Issuu on Google+

Standard of Conduct I. Introduction A Standard of Conduct sets forth an organization’s behavioral expectations of its employees, board, and entities with which it does business. The standards most often recount the policies and procedures that employees, board members, and other entities related to an organization should follow in relationship to preventing fraud and abuse of funding forces. Standards also reflect an organization’s commitment to compliance with federal and state laws and conducting business in accordance with the highest ethical standards. The mission of Family Health Centers is to “provide residents of Louisville and Jefferson County access to high quality primary and preventative health care services without regard to the ability to pay”. In order to provide health care services without cost to qualified patients, Family Health Centers relies upon financial support from other sources of funding. Often these funding sources include federal Medicaid and Medicare. The purpose of this policy is to provide safeguards to ensure Family Health Centers’ (FHC) compliance with laws and regulations relating to fraud and abuse; to ensure we uphold the highest standards of ethical and professional conduct; and to show commitment to the highest standards of patient care, quality, and integrity. These standards are in place to prevent employees, board members, and/or business associates from using their position for purposes that are, or give the appearance of, being motivated by a desire for private financial gain for themselves or others, such as those with whom they have family, business or other ties, and from violating their duty to FHC by inappropriately disclosing confidential information about FHC or its patients. II. Billing and Coding Standards; Liability for False Claims In order to comply with federal (Section 6032 of Deficit Reduction Act of 2005 and False Claims Act; 31 U.S.C. §§ 3729 – 3722) and state laws (KRS 205.211 and KRS 205.8467) regarding reimbursement of medical services, supplies, and equipment the following standards will be followed. Each employee, contractor, or vendor involved with providing or obtaining reimbursement for medical services, supplies, or equipment from or on behalf of FHC is responsible for submitting honest and accurate bills to Medicaid, Medicare, and other Federal and state health care programs, and for submitting honest and accurate invoices to FHC. In addition to complying with FHC’s Standards of Conduct, all employees, contractors, and vendors are expected to comply with Federal and state laws and administrative remedies designed to prevent fraud, abuse, and waste in Federal and state health care programs. A. Medically Necessary Services 1. All services, equipment and supplies provided to patients will be reasonable and medically necessary, in accordance with the standard of care of the specialty. 2. Providers who provide the services will be properly credentialed and licensed and provide services within their scope of practice.

Irwin, Rev. 2-20-2007

1


B. Completeness and Accuracy in Medical Records and Billing 1. Providers will document the treatment performed and in sufficient detail so that an accurate bill can be submitted for each treatment or procedure performed. 2. Provider numbers will be accurate and will not be shared. 3. Services performed by medical residents will be billed only in compliance with Federal laws and regulations, including the presence of a supervising physician and payment for teaching physicians’ services. 4. Bills submitted for services performed shall describe the services in sufficient detail, be based on proper documentation in the chart, not duplicate bills for the same services, be accurate, and be based on the correct provider number, and be in compliance with Federal and state law, as well as the payor’s contract. 5. Billing and Coding staff will comply with CMS program instructions and policies, National and Local Coverage Determinations (NCDs and LCDs), and Carrier Bulletins. C. Impermissible Billing Practices The following practices are not permitted: • Billing for services that were not performed at all or not performed as described • Submitting claims for medical equipment, supplies, or services that were not necessary • Double billing • Upcoding or assigning a code that secures a higher reimbursement, rather than the code that matches the services performed • Unbundling or billing the parts of a global fee separately • Knowingly misusing provider numbers • Failing to use coding modifiers accurately or appropriately • Preparing or submitting false cost reports • Billing for services performed by an unlicensed provider or one who has been excluded from a Federal health care program D. Compliance with Federal Law and State Laws 1. All FHC employees, contractors and board members will comply with Federal and state law and regulations concerning fraud and abuse in federal health care programs. 2. No FHC employee and/or contractor is permitted to give or accept cash, gifts, favors, payment, services, entertainment, tips or any other items of value from anyone in exchange for the referral of Medicaid, Medicare or other government health care program business to FHC. 3. FHC will not waive the collection of co-payment obligations to insurers unless it establishes that the patient meets FHC’s sliding fee scale requirements. FHC should keep a record of the patient’s financial indigence. E. Government Reporting 1. All reports required to be submitted to state or Federal health care programs must be truthful and accurate. No FHC board member, officer, or employee shall attest to the accuracy of a submitted report unless he or she has been able to satisfy himself or herself that the data submitted or the representations made are truthful and accurate.

Irwin, Rev. 2-20-2007

2


2. If FHC determines it has been overpaid by a government program, third party payor, or patient, it will promptly refund the payment to the proper party. 3. All cost report data, schedules and work sheets must be truthful, accurate, and complete. FHC will only report properly allowable costs that were actually and reasonably incurred by FHC. 4. No FHC employee or contractor will attempt to improperly influence the actions or decisions made by government bodies, officials, employees, or contractors. 5. FHC will cooperate and be truthful in responding to government inquiries, requests, and investigations, including audits, surveys, and certifications reviews. 6. FHC Employees, Board Members and Business Associates are also expected to fully cooperate with FHC’s internal investigations. III. Private Financial Gain A. Financial Interests No Employee, Board Member, or Business Associate may participate in the selection, award or administration of a contact in which he/she or his/her immediate family or partner has a financial interest or with whom he/she is negotiating or has any arrangement concerning employment. If an Employee, Board Member, or Business Associate believes that he/she, a member of his /her immediate family or partner has a financial interest in a Federally-funded contract of FHC, he/she must immediately disclose this in writing to the Executive Director or Compliance Officer. Disclosures by officers or members of the Board of Governors must also be made to the Chair Person (and if it is the Chair Person who has such a financial interest, he or she must make disclosures to the Vice-Chair Person). No member of the Board of Governors may vote on any matter which may directly or indirectly result in financial gain to that member, or which may conflict with that member’s obligation to another organization’s Board of Governors or to his/her employer. Provided that the member of the Board has first disclosed a conflict or potential conflict, and abstains from voting in that regard, he/she may participate in discussions relating to that matter. In addition, Board members may refer to the Board of Governors Bylaws and Conflict of Interest Policy. B. Compensation to Members of the Board of Directors Within the limits of available funds, FHC may reimburse members of the Board of Governors for reasonable expenses actually incurred by reason of their participation in Board activities, e.g. travel expenses, meals and incidentals. FHC will not compensate members of the Board of Governors for services rendered in the ordinary course of service as members of the Board of Governors. However, if a member of the Board who is not an officer is uniquely qualified to perform professional services for FHC, then they may consider contracting with that member of the Board of Governors for such professional services, provided that the affected member of the Board of Governors does not participate in Board discussions or vote on his/her selection, the contract is in all respects “arms length”, consistent with Federal procurement standards if federal funds will be used, and in the best interests of FHC. C. Gifts/Gratuities Employees, Board Members and Business Associates of FHC may not solicit or accept gratuities, favors or anything of value from patients, contractors or potential contractors of FHC. A gift is defined as anything offered directly by or on behalf of a contractor other than promotional materials of little or

Irwin, Rev. 2-20-2007

3


nominal value such as pens, calendars and other items intended for wide distribution. Gifts include (but are not limited to): personal gifts, such as sporting goods, household furnishings and liquor, social entertainment or tickets to sporting events, personal loans or privileges to obtain discounted merchandise, and the like. Employees, Board Members and Business Associates shall decline or return any gift and notify the Executive Director and/or Compliance Officer of such gift. D. Competition It is the policy of FHC to conduct all procurement transactions in a manner to provide, to the maximum extent practical, open and free competition. FHC will be sensitive to, and seek to avoid, organizational conflicts of interest or non-competitive practices among contractors. Consultants who want to bid for a contract from FHC are prohibited from drafting the contract’s specifications, responsive to the solicitation and most advantageous to FHC, price and other factors considered. FHC always retains the right to reject any and all bids when it is in FHC’s best interest to do so. FHC retains the right to determine, with respect to any particular procurement, that sole source procurement is justified. E. Bribery FHC will immediately dismiss any employee, remove any officer or member of the Board of Governors, and terminate the contract of any contractor/agent found to have offered or accepted a bribe to secure funding from FHC. F. Confidential Information Employees, Board Members and Business Associates may gain access to confidential (e.g., non-public) information by virtue of his/her position within FHC. Employees, Board Members and Business Associates are required to hold such information in confidence. Officers and members of the Board may not communicate confidential information about FHC to anyone who is not also an officer or member of the Board, respectively, absent the explicit authorization of the full Board of Governors. If as a result of negotiations in which FHC is engaged, an officer or member of the Board gains access to confidential information of another entity, the officer or member of the Board may not communicate this information about the other entity to anyone who is not also an officer or member of the Board, respectively, without the authorization of the full Board. If FHC executes an agreement with another entity which agreement includes provisions governing confidentiality of information, all officers and members of the Board are bound by those provisions and required to comply with them. IV. Political Activities and Nepotism A. Political Activities No employee, contractor, or agent to the Family Health Center may engage in political activities during business hours. No Employee, Board Member, or Business Associate may use FHC’s name, facility, or resources in connection with political activities. In particular, no Federal grant or related funds may be used to support the costs, if any are incurred, of prohibited lobbying activities as defined variously in OMB Circular A122, Department of Health and Human Services (HHS) rules implementing the Byrd Amendment and HHS appropriations riders. Employees, Board Members and Business Associates may not solicit political support in any manner, which might suggest that FHC supports any political party or candidate. No Employee, Board Member, or

Irwin, Rev. 2-20-2007

4


Business Associate shall, in any manner, solicit financial assistance or subscription for any political party, candidate, fund, publication, or any other political purpose from FHC employees in the workplace or otherwise in an employment related setting. In addition, employees must comply with Civil Service rules regarding political activity. B. Nepotism FHC will not hire any individual who is an immediate family member to an Employee, Board Member or Business Associate if, in the position being applied for, the applicant will supervise, or be supervised by the related employee or contractor. Employees may also refer to the Personal Policy on Hiring Practices for more information. No member of the Board of Governors shall be an employee of Family Health Centers, or spouse or child, parent, brother or sister, by blood or marriage, of such employee. V. Violations of Corporate Compliance Policy A. Responding to Detected Offenses and Developing Appropriate Corrective Action The purpose of this section is to set forth the procedures used by the FHC to respond to information received by the Compliance Officer/Contact that a Board member, officer, employee, consultant or vendor is engaging in activity that may be contrary to applicable Federal or State law or the requirements of the FHC’s compliance program. Violations of FHC’s Corporate Compliance Policy must be reported promptly to the Compliance Officer and/or Executive Director or by calling FHC’s Hotline. If the Executive Director has violated the standards, notice must be given to the Board Chair. C. Organizational Response to Non-Compliance/Suspected Criminal Activity. In the event the investigation identifies employee misconduct or suspected criminal activity, the FHC will undertake the following steps: 1. The FHC will, as quickly as possible, cease the offending practice. If the conduct involves the improper submission of claims for payment, the FHC will immediately cease all billing potentially affected by the offending practice. 2. The FHC will consult with legal counsel to determine whether voluntary reporting of the identified misconduct to the appropriate governmental authority is warranted. 3. If applicable, the FHC will calculate and repay any duplicate or improper payments made by a Federal or State government program as a result of the misconduct. 4. Initiate appropriate disciplinary action, which may include, but is not limited to, reprimand, demotion, suspension and/or termination. If the investigation uncovers what appears to be criminal conduct on the part of an employee, appropriate disciplinary action against the employee or employees who authorized, engaged in or otherwise participated in the offending practice will include, at a minimum, the removal of the person from any position of oversight and may include, in addition, suspension, demotion, and termination. Board Members who violate this policy may, depending on the severity of the violation, be subject to oral admonishment or removal from the Board. Business Associates who violate this policy may, depending on the severity of the violation, be subject to oral admonishment or termination of relationship with FHC.

Irwin, Rev. 2-20-2007

5


5. Promptly undertake appropriate training and education to prevent a recurrence of the misconduct. 6. Conduct a review of applicable FHC policies and procedures to determine whether revisions or the development of new policies and/or procedures are needed to minimize future risk of noncompliance. 7. Conduct, as appropriate, follow-up monitoring and auditing to ensure effective resolution of the offending practice. IX. Duty to Report Wrongdoing; Whistleblower Protection The following policy and procedure section advises employees, contractors, and volunteers when and how to report wrongdoing and of their protection against reprisal or retaliation for reporting. Any person who has knowledge of or, in good faith, suspects any wrongdoing in the documenting, coding, or billing for services, equipment, or supplies, in the Health Center’s financial practices, or violation of this policy should report it internally so that an investigation can be conducted and appropriate action taken. Retaliation or reprisal against anyone for such a report is strictly prohibited. Definition of Wrongdoing: In addition to a violation of Federal or state law, wrongdoing includes violation of FHC’s standards found in this policy (see Section II; billing for services not performed at all or not performed as described; submission of claims for unnecessary or undocumented services, equipment, or supplies; double billing; upcoding; unbundling; misuse of coding modifiers; false cost reports; billing for services by an unlicensed or excluded provider; paying or accepting money, gifts, or favors in return for referrals). Reporting and Responding to Wrongdoing 1. Persons who become aware of or in good faith suspects wrongdoing by another employee, a board member, a vendor, a contractor, or a volunteer should report it to their supervisor or Corporate Compliance Officer. 2. Individuals may report their concerns to the Corporate Compliance Officer in writing or by using the telephone hotline (502-772-8400). Individuals making anonymous report must realize that the Compliance Officer will not be able to ask additional questions of those persons reporting, nor advise those persons of the outcome. FHC’s Compliance Officer will attempt to maintain the confidentiality of the person reporting the concern. 3. Self-reporting is also encouraged. Anyone who self-reports wrongdoing or a violation of law will be given due consideration in mitigation of any disciplinary action that may be taken. 4. Upon a report of wrongdoing, the Compliance Officer will then conduct an investigation into the allegations to determine the nature, scope, and duration of wrongdoing, if any, and shall follow the steps set forth in this policy (see Section VIII: Responding to Detected Offenses and Developing Appropriate Corrective Action). 5. If the charges are substantiated, then the Compliance Officer will develop a plan for corrective action and will notify the Compliance Committee and Board of Directors pursuant to this policy (see Section VIII: Responding to Detected Offenses and Developing Appropriate Corrective Action). 6. Retaliation or reprisal in any form against anyone who makes a report of wrongdoing, cooperates in an investigation, or participates in the compliance program is strictly prohibited. If an employee or a contractor believes that an adverse action in the form of reprisal or retaliation has been

Irwin, Rev. 2-20-2007

6


taken against him or her as the result of making a report or cooperating in an investigation pursuant to this or any other compliance policy, he or she should report it to the Corporate Compliance Officer. 7. The Compliance Officer shall maintain a confidential log in a secure place of all reports of compliance concerns and shall update the Board of Directors twice a year. 8. Anyone who makes a report of wrongdoing maliciously, frivolously, or in bad faith will be subject to disciplinary action up to and including termination. 9. FHC seeks to investigate all non-frivolous claims of wrongdoing internally so that corrective action can be instituted. FHC encourages the reporting to the Compliance Officer so that appropriate corrective action can be instituted. However, any person who discovers wrongdoing that is a false claim or statement may report that information to the Department of Justice or the U.S. Attorney by filing a complaint under seal in the court pursuant to the False Claims Act (31 U.S.C. ‘3729 et seq.) X. References Deficit Reduction Act of 2005. Sec. 6032 False Claims Act – 31 USC §§ 3729 – 3733 KRS 205.211 KRS 205.8467 KRS 205.8463

Irwin, Rev. 2-20-2007

7


Standard of Conduct