arrangements Review.  The
Focus Arrangements Reviews shall be performed annually and shall cover full
twelve month periods in accordance with the first paragraph of this
Appendix.  The IRO shall perform all
components of the Focus Arrangements Reviews.

4.                                       IRO
Qualifications.  The IRO engaged by
Tenet shall have expertise in the Anti-Kickback Statute, the Stark Law, and the
general requirements of the Federal health care program(s) from which Tenet
seeks reimbursement.

5.                                       Focus
Arrangements Review Report.  The
IRO shall prepare a report based upon the Focus Arrangements Reviews performed
(Focus Arrangements Review Report).  The
Focus Arrangements Review Report shall include the IRO’s findings with respect
to whether Tenet has implemented the Arrangements Policies and Procedures
described in Section III.B.2.b of the CIA. 
In addition, the Focus Arrangements Review Report shall include any
observations, findings and recommendations on possible improvements to Tenet’s
policies, procedures, and systems in place to ensure that the Arrangements at
Tenet hospitals do not violate the Anti-Kickback Statute and Stark Law.

 50
 

 

 

APPENDIX E

CLINICAL QUALITY SYSTEMS
REVIEW

The IRO shall perform a Clinical Quality Systems
Review to assess the effectiveness, reliability, and thoroughness of Tenet’s
quality management infrastructure and systems throughout Tenet.  The Clinical Quality Systems Review will be
undertaken at all relevant levels of the organization, including but not
limited to corporate offices, regional offices, and individual hospitals.  The Clinical Quality Systems Review will
include site visits at 10% of Tenet’s hospitals for each Reporting Period.  The review shall be performed as follows:

1.                                       Selection
of Tenet Hospitals To Be Reviewed. 
Within 60 days after the start of each Reporting Period, the IRO shall
provide OIG with its recommendations of the hospitals to be reviewed and the
schedule of reviews for the Reporting Period. 
Within 30 days after OIG receives the IRO’s recommendations, OIG will
notify the IRO if the recommendations are unacceptable and provide a final list
of hospitals to be reviewed and the schedule of reviews.  Absent notification from OIG that the
recommendations are unacceptable, the IRO may proceed with the Clinical Quality
Systems Review.

2.                                       Clinical
Quality Systems Review.  The IRO
shall assess Tenet’s compliance with its Clinical Quality policies and
procedures described in Section III.B.2.c, the Medicare Conditions of
Participation and other standards designed to ensure that the delivery of
patient care items or services at Tenet hospitals meet professionally
recognized standards of health care and are reasonable and appropriate to the
needs of Federal health care program beneficiaries.  The IRO shall assess, among other things, the
following:

a.                                       Tenet’s
quality management infrastructure at all corporate levels, including, but not
limited to, an assessment of:

(i)                          whether
Tenet is carrying out its functions to review, analyze, and address quality of
care issues;

(ii)                       whether
systems are in place to sufficiently promote and respond to quality of care
issues;

(iii)                    whether systems are operating in a
timely and effective manner; and

(iv)                   whether
communication systems are effective, and results of decisions are transmitted
to 

the proper individuals in a timely fashion.

b.                                      Tenet’s
response at all corporate levels to quality of care issues, which shall include
an assessment of:

(i)                          Tenet’s
ability to identify the problem;

 51
 

 

 

(ii)                       Tenet’s
ability to determine the scope of the problem (e.g., systemic or
isolated);

(iii)                    Tenet’s
ability to create a corrective action plan to respond to the problem;

(iv)                     Tenet’s
ability to execute the corrective action plan; and

(v)                        Tenet’s ability to evaluate
whether the assessment, corrective action plan, and execution of 

that
plan were effective, reliable, and thorough and maintained.

c.                                       The
accuracy of Tenet’s internal reports, data and assessments that are required by
the Clinical Quality Policies and Procedures.

d.                                      The
extent to which Tenet’s Comprehensive Clinical Audits and other reviews are
occurring to identify and address quality management issues at Tenet hospitals.

e.                                       Tenet’s
compliance with the clinical quality training, Clinical Quality Policies and
Procedures, and performance standards and bonuses requirements of Section III
of the CIA.

3.                                       Frequency
of Clinical Quality Systems Review. 
The IRO shall perform the Clinical Quality Systems Review for each
Reporting Period of the CIA.  The IRO
shall perform all components of the Clinical Quality Systems Reviews.

4.                                       IRO
Qualifications.  The IRO engaged by
Tenet shall have expertise in evaluating clinical quality management in the
acute care setting.

5.                                       Clinical
Quality Systems Review Report.  The
IRO shall prepare a report based upon the Clinical Quality Systems Review
performed (Clinical Quality Systems Review Report).  The Clinical Quality Systems Review Report
shall include (a) the IRO’s findings with respect to the effectiveness,
reliability, and thoroughness of Tenet’s quality management infrastructure and
systems throughout the organization, and specifically, with respect to the
specific facilities visited, and (b) the IRO’s specific findings as to
whether Tenet has complied with all applicable Clinical Quality provisions of
the CIA.  In addition, the Clinical
Quality Systems Review Report shall include any observations, findings and
recommendations on possible improvements to Tenet’s clinical quality policies,
procedures, and systems.

 52

 

ATTACHMENT 1

FOCUS
ARRANGEMENTS DATABASE

Tenet shall
create and maintain a Focus Arrangements Database to track all new and existing
Focus Arrangements in order to ensure that each Focus Arrangement does not
violate the Anti-Kickback Statute or Stark Law.  The Focus Arrangements Database shall contain
certain information as appropriate to assist Tenet in evaluating whether each
Focus Arrangement violates the Anti-Kickback Statute or Stark Law, including
but not limited to the following:

1.                                       Each
party involved in the Focus Arrangement;

2.                                       The
type of Focus Arrangement (e.g., physician employment contract, medical
directorship, lease agreement);

3.                                       The
term of the Focus Arrangement, including the effective and expiration dates and
any automatic renewal provisions;

4.                                       The
amount of compensation to be paid pursuant to the Focus Arrangement and the
means by which compensation is paid;

5.                                       The
methodology for determining the compensation under the Focus Arrangements,
including the methodology used to determine the fair market value of such
compensation;

6.                                       Whether
the amount of compensation to be paid pursuant to the Focus Arrangement is
determined based on the volume or value of referrals between the parties;

7.                                       Whether
the written agreement for the Focus Arrangement complies with the requirements
of Sections III.B.2.b(viii), (ix), and (x) of the CIA; and

8.                                       Whether
the Focus Arrangement satisfies the requirements of an Anti-Kickback Statute
safe harbor and/or a Stark Law exception or safe harbor, as applicable.

 

 

 

 

ATTACHMENT
2

OVERPAYMENT REFUND

	
  TO BE COMPLETED BY MEDICARE CONTRACTOR

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Date:

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Contractor Deposit Control #

  	
   

  	
   

  	
   

  	
  Date of Deposit:

  	
   

  
	
  Contractor Contact Name:

  	
   

  	
   

  	
   

  	
  Phone #

  	
   

  
	
  Contractor Address:

  	
   

  	
   

  
	
  Contractor Fax:

  	
   

  	
   

  
	
   

  
	
  TO BE COMPLETED
  BY PROVIDER/PHYSICIAN/SUPPLIER

  
	
   

  
	
  Please complete and forward to Medicare
  Contractor. This form, or a similar document containing the following
  information, should accompany every voluntary refund so that receipt of check
  is properly recorded and applied.

  
	
   

  
	
  PROVIDER/PHYSICIAN/SUPPLIER NAME

  	
   

  
	
  ADDRESS

  	
   

  
	
  PROVIDER/PHYSICIAN/SUPPLIER #

  	
   

  	
   

  	
  CHECK NUMBER #

  	
   

  
	
  CONTACT PERSON:

  	
   

  	
   

  	
  PHONE #

  	
   

  
	
  AMOUNT OF CHECK

  	
  $

  	
   

  	
   

  	
  CHECK DATE

  	
   

  	 

	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  REFUND
  INFORMATION

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  For each Claim, provide the following:

  	
   

  	
   

  	
   

  
	
  Patient Name

  	
   

  	
   

  	
  HIC #

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Medicare Claim Number

  	
   

  	
   

  	
  Claim Amount Refunded 

  	
  $

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Reason Code for Claim Adjustment:

  	
   

  	
   

  	
  (Select reason code from list below. Use one reason
  per claim)

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  (Please
  list all claim numbers involved. Attach separate sheet, if necessary)

  
	
   

  
	
  Note:

  	
  If Specific Patient/HIC/Claim #/Claim Amount data
  not available for all claims due to Statistical Sampling, please 

  
	
   

  	
  indicate methodology and formula used to
  determine amount and reason for overpayment:

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  For Institutional Facilities Only:

  	
   

  	
   

  	
   

  	
   

  
	
  Cost Report Year(s)

  	
   

  	
   

  	
   

  	
   

  
	
  (If multiple cost report years are involved, provide
  a breakdown by amount and corresponding cost report year.)

  
	
   

  
	
  For OIG Reporting Requirements:

  	
   

  	
   

  	
   

  	
   

  
	
  Do you have a Corporate Integrity Agreement with
  OIG?

  	
  Yes

  	
   

  	
  No

  
	
   

  	
   

  	
   

  	
   

  
	
  Reason Codes:

  	
   

  	
   

  	
   

  	
   

  
	
  Billing/Clerical Error

  	
   

  	
  MSP/Other Payer Involvement

  	
   

  	
  Miscellaneous

  
	
  01 — Corrected Date of Service

  	
   

  	
  08 — MSP Group Health Plan 

  	
   

  	
   

  
	
  02 — Duplicate

  	
   

  	
  Insurance

  	
   

  	
  13 — Insufficient Documentation

  
	
  03 — Corrected CPT Code

  	
   

  	
  09 — MSP No Fault Insurance

  	
   

  	
  14 — Patient Enrolled in an HMO

  
	
  04 — Not Our Patient(s)

  	
   

  	
  10 — MSP Liability Insurance

  	
   

  	
  15 — Services Not Rendered

  
	
  05 — Modifier Added/Removed

  	
   

  	
  11 — MSP, Workers Comp.

  	
   

  	
  16 — Medical Necessity

  
	
  06 — Billed in Error

  	
   

  	
  (Including Black Lung)

  	
   

  	
  17 — Other (Please Specify)

  
	
  07 — Corrected CPT Code

  	
   

  	
  12 — Veterans Administration

Source: [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00112-of-00352.parquet"}, [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00112-of-00352.parquet"}]]