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Standards of Professional and Business Conduct

Quality of Care

Major Hospital is committed to providing high quality care and delivering services that are responsible, appropriate and cost-effective. We have a duty to report any quality of care issue to Management, Human Resources or the Major Hospital Compliance Hotline (Hotline).

Patients and Communities Served

We will provide patients with high quality services without discrimination due to gender, age, disability, race, color, religion, national origin or ability to pay.

We will treat patients with dignity, respect, and courtesy.

Only personnel with proper credentials, experience, license and expertise shall be employed in meeting the needs of our patient population.

Patient Communication

Patients have the right to know the identity and qualifications of all Major Hospital personnel who provide services for them, and the right to considerate, respectful and safe care.

In all circumstances, we will attempt to treat patients in a manner giving reasonable thought to their background, culture, religion and heritage.

All questions from patients will be answered promptly and courteously, or referred to the proper source.

Patients have the right to participate in decision making regarding their health care, including refusing treatment to the extent permitted by law, and patients should be informed of the consequences of such action.

The patient has the right to personal and medical privacy. Medical records and treatment are confidential. Those not directly involved in the patient's care must have patient permission to be present or obtain such information.

Patients have the right to voice their complaints about care and services provided.

We will seek to inform all patients about the therapeutic alternatives and risks associated with the care they are seeking. We will constantly seek to understand and respect their objectives for care.

Compliance with Laws and Regulations

Major Hospital will operate in accordance with all applicable laws and regulations. We have the duty to report any violation of applicable laws, regulations and professional standards to Management, Human Resources or the Hotline.

Patient Referrals

All agreements with an actual or potential patient referral source must be in writing and approved by management to ensure compliance with applicable laws, regulations, agreements with lenders and Major Hospital policies.

We shall not solicit or receive, or give or offer to give, anything of value to physicians or other health care professionals for the referral of patients or services. Kickbacks, bribes, rebates or flow of any kind of benefits intended to induce referrals are strictly prohibited.

Physicians will not refer Medicare or Medicaid patients to an entity with which the physician or an immediate family member has a financial relationship.No

NoThis standard, based on the Stark self-referral ban, prohibits referrals related to specific designated health services.

Contract payments or other benefits provided to clinicians and referral sources must be for the services and at the fair market value rates called for in the contract and must be specifically approved by management. Every payment must be supported by proper documentation that the services contracted for were provided.

Joint Venture with Physicians

Management must provide prior review and approval of any joint venture, partnership or other risk-sharing arrangement with any potential or actual referral source.

Medical Records

We shall maintain complete and accurate patient medical records. Legal and regulatory requirements will be recognized and followed in documenting and maintaining medical records.

We shall only sign a form for a physician with physician’s authorization and a cosigner signature.

We will make no unauthorized alterations to medical records.

We shall prescribe medications and perform procedures only with proper authorization.

The patient has the right to access information contained in his/her clinical records within a reasonable time frame.

Environmental Laws

We shall promote sound environmental and safety practices that will prevent damage to the environment and we will take steps to preserve community resources.

We shall be responsible for the proper handling of medical or hazardous waste as well as radioactive materials.

Antitrust Laws

We shall avoid agreements or practices “in restraint of trade” such as price fixing; boycotting suppliers or customers; pricing intended to run a competitor out of business; disparaging, misrepresenting or harassing a competitor; stealing trade secrets, bribery and kickbacks.

Billing and Coding

Major Hospital is committed to honesty, accuracy and integrity in all its billing, coding and documentation activities. We have a duty to report any false claim, misrepresentation, inaccuracy or problem in billing, coding or documentation to Management, Human Resources, or the Hotline.

We will only submit for payment or reimbursement claims for services actually rendered that are fully documented in patients’ medical records, using billing codes that accurately describe the services provided, and supported by any medical necessary requirements.

Submission of any claim for payment or reimbursement that is false, fraudulent, inaccurate or fictitious is strictly prohibited.

When satisfied that an overpayment has been made, we shall promptly refund any money received that is not due to us.

We will not submit a claim for physician services unless the service was rendered by a physician.

We shall take immediate steps to alert appropriate hospital or health system authorities if inaccuracies are discovered in claims that have been submitted for reimbursement.

The patient has the right to examine and understand the itemized hospital bill, regardless of source of payment. The patient has the right to be informed of the source of the facility’s reimbursement for his/her services, and of any limitations which may be placed upon his/her care.

Confidentiality

We will follow legal and regulatory requirements and ethical guidelines in maintaining patient confidentially.

We will maintain confidentiality of hospital proprietary and business information.

Conflicts of Interest

Major Hospital will take all reasonable steps to avoid conflicts, or the appearance of conflicts, between the private interests of our personnel and the official responsibilities and performance of our duties. We have a duty to report any conflicts of interest to Management, Human Resources or the Hotline.

Gifts

We will not solicit any tips, gifts or personal gratuities from patients, vendors, etc. Personnel are encouraged not to accept gifts, favors or hospitality; however, the acceptance of modest gifts or entertainment of nominal value is allowed. If an employee has doubts as to the appropriateness of a gift, he or she should seek guidance from Management, Human Resources or the Hotline.

Protection of Property

Major Hospital is committed to protecting its assets, and the assets of others entrusted to us, including physical property and proprietary information, against loss, theft or misuse. We have a duty to report any loss, theft or misuse of our organization’s property or the assets of others to Management, Human Resources or the Hotline.

We have a duty to safeguard the property of patients, employees and visitors which is entrusted to us.

We have a duty to preserve our organization’s assets, property, facilities, equipment and supplies.

We will be personally responsible and accountable for the proper expenditure of our organization's funds through appropriate approvals and for the proper use of our organization's property.

We will dispose of surplus, or obsolete property in accordance with our organization’s policies and procedures. Unauthorized disposal of property is a misuse of assets.

We will set forth our best work efforts and use our time productively in the best interest of Major Hospital and our patients.

We will not disclose, misuse or take any confidential or proprietary information or property of our organization.

Proper Consideration of Human Resources

Major Hospital is committed to protecting and supporting all personnel as well as helping them to achieve their fullest potential in a fair and equitable manner. We have a duty to report any mistreatment, discrimination, safety issue, hostile activity, legal violation or other non-compliance issue occurring in the workplace to Management, Human Resources, or the Hotline.

Our Responsibilities

We will give proper respect and consideration to everyone. Harassment of any type will not be tolerated.

We will conform to the standards of our professions and exercise reasonable judgment and objectivity in the performance of our duties.

Equal Employment Opportunities

We will ensure that everyone is afforded equal employment and advancement opportunities regardless of gender, age, disability, race, color, religion or national origin.

We will ensure that everyone is afforded equal pay for equal work regardless of gender, age, disability, race, color, religion, or national origin.

Safety

We will comply with all work and safety rules, regulations and policies.

We will take all reasonable precautions to ensure our safety as well as the safety of patients, visitors and other personnel.

We are committed to maintaining a smoke-free and drug-free environment.

Communication

Major Hospital will foster an environment, which encourages open communication. We have a responsibility to report any significant communication problem to Management, Human Resources or the Hotline.

We are responsible for sharing ideas, resolving problems or concerns and treating all opinions with respect and consideration.

We shall raise legitimate questions or concerns in an appropriate and efficient manner.

We will strive to understand the duties, responsibilities and challenges that face our fellow workers.

Supervisors and management shall respond in a timely manner to all questions raised to them.

Resolution of Problems and Concerns

Positive relations and morale can best be achieved and maintained in a working environment where ongoing and open communication exists among supervisors and personnel. This includes candid discussions of our problems and concerns. We are encouraged to express our concerns and opinions on any issue regarding potential violation of laws, regulations, ethics, policies or procedures or these Standards of Professional and Business Conduct. Initially, personnel should contact their own supervisor or Human Resources representative to voice their concerns. If the concerns remain unresolved, personnel are then encouraged to raise the issues with individuals at the next supervisory level, up to and including the highest level of management. If an employee is uncomfortable following this chain of command, or if their concerns are unresolved, they are encouraged to utilize the corporate compliance Hotline.

Compliance Hotline

Major Hospital recognizes that there will be times when concerns cannot be properly addressed through the normal chain of command. Under such circumstances, personnel are encouraged to report their concerns to the Compliance Office. Major Hospital has initiated a Hotline for this purpose. By dialing 800-808-3198, you will reach the Major Hospital Compliance Hotline. The Hotline should be used to report serious concerns about suspected or known instances of fraud or violations of law.

Calls to the Hotline will not be traced or recorded. All callers to the Hotline are encouraged to remain anonymous. If callers choose to identify themselves, their confidentiality will be protected to the extent permitted by law. Any callers who identify themselves will receive a follow up telephone call regarding the resolution of the stated concern.

Major Hospital has a non-retribution and non-retaliation policy. This means no action of retaliation or reprisal will be taken against anyone for calling the Hotline to make a report, complaint or inquiry. The Compliance Office will evaluate and respond to allegations of wrongdoing, concerns and / or inquires made to the Hotline in an impartial manner. The Compliance Office will respect and protect the rights of all personnel, including anyone who is the subject of a Hotline complaint. To this end, all allegations will be thoroughly investigated and verified before any action is taken. Furthermore, any disciplinary action or other response resulting from a call will be held confidential by the Hotline staff.

Please note: Disciplinary action, including termination, may occur if an employee has knowledge of non-compliance and fails to report it.


 



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