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Code Of Conduct
Introduction
Deaconess Hospital and its affiliates (“Deaconess”) are committed to complying with all laws. Deaconess expects its employees and business associates to comply with all legal requirements and to conduct themselves in an ethical manner. To meet this objective, Deaconess has adopted a Compliance Program. This page will provide a brief overview of the Compliance Program.
Compliance Program
The purpose of the Compliance Program is to prevent, detect and resolve conduct that does not comply with legal requirements. In particular, the Compliance Program addresses areas that may be prone to special government regulation or audit, such as billing and coding procedures, contracting and medical records confidentiality. The Compliance Program does not replace Hospital policies and procedures, but has been developed to work with those policies and procedures.
Deaconess expects all employees to fully comply with the Compliance Program. To assist employees in compliance matters, Deaconess has appointed a Compliance Officer and a Compliance Committee. The Compliance Officer is Sheila Henson. Compliance Committee members are:
John Hackbarth Sabrina Miller
Vice President, Finance Manager, Hefner Pointe Family Practice
Phone: Cancer Center
Email: Phone:
Email:
Sheila Henson (Compliance Officer) Barbara Wolf
Director, Corporate Compliance Director, Outreach Services
Phone: Phone:
Email: Email:
Nola Duncan Patti Pippin
Director, Nursing Director, Health Information Services
Phone: Phone:
Email: Email:
Priscilla Pierce, RN, BSN Charles Snow
Director, Quality Resource Management Director, Clinical Support Services
Phone: Phone:
Email: Email:
Debbie Elliott, RN Patti Newberry
Clinical Analyst, Corporate Compliance Director, Home Health
Phone: Phone:
Email: Email:
Joe McDonald, R.Ph
Director, Patient Support Services
Phone:
Email:
The Compliance Officer and members of the Compliance Committee are available to answer any questions you may have and consider suggestions about the Compliance Program.
Reporting
The Compliance Program includes information about reporting possible wrongdoing. Deaconess expects all employees to report conduct which appears to violate the Compliance Program, applicable law or Hospital policy. If you suspect wrongdoing, you should promptly report it to your supervisor. Physicians and practitioners not employed by Deaconess should bring the matter to the attention of the President and CEO or the Vice President of Medical Affairs. Employees who in good faith report possible wrongdoing will not be subject to disciplinary action for making a report, even if an investigation reveals that there was no actual wrongdoing.
If you wish to remain anonymous while reporting suspected wrongdoing, you may call the Hotline at 1(800) . The call will not be traced, and you are not required to give your name. However, you must identify Deaconess by entering the code “30008.” Once Deaconess receives a report of potential wrongdoing, Deaconess officials will investigate the matter in accordance with the Compliance Program. Employees who intentionally make false reports will be subject to disciplinary action.
Audits and Investigations
As a hospital, Deaconess is subject to audits by government regulatory agencies. In addition, Deaconess conducts its own internal audits as part of its routine monitoring of operations, particularly in matters related to coding, billing, claims submission and patient accounts.
The Compliance Officer is responsible for monitoring any audits or investigations being conducted at Deaconess. If you have questions about the legitimacy of an investigation or audit, you should ask the Compliance Officer. Deaconess expects employees to be truthful and to cooperate in audits and investigations.
Standards of Conduct
Deaconess expects employees to comply with its standards of conduct. The Compliance Program includes an explanation of standards of conduct. Some key areas of compliance are:
· Coding and Billing. Deaconess employees must accurately code, process and submit all claims for payment. You should promptly report any false, inaccurate, or questionable claim to a supervisor. Deaconess personnel must not engage in any improper or false coding or billing practices, including:
· Upcoding
· Unbundling
· Misrepresenting services actually rendered
· Billing for services not rendered
· Billing for services not medically necessary
· Billing excessive charges
· Contracting and Business Relationships. Deaconess conducts business in an ethical and legal manner. Before entering into any contracts or business relationships on behalf of Deaconess, you should be sure that your supervisor is aware of it, and consult the Compliance Officer, when appropriate.
· Financial Records and Reports. All financial reports, accounting records, and cost reports must accurately represent the true nature of the transaction. Deaconess employees must not falsify or create artificial financial records or reports. Records shall not be destroyed except in accordance with the Hospital’s record retention policies.
· Patient Referrals. Deaconess strictly prohibits anyone from paying anyone else for referrals of patients or to induce referrals of patients. No one acting on behalf of Deaconess may offer gifts, loans, services, payment or anything else of value to induce the referral of a patient.
· Emergency Services. Deaconess provides emergency services to anyone regardless of their ability to pay. Deaconess complies with all applicable laws related to the provision of emergency care.
· Patient Dignity. Deaconess employees shall treat all patients with the utmost dignity and respect.
· Abuse. State law requires healthcare providers to report suspected child abuse and abuse of the elderly. If you have a question about reporting a possible incident of abuse, you should speak with your supervisor or the Compliance Officer.
· Relationships With Physicians. Deaconess values its relationships with physicians. Federal and state law impose requirements on the terms and conditions of agreements with physicians. For this reason, a member of the Compliance Committee must approve any agreement or contract between Deaconess and a physician or physician group.
· Conflicts of Interest. Employees should avoid any activities which may conflict with their responsibilities at the Hospital. If you have a question about whether your participation in an activity may constitute a conflict of interest, you should speak with your supervisor or the Compliance Officer about it.
· Employment. As part of its routine employment process, Deaconess verifies references and performs background checks, when appropriate, before employing personnel.
· Confidentiality. Deaconess personnel have access to various types of confidential information, including patient information. The inappropriate use or disclosure of confidential information could negatively affect Deaconess, its patients, business associates, or employees. Deaconess employees must protect and safeguard confidential information to prevent unauthorized disclosure.
· Weapons. Deaconess strictly prohibits weapons, including concealed weapons, on its premises, except for weapons carried by security personnel or authorized law enforcement officials.
We Are Counting on YOU! You are a vital part of the Hospital’s compliance program. Deaconess is counting on you to assist in complying with applicable law and reporting possible wrongdoing. You can make a difference! If you have any questions about the Code of Conduct or the Compliance Program, you should contact the Compliance Officer or any member of the Compliance Committee.
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