Code of Ethical Conduct

Code of Ethical Conduct

Introduction For more than one hundred years, Cooper University Hospital has been dedicated to
providing high quality, comprehensive medical care to its patients. We continually strive
to carry forth our mission of an academic medical center committed to world-class patient
care, education and research, resulting in a healthier community. In achieving this mission,
we pledge to act ethically and in compliance with all applicable laws and regulations.

Every member of The Cooper Health System has been placed in a position of trust – by our
patients, by our organization, and by our community. That trust demands an unyielding
commitment to ethical decision-making at all times. We must recognize that Cooper’s
strength will always rest upon the solid foundation formed by our conduct and behavior
as individuals committed to acting ethically, honestly and with integrity in all that we do.

This Code of Ethical Conduct is an essential component of our Compliance Program and
is intended to provide common sense, guiding principles to be applied each and every day.
It is central to continuing and strengthening a system-wide environment committed to doing
what is right.

Of course, no code of conduct can substitute for integrity, candor, good judgment and
common sense by the individual. In that very real sense, Cooper’s long-term commitment
to the principles embodied here rests with all of us. If you reasonably feel that Cooper’s
standards are being compromised, it is your obligation as a member of the Cooper team to
correct the problem. Utilize the many resources that are provided to you, such as consulting
with a supervisor, seeking help from our Compliance, Legal or Human Resources Departments,
or contacting our Compliance Hotline (1.800.500.0333 or CooperHealth.alertline.com), to
ensure that Cooper realizes its high standards. Reports can be made anonymously and always
without fear of retaliation.

Thank you for your commitment to excellence and to the fundamental principles embodied
in this Code.

Very truly yours,

George E. Norcross, III Adrienne Kirby, PhD Leslie Gordon

Chairman President & CEO Audit/Ethics and Compliance
The Cooper Health System The Cooper Health System Committee Chair
Compliance Cooper Compliance Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cooper Compliance Department . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Program Scope of the Compliance Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Overview Obligations of All Cooper Representatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Special Responsibility of Supervisors and Managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Our Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
General Principles
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Code of Ethical Business Conduct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Ethical Caring for Our Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Communicating With Our Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Conduct Making Medical Decisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Ethics in Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Respecting Privacy Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Reporting Adverse Events and Near Misses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Collecting Payments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Respect for Our Workplace
Maintaining a Positive and Constructive Workplace . . . . . . . . . . . . . . . . . . . . . . . . . 4
Commitment to a Drug-Free Workplace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Ensuring Environmental Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Political Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Honesty in Record Keeping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Medical Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Financial Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Reports to Outside Entities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Record Retention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Integrity in Billing
Accurate and Truthful Billing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Special Rules for Teaching Hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
False Claims Laws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Interaction With Outside Entities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Referrals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Marketing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Fair Competition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Protecting Cooper’s Resources
Safeguarding Assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Electronic Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Confidential Business Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Avoiding and Resolving Conflicts
Duty to Avoid Conflicts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Specific Conflict of Interest Policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Interactions With Vendors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Education and Training
Learning About Compliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Disciplinary Action
Disciplinary and Remedial Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Raising Questions, Reporting Concerns
How to Report Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Whistleblower Protections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Compliance Cooper Compliance Program
Program The Cooper Health System (“Cooper”) Compliance Program was created to promote and
sustain Cooper’s commitment to provide high-quality medical services consistent with high
Overview standards of business ethics and in compliance with applicable law. This Code of Ethical
Conduct is distributed as part of the Compliance Program.
The Compliance Program provides a means to communicate all policies and procedures
related to ethical conduct and compliance to Cooper employees, as well as to those who
conduct business with and on behalf of Cooper. It contains detailed policies which govern
conduct undertaken in connection with Cooper, methods by which Cooper will measure
and assess compliance, and procedures to respond to noncompliant conduct.

Cooper Compliance Department

The Chief Compliance Officer and the Compliance Department oversee the implementation
of the Compliance Program. The Chief Compliance Officer reports to the Board of Trustee’s
Audit/Ethics and Compliance Committee, comprised of at least two members of the Board
and up to five additional members.
Members of the Compliance Department serve as a resource for anyone with questions
or concerns about how Cooper is conducting business. Members of the Compliance
Department provide education on compliance issues both through the Cooper Learning
Network and through live training.
The Compliance Department is available to receive reports of any conduct which may be
a violation of law or regulation, or which conflict with Cooper’s Code of Ethical Conduct,
policies or procedures. Reports received through the Compliance Department may be made
anonymously through the Compliance Hotline (1.800.500.0333 or CooperHealth.alertline.com)
and are investigated with due care and sensitivity.

Scope of the Compliance Program

The Compliance Program and this Code of Ethical Conduct apply to everyone who is part of
The Cooper Health System (“Cooper Representatives”), including:
• Members of the Board of Trustees and its committees.
• Cooper’s executives and officers.
• All Cooper Health System employees at all locations, including contract,
part-time and temporary employees.
• Residents, students and volunteers.
•M
 edical staff.
• Agents of Cooper.

Obligations of All Cooper Representatives

Cooper Representatives are, without exception, required to follow the Compliance Program
and this Code of Ethical Conduct. Cooper Representatives have an affirmative obligation to
report known or reasonably suspected violations of law, regulation or Cooper policy.

Special Responsibility of Supervisors and Managers

It is important for supervisors and managers to recognize their additional responsibilities in
ensuring adherence to Cooper policies. Supervisors and managers must strive to lead by
ethical example, create an environment where employees are free to raise concerns openly
and without fear of retaliation, and work to solve problems, obtaining help and advice where
needed.

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 Our Code of Overview
Ethical Conduct Cooper has implemented policies and procedures to foster and maintain an environment of
compliance with our high ethical standards. This Code of Ethical Conduct is designed to
represent common-sense guidelines for Cooper Representatives to follow in conducting
business on behalf of or in association with Cooper.
Many of the concepts discussed in this Code are embodied in more detailed policies of
specific Cooper departments - such as, Human Resources, Compliance, Administration,
Health Information Management and others. Cooper Representatives must remain familiar
with all policies pertinent to their specific role.
This Code of Ethical Conduct cannot anticipate every situation or circumstance that may be
encountered by Cooper Representatives. This Code is designed, however, to assist Cooper
Representatives in making ethical decisions, guided by integrity, good judgment and common
sense. When a course of action is unclear, Cooper Representatives must seek appropriate guidance.

General Principles
Ethical Business Conduct
Cooper is committed to providing high quality medical care to its patients in a welcoming
and healing environment. In so doing, Cooper pledges to follow high standards of ethics,
honesty, and integrity, and to comply with all applicable laws and regulations.

Cooper Representatives Shall:

• Provide high quality medical care and courteous service to all patients.
• Conduct business ethically and honestly, and with high standards of integrity.
• Treat others with dignity, respect and courtesy.
• Be truthful in all communications — with each other, with our customers, with our
business partners and with regulatory agencies.
• Understand and comply with applicable laws and regulations, and with Cooper’s
standards, policies and procedures.
• Avoid any activity that could reasonably be expected to reflect adversely upon the
integrity of Cooper.
• In good faith, report known or suspected violations of law or regulation, and conduct
which conflicts with Cooper’s standards, policies and procedures.

Caring for Our Patients

Cooper Representatives will treat all patients with care and compassion, with dignity, respect
and courtesy, and without discriminatory purpose.

Communicating With Our Patients

Cooper Representatives must communicate with patients and their families. This includes
listening to and following the choices made by Cooper patients in connection with their
clinical care, as appropriate. Communication must include obtaining appropriate consent,
detailing patient rights, explaining care options and risks, honoring advanced directives, and
respecting choice in the selection of care and service providers.

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Making Medical Decisions
Cooper Representatives must review medical procedures to confirm that they are medically
necessary and in accordance with medical and ethical standards, regardless of compensation
or financial risk. Emergency medical care – a hallmark of The Cooper Health System – will be
provided without regard to the ability to pay for services, in accordance with Emergency
Medical Treatment and Active Labor Act (EMTALA) regulations.

Ethics in Research
Cooper Representatives must conduct any research activities ethically and with scientific integrity,
providing appropriate patient notification and consent, and obtaining mandatory institutional review.

Respecting Privacy Rights

Cooper Representatives may have access to many kinds of confidential, proprietary or private
information. Indeed, our patients trust us to protect their privacy rights and safeguard their
personal information. Cooper Representatives must access and disclose protected or private
health information, financial information or other private material only when authorized and
necessary to perform job responsibilities. Cooper Representatives must be careful not to
discuss private information in public spaces.
Cooper maintains detailed policies regarding the Health Insurance Portability and Account-
ability Act (HIPAA), and other federal and state privacy regulations. Cooper Representatives
must maintain a firm commitment to complying with these privacy laws, regulations and
policies when dealing with patient information – whether in spoken, written or electronic
form. Guidance on issues related to privacy of patient information is available through
Cooper’s Privacy Officer (856.361.1697).

Reporting Adverse Events and Near Misses

Cooper Representatives have an ethical and legal obligation to report serious adverse events and
near misses involving patient care. Reporting is available online through the Event and Activity
Reporting System (EARS) from the hospital portal or any computer at (http://rlweb01.chsmail.
root.cooperhealth.edu/RL6_Prod/Homecenter/Client/Login.aspx?ReturnUrl=%2fRL6_Prod%2f)
and by telephone (856.342.2112). Reporting additionally allows Cooper to determine why
an event occurred and to prevent similar events from happening in the future. Cooper
Representatives are encouraged to report any concern they have about any aspect of patient
care. Cooper’s Patient Safety Hotline may be reached at 856.342.3047.

Collecting Payments
Cooper Representatives will pursue collections fairly and without harassment. Questions
about charges must be promptly reviewed and resolved. Cooper Representatives may not
settle debts, forgive co-payments or deductibles, or negotiate charges without appropriate
authorization and careful review of Cooper policies and procedures.

Respect for Our Workplace

Maintaining a Positive and Constructive Workplace
Cooper is committed to providing a safe and healthy environment at all of our facilities,
where Cooper Representatives can excel in a positive and constructive atmosphere. Cooper
Representatives shall treat others in the same way that they, themselves, would want to
be treated: with dignity, respect and courtesy. Equal employment opportunities will be
extended to all individuals.

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Cooper does not tolerate conduct that is unprofessional or disruptive in the workplace,
including any conduct that is discriminatory, harassing, disrespectful, intimidating,
threatening or violent. Cooper encourages all personnel to report any such conduct
immediately, either to a supervisor, to Human Resources, or through the Compliance Hotline.
Cooper prohibits retaliation against those making good faith reports of such conduct.

Commitment to a Drug-Free Workplace

Cooper maintains an alcohol, smoking and drug free workplace. Cooper Representatives may
not be under the influence of alcohol, illegal drugs or any other substances that may hinder
the ability to perform Cooper activities or while on Cooper property.
Prescription drugs, controlled substances and other medical supplies must only be accessed
to fulfill job responsibilities and in accordance with physician orders.

Ensuring Environmental and Employee Safety

Cooper Representatives must demonstrate care in ensuring the safety of our workplace and
our employees. It is particularly important to remain vigilant when handling and disposing
hazardous substances and when providing care to patients. Employ all proper safety personal
protective equipment (PPE) and safety measures when using equipment or when there is a
potential risk of splash/ exposure.
Cooper Representatives are required to report any conditions that they believe to be unsafe
or to pose an environmental hazard. If a condition is an immediate threat to the safety of
patients, visitors, staff or property, Cooper Representatives must immediately contact the
Safety Officer/designee by calling 856.342.2905 during normal business hours or the
Clinical Operations Director after normal business hours, holidays or if the Safety Officer/
designee phone is not answered.
Cooper Representatives must submit a report via the EARS System available on the hospital
intranet portal or from any computer at www.CooperHealth.org/EARS. Risk Management
may also be contacted (856.342.2112) or through the Hospital Operator.

Political Activities
As a tax exempt, not-for-profit entity, Cooper is prohibited from conducting political
activities as a condition of that status. Cooper Representatives must refrain from engaging in
activity that may jeopardize Cooper’s tax exempt status and must make sure that personal
political activities are not viewed as activities taken on behalf of Cooper. Additional information
about restrictions on political activities in the workplace can be found in the Compliance
Program and Human Resources policies.

Honesty in Record Keeping

Cooper Representatives are given the responsibility to create, access and modify many types
of important records that affect how we conduct business at Cooper and how we take care
of our patients.
Cooper Representatives must ensure that Cooper records honestly and accurately reflect the
true nature of the transactions or events represented by those records. Cooper Representatives
must not create records that are intended to mislead, to falsely or inaccurately report events,
or to conceal something that is improper. It is important to remember that “records” exist in
many forms including paper and all manners of electronic storage. The obligation to
maintain truthful and accurate records does not change with the type of record being used.

Medical Records
Accurate medical records are central to providing excellent medical care. Cooper Representatives
must make every effort to complete medical records clearly, completely and timely, with
every individual taking responsibility for the total content and accuracy of their medical
documentation. While computer and electronic tools can help save time in preparing
medical documentation, Cooper Representatives must exercise due care to document
accurately and ethically to reflect the nature of the care provided.

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Financial Records
Financial records must conform to generally accepted accounting principles. Financial
statements and reports must fairly present Cooper’s financial condition, operations and
cash flow. It is a violation of law and Cooper policy for any Cooper Representatives to
improperly influence or mislead any accountant preparing Cooper’s audit.

Reports to Outside Entities

As with all Cooper records, reports to outside entities – such as to government agencies,
accrediting bodies, and other authorized parties – must be truthful and accurate.

Record Retention
Cooper’s Compliance Program establishes record retention schedules and policies which
explain how long a record is to be kept. Disposal of Cooper records is not discretionary.
Cooper Representatives may only dispose of Cooper records when they are following
Cooper’s retention policies. Records must not be destroyed whenever litigation, government
investigation or audit is pending, as improper destruction may constitute a criminal
offense or result in other civil sanctions.

Integrity in Billing
Accurate and Truthful Billing
Whether involved in patient care directly or indirectly, Cooper Representatives provide services
that result in bills for medical care or other types of services. Cooper’s bills – whether
submitted to patients, government agencies or private insurance companies – must be
accurate and truthful in all ways.
For example, Cooper Representatives must not:
• Bill for items or services that were not actually provided.
• Seek reimbursement for services that were not medically necessary.
• Misrepresent the type or level of service provided.
• Upcode (or assign a billing code that is higher than accurately reflects the service provided).
•B
 ill for undocumented or duplicate items or services.
• Unbundle where services are required to be billed together.
• Misrepresent a diagnosis in order to obtain payment.

Special Rules for Teaching Hospitals

As an academic medical center authorized to train physicians, Cooper receives government
funding in connection with graduate medical education and the training of residents, interns
and fellows. The federal government has created special rules (known as PATH guidelines) for
teaching hospitals, which Cooper Representatives are required to follow. These rules include
special documentation, billing and coding requirements that govern the training of residents
and the billing of teaching physician services, when provided in conjunction with residents.
Detailed information about the PATH guidelines is available through the Compliance
Program and Health Information Management.

False Claims Laws

Federal and state laws, including the federal False Claims Act, seek to protect the integrity of
government programs, such as Medicare and Medicaid, by making sure that government
funds are appropriately spent. Cooper has implemented policies and procedures designed to
achieve compliance with these laws and to prevent fraud, waste and abuse in government
programs.

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A “false claim” can take many forms and include not only the intentional submission of an
inflated bill to a government program, but also the failure to return a known overpayment
from a government program.
If you are aware of an incorrect claim prior to submission, the claim must be corrected before
it is submitted. If you become aware that a previously submitted claim is incorrect, you have
an affirmative obligation to immediately contact the Compliance Department or make a
report using the anonymous Compliance Hotline.

Interaction With Outside Entities

When Cooper needs to obtain goods or services from outside entities, Cooper Representatives
must enter into contractual relationships for fair market consideration, based upon ability
to meet contractual terms, necessity of the arrangement and demonstrated quality and
service. Through the Compliance Program, Cooper Representatives ensure that Cooper
does not do business with individuals or companies excluded by state or federal law from
participating in health care programs. Cooper Representatives and their families must not
receive personal kickbacks or rebates as a result of the purchase or sale of goods and
services at Cooper.

Referrals
Cooper makes and accepts referrals of patients based upon patient needs, ability to render
necessary services, and patient choice. Cooper Representatives must not offer, give or receive
something of value in hopes of inducing referrals or as a reward for obtaining referrals from
others. “Something of value” does not just include money, but could also be services, gifts,
entertainment or anything else that has value to the recipient. Offering or accepting
something of value from a referral source may constitute both a criminal and civil offense.
Cooper Representatives will refer patients to other providers based upon clinical needs,
capabilities and patient choice.
Financial relationships with those who are in a position to refer patients to Cooper must be in
accordance with federal and state law, including the federal Stark law and the Anti-Kickback
statute, and may not be entered without approval by the Legal Department and in
accordance with Cooper’s policies. (See Admin. 1.140, Agreements with Referral Sources.)
It is illegal under federal, state and local law to offer any government official, directly or
indirectly, anything of value in exchange for official action, inaction or influence.

Marketing
Cooper Representatives will endeavor to market Cooper’s services in a fair, accurate and
ethical manner. Cooper Representatives may not induce Medicare, Medicaid or other federal
or state health care beneficiaries to use our services by offering gifts that would likely
influence these beneficiaries to obtain services from Cooper.

Fair Competition
Cooper Representatives must compete fairly and comply with all antitrust laws. Cooper
Representatives must not make agreements with competitors that set prices or stifle competition.
Cooper Representatives must not illegally access or obtain proprietary information from competitors.

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Protecting Cooper’s Resources
Safeguarding Assets
Cooper Representatives must safeguard Cooper resources, using them responsibly, for proper
business purposes, and not for personal gain.
Cooper Representatives must not use Cooper funds or assets for any unlawful or unethical
purpose. Payments to third parties – such as vendors, contractors or consultants – for any
purpose other than that on the payment documentation are also prohibited.

Electronic Communications
In order to perform their jobs, Cooper Representatives are given access to many types of elec-
tronic communications systems and devices – for example, telephones, cell phones, computers,
internet access, e-mail and messaging services, handheld devices, and media storage devices.
Cooper Representatives must always use these tools properly and professionally, recognizing
that misuse can have a widespread and long-lasting impact upon Cooper, and its reputation.

Confidential Business Information

Cooper Representatives must protect confidential business information and trade secrets,
being particularly mindful not to discuss confidential information in public areas or social
conversation. Examples of confidential business information include:
• Salary or benefits information • Billing information
• Financial data • Planned capital projects
• Employee information • Proposed business deals
• Social security numbers or arrangements

In addition, Cooper will not discharge or in any manner discriminate against employees or
applicants because they have inquired about, discussed, or disclosed their own compensation
or the compensation of another Cooper employee or applicant. However, Cooper
Representatives, such as Human Resources personnel, who have access to the compensation
information of other Cooper employees or applicants as a part of their essential job
functions, cannot disclose the compensation of other employees or applicants to individuals
who do not otherwise have access to compensation information unless the disclosure is (a) in
response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding,
hearing, or action, including an investigation conducted by the employer, or (c) consistent
with our organization’s legal duty to furnish information.

Avoiding and Resolving Conflicts

Duty to Avoid Conflicts
The actions and decisions of Cooper Representatives must be made in a manner that promotes
the best interests of Cooper. Cooper Representatives must avoid situations in which their
personal interests could conflict or appear to conflict with the interests of Cooper.
Cooper’s policies address two types of conflicts: conflicts of interest – where outside relation-
ships might affect the exercise of professional judgment on behalf of Cooper; and conflicts of
commitment – where outside activities affect the ability of Cooper Representatives to devote
the time, talent and loyalty required to fulfill the terms of employment.
Conflicts, however, may take many forms and may be difficult to identify. Cooper
Representatives must remain vigilant in identifying actual and potential conflicts of interest
and conflicts of commitment.

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What should you do if a conflict or potential conflict of interest arises? If a conflict of interest
or potential conflict of interest arises, Cooper Representatives must notify their supervisor
and the Legal Department (either directly or through their supervisor) and withdraw from
any related participation or decision-making until the matter is reviewed and addressed. It
is important that conflicts be reported immediately so that the situation can be managed
effectively and Cooper’s interests in conflict-free decision-making can be protected.
Who examines a conflict or potential conflict? The Legal and Compliance Departments will
work to fashion an appropriate solution, based upon the individual facts of the situation. For
example, Cooper Representatives may be required to disclose the conflict to others and
withdraw from any decision-making role potentially affecting the conflicted interest.

Specific Conflict of Interest Policies

Cooper recognizes that Cooper Representatives perform many different and varied functions
on behalf of Cooper. In addition to Cooper’s primary conflicts policy within the Compliance
Program, some Cooper Representatives are required to follow additional policies, procedures
and disclosure requirements. Other specific conflicts policies cover:
• Medical Staff
• Research
• Members of the Board of Trustees, executives and other high-ranking Cooper employees
Cooper Representatives whose roles are affected by these policies must remain knowledgeable
of and compliant with them.

Gifts, Entertainment and Promotional Items

Interactions With Vendors
Cooper has enacted a detailed policy regarding interactions with vendors and the acceptance
of gifts (Corporate Policy 1.139).
For example, this policy prohibits Cooper Representatives (including Cooper Representative
family members or guests) from accepting:
• Entertainment, such as tickets to sporting events or trips, from vendors.
• Tickets to Cooper fundraising events.
• Gifts from referral sources.
• Cash, gift cards or other gifts from vendors.
• Expensive meals in connection with a dinner meeting.
• Lunch or dinner, including staff lunches, in the absence of an educational program,
business discussion or product demonstration. The vendor representative must
be present.
• Branded promotional items, such as notepads, pens or coffee mugs, with a vendor
or product name on the item.
On behalf of their department, Cooper Representatives may only accept an occasional
gift from a vendor for the benefit of that department which serves a genuine educational
function, which should have a fair market value of less than $100. Cash, cash gifts or their
equivalent (e.g., gift cards or vouchers) may not be accepted under any circumstances.

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Grateful Patients, Families or Friends
Cooper discourages staff from accepting gifts from patients, patient family members or
patient friends under any circumstances. The Cooper Foundation has a Grateful Patient
Program and patients, families or others wishing to show their appreciation should be
referred to the Cooper Foundation. Gifts of all denominations are accepted by the
Foundation and gifts may be directed to the Cooper program or unit of the donor’s choice.
If a Cooper Representative is offered a gift that may be inappropriate, he or she should
politely refuse it and explain that Cooper policy discourages them from accepting gifts.
If a Cooper Representative receives a gift without an opportunity to refuse it, he or she
should consult their manager or the Chief Compliance Officer for guidance. If Cooper
Representatives have any questions about the appropriateness of accepting a gift or
event invitation, they should discuss the matter with his or her manager or contact the
Chief Compliance Officer prior to participation or acceptance.
The Cooper Code of Ethical Conduct does not limit gifts exchanged between friends. A
Cooper Representative who is friends with a patient, patient family member, patient friends
or friends with an individual who has a business relationship with Cooper may exchange or
receive personal gifts from that person. A Cooper representative may not include a personal
gift as a business expense for tax purposes and/or charge Cooper for the gift or otherwise
receive reimbursement from Cooper to cover this expense.

Education and Training

Learning About Compliance
Cooper Representatives are required to complete educational training related to health care
compliance, confidentiality and other mandatory topics. Courses are offered through the
Cooper Learning Network, an online training academy that can be accessed either at
Cooper facilities or on personal computers. Cooper Representatives may also be required
to attend live training sessions. Cooper Representatives are encouraged to contact the
Compliance Department to arrange educational programs that address training needs.

Disciplinary Action
Disciplinary and Remedial Action
Cooper Representatives who knowingly violate the Code of Ethical Conduct, Cooper policy
or procedure, or law or regulation will be subject to appropriate corrective action, which
may include termination, civil liability or referral to law enforcement agencies. Cooper
Representatives who feel that they have been disciplined unfairly will have the opportunity
to appeal disciplinary action, pursuant to Cooper employment policies.

Raising Questions, Reporting Concerns

How to Report Concerns
Cooper Representatives have an affirmative obligation to report known or reasonably suspected
violations of law, regulation or Cooper policy. Further, failure to report may result in disciplinary
action. All reports must be made in good faith. When reporting, it is important to have as
many facts as possible so that you can obtain the most complete advice and so that the most
appropriate inquiry can be conducted.

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Suspected violations of health care compliance laws, regulations or policies must be conveyed
to the Compliance Department or through the Compliance Hotline. Reports may be made
anonymously. Identified callers may request confidentiality.
Toll-free telephone number: 1.800.500.0333
Internet address: CooperHealth.alertline.com
Examples of health care compliance concerns include:
• Billing and coding practices. • Accuracy of record-keeping.
• Arrangements with referral sources. • Compliance with Medicare and
• Gifts or benefits from vendors. Medicaid regulations.
When someone, in good faith, raises a concern or makes a report, calls the Compliance
Hotline, or cooperates with an investigation or corrective action, retaliation against that
individual is prohibited.
If a caller discloses his or her name but requests confidentiality, the Compliance Department
will keep information confidential to the extent permitted by law.
Other questions or concerns may be referred to: supervisors, the Compliance Department,
the Legal Department or the Human Resources Department, or may be reported
anonymously through the Compliance Hotline.

Whistleblower Protections
Federal and state laws establish the rights of individuals – known as “whistleblowers” – to
bring legal action against people or companies engaged in illegal behavior. Cooper provides
protection for whistleblowers from retaliation. Additional detail can be found in Cooper
University Health Care Policy - Education About the False Claims Act.

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