Attachment_J.5_Ktr_Personal_COI_Financial_Disclosure_Template.docx

Attachment J.5

CONTRACTOR PERSONAL CONFLICTS OF INTEREST

FINANCIAL DISCLOSURE TEMPLATE

(OCT 2015)

Offerors/Contractors:

· Use of this actual template is not required. This template is provided as a sample for the kind of information CMS has found to be vital for proper personal COI analysis. If the offeror/contractor uses its own template or form for personal conflict of interest information collection and disclosure, the offeror/contractor should ensure that, at a minimum, the information captured on this template is collected.

· Personal Conflict of Interest Financial Disclosure information shall NOT BE submitted to CMS. However, such information shall be collected and analyzed for all Governing Body members (e.g., Board of Directors, Trustees, etc.), and principals of the organization as defined by FAR 52.203-13, Contractor Code of Business Ethics and Conduct, and for each manager and key personnel who would be, or are involved with, the performance of the contract. NOTE: References to organizational and/or personal conflicts of interest will be referred to individually and collectively as conflicts of interest (COI).

· Compliance Officer Analysis. Offeror/Contractor Compliance Officer Analysis of Individual Personal Conflicts Of Interest is required – See end of this template for a sample of Reporting Employee Disclosure and analysis.

Reporting Employee (Also includes Board of Director members or others, as applicable):

· Please complete the “Reporting Employee Information” below that will identify you as the reporter. None of the below information will be submitted to the government; it is for internal collection and analysis only. However, if you have concerns regarding personal information requested in this Form, please consult with the company Compliance Officer.

· Read the instructions for Parts I through IV (Identified in Blue Headers) on the following pages.

· General Statements (Below Reporting Employee Information): If you selected “Yes” for any statement, you must describe the reportable interests in the corresponding Parts I, II, III, and/or IV below in the Purple Header Sections. If additional space is required, please expand the space provided or provide additional pages.

· Sign and date the disclosure of information. Our Compliance Officer will retain this disclosure information and signature page on file.

· Submit completed documents to our Corporate Compliance Officer.

REPORTING EMPLOYEE INFORMATION

Company

Business/Unit and Address Updated __

Employee Identification

Reporting Status Initial __Annual __ Updated __

I. I have reportable assets or sources of income for myself, my spouse/domestic partner and/or any dependent of the respondent.

II. I have reportable liabilities for myself, my spouse/domestic partner and/or any dependent of the respondent.

III. I have reportable outside positions for myself, my spouse/domestic partner and/or any dependent of the respondent.

IV. I have reportable gifts and/or travel reimbursements for myself.

Part I: ASSETS AND INCOME

I.A. REPORTABLE ASSETS

• Healthcare Related Assets held for investment with a value greater than $10,000 as of the date of disclosure OR assets held for investment which produced more than $2,500 in income, including but not limited to:

· Healthcare-related assets, such as stocks, bonds, annuities, trust holdings, partnership interests, investment real estate, or a privately-held trade or business;

· Healthcare sector mutual funds (report the full name of the fund, not just the general family fund name);

· Holdings of Healthcare Related self-directed retirement plans, such as 401(k)s, IRAs or SEPs (list each holding);

· Defined benefit pension plans provided by a Healthcare related former employer (include the name of the employer); and,

· Type/location of healthcare related real estate.

Value Fund or XYZ Large Capital Fund.

I.B. HEALTHCARE-RELATED ANNUAL INCOME, ARRANGEMENTS OR AGREEMENTS

· For Yourself/your Spouse/Domestic Partner and/or any Dependent of the respondent for all Healthcare Related :

· Sources of salary,

· Severance,

· Bonuses,

· Fees,

· Commissions,

· Honoraria, and

· Other earned income, arrangements or agreements, as well as other non-investment income such as scholarships, patents, royalties, etc.

· For yourself only:

· Continuing participation in an employee pension or benefit plan maintained by a former Healthcare Related employer;

· A leave of absence in order to perform duties for this present organization; and,

· Known future Healthcare Related employment, including date you accepted employment offer.

· Alimony and Child Support

· Veterans’ benefits Social Security or disability benefits

· Any of the following for spouse/domestic partner and/or any dependent of the respondent:

· Continuing participation in an employee pension or benefit plan maintained by a former employer;

· A leave of absence to perform duties for this present organization; and,

· Known future employment, including date you accepted employment offer.

IMPORTANT DEFINITIONS

Dependent – A son, daughter, stepson or stepdaughter who is either unmarried and under age 21 and living in the filer’s house, or considered dependent under the U.S. tax code.

Diversified Mutual Fund – A mutual fund that does not have a stated policy of concentrating its investments in one industry, business, or single country other than the United States.

Sector Mutual Fund – A mutual fund that concentrates its investments in an industry, business, single country other than the United States, or bonds of a single state within the United States.

REPORTABLE ASSETS AND HEALTHCARE RELATED INCOME, ARRANGEMENTS OR AGREEMENTS

(I.A and I.B. Information should be provided in the white space below)

Part II: LIABILITIES

• Loans over $10,000 from an individual, such as a friend or a business associate who is employed by a Healthcare related entity or has a business association with a Healthcare related entity.

• Loans that you owe to your parent, spouse/domestic partner, sibling and/or any dependent.

REPORTABLE LIABILITIES

Part III: ADDITIONAL POSITIONS

Part IV: GIFTS AND/OR TRAVEL REIMBURSEMENTS Report for Yourself, Spouse/Domestic Partner, and/or any Dependent of the Respondent:

Do Not Report:

· Anything received from relatives, the U.S. Government, D.C., state, or local governments;

· Bequests and other forms of inheritance;

· Gifts and travel reimbursements provided by your organization in connection with your official travel;

· Gifts of hospitality (food, lodging, entertainment) at the donor’s residence or personal premises; or, anything received by your spouse/domestic partner and/or any dependent of the respondent, totally independent of their relationship to you.

REPORTABLE INFORMATION

(For Travel, also include purpose of trip)

PERSONAL CONFLICTS OF INTEREST

FINANCIAL DISCLOSURE

EMPLOYEE SIGNATURE PAGE

(To Be Retained By Compliance Officer)

CERTIFICATION OF REPORTING EMPLOYEE:

I, (Print Name)___________________, certify that the statements I have made herein and on all attachments are true, complete, and correct to the best of my knowledge.

OFFEROR/CONTRACTOR COMPLIANCE OFFICER

ANALYSIS OF INDIVIDUAL

PERSONAL CONFLICTS OF INTEREST

Description of Project:

· <Provide a summarized description of the work being performed on the CMS contract.>

Potential Conflicts for this Project:

· Employee’s Role on Contract: <Provide a high level description of the employee’s role on the project. Be sure to de-identify any PII.>

· Description of Conflict(s): <Provide a list of reportable interests that create an actual, apparent and/or potential conflict for the work described above in Description of Project.>

Compliance Officer Assessment: (If none, state “None”):

< Provide the Compliance Officer’s assessment and determination of whether any conflict(s) exist that must be mitigated and how the conflict is/will be resolved.>

(Check here if continued on additional page(s) ___)

CORPORATE COMPLIANCE OFFICER REVIEW:

To the best of my knowledge and belief, based on the information disclosed, all actual, potential and/or apparent COIs have been mitigated.

EXAMPLE:

Delete this Page in Submissions

OFFEROR/CONTRACTOR COMPLIANCE OFFICER

ANALYSIS OF INDIVIDUAL

PERSONAL CONFLICTS OF INTEREST

Description of Project: The Program Integrity contract is responsible for identifying fraud, waste and abuse in the Medicare Part A, B and HH+H in the state of Texas.

Potential Conflicts for this Project: It is the policy of XYZ to avoid situations that place officers, directors, managers, key employees in positions where their judgment may be biased in any way, or where their responsibilities may give them an unfair competitive advantage with respect to other business ventures.

· Provide a description of the employee’s role on the project: Employee #1 (Dr. John Smith has been de-identified) will work as the AB (Medical Director has been de-identified) on the contract. In doing so, Employee #1 will perform review of Medicare Part A, B and HH+H claims in the State of Texas.

· Provide a list of reportable activities that create an actual, apparent or potential conflict for the work described above in Description of Project:

· Provides or furnishes products and/or services that are billed to Medicare or Medicaid. Healthcare providers and suppliers include, but are not limited to, hospitals, doctors, skilled nursing facilities, home health agencies, ambulance companies, durable medical equipment companies, physical therapists, pharmacies, pharmacist, and clinical laboratories.

· Conducts audits of health benefit payments or cost reports, or conduct statistical analysis of health benefit utilization.

· Performs work of a Medicare Administrative Contract, Recovery Audit Contract or Qualified Independent Contractor.

Compliance Officer Assessment:

Description of Conflict and Mitigation:

Employee #1 (Dr. Smith has been de-identified) has two conflicts that require a mitigation strategy. Employee #1’s financial disclosure revealed that the spouse (wife is de-identified) is a provider performing emergency room services in in Hospital XYZ located in Houston, TX and that Employee #1 has a position on the Board of QSR Medical Center located in Dallas, TX. The services being performed by Employee #1’s spouse at XYZ hospital may be reviewed under the contract. It is, therefore, determined that Employee #1 could or would be biased in any review of XYZ hospital. As a result, the mitigation is that Employee #1 must self-recuse from any and all work related to XYZ hospital. Regarding the position on the board of QRS Medical Center, Employee #1 could or would be biased in any review of services provided by QRS Medical Center. As a result, the mitigation is that Employee #1 must self-recuse from any and all work related to QRS Medical Center.

CONFIDENTIAL INFORMATION - NOT TO BE DISSEMINATED Page 8 of 8