Related Conflict of Interest Policies

Related Policies

Ethics & Compliance Department

Related Conflict of Interest Policies

Table of Contents

1. Compliance: Acceptance of Items from Outside Business Associates

3

2. Compliance_Business Courtesies to Physicians and Immediate Family Members

18

3. CP 5024 Conflict of Interest

27

4. Relationships with Post-Acute Services Providers

30

5. Research Conflict of Interest – Disclosure, Review and Management

35

6. Research Financial Conflict of Interest Relating to PHS Grants, Cooperative Agreements and Contracts

46

7. Secondary_Additional Professional Activities and Outside Activities of Employed Practitioners Policy and Procedure

59

8. Standards for Determining Independence of Members of Board of Directors

77

Title : Compliance: Acceptance of Items from Outside Business Associates Number : 256 Version : 12 Original Date : 09/24/2002 Effective Date : 12/02/2021

Last Review/Revision Date : 04/07/2023 Owner : Ethics & Compliance Department; Andrew Glosenger

Next Review Date : 04/08/2024

Approved by : Administrative Policy Committee, PolicyTech Administrators

Discrete Operating Unit/Facility : Banner Baywood Medical Center Banner Behavioral Health Hospital Banner Boswell Medical Center Banner Casa Grande Medical Center Banner Churchill Community Hospital Banner Del E Webb Medical Center Banner Desert Medical Center Banner Estrella Medical Center Banner Fort Collins Medical Center Banner Gateway Medical Center Banner Goldfield Medical Center Banner Heart Hospital Banner Ironwood Medical Center Banner Lassen Medical Center Banner McKee Medical Center Banner North Colorado Medical Center Banner Ocotillo Medical Center Banner Payson Medical Center Banner Thunderbird Medical Center Banner--University Medical Center Phoenix Banner--University Medical Center South Banner--University Medical Center Tucson

Banner Corporate Ambulatory (Outpatient) Services Banner Health Clinics Banner Imaging Services

Banner Imaging Services Colorado Banner MD Anderson Cancer Center Banner Sleep Center Banner Surgery Centers Banner Urgent Care Services Occupational Health/Employee Health Services Rural Health Clinics Banner Home Care and Hospice (BHCH) Insurance Banner Health Network Banner Plan Administration

Banner University Health Plan Banner Pharmacy Services Post Acute Services (PAC) Research

East Morgan County Hospital Ogallala Community Hospital Page Hospital Platte County Memorial Hospital Sterling Regional Medical Center Torrington Community Hospital Washakie Medical Center Wyoming Medical Center

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May not be current policy once printed

Title : Compliance: Acceptance of Items from Outside Business Associates Number : 256 Version : 12

I. Purpose/Population: A. Purpose : To provide guidelines at Banner Health (Banner) regarding the acceptance of the following items from Outside Business Associates: (1) business or personal gifts, (2) meals and entertainment, (3) training, education, travel expense reimbursement, or other remuneration. B. Population : All Employees II. Definitions: A. Advanced Practice Provider: A nurse practitioner, physician assistant, clinical nurse specialist, clinical psychologist, nurse midwife, or a certified registered nurse anesthetist. B. Banner Employees: Includes 1. All full-time and part-time employees and volunteers of Banner and of any discrete operating unit owned, operated, or controlled by Banner (except Sonora Quest Laboratories and other entities approved by the Chief Legal Officer/General Counsel); and 2. Any other persons or organizations acting on behalf of Banner and of any discrete operating unit owned, operated, or controlled by Banner (except Sonora Quest Laboratories and other entities approved by the Chief Legal Officer/General Counsel). This includes Advanced Practice Providers, Employed Advanced Practice Providers, Employed Physicians, and Employed Practitioners, except as otherwise indicated. 3. For purposes of this policy, “Banner Employees” includes Immediate Family Members. C. Cash Equivalents: Items convertible to cash (such as a check) or that can be used like cash (such as a general purpose debit card, but not a gift card that can be redeemed only at certain stores or for a certain purpose, like a gasoline gift card). D. Employed Advanced Practice Provider: An Advanced Practice Provider who is employed by the applicable Medical Group. E. Employed Physician: A physician who is employed by the applicable Medical Group; provided, however , that for purposes of this Policy, an Employed Physician does not include a Physician who is employed by Banner (1) on a per diem basis, (2) on a part-time basis with Banner as the Physician’s secondary employer, or (3) solely for the purpose of providing medical director services or other full-time administrative leadership services. An Employed Physician also does not include a Physician who is employed by the University of Arizona. F. Employed Practitioner: An Employed Physician or an Employed Advanced Practice Provider. G. Federal Health Care Program: Any plan or program that provides health benefits, whether directly, through insurance, or otherwise, which is funded in whole or in part by the United States Government (other than the Federal Employees Health Benefit Program) or any State health care program (as defined in 42 U.S.C. § 1320a-7(h)). Federal Health Care Programs include, but are not limited to, Medicare, Medicaid, Indian Health Services, TRICARE/CHAMPUS/Department of Defense health care programs, and Veterans Administration. H. Honorarium (pl. Honoraria): A one-time payment made to an individual for making a speech or presentation, for participating in a meeting, or for some other specified service (e.g., conducting a survey or providing an interview). I. Immediate Family Member: For purposes of this policy, an “Immediate Family Member” includes husband or wife, domestic partner, and birth, adoptive or step child. J. Medical Group: The Banner entity that employs the Employed Practitioner, which may be Banner Medical Group, Banner Medical Group Colorado, Banner—University Medical Group, Banner Urgent Care Services, or Banner Health.

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Title : Compliance: Acceptance of Items from Outside Business Associates Number : 256 Version : 12

K. Outside Business Associate: An entity or individual with which Banner does business or may do business, including anyone who has an ownership or interest in or a compensation arrangement with any entity or individual with which Banner does or may do business. 1. An ownership or investment interest can be direct or indirect and includes, but is not limited to, monetary ownership investments, stock, stock options, partnership shares, and limited liability company memberships. An ownership or investment interest does not include ownership of less than 2% of the outstanding stock of a publicly held company. 2. A compensation arrangement is any arrangement involving direct or indirect remuneration (whether in cash or in kind), including, but not limited to, employment, contractual relationships, and consulting relationships. L. Physician: A doctor of medicine or osteopathy, a doctor of dental surgery or dental medicine, a doctor of podiatric medicine, a doctor of optometry, or a chiropractor. III. Policy: A. GENERAL POLICY STATEMENTS 1. General Restrictions. Banner Employees cannot accept anything from an Outside Business Associate that is intended to or does unduly influence business decisions that involve Banner. An item cannot be accepted from an Outside Business Associate if it is offered, given, requested, or accepted in exchange for or to induce referrals or other business that may be reimbursed by a Federal Health Care Program. Anything with “strings attached” cannot be accepted. 2. Non-Solicitation. Nothing in this Policy should be understood as encouragement to seek or accept items from Outside Business Associates. Except as permitted below, Banner Employees cannot solicit items from Outside Business Associates. 3. Reasonable Judgment. Banner Employees are not required to ask an Outside Business Associate about the actual cost of an item. Instead, Banner Employees must use reasonable judgment in determining whether the cost of an item exceeds the amount allowed under this Policy. Reasonable judgment may include, for example, researching the cost of fruit baskets, green fees, theater tickets, or typical menu items. 4. Conflict of Interest Disclosures. If a Banner Employee accepts an item from an Outside Business Associate, he/she should consider whether that acceptance creates a conflict of interest as described in Banner’s Conflict of Interest policy. If a conflict of interest arises, the Banner Employee must disclose that conflict in accordance with the Conflict of Interest policy and refrain from participating in corporate decisions involving the Outside Business Associate. B. PROVISION OF BUSINESS OR PERSONAL GIFTS BY OUTSIDE BUSINESS ASSOCIATES 1. Individual Gifts. Banner Employees can accept a non-monetary gift that is a token of respect or friendship from an Outside Business Associate subject to the following guidelines: a. Nominal Value. A gift must be of nominal value, which is $50 or less. All gifts received from the same Outside Business Associate during any three-month period are considered a single gift for the purpose of determining nominal value. In other words, the total value of all gifts accepted from the same Outside Business Associate during a rolling three-month period cannot exceed $50. i. Example: In December, a Banner employee receives a fruit basket valued at $45

from an equipment vendor. In January, the same vendor sends the Banner Employee a floral arrangement valued at $35. The value of the fruit basket and the floral arrangement would be combined ($80 total) and would exceed the

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Title : Compliance: Acceptance of Items from Outside Business Associates Number : 256 Version : 12

nominal value requirement. In this situation, the floral arrangement could not be accepted. b. Frequency. No more than four gifts can be accepted from an Outside Business Associate in a calendar year. Gifts from different representatives of an Outside Business Associate will be considered multiple gifts from the same Outside Business Associate for the purpose of assessing frequency. i. Example: A Banner officer receives a holiday fruit basket from representative A and a bottle of wine from representative B, both of whom are employees of Firm X. The Banner officer has received two gifts from Firm X and may only accept two additional gifts from Firm X during the current calendar year. 2. Cash or Cash Equivalents. Subject to the limited exceptions below, Banner Employees cannot accept cash or cash equivalents from an Outside Business Associate. Cash and cash equivalents must be returned to the Outside Business Associate, or in the rare case in which this is not possible (e.g., the giver cannot be identified or is deceased), must be surrendered to a Banner-affiliated charitable foundation for its unrestricted use. a. Fundraisers. Banner Employees can ask Outside Business Associates for financial gifts that constitute support of or participation in Banner-sponsored fundraising events for the benefit of a Banner entity (e.g., Candlelight Capers) or the community (e.g., a United Way campaign) provided that no promise, express or implied, is made that any Banner entity will do business or continue to do business with a contributor in exchange, in whole or in part, for any such support or participation. b. Political Candidates. Banner Employees who are bona fide candidates for elective public office can accept campaign contributions from Outside Business Associates provided that no promise, express or implied, is made that any Banner entity will do business or continue to do business with a contributor in exchange, in whole or in part, for any such contribution. 3. Department Gifts. A department can accept a gift that does not exceed $200 to celebrate events that are significant to the department (e.g., Nurse Practitioner Week) provided that the gift is of nominal value ($50 or less) to each department employee. Nominal value is calculated by dividing the value of the gift by the number of employees in the department. No more than four department gifts can be accepted from the same Outside Business Associate in a calendar year. 4. Gifts of Food. Food items intended as gifts (e.g., a fruit basket, a tin of holiday cookies, or a bottle of wine) are considered gifts for purposes of this policy. Gifts of food given to a department are not considered in determining the frequency of gifts given to any individual. 5. Gifts from Patients. Banner Employees are prohibited from accepting gifts from patients, former patients, or friends or relatives of patients unless: a. The gift is of nominal value ($50 or less); b. The gift is not cash or a cash equivalent; and c. The circumstances are such that refusal of the gift could hurt a patient’s feelings or be counterproductive to a patient relationship. If possible, patients, former patients, or friends or relatives of patients who wish to give a gift should be directed to one of Banner’s charitable foundations. 6. Excessive Gifts. To the extent that it is reasonably possible, gifts that exceed the limitations established by this policy must be returned to the Outside Business Associate from which they were received or, if this is not possible, must be surrendered to one of Banner’s charitable foundations for its unrestricted use. 7. Exceptions. Acceptance of a gift that exceeds the limitations established by this Policy must be approved by the Ethics & Compliance Department.

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Title : Compliance: Acceptance of Items from Outside Business Associates Number : 256 Version : 12

C. PROVISION OF MEALS AND ENTERTAINMENT BY OUTSIDE BUSINESS ASSOCIATE 1. Social Meals and Entertainment Events. Banner Employees may accept a meal or entertainment event from an Outside Business Associate that is primarily social in nature and designed to further develop a business relationship subject to the following guidelines: a. Reasonable Cost and Frequency. Social meals and entertainment events from Outside Business Associates must have a reasonable cost and be relatively infrequent. Banner Employees may accept social meal(s) and/or entertainment event(s) with a total value of $500 or less per calendar year provided that such meals and events are received no more than four times in a calendar year from the same Outside Business Associate. The cost of the event is usually the amount actually paid for the event; but where the amount actually paid varies significantly from the amount normally paid, the cost of the event is the amount normally paid (i.e., its value). i. Example: A Banner vendor is a major contributor to the Phoenix Symphony and receives free box seat season tickets to the Symphony’s concerts. If the vendor offers to take a Banner employee to a symphony concert using these tickets, the cost of the concert is the amount normally paid for the box seat tickets. The fact that the vendor paid nothing for the tickets does not mean that the cost of the tickets is $0. b. Spouses or Guests. If spouses or guests are included in an invitation, the reasonable cost limitation of $500 per year applies individually to Banner Employees and to the spouses or guests. i. Example: A Banner manager and her spouse are invited to attend a professional football game by a Business Associate. The value of the tickets is $275 per person. Although the total cost for the Banner manager and her spouse is $550, the cost of the event for purposes of this Policy is $275 per person. The invitation may be accepted. c. Consecutive Events. Consecutive events occurring on a single day will be considered a single event for the purpose of determining reasonable cost. i. Example: A vendor invites Banner managers to a golf outing that will cost $450 per person followed by dinner at a local restaurant that will cost $150 per person. The cost of the golf outing and the cost of the dinner are combined to determine the cost of the event. In this case, the total cost of $600 exceeds the $500 limit established by this Policy. d. Charitable Events. If the event is a fundraiser for a non-profit organization, the portion of the ticket price that is deemed a charitable contribution is excluded from the cost of the event. Banner Employees can attend a fundraising event for the benefit of a Banner entity as the guest of a contributor to the event without regard to the limitations established by this Policy. e. Attendance of the Host. The hosting individual must attend the event. f. Travel. Travel costs other than any cost associated with travelling in an automobile owned by the Outside Business Associate cannot be included in the cost of the event. 2. Business Meals. Banner Employees may accept an invitation to a meal that has a predominant business purpose from an Outside Business Associate subject to the following guidelines: a. Predominant Business Purpose. Banner Employees must use their own judgment in determining whether a meal has a predominant business purpose, such as when: i. Circumstances surrounding and making a meal necessary involve Banner business; or

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Title : Compliance: Acceptance of Items from Outside Business Associates Number : 256 Version : 12

(i) Example: A Banner manager shares a meal with a business associate who is currently working in a Banner facility with Banner personnel, and the meal provides a brief break from work. ii. A meal is shared during a meeting where the primary purpose is to discuss Banner business and the discussion of Banner business predominates. (i) Example: A vendor shares a meal with a Banner employee while meeting to discuss the vendor’s product/services or ongoing business matters. b. Reasonable Cost. The cost of the business meal must be reasonable and appropriate and, as a general rule, must not exceed $50 per person. The cost of a business meal will usually be the amount actually paid for the meal; but where the amount actually paid for a meal varies significantly from the amount that would normally be paid, the cost of the meal is the amount normally paid (i.e., the meal’s value). c. Frequency. Business meals should be infrequent and generally should not be accepted more than four times in a calendar year from the same Outside Business Associate. Because circumstances can significantly alter the frequency of business meals that would be appropriate, Banner Employees must use reasonable judgment in determining whether business meals have become so frequent that an appearance of impropriety (i.e., undue influence or bribe) may result. d. Attendance of the Host. The hosting individual must attend the business meal. e. Travel. Travel costs other than any cost associated with travelling in an automobile owned by the Outside Business Associate cannot be included in the cost of the meal. 3. Sponsored Department Meals . Banner departments may periodically accept food from an Outside Business Associate that is intended to be shared as a meal by department personnel subject to the following guidelines: a. Reasonable Cost. The cost of the sponsored department meal must be reasonable and appropriate and, as a general rule, must not exceed $20 per person. The cost of a department meal will usually be the amount actually paid for the meal; but where the amount actually paid for a meal varies significantly from the amount that would normally be paid, the cost of the meal is the amount normally paid (i.e., the meal’s value). b. Frequency. Sponsored department meals should be infrequent and generally should not be accepted more than four times in a calendar year from the same Outside Business Associate. c. Attendance of the Host. The hosting individual must attend the department meal. 4. Exceptions. Acceptance of a meal or entertainment event that exceeds the limitations established by this Policy, either in cost or frequency, must be approved in advance by the Ethics & Compliance Department. If a meal or entertainment event is reasonably expected to be within the limits established by this Policy and unexpectedly exceed such limits, Banner Employees must disclose it as soon as practicable to their direct supervisor. D. PROVISION OF TRAINING, EDUCATION, TRAVEL EXPENSE REIMBURSEMENT OR OTHER REMUNERATION BY OUTSIDE BUSINESS ASSOCIATES 1. Internal Training by Vendors. Formal training sessions provided by vendors at Banner must be approved in advance by the applicable department chair or designee or, if part of a Banner Graduate Medical Education program, by a Medical Education Committee. Training topics must be relevant to the job function of those attending the training, and the speaker’s credentials must be valid. Vendors may not engage in sales activities during or immediately before or after the training session. 2. Subsidies to Attend Outside Training Event. An Outside Business Associate can subsidize Banner Employees to attend a designated outside conference, educational

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Title : Compliance: Acceptance of Items from Outside Business Associates Number : 256 Version : 12

meeting, or training event hosted by another organization or party (collectively referred to as (“Outside Training Event”) subject to the following guidelines: a. Legitimate Purpose. The Outside Training Event must serve a legitimate educational purpose in that: i. The Outside Training Event must be primarily dedicated, in both time and effort, to educational or training activities that are consistent with the sponsored person’s role or responsibilities with Banner, and ii. The primary objective of bringing attendees together must be to further knowledge of the topic(s) being presented. b. Subsidies. i. Registration Costs: Banner Employees cannot directly accept subsidies from an Outside Business Associate to cover the cost of registering for an Outside Training Event. Instead, subsidies to underwrite the cost of registration must be paid by the Outside Business Associate either (1) directly to the conference promoter who can use the subsidies to reduce the cost of registration or (2) to a training and education fund established in cooperation with a Banner affiliated charitable foundation that can be used to pay the registration fee. No Banner department or entity other than a training and education fund can directly accept subsidies from an Outside Business Associate. ii. Expenses: Unless pursuant to paragraphs 2(b)(iv) below, Banner Employees cannot accept, either directly or indirectly, subsidies to underwrite the cost of travel, lodging, or personal expenses associated with attending an Outside Training Event. iii. Attendee’s Time: Banner Employees cannot accept, either directly or indirectly, subsidies that are intended to compensate them for their time while attending an Outside Training Event. iv. Graduate Medical Education (GME): Banner’s GME programs are subject to this Policy. Subsidies to permit faculty and residents to attend Outside Training Events must meet the requirements outlined above. Banner’s GME programs may also use undesignated gifts that have been received from third parties and deposited into a fund established in conjunction with a Banner foundation to underwrite the cost of attendance (including tuition, travel, and lodging) for residents, fellows, and other personnel who are currently in a training program in a Banner facility. 3. Education/Training at Outside Business Associate’s Sponsored Event. Outside Business Associates may sponsor and directly host seminar’s, conferences, user review group meetings, or other educational sessions (collectively referred to as “Outside Business Associate’s Event”). a. Banner Employees may accept an invitation to attend an Outside Business Associate’s Event, which includes free or reduced registration fees, travel, lodging, and/or meals, only if: i. The event is not limited to Banner Employees (e.g., individuals from various companies and organizations have been invited to attend the event); ii. No registration fee is charged to any invitee or the same fee is charged to every invitee; iii. The event primarily covers substantive matters directly related to the invitee’s responsibilities; iv. The value to Banner outweighs any recreational or entertainment value of the Outside Business Associate’s Event; and v. The reimbursement of travel, lodging, and/or meals is reasonable and explicitly spelled out in writing.

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Title : Compliance: Acceptance of Items from Outside Business Associates Number : 256 Version : 12

(i) Example: If an employee is invited to a 2-hour meeting at a resort location, a vendor can reimburse the employee for the travel days and the day of the meeting, but not for a five-day stay at the resort. b. Attendance at an Outside Business Associate’s Event must be approved in advance by a supervisor or compliance officer. 4. Travel Expenses for Vendor Inspection. Banner Employees can accept Travel Expenses to an out-of-town location from a vendor, if travel to that location is necessary to allow inspection of a vendor’s products, plant, or operations in the context of an active purchasing decision provided the following conditions are met: a. Travel Must be Necessary: Out-of-town travel is necessary only if (1) it is not reasonably possible to conduct the inspection locally (e.g., the vendor does not have a similar product installation in the local market) and (2) an inspection is a critical factor in the decision to purchase the vendor’s product. b. Advance Approval is Obtained: When Travel Expenses will be paid for in whole or in part by an Outside Business Associate, travel must be approved in advance by a supervisor or, if international, by a member of the Senior Leadership Team (SLT). 5. Travel Expenses Pursuant to Written Contract. Banner Employees can accept Travel Expenses to an out-of-town location from an Outside Business Associate, if travel to that location is necessary as part of an existing written contractual arrangement between Banner and the Outside Business Associate provided each of the following conditions is met: i. Travel Must be Necessary: Out-of-town travel is necessary only if it is not reasonably possible to accomplish the purposes of the travel locally. ii. Advance Approval is Obtained: The contract that provides for Travel Expenses must have been executed in accordance with the Contract Review policy, and the travel must be approved in advance by a supervisor or, if international, by a member of SLT. 6. Compensation for Outside Teaching Activities. Banner Employees who teach a course a university or other educational institution may accept compensation for preparation, planning, and teaching time. Such teaching activities must be approved in advance by a supervisor, must be outside of work hours, and cannot conflict or interfere with the Banner Employee’s work schedule or job responsibilities. 7. Honoraria and Expense Reimbursement for Speaking at Outside Training Events and Public Service Activities a. Employed Practitioners: See Secondary/Additional Professional Activities and Outside Activities of Employed Practitioners Policy and Procedure. b. All Other Banner Employees: If certain conditions are met, Banner Employees may be able to accept Honoraria as well as reasonable reimbursement for travel, lodging, and meal expenses, if they speak at Outside Training Events or participate in public service activities that are designed or intended to serve the larger community of health care providers. Banner Employees cannot accept Honoraria or expense reimbursement, if their participation is token or merely designed to circumvent the requirements of any Banner policy. i. Honoraria: Banner Employees may accept Honoraria if (1) the payments are fair market compensation for the services provided; (2) the services provided have a legitimate business purpose; and (3) the Honoraria are approved in advance by a supervisor or the Ethics & Compliance Department, except that Honoraria that exceed $1,000 in annual aggregate must be approved in advance by the Ethics & Compliance Department. (i) If it is determined that Honorarium cannot be accepted by a Banner Employee, the Honorarium must be paid directly to one of Banner’s charitable

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Title : Compliance: Acceptance of Items from Outside Business Associates Number : 256 Version : 12

foundations, or if approved by the Ethics & Compliance Department, to another organization or department. ii. Use of PTO: Unless the Outside Training Event furthers Banner’s interests and has been approved in advance by a supervisor, Banner Employees must use PTO when preparing for and participating in Outside Training Events. iii. Expense Reimbursement: If Banner paid or reimbursed any expenses, Banner Employees must remit those received from an Outside Business Associate to Banner. 8. Exceptions. Acceptance of Training, Education, Travel Expense Reimbursement, and Other Remuneration that exceeds the limitations established by this Policy must be approved in advance by the Ethics & Compliance Department. IV. Procedure/Interventions: A. To accept an item that does not meet requirements of this Policy, obtain written approval from the Ethics & Compliance Department by emailing a request with the following information: ( BANNER EMPLOYEES ) 1. Business or Personal Gifts: a. Include a description of the gift; a reasonable estimate of the gift’s value; the name of the person or department receiving the gift; the name of the Outside Business Associate giving the gift; and a description of any relationship between the Outside Business Associate, Banner, and/or the recipient of the gift. 2. Meals and Entertainment: a. Include a description of the meal or event; the reason for the meal or event; a reasonable estimate of the meal or event’s cost; the name of the person(s) or department attending the meal or event; the name of the Outside Business Associate providing the meal or event; and a description of any relationship between the Outside Business Associate, Banner, and/or the attendee(s) of the meal or event. 3. Training, Education, Travel Expense Reimbursement, and Other Remuneration: a. Training and Education: i. Include the purpose of the training; the name of the person(s) who will attend the training; the identity of the sponsor(s) and presenter(s) of the training; the location of the training; any ancillary activities that will be provided as part of the training (e.g., meals, golf outings); an estimate of the time that will be spent in training and non-training (i.e., recreational) activities; the dates of the training; a description of any travel expenses that will be reimbursed and an estimate of their value; and a description of the relationship between the Outside Business Associate, Banner, and/or the person(s) who attend the training. ii. Submit a copy of the meeting agenda, other meeting materials, their travel schedule, and lodging information. b. Travel Expense Reimbursement: i. Include the name of the traveler(s); the purpose of the travel (including non business purposes, if any); an estimate of the time that will be spent on business and non-business activities; the destination(s); the dates of travel and the length of trip in days; the mode of travel; a description of the Travel Expenses that will be reimbursed; an estimated amount of the Travel Expenses; and a description of the relationship between the Outside Business Associate, Banner, and/or the traveler(s). c. Compensation for Teaching Activity: i. Include the name of the person(s); the educational institution(s); the course(s); the schedule(s); and the expected compensation. d. Honoraria and Expense Reimbursement:

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Title : Compliance: Acceptance of Items from Outside Business Associates Number : 256 Version : 12

i. Include the names of the person(s) who will attend the event or activity; the identity of the Outside Business Associate; the location of the vent or activity; the proposed Honoraria payments; any ancillary activities that will be provided as part of the training (e.g., meals, golf outings); and estimate of the time that will be spent in training and non-training (i.e., recreational) activities; the dates of the training; a description of any travel expenses that will be reimbursed and an estimate of their value; and a description of the relationship between the Outside Business Associate, Banner, and/or the person(s) who will attend the training.

V. Procedural Documentation: A. N/A VI. Additional Information: A. N/A VII. References:

A. PhRMA Code on interactions with Healthcare Professionals B. Policy E-8.061: Gifts to Physicians from Industry

VIII. Other Related Policies/Procedures: A. Compliance: Prohibition on Kickbacks and Bribes

B. Conflict of Interest C. Contract Review D. Travel, Business Expense, and Entertainment Policy E. Solicitation and Distribution F. Secondary/Additional Professional Activities and Outside Activities of Employed Practitioners Policy and Procedure IX. Keywords and Keyword Phrases: A. N/A X. Appendix: A. Appendix A: Items from Outside Business Associates

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Appendix A Items from Outside Business Associates

Banner Health has established parameters for all of its employees regarding the acceptance of gifts, entertainment, travel, or other items from outside business associates. These items must never be solicited and must be reasonable and small enough that they do not influence decision making. Employees may never offer or accept anything of value in exchange for referrals or other business. The following table will guide the acceptance of any gifts, entertainment, travel, or other items offered by an outside business associate (“BA”). Any questions about exceeding the limits provided below must be directed to the Ethics & Compliance Department. Item Allowed Parameters Dollar Limits BUSINESS OR PERSONAL GIFTS Non-monetary gift o Floral arrangement Y o Must be of nominal value ($50 or less); all gifts during 3 month period are a single gift. o No more than 4 gifts per calendar year per BA. $50 or less

o May never be accepted o Must either be returned or in rare circumstances surrendered to a Banner charitable foundation for its unrestricted use. o Must be of nominal value, which is calculated as gift value divided by number of employees. o No more than 4 gifts per calendar year per BA or Entity/Company. o Reasonable cost is generally equal to the amount actually paid. o Consecutive events on a single day are considered a single event o Fundraiser for a Non Profit, portion of the ticket price deemed a charitable contribution will be excluded from the cost of the event. o If a Banner fundraiser, there are no limitations. o No more than 4 events per calendar year per BA. o The hosting individual must be in attendance at the event. o Travel expenses for this category are not reimbursable. o Must have a predominant Banner business purpose. o Reasonable cost is generally equal to the amount actually paid. o Should be infrequent, generally, not more than 4 times per year. o The hosting individual must be in attendance at the meal. o Reasonable cost is generally equal to the amount actually paid. o Should be infrequent, generally, not more than 4 times per year with the same BA. o The hosting individual must be in attendance at the meal.

Cash and Cash Equivalents (Gift certificates or pre-paid gift cards) Department Gifts (example: for Nursing Week)

N

N/A

Y

$200 or less per department $50 or less for department individuals

MEALS AND ENTERTAINMENT Social Meals and entertainment events o Charitable events

Y

$500 per year per person

Business Meals with a current or possible BA

Y

$50 or less per person

Sponsored Department Meals

Y

$20 or less per person

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Title : Compliance: Acceptance of Items from Outside Business Associates Number : 256 Version : 12 TRAINING, EDUCATION, TRAVEL EXPENSE REIMBURSEMENT, OR OTHER REMUNERATION Internal Training by Vendors Y

o Internal training by a BA must have advance approval by department chair or designee or, if for Banner’s GME program, by Medical Education Committee. o Subsidies for the cost of registering for the outside training event may be paid by BA either directly to the conference promoter or to a fund established by a Banner charitable foundation. o Subsidies for travel, lodging, personal expenses or to cover the cost of time while attending the outside conference usually cannot be accepted. o GME programs may use undesignated gifts received from third parties and deposited into a Banner foundation fund to underwrite cost of attendance (tuition, travel, and lodging). o Invitation to attend a BA sponsored educational event may be accepted when (1) the event is not limited to Banner, (2) either no fee is charged or same fee is charged to all, (3) the event is related to invitees responsibilities, (4) educational value outweighs entertainment value, and (5) any reimbursement of expenses is reasonable and explicitly spelled out in a contract. o Invitation may include free or reduced registration fees, travel, lodging, and/or meals. o Advance approval must be obtained by supervisor and compliance officer. o Approved in advance by a supervisor (international travel by an SLT member) for the following types: o Inspection of a vendor’s products or operations pursuant to an active critical purchasing decision; cannot inspect locally. o Pursuant to an existing written contract that has been executed in accordance with the Contract Review policy; cannot accomplish the business purpose locally o May accept compensation for teaching at a university or other educational institution with advance approval from supervisor. o Employed Practitioners: See Secondary/Additional Professional and Outside Activities of Employed Practitioners policy. o All other Banner Employees: May accept reasonable honoraria, if certain conditions are met as well as reimbursement for travel, lodging, and meal expenses associated with attending conference. o Any funds received from Banner for expenses must be returned to Banner. o A BA may subsidize a legitimate outside training event.

N/A

Subsidies to Attend Outside Training Event

Y

N/A

Education/Training at BA Sponsored Educational Event

Y

N/A

Travel Expenses for Vendor Inspection or Pursuant to Written Contract

Y

N/A

Compensation for Outside Teaching Activities Honoraria and Expense Reimbursement

Y

N/A

Y

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Title : Compliance: Business Courtesies to Physicians and Immediate Family Members Number : 190 Version : 16 Original Date : 06/09/2007 Effective Date : 02/02/2024 Last Review/Revision Date : 02/02/2024 Next Review Date : 02/02/2025 Owner : Ethics & Compliance Department; Andrew Glosenger Approved by : Administrative Policy Committee, Chief Legal Officer/General Counsel, PolicyTech Administrators

Discrete Operating Unit/Facility : Banner Baywood Medical Center Banner Behavioral Health Hospital Banner Boswell Medical Center Banner Casa Grande Medical Center Banner Churchill Community Hospital Banner Del E Webb Medical Center Banner Desert Medical Center Banner Estrella Medical Center Banner Fort Collins Medical Center Banner Gateway Medical Center Banner Goldfield Medical Center Banner Heart Hospital Banner Ironwood Medical Center Banner Lassen Medical Center Banner McKee Medical Center Banner North Colorado Medical Center Banner Ocotillo Medical Center Banner Payson Medical Center Banner Thunderbird Medical Center Banner--University Medical Center Phoenix Banner--University Medical Center South Banner--University Medical Center Tucson

Banner Corporate Ambulatory (Outpatient) Services Banner Health Clinics Banner Imaging Services

Banner Imaging Services Colorado Banner MD Anderson Cancer Center Banner Sleep Center Banner Surgery Centers Banner Urgent Care Services Occupational Health/Employee Health Services Rural Health Clinics Banner Home Care and Hospice (BHCH)

Banner Pharmacy Services Post Acute Services (PAC) Research

East Morgan County Hospital Ogallala Community Hospital Page Hospital Platte County Memorial Hospital Sterling Regional Medical Center Torrington Community Hospital Washakie Medical Center Wyoming Medical Center

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May not be current policy once printed

Title : Compliance: Business Courtesies to Physicians and Immediate Family Members Number : 190 Version : 16

I. Purpose/Population: A. Purpose : To establish parameters governing the provision and recording of Business Courtesies from Banner Health (Banner) Team Members to Physicians and their Immediate Family Members in order to maintain compliance with Federal and State laws and regulations, including, but not limited to, the Physician Self-Referral Law (Stark Law) and the Anti Kickback Statute. The Stark Law, in particular, limits Business Courtesies to Physicians and their Immediate Family Members to the Annual Monetary Limits. B. Population : All team members. II. Definitions: A. Annual Monetary Limits: The annual dollar limit for NMC, and the dollar limit for MSIB, that are annually adjusted by the increase in the Consumer Price Index-Urban All Items (CPI-U) for the 12-month period ending the preceding September 30. Exhibit A lists the current Annual Monetary Limits for NMC and MSIB, which Exhibit will be updated on an annual basis to reflect changes in such Index. B. Anti-Kickback Statute: Federal law that prohibits the knowing and willful offer or payment of “remuneration,” directly or indirectly, overtly or covertly, to induce or reward patient referrals or the generation of business involving any item or service payable by a Federal health care program. Remuneration includes anything of value. C. Business Courtesies: Gifts and entertainment from Banner or from Banner Team Members to Physicians and their Immediate Family Members. They include items of value given to a Physician or an Immediate Family Member free of cost; social events sponsored or hosted by Banner such as meals, sporting events, theatrical events, and receptions; and items of value that are funded personally by a Banner employee or agent, acting on Banner’s behalf, regardless of whether or not it is reimbursed as a business expense. For purposes of this policy, any gifts, entertainment or other items of value paid from medical staff accounts are considered to be Business Courtesies. Business Courtesies also include both Medical Staff Incidental Benefits and Non-Monetary Compensation, as defined below. D. Cash Equivalents: Items convertible to cash (such as a check) or that can be used like cash including general-purpose debit cards or gift cards. E. Designated Health Services (DHS): includes any of the following services: 1. Clinical laboratory services; 2. Physical therapy, occupational therapy, and outpatient speech-language; pathology services; radiology and certain other imaging services; 3. Radiology and certain other imaging services; 4. Radiation therapy services and supplies; 5. DME and supplies;

6. Parenteral and enteral nutrients, equipment, and supplies; 7. Prosthetics, orthotics, and prosthetic devices and supplies; 8. Home health services; 9. Outpatient prescription drugs; and 10. Inpatient and outpatient hospital services.

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Title : Compliance: Business Courtesies to Physicians and Immediate Family Members Number : 190 Version : 16

F. Immediate Family Member: Husband or wife; birth or adoptive parents, child or sibling; stepparent, stepchild, stepbrother, or stepsister; father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, or sister-in-law; grandparent or grandchild; and spouse of a grandparent or grandchild. G. Medical Staff Incidental Benefit (MSIB): Remuneration in the form of items or services (not including cash or Cash Equivalents) from a hospital to a member of its medical staff when the item or service is used on the hospital’s campus. The value of the benefit is adjusted annually by the increase in the Consumer Price Index-Urban All Items (CPI-U) for the 12-month period ending the preceding September 30. Exhibit A lists the current MSIB Amount which Exhibit will be updated on an annual basis to reflect changes in such Index. H. Non-Monetary Compensation (NMC): Remuneration from an entity in the form of items or services (not including cash or Cash Equivalents). NMC’s Annual Monetary Limit is adjusted annually by the increase in the Consumer Price Index-Urban All Items (CPI-U) for the 12 month period ending the preceding September 30. Exhibit A lists the current Annual Monetary Limit for NMC. I. NMC Database: Banner’s internal system for reporting NMC provided to a Physician and/or their Immediate Family Member. J. Physicians: A doctor of medicine or osteopathy, a doctor of dental surgery or dental medicine, a doctor of podiatric medicine, a doctor of optometry, or a doctor of chiropractic. It does not, however, include any such doctors who do not practice any clinical care or order any tests for patients (e.g., physicians who provide non-clinical consulting or other leadership services to a Banner-affiliated entity and do not provide clinical services). K. Solicit: To request a Business Courtesy. L. Stark Law (Physician Self-Referral Law): Federal law that prohibits physicians from referring patients for services payable by Medicare or Medicaid, to entities with which the Physician, or an Immediate Family Member, has a financial relationship, unless an exception applies. M. Team Member: For purposes of this policy, a Team Member refers to any individual employed by or acting as an agent on behalf of Banner. III. Policy: A. Except for Physicians employed by Banner, all Business Courtesies offered or provided to Physicians and/or their Immediate Family Members must: 1. be either NMC or MSIB and meet all applicable guidelines stated in this Policy; and 2. not be offered or provided as an inducement to refer patients or business or as a reward for such referrals. B. If a Banner Team Member has a personal relationship with a Physician and socializes with such individual(s) with respect to such personal relationship, they may personally pay for social events and it would not be considered Business Courtesies, however it would be expected that such incidences would be reciprocal from time to time.

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Title : Compliance: Business Courtesies to Physicians and Immediate Family Members Number : 190 Version : 16

C. Exhibit B provides examples of Business Courtesies, including those that should be recorded and those that are exempt from being recorded. Note: Business Courtesies extended on behalf of Banner to individuals and entities other than Physicians are governed by Banner’s Code of Conduct, and the Service Recovery Policy . Moreover, the Code of Conduct and the Compliance: Acceptance of Items from Outside Business Associates P olicy also address the receipt by Banner employees of gifts and entertainment from business associates, including Physicians. D. Permissible Business Courtesies Consistent with Applicable Stark Law Exceptions 1. NMC: a. NMC Requirements. Consistent with the NMC exception to the Stark Law, a Banner Team Member may provide Business Courtesies to a Physician and/or their Immediate Family Member that do not exceed in the aggregate the Annual Monetary Limit, so long as each of the following conditions are met: i. The compensation is not determined in any manner that takes into account the volume or value of referrals or other business generated by the referring Physician. ii. The compensation is not Solicited by the Physician or the Physician’s practice or an Immediate Family Member (including their employees and staff members). iii. The compensation arrangement does not violate the Anti-Kickback Statute or any Federal or State law or regulation governing billing or claims submission. b. Recording NMC: i. Team Members providing NMC to a Physician and/or their Immediate Family Member must record it in the NMC Database before the 10 th day of the following month. ii. On a quarterly basis, Banner entity CEO’s (or their designee, approved by the Ethics & Compliance Department) must complete an attestation by the last day of the month after the end of each quarter, that indicates one of the following: (i) To the best of their knowledge, there was no NMC to report for the quarter; or (ii) To the best of their knowledge, the NMC reported for that quarter for their respective entity is accurate and complete. iii. Any exceptions to the recording of NMC or the quarterly attestation process must be approved in advance by the business area’s Compliance Officer. iv. For NMC provided to a Physician and/or their Immediate Family Member by Team Members affiliated with a Banner entity that does not provide DHS (e.g., Banner Health Foundation, Banner Medical Group, and Banner Urgent Care), the Team Member providing the NMC must record the NMC in the NMC Database designating the hospital at which the Physician has, or will have, privileges. If the Physician is not a member of a Banner medical staff, the NMC must be recorded using the business area where they refer patients for DHS. (i) Unless the NMC is being given to a Physician and/or their Immediate Family Member on behalf of a specific hospital/business area that provides DHS, the dollar value may be divided evenly across all business area(s) where the

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Title : Compliance: Business Courtesies to Physicians and Immediate Family Members Number : 190 Version : 16

Physician has, or is expected to have, privileges and/or refers patients for DHS. v. Failure to record NMC in accordance with this Policy may lead to corrective action, up to and including, termination. c. NMC in Excess of Limits: Where an entity has provided NMC to a Physician in excess of the Annual Monetary Limit contained in Exhibit A, such compensation is deemed to be within the limit if: i. The value of the excess NMC is no more than 50% of the Annual Monetary Limit; and ii. The Physician returns the excess NMC (or an amount equal to the value of excess NMC) to the entity by the end of the calendar year in which it was received or within 180 consecutive calendar days following the date that it was received by the Physician, whichever is earlier. Note : This repayment provision may be used by a hospital only once every 3 years with respect to the same Physician. 2. MSIB: a. MSIB Requirements: Consistent with the MSIB exception to the Stark Law, Banner may provide items or services that are used on the applicable hospital’s campus to members of its medical staff, as long as the following conditions are met: i. With respect to each occurrence of the MSIB, the MSIB value must be less than the allowable limit listed in Exhibit A. ii. The MSIB is offered to all members of the medical staff of that hospital practicing in the same specialty (whether or not such compensation is accepted by every member to whom it is offered) and is not offered in a manner taking into account the volume or value of referrals or other business generated between the parties. iii. Except with respect to identification of medical staff on a hospital Web site or in hospital advertising, the MSIB is provided only during periods when the medical staff members are making rounds or are engaged in other services or activities that benefit the hospital or its patients. Note: For more information on physician advertising, see Banner’s policy #761, Physician Advertising. iv. The MSIB is provided by the hospital and used by the medical staff members only on the hospital’s campus. (i) Internet access, pagers, or two-way radios, used away from the campus only to access hospital medical records, communicate with patients or personnel who are on the hospital campus, or to identify the medical staff on a hospital Web site or in hospital advertising, are considered to be “on campus” for compliance with the requirements of this paragraph. v. The MSIB is reasonably related to the provision of, or designed to facilitate directly or indirectly the delivery of medical services at the hospital.

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