DEPARTMENT: Legal
POLICY DESCRIPTION: Reimbursement of
Expenses and Extending Tokens Related to
Voluntary Leadership Service by Potential Referral
Sources
PAGE: 1 of 8
REPLACES POLICY DATED: 7/8/98, 4/16/99,
1/4/02, 6/30/02, 5/31/04 (EC.009), 4/1/05, 8/31/05,
1/1/06, 5/1/06, 7/1/06, 1/1/07, 12/1/07, 3/1/08,1/1/09,
1/1/11, 1/1/12, 1/1/13, 1/1/14
EFFECTIVE DATE: January 1, 2015
REFERENCE NUMBER: LL.022
APPROVED BY: Ethics and Compliance Policy Committee
SCOPE: All Company-affiliated facilities including, but not limited to, hospitals, ambulatory
surgery centers, outpatient imaging centers, home health agencies, physician practices, service
centers and all Corporate Departments, Groups, Divisions and Markets.
PURPOSE: To establish guidelines for reimbursing (or paying directly for) expenses incurred by
potential referral sources when undertaking voluntary leadership efforts on behalf of the Company
or a Company-affiliated facility. Examples of such efforts include attendance at meetings of
hospital boards and medical executive committees, and conferences relevant to their hospital
duties.
To establish guidelines for extending tokens of appreciation in recognition of voluntary leadership
efforts by potential referral sources on behalf of the Company or Company-affiliated facility.
POLICY:
1. Expenses. Company-affiliated facilities may pay or reimburse in a manner consistent with the
Company’s Corporate Travel Policy the reasonable expenses of potential referral sources, who
hold voluntary leadership positions, to participate in facility-sponsored events, such as retreats
of their hospital board or Medical Executive Committee (MEC), or to attend conferences
integral to the performance of their leadership responsibilities subject to completion of the
attached appointment letter. No payment or reimbursement will be made for the expenses of a
guest or spouse of the individual in the voluntary leadership position, unless such payment is
specifically permitted in this policy.
2. Tokens of Appreciation. Tokens of appreciation may be given to potential referral sources in
recognition of voluntary efforts on behalf of the Company subject to a facility determination in
advance, before the furnishing of items or services for which the token is to be provided, as to
the value of such tokens to be provided and completion of the relevant version of the attached
appointment letters.
a. Consistent with the language in the appointment letter, the total value of tokens to be
provided pursuant to the agreement must be set in advance, must not exceed $1000 during
any one year of the term of the agreement and must be based on an hourly rate as set forth
below.
i. Committees other than the MEC or Facility Board of Trustees or other voluntary
12/2014
DEPARTMENT: Legal
POLICY DESCRIPTION: Reimbursement of
Expenses and Extending Tokens Related to
Voluntary Leadership Service by Potential Referral
Sources
PAGE: 2 of 8
REPLACES POLICY DATED: 7/8/98, 4/16/99,
1/4/02, 6/30/02, 5/31/04 (EC.009), 4/1/05, 8/31/05,
1/1/06, 5/1/06, 7/1/06, 1/1/07, 12/1/07, 3/1/08,1/1/09,
1/1/11, 1/1/12, 1/1/13, 1/1/14
EFFECTIVE DATE: January 1, 2015
REFERENCE NUMBER: LL.022
APPROVED BY: Ethics and Compliance Policy Committee
leadership service. The hourly rate is $100 per hour of service provided by the
physician subject to the $1000 annual aggregate limit (or lesser amount the facility may
have determined and included in the letter agreement)
ii. MEC or Facility Board of Trustees. The hourly rate is $150 per hour of service
provided by the physician subject to the $1000 aggregate (or lesser amount the facility
may have determined and included in the letter agreement). Physician entertainment
that is integral to the meeting and spouse or guest expenses and entertainment
associated with a Board or MEC retreat may be provided to a potential referral source
above and beyond the $1000 annual aggregate (or lesser amount the facility may have
determined and included in the letter agreement), provided the physician has provided
services, the value of which, equals or exceeds the value of the entertainment,
expenses, and any tokens of appreciation. These items are not considered business
courtesies.
b. Tokens listed in an appointment letter, PSA or Physician Leadership Agreement must be
provided to the potential referral source either (i) within each calendar year of the
agreement, or (ii) over the term of the appointment letter if the letter states that the term
applies to the provision of any tokens of appreciation.
c. If, toward the end of the agreement term, a facility has not provided, and does not
anticipate providing additional tokens that total $1000 (or a lower limit the facility has set),
the facility must provide the physician with a gift certificate in the value of the difference
between the tokens provided and the $1000 (or lower limit the facility has set) limit.
d. Tokens of appreciation are to be reasonable (i.e., not lavish) and like tokens should be
provided for like service by different individuals (e.g., if one committee member receives a
token for his/her committee service, then all committee members should receive like
tokens of appreciation). However, if a physician indicates a preference not to accept a
particular token (e.g., the individual is not interested in attending a sporting event that
others are attending), the facility may provide a different token of like value or a gift
certificate.
12/2014
DEPARTMENT: Legal
POLICY DESCRIPTION: Reimbursement of
Expenses and Extending Tokens Related to
Voluntary Leadership Service by Potential Referral
Sources
PAGE: 3 of 8
REPLACES POLICY DATED: 7/8/98, 4/16/99,
1/4/02, 6/30/02, 5/31/04 (EC.009), 4/1/05, 8/31/05,
1/1/06, 5/1/06, 7/1/06, 1/1/07, 12/1/07, 3/1/08,1/1/09,
1/1/11, 1/1/12, 1/1/13, 1/1/14
EFFECTIVE DATE: January 1, 2015
REFERENCE NUMBER: LL.022
APPROVED BY: Ethics and Compliance Policy Committee
DEFINITIONS:
Expenses include, but are not limited to, the costs of food, lodging, and travel.
Entertainment includes any sporting event; concert; performance by any musician, comedian or
other entertainer; spa treatments; greens fees; or other similar events or activities.
Potential referral source includes: a doctor of medicine or osteopathy, a doctor of dental surgery
or dental medicine, a doctor of podiatric medicine, a doctor of optometry, a chiropractor or any
family member of a potential referral source.
Tokens of appreciation include, but are not limited to, tangible items, such as a watch, briefcase,
or vase; gift certificates; meals with a representative of the Company or facility administration;
tickets to, or attendance with a representative of the Company or facility representative at, sporting
or other entertainment events.
Voluntary leadership positions include, but are not limited to, positions on facility boards and
MECs for which the potential referral source is not compensated, as well as service as an unpaid
medical director.
PROCEDURE:
1. Agreement. Facilities that intend to reimburse physicians for expenses associated with
uncompensated service on MECs, Boards of Trustees or other committees or otherwise on
behalf of the facility and/or which wish to extend tokens of appreciation for such service must
enter into an agreement with each physician who will be serving in such capacity (using one of
the attached letters) and must provide the tokens to the maximum extent permitted in the
agreement. Each agreement must be signed by the physician and the facility CEO, or other
approved delegate, before token may be provided and before any service hours may begin to
accrue for the physician.
2. Board Retreats, MEC Retreats, Conferences and Similar Events.
a. Company facilities may pay or reimburse in a manner consistent with the Company’s
Corporate Travel Policy the reasonable expenses of potential referral sources incident to
the potential referral sources’ attendance at and participation in facility-sponsored events,
12/2014
DEPARTMENT: Legal
POLICY DESCRIPTION: Reimbursement of
Expenses and Extending Tokens Related to
Voluntary Leadership Service by Potential Referral
Sources
PAGE: 4 of 8
REPLACES POLICY DATED: 7/8/98, 4/16/99,
1/4/02, 6/30/02, 5/31/04 (EC.009), 4/1/05, 8/31/05,
1/1/06, 5/1/06, 7/1/06, 1/1/07, 12/1/07, 3/1/08,1/1/09,
1/1/11, 1/1/12, 1/1/13, 1/1/14
EFFECTIVE DATE: January 1, 2015
REFERENCE NUMBER: LL.022
APPROVED BY: Ethics and Compliance Policy Committee
such as Board retreats, MEC retreats, or to attend conferences relevant to the performance
of their leadership responsibilities, provided that:
i. the event is not held at a facility more than 500 miles from the Company facility and,
for facilities within the continental United States, the event is held within the
continental United States (unless approved by the SVP and Chief Ethics and
Compliance Officer );
ii. the retreat or event is not or does not appear to be lavish or extravagant;
iii. the event will not occur on a mode of transportation (e.g., cruise ship) unless approved
by the SVP and Chief Ethics and Compliance Officer;
iv. the substantive component of the event predominates over any entertainment or
recreational activities; and
v. the potential referral source has signed an appointment letter.
b. Reasonable expenses incurred, allocated or reimbursed for entertainment of the potential
referral source shall not exceed $150 per hour of service previously performed by the
potential referral source during the year and/or while on the retreat, provided such service
has not already been “compensated” with other tokens.
c. Facilities may pay or reimburse the expenses and entertainment of a spouse or guest of a
potential referral source to attend a Board retreat, a MEC retreat or a combined Board and
MEC retreat provided spouses or guests of all participants (e.g., non-referral source board
members as well as referral source board members) are invited to attend. The amount
reimbursed for spouses and guests shall not exceed $150 per hour of service previously
performed by the potential referral source during the year and/or while on the retreat,
provided such service has not already been “compensated” with other tokens.
d. Retreat Amenities. A potential referral source who receives a non-consumable retreat
amenity (e.g., golf club, apparel, watch, towel, luggage) must either (i) provide volunteer
service hours equivalent in value to the amenities and accept the amenity as a token of
appreciation, pursuant to a letter agreement that was signed at the inception of the
physician's service period, or (ii) accept the amenity as a business courtesy, subject to the
limitations set out in the Business Courtesies to Potential Referral Sources policy, EC.005.
12/2014
DEPARTMENT: Legal
POLICY DESCRIPTION: Reimbursement of
Expenses and Extending Tokens Related to
Voluntary Leadership Service by Potential Referral
Sources
PAGE: 5 of 8
REPLACES POLICY DATED: 7/8/98, 4/16/99,
1/4/02, 6/30/02, 5/31/04 (EC.009), 4/1/05, 8/31/05,
1/1/06, 5/1/06, 7/1/06, 1/1/07, 12/1/07, 3/1/08,1/1/09,
1/1/11, 1/1/12, 1/1/13, 1/1/14
EFFECTIVE DATE: January 1, 2015
REFERENCE NUMBER: LL.022
APPROVED BY: Ethics and Compliance Policy Committee
3. Tokens of Appreciation
Tokens of appreciation may be given to potential referral sources in recognition of volunteer
efforts on behalf of the Company only after obtaining a written agreement from the potential
referral source (using the attached appointment letter) that he or she may receive such tokens in
exchange for his or her voluntary leadership service and only after the individual has provided
services consistent with such agreement, the fair market value of which equals or exceeds the
value of the token(s).
a. Value of tokens given to physicians who serve on committees other than the MEC or
Facility Board of Trustees or other voluntary leadership service. The value of the token(s)
that may be extended to a particular individual is to be calculated at a rate of $100 per hour
of service completed with an annual aggregate total not to exceed $1000. A facility should
tailor the maximum to fit the intentions of the facility, although the $100 and $1000
figures may not be increased. For example, a facility that does not intend to give
more than $200 in tokens in a given year to a physician would use $200 for its
aggregate in the appointment letter with the physician.
b. Value of tokens given to physicians who serve the MEC or Facility Board of Trustees. The
value of the token(s) that may be extended to a particular individual is to be calculated at a
rate of $150 per hour of service completed with an annual aggregate total not to exceed
$1000. A facility should tailor the maximum to fit the intentions of the hospital,
although the $150 and $1000 figures may not be increased. For example, a facility
that does not intend to give more than $200 in tokens in a given year to a physician
would use $200 for its aggregate in the appointment letter with the physician.
c. If a facility elects not to include entertainment – i.e., sporting or social events – in its letter
agreement, then any entertainment extended to potential referral sources would be subject
to the $392 limit in the Business Courtesies to Potential Referral Sources Policy, EC.005.
d. Tokens may be extended at any point in the year, provided the requisite number of hours of
service have been completed prior to the token being extended. See Example b in Section
6 below.
e. Tokens of appreciation given to potential referral sources in recognition of volunteer
12/2014
DEPARTMENT: Legal
POLICY DESCRIPTION: Reimbursement of
Expenses and Extending Tokens Related to
Voluntary Leadership Service by Potential Referral
Sources
PAGE: 6 of 8
REPLACES POLICY DATED: 7/8/98, 4/16/99,
1/4/02, 6/30/02, 5/31/04 (EC.009), 4/1/05, 8/31/05,
1/1/06, 5/1/06, 7/1/06, 1/1/07, 12/1/07, 3/1/08,1/1/09,
1/1/11, 1/1/12, 1/1/13, 1/1/14
EFFECTIVE DATE: January 1, 2015
REFERENCE NUMBER: LL.022
APPROVED BY: Ethics and Compliance Policy Committee
efforts on behalf of the Company pursuant to a letter agreement are not considered
“business courtesies” subject to the $392 annual limit established by the Business
Courtesies to Potential Referral Sources Policy, EC.005 and, therefore, are not required to
be tracked using the Business Courtesies Log described in EC.005. In other words, tokens
of appreciation given pursuant to this policy are in addition to gifts and entertainment that
may be given pursuant to EC.005.
4. Tracking
a. Voluntary service performed pursuant to the appointment letter must be documented. This
may be accomplished by collecting and retaining meeting sign-in sheets or minutes,
assuming such documents indicate the duration of the meeting; timesheets; or other
writings that evidence the time the potential referral source has performed pursuant to the
appointment letter.
b. Tokens of appreciation, spouse or guest expense reimbursement, and entertainment
extended pursuant to this policy must also be tracked. Facilities must demonstrate that in
the period covered by the letter agreement, the facility provided to the potential referral
source the aggregate of 1) any tokens specified in the letter, 2) reimbursement for spouse or
guest entertainment and expenses while on any retreat, and/or 3) reimbursement for the
physician’s entertainment while on any retreat, up to the number of hours the physician
provided voluntary service.
c. Use of the Tokens of Appreciation Log, which is available to Facility Ethics and
Compliance Officers (ECOs) and their designees, is the preferred method of tracking
tokens of appreciation to potential referral sources and their immediate family members.
The Tokens of Appreciation Log is available at:
http://tokens.hca.corpad.net/default.aspx. If a facility does not choose to use the
Tokens of Appreciation Log, the facility must establish its own tracking mechanism that is
approved in advance by the Ethics and Compliance Department.
5. Tax Consequences
Federal tax laws require a facility to treat tokens of appreciation as taxable income. If the
aggregate taxable income (i.e., tokens as well as any other compensation the facility might
provide) provided by a facility to a particular physician in a calendar year totals $600 or more,
12/2014
DEPARTMENT: Legal
POLICY DESCRIPTION: Reimbursement of
Expenses and Extending Tokens Related to
Voluntary Leadership Service by Potential Referral
Sources
PAGE: 7 of 8
REPLACES POLICY DATED: 7/8/98, 4/16/99,
1/4/02, 6/30/02, 5/31/04 (EC.009), 4/1/05, 8/31/05,
1/1/06, 5/1/06, 7/1/06, 1/1/07, 12/1/07, 3/1/08,1/1/09,
1/1/11, 1/1/12, 1/1/13, 1/1/14
EFFECTIVE DATE: January 1, 2015
REFERENCE NUMBER: LL.022
APPROVED BY: Ethics and Compliance Policy Committee
the facility must provide the physician with an IRS Form 1099. A physician who wishes not to
receive taxable income may refuse to accept any tokens of appreciation. Such physician
should not sign a letter agreement. A physician who refuses to sign the agreement will not be
entitled to receive tokens pursuant to this policy. In some (but not all) situations entertainment
expenses of the physician may be considered working conditions fringe benefits which are not
taxable income. If you question whether an item is a working condition fringe benefit or a
taxable benefit, contact the Tax Department.
6. Examples
a. A facility has set a limit of $500 for tokens of appreciation to be given to members of the
Credentialing Committee in exchange for their voluntary service and has collected signed
letter agreements from each member of the Committee. A member of the Committee has
been unable to attend many of the meetings and has only provided four hours of service
throughout the year. The facility must provide the physician with tokens of appreciation
totaling $400.
b. A facility has adopted a limit of $750 for tokens of appreciation to be given to members of
its MEC. It is two months into the year, and the Committee member in question has
provided 6 hours of service. The facility elects to extend a token of $300 value to MEC
members. The Committee member may receive the token. If the facility has not provided
and does not anticipate that by the end of the year it will provide any further tokens to the
physician pursuant to the letter agreement, the facility must provide the physician with a
gift certificate in the amount of $450. The total $750 provided to the physician must be
included on that year’s IRS Form 1099.
c. A physician member of the facility’s Board of Trustees has participated in several Board
meetings and planning sessions (for a total of 15 hours of service) and attended the Board
retreat, which included 8 hours of substantive work. The letter agreement between the
physician and facility specifies that the facility will provide tokens of a total value of $600
for Board service, at a rate of $150 per hour of physician service. The cost of the
physician’s entertainment and spouse expenses and entertainment at the retreat were
$2400. The facility must provide the $600 of tokens to the physician, and may provide the
entertainment and spouse expenses. The Facility must report the $600 in tokens, the
amount attributed to the physician’s entertainment (unless it is a working condition fringe
12/2014
DEPARTMENT: Legal
POLICY DESCRIPTION: Reimbursement of
Expenses and Extending Tokens Related to
Voluntary Leadership Service by Potential Referral
Sources
PAGE: 8 of 8
REPLACES POLICY DATED: 7/8/98, 4/16/99,
1/4/02, 6/30/02, 5/31/04 (EC.009), 4/1/05, 8/31/05,
1/1/06, 5/1/06, 7/1/06, 1/1/07, 12/1/07, 3/1/08,1/1/09,
1/1/11, 1/1/12, 1/1/13, 1/1/14
EFFECTIVE DATE: January 1, 2015
REFERENCE NUMBER: LL.022
APPROVED BY: Ethics and Compliance Policy Committee
benefit) and spouse expenses and entertainment, as well as any other compensation
provided on an IRS Form 1099 for the physician. The physician’s total time expended on
Board service is 23 hours, which equates to $3450. The amount the facility will expend
($3000) does not exceed the hourly rate for the service the physician has provided and,
therefore, all expenditures are within the parameters of this policy.
d. Continuing with the facts in example c immediately above, the physician, like all board
members, receives a gift basket upon arrival at the retreat. The gift basket includes a $100
golf shirt, bottled water, and snacks. The bottled water and snacks are considered part of
the facility’s expenses associated with the retreat. Because the physician has served a
sufficient number of hours, the physician may receive the golf shirt as a token of
appreciation. Alternatively, should the facility desire for some reason to count the golf
shirt as a business courtesy it may.
e. The facility has invited several physicians who recently completed their medical training to
participate in the facility’s “new physicians committee.” The committee, which has been
developed to better understand the needs and concerns of new physicians, is anticipated to
meet about quarterly for approximately two hours each meeting. The meetings will be
conducted pursuant to an agenda, and minutes will be taken. The facility wants to hold
these meetings over dinner at a restaurant in the community. While a new committee, it is
an appropriate committee for the use of the attached letter agreement (Attachment 2).
Provided the physicians complete letter agreements and provide the requisite hours of
service as described in the letter, the facility may hold the meetings at a restaurant and pay
up to $200 for each physician’s meal (2 hours x $100/hour = $200).
REFERENCES:
1. Business Courtesies to Potential Referral Sources Policy, EC.005
2. Approval of Tokens of Appreciation in Recognition of Volunteer Service Efforts from NonReferral Sources Policy, EC.008
3. Physician Expense Reimbursement Agreement
12/2014
Sample Appointment Letter for Members of the
Medical Executive Committee or Board of Trustees
Note to facility representatives prior to drafting your facility’s specific letter agreement:
This is not part of the agreement; rather, it is included to emphasize that choosing to enter into
this letter agreement obligates your facility to give tokens or invitations to social activities or
events commensurate with the hours served, subject to the limits set forth herein.
(date)
Physician Name
Address
City, State, Zip
Dear Dr.
:
Hospital (d/b/a
hereafter the “Hospital”) is writing this letter to you (the “Physician”) to confirm the parties’
agreement regarding your appointment to the
(Board of Trustees or Medical Executive
Committee)
for the period of
, 20
to
, 20
The Hospital appreciates your willingness to serve in this important role.
.
In exchange for the Physician’s time spent preparing for Board or committee planning
sessions and attending meetings and other sessions, the Hospital agrees to pay all reasonable
expenses of the Physician, consistent with Hospital policies, associated with the Physician’s
service, including but not limited to the costs of meals, travel, and lodging, provided such
expenses are incurred in connection with planning sessions, retreats, educational sessions, or other
similar events. Only those expenses which the Physician incurred consistent with this
Agreement, and not the incremental expenses incurred by a spouse or other similar social
guest shall be reimbursed except as otherwise specifically set forth herein.
In exchange for the Physician’s time, the Hospital will pay or reimburse the Physician’s
reasonable expenses incident to the Physician’s attendance and participation in Board [and/or
Medical Executive Committee] retreats consistent with [Hospital or Company] policies.
Expenses and entertainment paid for or incurred by the spouse or other social guest of the
Physician and entertainment allocated or paid or incurred for the Physician related to the retreat
will be reimbursed up to an amount of one hundred fifty dollars ($150) per hour of services the
Physician provides pursuant to this Agreement up to and including the retreat.
In addition, in further consideration of the Physician’s time and efforts not already
“compensated” pursuant to this agreement, the Hospital will provide [insert description of
actual tokens/social events or functions if known at the time the letter is prepared or the
following language if actual tokens/social events or functions are not known: “a tangible
token(s) of its appreciation for the Physician’s service or may invite the Physician to a social
event(s) or function(s) as a token(s) of appreciation”] for the Physician’s services
commensurate with the number of hours the Physician has performed services consistent with this
Agreement at the time of payment at a rate of one hundred fifty dollars ($150) per hour and not to
exceed an aggregate of one thousand dollars ($1000) during any one year of the term of this
Agreement. [This paragraph should be tailored to fit the intentions of the Hospital, although
the $150 and $1000 figures may not be increased. For example, a Hospital that does not
1/2012
1
Attachment 1 to LL.022
Sample Appointment Letter for Members of the
Medical Executive Committee or Board of Trustees
intend to give more than $200 in tokens in a given year would use $200 for its aggregate. A
Hospital that does not intend to extend any tokens of appreciation should remove this
paragraph from this letter agreement.]
As part of this Agreement, the Physician represents and warrants to the Hospital that the
Physician is not currently excluded, suspended, debarred or otherwise ineligible to participate in
Federal health care programs.
The parties agree that this payment is fair market value for the service/expense only and
nothing contained herein shall require the Physician to refer or admit patients to, or order any
goods or services from, Hospital. Notwithstanding any unanticipated effect of any provision of
this Agreement, neither party will knowingly or intentionally conduct himself/herself/itself in a
manner as to violate the prohibition against fraud and abuse in connection with the Medicare and
Medicaid programs (42 USC § 1320a-7b).
The following list constitutes all agreements (including space leases, equipment leases,
professional service agreements, medical directorships or any other agreement), existing as of the
date of this Agreement between the Hospital and the Physician or the Physician’s immediate
family members.
Name of Contract
Party
Relation to
Physician Source
of Referrals
Description of Contract
Start of
Term
End
of
Term
To the extent applicable to this Agreement, the Physician agrees to comply with the Health
Insurance Portability and Accountability Act of 1996, as codified at 42 USC § 1320d (“HIPAA”)
and any current and future regulations promulgated thereunder. The Physician further agrees not
to use or disclose any Protected Health Information (as defined in 45 C.F.R. § 164.501) or
Individually Identifiable Health Information (as defined in 42 USC § 1320d), other than as
permitted by HIPAA Requirements and the terms of this Agreement.
Your appointment will be effective when you sign and return this letter to the Hospital
agreeing to serve on the terms set forth herein.
If the amounts you receive pursuant to this agreement (combined with any other payments
to you as an individual from Hospital) are valued at $600 or greater, all amounts received must be
reported to you individually on Form 1099-MISC. Other compensation arrangements with
Hospital, if any, will be treated in accordance with applicable IRS regulations.
1/2012
2
Attachment 1 to LL.022
Sample Appointment Letter for Members of the
Medical Executive Committee or Board of Trustees
This Agreement is intended to comply with Policy LL.022.
PER HOSPITAL POLICY LL.001, GENERAL STATEMENTS ON AGREEMENTS WITH
REFERRAL SOURCES; APPROVAL PROCESS, ET SEQ., PAYMENTS PURSUANT TO
THIS AGREEMENT, IF ANY, WILL BE MADE ONLY FOR SERVICES PERFORMED
AFTER THE AGREEMENT HAS BEEN SIGNED BY BOTH THE CONTRACTOR AND THE
FACILITY.
SERVICES PERFORMED PRIOR TO THIS DATE WILL NOT BE
COMPENSATED.
HOSPITAL
PHYSICIAN
Hospital CEO (signature)
(signature)
Date:
(printed name)
_________________________________
____________________________
Operations Counsel
Date:
Date: ____________________________
_________________________________
Division or Market President
Date: _____________________________
1/2012
3
Attachment 1 to LL.022
Sample Appointment Letter for Members of Committees other than the Medical Executive
Committee or Board of Trustees or Other Voluntary Service on Behalf of the Hospital
Note to facility representatives prior to drafting your facility’s specific letter agreement:
This is not part of the agreement; rather, it is included to emphasize that choosing to enter into
this letter agreement obligates your facility to give tokens or invitations to social activities or
events commensurate with the hours served, subject to the limits set forth herein.
(date)
Physician Name
Address
City, State, Zip
Dear Dr.
:
Hospital (d/b/a
hereafter the “Hospital”) is writing this letter to you (the “Physician”) to confirm the parties’
agreement regarding your appointment to the
(Unit Planning Team, Performance
Improvement Team, or other committee benefiting the Hospital)
for the period of
, 20
to
, 20
. The Hospital appreciates your willingness
to serve in this important role.
In exchange for the Physician’s time spent preparing for committee, department chair, and
Medical Staff planning sessions and attending meetings and other sessions, the Hospital agrees to
pay all reasonable expenses of the Physician, consistent with Hospital policies, associated with the
Physician’s service, including but not limited to the costs of meals, travel, and lodging, provided
such expenses are incurred in connection with planning sessions, retreats, educational sessions, or
other similar events. Only those expenses which the Physician incurred consistent with this
Agreement, and not the incremental expenses incurred by a spouse or other similar social
guest shall be reimbursed except as otherwise specifically set forth herein.
In addition, in further consideration of the Physician’s time and efforts not already
“compensated” pursuant to this agreement, the Hospital will provide [insert description of
actual tokens/social events or functions if known at the time the letter is prepared or the
following language if actual tokens/social events or functions are not known: “a tangible
token(s) of its appreciation for the Physician’s service or may invite the Physician to a social
event(s) or function(s) as a token(s) of appreciation”] for the Physician’s services
commensurate with the number of hours the Physician has performed services consistent with this
Agreement at the time of payment at a rate of one hundred dollars ($100) per hour and not to
exceed an aggregate of one thousand dollars ($1000) during any one year of the term of this
Agreement. [This paragraph should be tailored to fit the intentions of the Hospital, although
the $100 and $1000 figures may not be increased. For example, a Hospital that does not
intend to give more than $200 in tokens in a given year would use $200 for its aggregate. A
Hospital that does not intend to extend any tokens of appreciation should remove this
paragraph from this letter agreement.]
As part of this Agreement, the Physician represents and warrants to the Hospital that the
Physician is not currently excluded, suspended, debarred or otherwise ineligible to participate in
1
Attachment 2 to LL.022
Sample Appointment Letter for Members of Committees other than the Medical Executive
Committee or Board of Trustees or Other Voluntary Service on Behalf of the Hospital
Federal health care programs.
The parties agree that this payment is fair market value for the service/expense only and
nothing contained herein shall require the Physician to refer or admit patients to, or order any
goods or services from, Hospital. Notwithstanding any unanticipated effect of any provision of
this Agreement, neither party will knowingly or intentionally conduct himself/herself/itself in a
manner as to violate the prohibition against fraud and abuse in connection with the Medicare and
Medicaid programs (42 USC § 1320a-7b).
The following list constitutes all agreements (including space leases, equipment leases,
professional service agreements, medical directorships or any other agreement), existing as of the
date of this Agreement between the Hospital and the Physician or the Physician’s immediate
family members.
Name of Contract
Party
Relation to
Physician Source
of Referrals
Description of Contract
Start of
Term
End
of
Term
To the extent applicable to this Agreement, the Physician agrees to comply with the Health
Insurance Portability and Accountability Act of 1996, as codified at 42 USC § 1320d (“HIPAA”)
and any current and future regulations promulgated thereunder. The Physician further agrees not
to use or disclose any Protected Health Information (as defined in 45 C.F.R. § 164.501) or
Individually Identifiable Health Information (as defined in 42 USC § 1320d), other than as
permitted by HIPAA Requirements and the terms of this Agreement.
Your appointment will be effective when you sign and return this letter to the Hospital
agreeing to serve on the terms set forth herein.
If the amounts you receive pursuant to this agreement (combined with any other payments
to you as an individual from Hospital) are valued at $600 or greater, all amounts received must be
reported to you individually on Form 1099-MISC. Other compensation arrangements with
Hospital, if any, will be treated in accordance with applicable IRS regulations.
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Attachment 2 to LL.022
Sample Appointment Letter for Members of Committees other than the Medical Executive
Committee or Board of Trustees or Other Voluntary Service on Behalf of the Hospital
This Agreement is intended to comply with Policy LL.022.
PER HOSPITAL POLICY LL.001, GENERAL STATEMENTS ON AGREEMENTS WITH
REFERRAL SOURCES; APPROVAL PROCESS, ET SEQ., PAYMENTS PURSUANT TO
THIS AGREEMENT, IF ANY, WILL BE MADE ONLY FOR SERVICES PERFORMED
AFTER THE AGREEMENT HAS BEEN SIGNED BY BOTH THE CONTRACTOR AND THE
FACILITY.
SERVICES PERFORMED PRIOR TO THIS DATE WILL NOT BE
COMPENSATED.
HOSPITAL
PHYSICIAN
Hospital CEO (signature)
(signature)
Date:
(printed name)
Date: _______________________________
_____________________________
Operations Counsel
Date: ____________________________
_________________________________
Division or Market President
Date: _____________________________
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Attachment 2 to LL.022