Our chief compliance officer, who reports to the CEO and has a direct reporting line to our board of directors, oversees the day-to-day activities of our compliance program. The CCO works closely with two groups of leaders within Ensemble to design, maintain, implement and enforce the program.

The Compliance Advisory Group (“CAG”) comprises leaders from each of the functional areas of our organization. The primary role of the CAG is to assist the CCO in ensuring the Compliance Program (e.g.. standards of conduct, policies, procedures, training, risk assessment, auditing and monitoring) is tailored to our business.

The Executive Compliance Committee (“ECC”) comprises our most senior executives. This group works closely with the CCO and other company leaders to promote an organizational culture that encourages ethical conduct and legal compliance. They ensure the compliance program is reasonably designed, implemented and enforced and is generally effective in preventing and detecting misconduct.

We have developed written standards of conduct and policies and procedures that incorporate the culture of compliance into our day-to-day operations. These standards guide our Associates in: 1) conducting business professionally and properly, 2) include a clearly delineated commitment to the Compliance Program, 3) address awareness, prevention and detection of specific fraud and abuse risk areas, 4) provide guidance to Associates on how to communicate compliance issues to appropriate compliance personnel, 5) describe how potential compliance issues are investigated and resolved by the organization, and 6) prohibit retaliation for good faith participation in the Compliance Program.

Our standards of conduct are memorialized in our Core Values in Action booklet and referred to as our “Code of Responsibility.”

Compliance training is at the very heart of our Compliance Program and is the proverbial “means to an end” inasmuch as it is a central mechanism used to communicate and educate all Associates on our commitment to professional, legal, and ethical conduct and risks, expectations, resources and responsibilities.

While various forms of compliance training occur throughout a year, all new Associates receive general compliance training upon hire and existing Associates receive at least one hour of general compliance training annually emphasizing our commitment to compliance with state and federal fraud and abuse statutes, regulations and payor policies.

At the completion of general compliance training, all Associates are required to attest to their knowledge of and commitment to the standards of conduct and Compliance Program. In addition, all Associates involved in the coding and billing process are required to attend additional training sessions tailored to their job responsibilities.

The use of audits and/or other risk evaluation techniques to identify and prioritize risks, monitor compliance and assist in the reduction of identified problem areas is a core element of our Compliance Program.

Annually, the Compliance and Internal Audit teams collaborate with the Compliance Advisory Group and other Associates to conduct a comprehensive self-administered risk assessment that identifies and ranks the various compliance and business risks most likely to occur. Utilizing the data from the yearly risk assessment, the Compliance and Internal Audit teams develop a Compliance Work Plan and an Internal Audit Work Plan that identifies auditing and monitoring activity to be performed throughout the year.

We have established a process for the independent investigation of reports of suspected violations of our Compliance Program by qualified personnel.

This process is memorialized in a compliance investigations policy publicized to all Associates and informing them of the process that occurs when they report suspected misconduct.

Our non-retaliation policy details existing protections against any form of retaliation including discharge, demotion, suspension threats, harassment or discrimination for making a good faith report of suspected misconduct and the consequences of retaliating against an Associate that makes a good faith report of suspected misconduct.

An effective Compliance Program depends on setting standards of behavior and conduct through adequate written guidance and training and then exercising consistent enforcement, corrective action and discipline for violations of the Compliance Program.

We have developed a corrective and disciplinary action policy that sets guidelines for uniform corrective/disciplinary actions for violations of our Compliance Program consistent with human resources policies and procedures.