
Ethics and Compliance
We are committed to the highest standards of ethics and compliance – individually, as a team and a company.
Our operating philosophies are grounded by a clear commitment to doing the right thing. It’s about acting with integrity and behaving ethically and responsibly. It’s fundamental to our mission, helping us to earn the trust of our patients and fulfill our obligations to the many stakeholders we serve.
Resources, Governance & Policies
Tenet’s Ethics and Compliance program helps to ensure that employees understand and comply with all related laws and policies as outlined in our Code of Conduct. We regularly engage with team members on the policies and procedures that govern our business as outlined in the Code of Conduct.
Resources to help every team member
Employees are encouraged to speak up if something is not right, if they need guidance about an ethics question or want to report a concern.
Our Ethics Action Line is available to help, 24 hours a day, seven days a week, by calling 1-800-8-ETHICS (1-800-838-4427). Employees may also send an email to ethics@tenethealth.com. We respect your confidentiality if you decide to remain anonymous.
We also have a mobile app, The Tenet Way, which serves as a guide for all stakeholders to use as a resource for policies, making ethical decisions and to report concerns. The free app is available on the Apple App Store and Google Play Store.
Governance measures to maintain a strong culture of compliance
Our Ethics and Compliance Program functions in accordance with a Quality, Compliance and Ethics Program Charter and reports to the Board of Directors. Every Tenet employee is expected to follow the Charter requirements which include:
- Follow the Code of Conduct as a condition of employment;
- Participate in annual and refresher ethics training and role-based compliance training;
- Work with facility and enterprise compliance teams to resolve compliance matters; and
- Contact the Ethics Action Line if concerns are not resolved timely or to their satisfaction.
Policies and procedures that reflect our values
At Tenet, we hold ourselves to rigorous standards for ethics and compliance that reflect our values. That includes promoting open identification, discussion, reporting and resolution of ethics and compliance matters without fear of retaliation.
Read more about the policies that support our Ethics and Compliance Program by accessing the Policy Library below:
Policy Library
COMP-RCC 3.01 Deficit Reduction Act of 2005
COMP-RCC 4.21 Internal Reporting of Potential Compliance Matters
L-28 Exceptions for Certain Policy Terms During State of Emergency
EC.PS.04.11 Cybersecurity
COMP-RCC 3.01FAQ Tenet Our Contractors and the Deficit Reduction Act
CMT.101 INTERQUAL Application and Training
CMT.102 Requirements for Patient Choice for Post-Hospitalization Service
CMT.103 Hospital Case Management Transition Planning
CMT.104 Hospital Case Management Utilization Review Process
CMT.105 Case Management Documentation System Downtime
CO-5.006 Operative and Invasive Procedures Appropriateness Review Cardiac
CO-5.007 Operative and Invasive Procedures Appropriateness Review
COMP-RCC 4.11 Inpatient Rehabilitation Facility Admission Continued Stay...
COMP-RCC 4.18 Clinical Determination of Appropriate Patient Status
COMP-RCC 4.25 Hospital Coverage Notices for Medicare Inpatients
COMP-RCC 4.52 Utilization Management Plan
COMP-RCC 5.00 Medical Necessity and Advance Beneficiary Notice
CO-2.001 Patient Clinical Alarms
CLN.02.01 Safety Event Management
CLN.04.03 Universal Protocol Site Procedure
CO.Gl.2.025 Clinical Guidelines: Indwelling Urinary Catheter Insertion And Maintanence
CLN.02.05.MOD Suicide Risk Assessment
CO-2.034.MOD High Alert Medication Administration
CO-3.004 Medications Brought to the Hospital by the Patient
CO-3.006 Radiographic Contrast Media
CO-3.009 Automatic Stop Orders Model Policy
CO-5.012 Surgical Instrument Point-of-Use and Pre-Cleaning
COMP-RCC 4.22 Federal Program Eligibility Screening and Exclusion Disclo...
COMP-RCC 4.27 Disclosure of Hiring of Intermediary's Former Employee
COMP-RCC 4.58 Research Misconduct
AD 1.04 Monitoring of the Credentialing and Privileging Process
CO-5.002 Identification, Assessment, and Management of Disruptive Behavior
CO-5.008 Request for Membership Application Hospitals
COMP-RCC 4.48 Role Definition in Pre-Admission Assessment
COMP-RCC 5.17 Hospital Outpatient Orders From Non-Privileged Providers
COMP-RCC 4.02 Reduction or Waiver of Copayments and Deductibles
COMP-RCC 4.03 HIM Operations Hospital Chart Completion Documentation and Security
COMP-RCC 4.04 Establishing Facility Charges
COMP-RCC 4.05 Billing and Discounting Outpatient Self-Administerable Drugs
COMP-RCC 4.07 Medicare Bundling Requirements
COMP-RCC 4.08 Skilled Nursing Facilities Consolidated Billing Requiremen...
COMP-RCC 4.12 Inpatient Rehabilitation Facility Patient Assessment Instrument
COMP-RCC 4.16 Compliance With IPPS Exempt Requirements
COMP-RCC 4.17 Legal Medical Record
COMP-RCC 4.20 OP Therapy in Hospital Provider Based Setting
COMP-RCC 4.23 Outpatient Dialysis Provided to ESRD Medicare Patients in ...
COMP-RCC 4.04 Establishing Facility Charges
COMP-RCC 4.32 Inpatient Rehabilitation Facility-Unit Medicare Interrupte...
COMP-RCC 4.36 Supervision of Outpatient Diagnostic and Therapeutic Services
COMP-RCC 4.46 Medical Billing Audit
COMP-RCC 4.47 Clinical Research Compliance Requirements
COMP-RCC 4.51 Inpatient Psychiatric Facilities-Units Medicare Interrupted Stay
COMP-RCC 4.61 EHR Carry-Forward and Auto-Populate Functionalities
COMP-RCC 4.62 Scribes in the Hospital Provider Based Setting
COMP-RCC 4.70 Coding Compliance Program
COMP-RCC 5.00 Medical Necessity ABN Non-Coverage of Outpatient Services
COMP-RCC 5.01 Orders for Outpatient Tests and Services
COMP-RCC 5.02 Outpatient Laboratory Requisitions
COMP-RCC 5.03 Laboratory Panels
COMP-RCC 5.04 Automatic, Linked, or Exploding Codes
COMP-RCC 5.05 Standing Orders For Outpatient Tests or Services
COMP-RCC 5.06 Reflex Testing
COMP-RCC 5.07 Protocol Orders
COMP-RCC 5.08 Standards for Specimen Handling Charges
COMP-RCC 5.09 Laboratory Annual Notice to Physicians
COMP-RCC 5.10 Advanced Practice Practitioners and Residents in the Inpatient Rehabilitation Facility
COMP-RCC 5.12 Medicare National and Local Coverage Determination
Tenet Quality Compliance Ethics Program Charter
COMP-RCC 4.33 Compliance with Federal Health Care Claims and Cost Report...
COMP-RCC 4.34 Reporting of Overpayments to Commercial Managed Care Plans
COMP-RCC 4.35 Reporting of Overpayments to Federal Health Care Programs
GP-6 Medicare Bad Debts
CO-4.004 Restraint and Seclusion
COMP-RCC 4.49 Informed Consent Requirements For Patient Specimens Used In Clinical Research
COMP-RCC 4.60 Reporting of Allegations of Patient Neglect Abuse or Assault
COMP-RCC 4.80 Disclosure of Physician Ownership in a Hospital
COMP-RCC 4.81 California End of Life Option
COMP-RCC 4.90 Ambulatory Surgery Center Notice of Patient Rights and Responsibilities
EC.PS.01.00 Information Privacy Security Administration Policy
EC.PS.01.01 Information Privacy and Security Incident Handling Standard
EC.PS.01.02 Breach Notification Standard
EC.PS.01.03 Business Associate and Data Use Agreement Standard
EC.PS.01.04 Risk Management Program Standard
EC.PS.01.05 Contingency Planning Program Standard
EC.PS.01.06 Disciplinary Guidelines Standard
EC.PS.02.00 Patient Information Privacy Policy
EC.PS.02.01 Uses Disclosure and Minimum Necessary Standard
EC.PS.02.02 Personal Representatives and Minors Standard
EC.PS.02.03 Public Interest and Benefit Activities
EC.PS.02.04 Research Standard
EC.PS.02.05 Marketing Standard
EC.PS.02.06 Non Workforce Member Observeration Standard (Shadowing)
EC.PS.03.00 Patient Rights Policy
EC.PS.03.01 Notice Of Privacy Practices (NPP) Standard
EC.PS.03.02 Patient Right To Access Phi Standard
EC.PS.03.03 Patient Right to Amend PHI Standard
EC.PS.03.04 Patient Right To Restrict And Communication Standard
EC.PS.03.05 Accounting of Disclosures Standard
EC.PS.04.00 Information Security Policy
EC.PS.04.01 Record Processing Information Handling Standard
EC.PS.04.02 User Security and Conduct Standard
EC.PS.04.03 Physical Safeguards for Information Asset Standard
EC.PS.04.04 Activity Logs and User Monitoring Standard
EC.PS.04.05 Technical Controls Security Standard
EC.PS.04.06 Application Security Standard
EC.PS.04.07 Backup Security Standard
EC.PS.04.08 Network-PBX-Transmission Security Standard
EC.PS.04.09 Operating System Security Standard
EC.PS.04.10 Text Messaging Standard
COMP-RCC 5.13 Auxiliary Aids and Services
COMP-RCC 5.16 EMTALA
COMP-RCC 5.14 Service Animals
COMP-RCC 3.02 Controls and Monitoring of Payments to Physicians or Other Referral Sources
COMP-RCC 4.26 Marketing, Advertising and Community Events with Physician...
COMP-RCC 4.50 Offering Free or Discounted Goods and Services
COMP-RCC 4.53 Financial Assistance for Uninsured Patients
COMP-RCC 4.55 Payment of Patient Insurance Premiums
COMP-RCC 4.56 Implementation of Tenets Compact With Uninsured Patients
COMP-RCC 4.57 Cash Pay Rates
COMP-RCC 5.24 Corporate Integrity Agreement (CIA)
L-01 Business Courtesies
L-02 Physician Relocation
L-03 Medical Directorships
L-04 Office Space and Equipment Leases With Physicians and Other Potential Referral Sources
L-05 Personal Services Arrangements with Physicians
L-06 Hospital-Provided Post-Discharge Assistance to Federal Health Care Program Beneficiaries
L-07 Complimentary Local Transportation
L-08 Ambulatory Surgery Center Joint Ventures
L-09 Purchases by Physicians
L-10 Physician Employment Arrangements
L-11 Loans and Guarantees to Physicians and Other Referral Sources
L-12 Charitable Contributions
L-13 Courtesy Discounts
L-14 Mission Support Arrangements
L-15 Electronic Contract Approval Term Sheet (eCATS)
L-16 Monitoring Use of Resources Provided to or Received From Referral Sources
L-17 Limitations on Pre-Authorization Services
L-18 Remediation of Noncompliance with Referral Source Arrangement Policies
L-19 Purchasing Implantable Devices from Physician-Owned Distributorships
L-20 Hospital Relations wAmbulance and EMS Providers
L-21 Non-Physician Providers Engaged By Hospitals
L-22 Hospital Assistance for Relocation of Nonphysician Practitioners to Physician Practice
L-23 Personal Services Arrangements With Non Physician Referral Sources
L-25 Referral Source FMV