Code of Conduct and Business Ethics
Compliance Committee Approved: Health Commission Approved:
I.
A Message from Lizeth Granados, CEO
Dear Colleagues,
As we navigate a consistently changing healthcare landscape, I am reminded of the profound trust that our members, provider partners, and communities place in Health Plan of San Joaquin (HPSJ). This is a tremendous responsibility that goes beyond meeting regulatory requirements, extending into the very core of who we are and the values we uphold.
At HPSJ, we are not just an organization bound by rules and regulations – we are a mission-driven workforce dedicated to the highest standards of ethical conduct. Each day, we strive to do what is right, not as an obligation, but as an embodiment of
our values that encompass accountability, stewardship, excellence, partnership, teamwork, and the principles of diversity, equity, and inclusion.
HPSJ’s Code of Conduct embodies our values and signifies our steadfast dedication to those in our care. This document outlines actions that guide our integrity, emphasizes our compliance with regulatory requirements, and establishes a framework for leading as the foremost Medi-Cal managed care plan in our region. I encourage each of you to familiarize yourselves with our Code of Conduct, as it directs our daily service to the community.
Let us come together as a health plan, united by a shared commitment to our values, and strive to uphold the principles detailed in our Code of Conduct. Compliance is not limited to one department, but it is a collective responsibility that each of us bears. We all play a critical role in supporting the integrity of HPSJ and it is through these efforts that we can continue making a positive impact.
Thank you for your unwavering dedication and attention to this vital matter.
Sincerely,
Lizeth Granados Chief Executive Officer
VISION
Healthy communities with equitable access to quality care.
MISSION
Provide high quality healthcare for our members through community partnerships.
OUR CORE VALUES
Accountability
We are accountable to members, providers, our communities, and each other.
Diversity,
Equity, and Inclusion
We believe in promoting a foundation of compassion and respect for diversity, equity, and inclusion strengthening our organization and community by embracing opportunities for growth and leveraging the uniqueness of individual ideas, thoughts, and cultures.
Partnership
We actively engage in community partnerships to advance quality care and health equity.
Stewardship
We serve as a responsible steward of entrusted resources.
Excellence
We act with integrity and aim for excellence in all we do.
Teamwork
We demonstrate teamwork in all our interactions.
III. About the Health Plan Code of Conduct and Business
Health Plan is COMMITTED to honest and ethical practices
We are committed to the highest standards of ethics, integrity and professionalism in everything we do. We are also committed to full compliance with all federal and state health care program requirements. These values apply to all our work and dictate how we conduct our business. They are vital to our individual success and the success of the health plan.
The Code of Conduct and Business Ethics (Health Plan Code) describes the general principles that guide our business activities. It is based on the laws regulations, and other rules that apply to our work and help us comply with all health care program requirements.
It is important that you understand and comply with the Health Plan Code. This includes reporting to Health Plan any violations of the Health Plan Code of which you become aware.
While the Health Plan Code may not address every situation that may arise, Health Plan believes that good judgement, honesty and integrity should always guide us in our work. Our Health Commission has approved and adopted this Code to provide us with the expectations about how they want us to conduct business. The following questions may help you evaluate specific situations on conducting appropriate business:
• Will my action comply with the intent of Health Plan’s Code and other policies?
• Will I compromise myself or the reputation of Health Plan by this action?
• Is this action honest in every way?
• Could this action appear wrong to others, even if it is legal?
Regardless of the specific situation you may face, the best action at all times is to be honest.
In addition to the Code, Health Plan has extensive policies and procedures to further clarify parts of the Health Plan Code to help ensure proper operation of the health plan. You must comply with Health Plan policies and procedures.
IV. Your Duties Under the Health Plan Code
Acknowledgement-You are REQUIRED to read the Health Plan Code. If there is anything you do not understand, ask your supervisor or someone in the Compliance Department for clarification. You must complete the Acknowledgement form within 30 days of hire and any time the Health Plan Code is revised. Health Plan’s Compliance Department will notify you in the event the Health Plan Code is revised. The Acknowledgement form is on the last page of the Health Plan Code.
Training- Health Plan provides training for all its employees on a number of subjects. Many of these training sessions are mandatory and relate to subjects such as:
• General Compliance
• Fraud Waste and Abuse (FWA)
• Health Insurance Portability and Accountability Act (HIPAA)
• False Claims Act
• Conflict of Interest
• Annual Privacy & Information Security Training
• Diversity, Equity, and Inclusion
• Harassment Prevention
• Other important job specific subjects
It is your responsibility to complete these trainings within the timeframe provided.
Reporting Violations-You MUST report to your supervisor or the Compliance Department, any potential or suspected violations of:
• The Health Plan Code
• Compliance issues/concerns
• Potential HIPAA incidents or breaches
• Laws or regulations
• Health Plan Policies and Procedures
• Any federal or state health care program requirements
This includes any time you know or suspect a violation of fraud or abuse or any other illegal or unethical activity. If you know or suspect a delegated vendor or business associate with which we do business of inappropriate conduct, you must report that as well. You must also report to the Compliance Department immediately any investigation to which you are the targeted subject or any adverse action taken against you by a government agency, including a potential or final decision that you are an excluded person.
Health Plan also has anonymous reporting, should you prefer. You can access the anonymous reporting form online via the main SharePoint page, you may contact Lighthouse directly by calling 855-400-6002, or you may go directly to their website www.lighthouse-services.com/hpsj.
In some cases you may learn about a situation and you may not be sure whether it is a violation. You should always seek advice when you are unsure about the legal or ethical action you should take. If you have any questions or concern about a particular practice or activity, you should not guess the answer. This includes situations when:
• Applicable policies are difficult to interpret
• The relevant laws or standards are complex
• You have limited experience dealing with the issue
• You find yourself in a gray area and need guidance
Audits and Investigations-You MUST cooperate fully with all Health Plan audits, investigations or other reviews. It is important that you comply with all request for documents, information and interviews without delay. Your responses must be complete and truthful. In the instances where an investigation may be conducted by an outside attorney, you must cooperate with review under the direction of Health Plan Legal Counsel and the Compliance Department.
In addition, you must notify the Executive Team or Compliance Department in the event you receive:
• A request to appear to testify before a grand jury, government agency or similar organization.
• A notice from DHCS, DMHC or similar regulatory authority has begun an investigation.
• A request for inspection or interview by a government agency (outside of a routine request).
• A notice from any federal or state governmental authority imposing or threatening substantial fines, penalties or other action.
Non-Retaliation- Health Plan will not retaliate against you for reporting in good faith a possible violation of this Code or of a law, rule or regulation. Retaliation for reporting a federal offense is illegal under the federal law. This means that Health Plan cannot fire you, demote you, cut your pay or take any other action against you for reporting a suspected violation in good faith. A report made in good faith means you honestly believe that a violation of the Health Plan Code, law, rule or regulation has happened or will happen.
We will not take or threaten action against you in retaliation for making a complaint, disclosing or reporting information in good faith. However, if the person reporting the violation was also involved in the violation, he/she may be disciplined appropriately. When this happens, we may consider that the person reported the violation as a positive factor in the disciplinary decision.
Reporting off Duty Conduct-As a government sponsored health plan, Health Plan may not employ or contract with anyone who has:
• Been excluded from participation in federal health care programs
• Been convicted of certain crimes
• Plead guilty or no contest to certain crimes
You MUST notify Human Resources if you have met any one of the above criteria. You must also notify Human Resources when any type of license (DMV, professional, etc.) that is required to perform your job is revoked, expired or suspended.
V. Duties of Leadership Under the Health Plan Code
At Health Plan, ethical leadership is a very important part of effective leadership. We hold our managers to the highest standard of ethical conduct. If you supervise any associates, you have the responsibility to:
• Ensure your direct reports are familiar with the policies that apply to their jobs and understand the importance of the Health Plan Code.
• Be a role model for ethical behavior through your own conduct.
• Maintain a workplace environment in which employees feel comfortable raising concerns.
• Support employees who in good faith raise questions or concerns about compliance.
As a Manager you must promptly report any potential violation of the Health Plan Code to the Chief Compliance Officer or their designated staff.
Nobody at Health Plan is authorized to commit an illegal or unethical act or may violate the law or the Health Plan Code. No manager is authorized to tell anyone to commit an illegal or unethical act or to violate the law or the Health Plan Code.
Discipline-Health Plan takes it commitment to highest ethical standards very seriously. Any act against the policy and purpose of the Health Plan Code may be cause for disciplinary action. Health Plan will enforce discipline fairly and consistently.
Health Plan may take corrective action against managers who fail to detect or report misconduct on the part of employees or business partners under their supervision. It is your responsibility to know the violations of law, regulations, the Health Plan Code or Health Plan policies and procedures that could trigger external legal action against you, your colleagues, and/or the health plan. Criminal or governmental enforcement action can include suspension or revocation of licenses, sanctions, fines, criminal penalties and imprisonment.
VI. Amendments and Waivers Under the Health Plan Code
Health Plan’s Health Commission, CEO and Chief Compliance Officer may amend the Health Plan Code from time to time.
VII. We are Committed to Our Members
Our Mission is to provide high quality healthcare for our members through community partnerships.
Quality of Care-our members are why we are here. Health Plan is committed to ensuring that each and every one of our members receives quality care. Quality of care is one of our highest priorities and helps us to achieve our mission to enhance our member’s health and quality of life. It is our goal to ensure every member receives the right care, at the right time and in the right setting. Our commitment to quality of care means not only do we try to improve the quality scores of the health plan but each of us considers what impact our actions have on member care.
Federal and state laws, rules and regulations require that we provide our members appropriate services to meet their needs. Health Plan wants to ensure that members have access to care and expects you to help with underutilization of care. It is important that
we never deny members access to a service that the member should receive. For example:
• We must never deny payment of a qualified claim that is authorized for coverage.
• We must never delay or deny approval of a medically necessary referral that was submitted timely.
• We must ensure that our members have access to sufficient providers in our network to meet their needs.
Confidentiality-It is important in the course of our business to have access to health information and other personal information of our members. It is important that you treat all member health information and other personal information as confidential. Health Plan does not tolerate misuse of health or personal information.
It is your responsibility to know and comply with all privacy laws and regulations, including state privacy laws. You may make use of confidential member information only to perform your job duties and must comply with all Health Plan safeguards and the HIPAA related to member privacy. You may contact the Privacy Officer and/or Compliance Department if you have any questions or concerns about your duties under these laws.
HSPJ provides new hire and annual privacy training for all employees. Remember, it is your responsibility and duty to report any known or suspected violations of the Health Plan Code, law, or regulations. This means that if you suspect or know that a member’s confidential information has been compromised, you must report it immediately. You can report directly to PIU@hspj.com or use the Report an Incident Form on Health Plan Intranet.
What is considered a breach of member’s confidential information? A breach happens when an unauthorized person gets access to a member’s confidential information. A breach can happen in many different ways. The following are examples of breaches:
• A hacker accesses Health Plan systems and gains access to member information.
• An employee prints the names and phone numbers of our members and sells the list.
• An employee looks up information on his/her family member out of curiosity rather than for work reasons.
It is impossible to list all the ways confidential information can be breached or misused. Use good moral judgement when accessing confidential information and be mindful of your work stations, work areas and your discussions regarding members in open and populated areas.
Marketing-There are many federal and state laws and regulations that apply to the marketing of health care plans. There are specific rules about marketing to people who are enrolled in Medi-Cal. It is important to be honest and accurate in promoting Health Plan.
If you are involved in marketing or promoting the health plan or enrolling members, you MUST be familiar with and comply with all applicable rules and regulations.
VIII. We are Committed to Compliance
Compliance Department Vision: A Trusted Partner in Compliance and Service.
Compliance Department Mission: To Support our Partners with Respect, Integrity and Clarity.
Health Plan’s goal is 100% compliance with all laws and regulations that apply to us and we expect you to have the same goal. Our commitment extends to all laws and regulations that apply to our business.
The Compliance Program-Health Plan has implemented a Compliance Program that is intended to demonstrate Health Plan commitment to the highest standards of ethics and compliance. Compliance is everyone’s responsibility!
The Compliance Department is committed to investigating all reported concerns promptly and confidentially to the extent possible. Our team will work with the appropriate business units and their staff to coordinate any findings from the investigations and immediately recommend remediation or corrective action, if applicable. It is important that all business units cooperate and participate with investigation efforts.
Fraud, Waste and Abuse (FWA)-FWA is a serious concern for our health plan. We are constantly reviewing our data for red flags that identify potential FWA. Health Plan investigates all allegations and situations.
Fraud is knowing and willfully attempting to defraud any health care benefit program or to obtain any money or property owned by or under the custody or control of any health care benefit program.
Waste is overutilization of services or other practices that directly or indirectly result in unnecessary costs to the health care system. It is caused by the misuse of resources.
Abuse is payment for items or services when there is no legal entitlement to that payment and the individual or entity has knowingly or intentionally mispresented facts to obtain payment.
Some of the most common coding and billing issues are:
• Billing for services not rendered.
• Billing for services at a frequency that indicates the provider is an outlier compared to their peers.
• Billing for non-covered services using incorrect, CPT, HCPCS and diagnosis codes in order to have services covered.
• Billing for services that are actually performed by another provider.
• Upcoding.
• Modifier misuse; example modifiers 25 and 59.
• Unbundling.
• Billing for more units than rendered.
• Lack of documentation to support services billed.
• Services performed by unlicensed professionals.
• Altered records to get services covered.
False Claims Act-The detection, correction and prevention of FWA are essential to developing a strong compliance program. It is illegal under the law for a health plan or provider to file a claim for money from the government if it is not entitled to it. Health Plan must never seek money from the government for a service that was never provided.
The False Claims Act prohibits filing false information in order to increase the payment we receive or to avoid a fine or other obligation. In addition to the federal False Claims Act, California has enacted their own False Claims Act.
The California False Claims Act (Act) permits the Attorney General to bring a civil law enforcement action to recover treble damages and civil penalties against any person who knowingly makes or uses a false statement or document to either obtain money or property from the State or avoid paying or transmitting money or property to the State. It also permits a whistleblower to file an action to enforce the Act. The whistleblowers lawsuit is filed under seal to permit the Attorney General or local prosecuting authority to investigate and, if warranted, intervene in the action. The Act provides protection against retaliation of the whistleblower.
If you have any concerns of the accuracy of documentation, speak up and bring it to the attention of your supervisor or the Compliance Department. Health Plan has zero tolerance for any activity that constitutes fraud, waste or abuse.
Accurate Books and Records-Health Plan books and records must be accurate and reflect our business transactions and assets in a fair manner. You must never falsify business records. You must not create any misleading reports or any records that hide something that was done improperly. You MUST not:
• Make a false or misleading statement or report
• Ask someone else to make a false statement or report
• Be dishonest or deceptive in any other way in reporting business or maintaining its records
All employees who have access to Health Plan’s books and financial records must accurately record our profits, losses, financial transactions and any other financial business. Health Plan provides full, fair, accurate, timely and understandable disclosure in reports and
documents that Health Plan files with the appropriate governmental agencies and Health Commission.
Our commitment to accurate books, records and reports applies to all records and transactions. If you are not sure whether the information is accurate or complete, do not guess and do not include it in a report. Advise your supervisor of the situation.
Procurement Integrity-Health Plan will be ethical in obtaining new business. We will comply with all laws and regulations that apply to the procurement of goods and services. This means that all proposals we submit will accurately describe our experience and capabilities.
In addition, when Health Plan seeks bids for its business, our decisions will be based on price, quality, service and the vendor’s ability to meet the health plan’s needs.
Interacting with the Health Commission-As Health Plan employees you are bound by strict rules with respect to gifts, you may not offer any illegal gifts or entertainment to any Health Commissioner or governmental representative. You must comply with applicable laws, regulations and policies with respect to such gifts and courtesies. If a governmental representative asks for a gift, you MUST report it immediately to the Chief Compliance Officer.
Bribes, Kickbacks and Inducements-Health Plan complies with all federal and state anti- kickback laws and regulations. Under these laws a person may not:
• Give anything of value to influence or reward a member referral for a service that may be paid for by a government health care program.
• Receive anything of value to make a member referral or as a reward for a past referral for a service that may be paid for by a government health care program.
• Give anything of value to encourage someone to buy, rent or recommend an item or service that may be paid for by a government health care program.
• Receive anything of value for buying renting or recommending an item or service that may be paid for by a governmental health care program.
You may not offer anything of value to a provider, member or other person that could be seen as a bribe or construed as an improper inducement. You may not make any illegal or improper payment from health plan funds or assets, whether directly or indirectly.
Lobbying-Health Plan complies with all laws and regulations relating to the lobbying of government officials on its behalf, including reporting and certification requirements.
Money Laundering and Financing Terrorism-Health Plan conducts business only with customers and vendors who engage in legitimate business activities with legitimate financial sources. Health Plan will comply with laws and regulations aimed at stopping money laundering and fighting the financing of terrorism. If you believe that Health Plan has received suspicious payment, you MUST report it immediately to your supervisor and/or Compliance Department.
Records Retention-You MUST comply with the Health Plan Records Retention Policy. The policy outlines how long records should be kept and when and how they should be destroyed.
Records that are relevant to a legal action or governmental investigation must not be destroyed until the action or investigation has concluded. You must heed any notification from management telling you to preserve records, even if that means keeping them longer than the retention policy states.
Oversight and Monitoring-Health Plan is committed to the monitoring of Compliance. Monitoring efforts are achieved by the completion of internal audits in areas of risk, reported issues that have regulatory or compliance implications and updates or changes to applicable regulations that impacted current policies and processes.
IX. We are Committed to Health Plan of San Joaquin
Conflict of Interest describes any circumstance that could cast doubt on your ability to act in the health plan’s best interest.
Conflict of Interest-A conflict of interest exists when your personal interests interfere with your ability to make an objective decision when performing your job. Even the appearance of a conflict may violate the Health Plan Code and could harm Health Plan’s reputation. You MUST avoid situations where your personal interests could conflict with the interests of Health Plan.
Health Plan strongly discourages investing in a supplier or company that is conducting business with us. You may not have a significant financial interest in any business that does business with, seeks to do business with or competes with Health Plan
You should know federal, state and local governments also have specific rules about conflict of interest. If you have a conflict of interest, you MUST report it to the Compliance Department promptly. It is your duty to disclose a potential conflict of interest by using the Conflict of Interest form located on the Health Plan intranet.
Proper Use of Health Plan’s Property-All HSPJ property should be used for legitimate business purposes. You may not use Health Plan property for your own personal benefit. The expectation is that you will use proper care when you use Health Plan property and equipment. We expect you to protect our property against theft and misuse and you may not remove any property from the premises without proper authorization.
You must use all property in a responsible manner. Personal use of electronic equipment and systems may be subject to restrictions. You should not expect a right to privacy in your email or internet use. As permitted by law, Health Plan may review all electronic information and communications. All Health Plan equipment, systems and networks may be subject to monitoring.
You are prohibited from accessing, sending or downloading websites that contain sexually explicit, illegal and/or discriminatory content. If you are considering accessing a site and think it may not be appropriate, ask yourself whether you would be comfortable with your supervisor and co-workers knowing you accessed the site. You are prohibited from accessing or attempting to access another individual’s electronic communications without appropriate authorization. You may not access or try to access any part of the Health Plan system that you are not authorized to access. This behavior is subject to immediate disciplinary action.
Confidential and Propriety Information-Our information is considered valuable property. All information about Health Plan operations and business affairs must be kept as confidential as possible. Confidential information includes all non-public information that might be of use to competitors or might be harmful to Health Plan or its members if disclosed. Never disclose confidential information without prior approval.
Public Communications-Information we release about Health Plan must be accurate, consistent and understandable. For this reason, the External Affairs Department coordinates all of Health Plan media communications in both routine and crisis situations.
Political Activities-Health Plan encourages you to become involved in civic affairs and the political process. However, you must make sure it is clear that you are not speaking or acting on Health Plan’s behalf. Health Plan has directed our CEO and the External Affairs Department to speak on our behalf. You may participate in partisan political activities but only on your own time and at your own expense.
X. We are Committed to Our Workforce
At Health Plan we are a team and our success depends on your ability to inspire the trust and confidence of your co-workers, supervisors, our members and our government regulators.
Respect for all-Health Plan believes in attracting and retaining a highly talented workforce. We recruit, hire, train, promote and administer all personnel actions on the basis of qualifications and performance. We believe in treating our entire workforce with respect and dignity.
This means:
• We do not discriminate on the basis of race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information or any other legally protected basis.
• We have zero tolerance for harassment of others.
• We make safety and security of our facilities a priority.
• We respect the rights and dignity of our workforce.
Workplace Violence-Health Plan has zero tolerance for violent acts or threats of violence against its employees, applicants, regulators, providers, members, visitors, contingent workforce members and/or vendors. We will not tolerate threatening, violent or abusive conduct. Example of prohibited conduct include:
• Intimidating or hostile behavior
• Physical or verbal abuse
• Assault
• Battery
• Vandalism or destruction of property or personal property of others
If you require additional information on appropriate workplace conduct, please refer to your direct manager or contact the Human Resources Department directly.
Firearms and Other Weapons- Health Plan has zero tolerance for possession of firearms or other weapons on Health Plan property or at work sponsored events.
Alcohol and Drug Use-Health Plan maintains a drug-free work environment. You may not use or possess illegal substances on our property or while conducting business elsewhere on our behalf. You MUST not report to work under the influence of drugs or alcohol.
If you choose to consume alcohol at events in which you are representing Health Plan, you must do so in a safe and responsible manner.
Legal prescribed medications must be used in a safe and responsible manner while on Health Plan property or while conducting Health Plan business elsewhere. If you must take a legal medication that may interfere with your work performance, please contact your supervisor or Human Resources to determine if a reasonable accommodation is available.
OIG Exclusion List-Health Plan does not hire employees, contractors, temporary employees, consultants or contract with vendors who have been excluded from participating in Federal and State healthcare programs. We conduct background checks and OIG exclusions checks on all potential employees and subcontractors upon hire and monthly thereafter.
XI. We are Committed to Our Partners
Intellectual Property Rights and Confidentiality to our Partners-We respect the intellectual property of others, this includes our suppliers, vendors, business partners, providers, and competitors. Health Plan will comply with applicable licensing and contracted agreements. Our expectation is that you will do the same. You MUST not make
unauthorized copies of software or any other copyrighted material. It is both illegal and unethical to break copyright laws or licensing agreements.
Intellectual property is property that cannot be touched and that has been developed through creativity or intellect. Common examples are software code, videos, or even the Health Plan Code.
Sometimes partners, suppliers, contractors, competitors, providers or others, provide us with information in confidence. You MUST respect the confidentiality of this information. Do not accept any confidential information from others unless an appropriate agreement is in place. If you are not sure whether there is an agreement, check with your supervisor or the Compliance Department.
Accepting Gifts-You must not accept a gift, money or anything else valuable from a prospective or current vendor, provider, contractor or member if it might look like a bribe or other unfair influence. You should not personally gain from anyone doing business with us, trying to do business with us, or in competition with us. You must NEVER ask for a gift or money.
If offered as a thank you for your business or at the holiday season, you may accept occasional non-cash gifts that are worth $50 or less and they must be shared with the entire company. Items such as gift cards or similar items that can be used like cash are considered cash gifts and are not acceptable. Please present any gift card received to your Executive Team leader to be returned.
Accepting Meals and Other Entertainment-You must not ask anyone, including any prospective or current vendor, provider, contractor or member, for meals, sports tickets or other entertainment. If offered, you may accept only if the entire company is participating and it is reasonable, infrequent and in good taste.
Antitrust Laws-Antitrust laws apply to any business. For example, the following situations may create issues under the antitrust laws. Therefore, you MUST not:
• Speak with a competitor about provider contracts in which Health Plan has executed or plans to execute
• Speak with a competitor about the pricing or other terms of our provider contracts
• Speak with a competitor about benefits or services Health Plan plans to offer
• Speak with a competitor about pricing or other terms of our benefits or services
If a competitor asks to speak with you about our providers, benefits or other business information, refer them directly to our Provider Networks team.