This booklet was designed to provide information to assist you in making the right decision when you encounter a situation involving legal or ethical issues in your daily activities. Obviously, the Hospital’s Code of Conduct (the Code) cannot cover every aspect of your job. The Hospital has many employees and contractors that are all governed by specific laws, regulations, and policies. The Code contains the principles that govern our conduct. Specific compliance policies are included in the Compliance Program and in the written policies and procedures of each department. When you are confronted with an unusual situation or you have any doubts about the proper course to follow, a variety of resources are available to answer your questions and concerns.
Each contractor and related entity must comply with the Hospital’s Code of Conduct. The Hospital will develop processes and procedures for each contractor in working with the compliance committee to promote and ensure that all contractors or related entities are in compliance with all applicable laws, rules, and regulations. Contractual provisions in arrangements with contractors must require ongoing monitoring to be performed by or on behalf of the Hospital. See Communication of Code of Conduct, Policy No. 001
Over the years, the Hospital, and its affiliates have established numerous policies and procedures to promote compliance with sound legal and ethical principles. Those policies and procedures are not all included or described in this Code of Conduct. Nothing contained in this booklet is intended to replace or supersede those established policies and procedures.
QUALITY OF CARE
The Hospital is committed to providing the highest quality patient care and delivering services that are responsible, appropriate, and cost-effective. We have a duty to report any actual or perceived quality of care issues to our supervisor or the Compliance Officer, either directly or by calling the compliance hotline.
It is the Hospital’s policy to conduct its business in full compliance with all applicable laws, regulations, and professional standards. As employees and contractors, we have the duty to report any actual or perceived violation of applicable laws, regulations, and professional standards to our supervisor or the Compliance Officer, either directly or by calling the compliance hotline.
The Hospital expects its employees and contractors to refrain from conduct that may violate fraud and abuse laws. These laws prohibit: (1) direct or indirect payments in exchange for patient referrals; (2) the submission of false, fraudulent, or misleading claims to any government entity or third party payer; and (3) making false representations to any person or entity in order to gain or retain participation in a program or to obtain payment for any service.
The False Claims Act prohibits a variety of fraudulent acts. The False Claims Act establishes liability when any person or entity improperly receives from, or avoids payment to, the Federal government, with the exception of tax fraud. In summary, the False Claims Act prohibits:
In most actions brought pursuant to the False Claims Act, the defendant must have either: (1) had “actual” knowledge of the false nature of the claim; (2) acted in “deliberate ignorance” of the truth or falsity of the claim; or (3) acted in “reckless disregard” of the truth or falsity of the claim. All employees and contractors have a responsibility to report any actual or perceived violation of the False Claims Act.
The False Claims Act includes a provision, known as a “qui tam” provision, which permits private citizens to file suit on behalf of the federal government to recover damages incurred by the federal government as a result of contractor fraud or other false claims. If such a suit is successful, a whistleblower is entitled to a significant portion of the proceeds. Once such a qui tam suit is filed, the federal government conducts an investigation and at the end of the investigation, the Department of Justice must choose one of the following three options: (1) intervene in one or more counts of the pending qui tam action; (2) decline to intervene in one or all counts of the pending qui tam action; or (3) move to dismiss the complaint, either because there is no case, or the case conflicts with significant statutory or policy interests of the United States. Remedies for the federal government with regard to qui tam claims include recoupment of overpayments, program exclusions, and civil monetary penalties. Specifically, if the federal government proceeds with the action, the qui tam Plaintiff will receive between fifteen and twenty-five percent of the proceeds. If the federal government does not proceed with the action and the qui tam Plaintiff does proceed, the qui tam Plaintiff will receive between twenty-five and thirty percent of the proceeds. Such cases must be brought within six years of the filing of the false claim.
The Fraud Enforcement and Recovery Act of 2009 (FERA) and the Patient Protection and Affordable Care Act of 2010 (PPACA) amendments to the False Claims Act (FCA) have expanded potential FCA liability. The FCA was made apart of the FERA, which expanded liability to include claims made to all recipients of federal funds (i.e., contractor, grantee, etc.), Formerly, the FCA only applied to claims made to the government. The term “claims” now means demands made to a “contractor, grantee or other recipient, if the money or property is to be spent or used on the government’s behalf or to advance a government program or interest, as long as the government has provided or will reimburse the recipient for any portion of the money or property requested.” The Hospital does not have to intend for the Government to pay the claim. Instead, the use of false records or statements that have a tendency to influence, or be capable of influencing, the payment or receipt of money or property to the fraudulent claim will impose liability. The FERA also amended the reverse false claims provision by removing the requirement that FCA Plaintiffs prove a defendant committed an affirmative act in order for that defendant to be subject to FCA liability for avoiding or decreasing an obligation to pay. Conscious disregard of claims processing rules or recklessly improper conduct in submitting claims is sufficient for FCA liability to attach under the reverse false claims provision.
Prior to the PPACA, a whistleblower needed to have direct and independent knowledge of false claims submitted to the government. Now, a whistleblower need not be the “original source” of the information. As a result, information disclosed in private litigation and during state or local administrative proceedings may potentially be used, as the basis of a whistleblower suit under the FCA, and a person may be a whistleblower merely by having knowledge that materially adds to allegations that have already been publicly disclosed. In addition, the PPACA expanded the FCA to enhance whistleblower protection from retaliation. Under the new law, employees, agents, and contractors of the Hospital are protected. Ultimately, the pool of potential Plaintiffs who qualify as an “original source” has increased due to PPACA.
The cost of non-compliance with the False Claims Act can lead to costly penalties. Civil and administrative penalties range anywhere from $5,500-$11,000 per claim. A guilty party may also be liable for treble damages of the government’s loss, plus discretionary exclusion from participation in the Medicare program. If a violation of the law is voluntarily disclosed, damages under the FAC are limited to double damages suffered by the government if it is disclosed to the government within thirty (30) days of learning of the violation and prior to any government investigation involving the claims.
If you believe that you have evidence or knowledge of an actual or perceived violation of the False Claims Act, you should report it immediately to your supervisor, the relevant member of the Compliance Committee, to the Chief Compliance Officer, or call the compliance hotline.
See: False Claims Act Education Policy No. 005, State and Federal False Claims Act Policy No. 005A, Non-Retaliation for Employee Reporting Policy No. 006.
GEORGIA ANTI-FRAUD LAW
The Georgia Medicaid Unlawful Payment Statute (O.C.G.A. §49-4-146.1) provides that it shall be unlawful:
(1) For any person or provider to obtain, attempt to obtain, or retain for himself, herself, or any other person any medical assistance or other benefits or payments under this statute, or under a managed care program operated, funded, or reimbursed by the Georgia Medicaid program, to which the person or provider is not entitled, or in an amount greater than that to which the person or provider is entitled, when the assistance, benefit, or payment is obtained, attempted to be obtained, or retained, by:
(A) Knowingly and willfully making a false statement or false representation;
(B) Deliberate concealment of any material fact; or
(C) Any fraudulent scheme or device; or
(2) For any person or provider knowingly and willfully to accept medical assistance payments to which he or she is not entitled or in an amount greater than that to which he or she is entitled, or knowingly and willfully to falsify any report or document required under this statute.
Any person violating this statute will be guilty of a felony, which is punishable by a fine of not more than $10,000 and imprisonment of from one to ten years. In addition, violators will be liable for a civil penalty for committing abuse equal to the greater of three times the amount of any such excess benefit or $1,000 for each prohibited claim.
The Georgia False Medicaid Claims Act (GFMCA) imposes liability on people and corporations who knowingly submit false or fraudulent claims to Georgia's Medicaid program. The defendant may be ordered to pay up to three times the actual damage to the State, plus a fine ranging from $5,500 to $11,000 for each violation of the GFMCA. The Plaintiff in a successful GFMCA case may recover between 15 and 25 percent of the proceeds from the action if the Georgia Attorney General joins the case. The Plaintiff may recover between 25 and 30 percent of the amounts recovered if the whistleblower pursues the case on his or her own. The court may reduce a whistleblower's award if he or she was a planner or initiator of the fraud, or if the action is largely based on information disclosed in the media or public hearings. The GFMCA also protects whistleblowers from retaliation by their employers. Plaintiffs may not file their complaint more than six years after the date on which the violation occurred.
If you believe that you have evidence or knowledge of an actual or perceived violation of the Georgia Medicaid Unlawful Payment Statute or Georgia False Medicaid Claims Act, you should report it immediately to your supervisor, the relevant member of the Compliance Committee, to the Chief Compliance Officer, or call the compliance hotline.
The Anti-Kickback Statute (AKS) prohibits the offer or receipt of anything of value in exchange for a referral of any item or service for which payment may be made under a federal health care program, including Medicare and Medicaid. The AKS was amended by the PPACA to state that: 1) claims resulting from violations of the AKS also constitute false or fraudulent claims for purposes of the FCA; and 2) a person need not have actual knowledge of the AKS or specific intent to commit a violation of it. The PPACA has reduced the level of intent required to establish a healthcare fraud offense violation.
If you believe that you have evidence or knowledge of an actual or perceived violation of the Anti-Kickback Statute, you should report it immediately to your supervisor, the relevant member of the Compliance Committee, to the Chief Compliance Officer, or call the compliance hotline. The amendments to the AKS have created significant civil penalties, as well as criminal sanctions. With the decreased standard of proof, providers need to be aware of the increased risk of potential criminal and civil prosecution.
Violation of the Anti-Kickback Statute can lead to fines and imprisonment of up to $25,000 and five years in prison. Civil monetary penalties can reach $50,000 plus three times the amount of the remuneration. Violators may also be excluded from participation in federal programs. In addition, the PPACA establishes that every claim for items or services resulting from a violation of the AKS automatically constitutes a “false or fraudulent claim” under the False Claims Act.
See: Stark and Anti-Kickback Policy No. 025
The Stark Law prohibits physicians who have a financial relationship with an entity from referring patients to that entity for a designated health service for which payment may be made under Medicare or Medicaid. Under PPACA, the Inspector General of HHS must establish a Medicare Self-Referral Disclosure Protocol (SRDP) that sets forth a process to enable providers and suppliers to self-disclose actual or potential violations under the Stark Law. The SRDP requires health care providers and suppliers to submit all information necessary for CMS to analyze the actual or potential violation(s). A disclosing party should make a submission with the intention of resolving its overpayment liability exposure for the identified conduct.
Further changes require physicians who refer patients for in-office ancillary services to, at the time of the referral, inform the patient in writing that he or she may obtain the ordered services from a person other than the ordering physician or the physician’s group. The Physician is then required to provide the patient with a list of providers who perform that service in the area in which the patient resides.
The Self-Referral Protocol Procedures can be found at: https://www.cms.gov/physicianselfreferral/65_self_referral_disclosure_protocol.asp
See Stark and Anti-Kickback Policy No. 025
The Hospital is committed to honesty, accuracy, and integrity in all of its billing, coding, and documentation activities. We have a duty to report any actual or perceived false claim, misrepresentation, inaccuracy, or problem in billing, coding, or documentation to our supervisor or the Compliance Officer, either directly or by calling the compliance hotline.
See Documentation and Reimbursement Policy No. 003, Federal Health Care Program Payor Overpayment Policy No. 019, Billing and Coding Policy No. 028, Physician Billing Practice Policy No. 29, Billing Documentation Policy No. 030
CONFLICTS OF INTEREST
A “conflict of interest” will be considered to exist in any instance where the actions or decisions of an employee, when acting on behalf of the Hospital, also involves obtaining an improper gain or advantage or results in an adverse effect on the Hospital’s interests. Conflicts of interest may also arise in other instances. The Hospital employees will take all reasonable steps to avoid conflicts, or even the appearance of a conflict, between their private interests and the performance of their official responsibilities and duties. We have a duty to report any actual or perceived conflicts of interests to our supervisor or the Compliance Officer, either directly or by calling the compliance hotline.
See Conflicts of Interest Policy No. 007
See Physician Recruiting Policy No. 024
See Improper Inducements Policy No. 031
The Hospital is committed to protecting all assets in its care, including the assets of others that are entrusted to us, as well as physical property and proprietary information, against loss, theft, or misuse. We have a duty to preserve our organization’s assets, property, facilities, equipment, and supplies. We have a duty to report any actual or perceived loss, theft, or misuse of our organization’s property, or the assets of others to our supervisor, or the Compliance Officer, either directly or by calling the compliance hotline.
The 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 actual or perceived mistreatment, discrimination, safety issue, hostile activity, legal violation, or other non-compliant issue occurring in the workplace to our supervisor or the Compliance Officer, either directly or by calling the compliance hotline.
See Compliance Hotline Policy No. 002, Non-Retaliation for Employee Reporting Policy No. 006, Disclosure Program Policy No. 020
This Code is one part of the Hospital’s Compliance Program. The Hospital has appointed the Compliance Officer to oversee the day-to-day operations of our Compliance Program. The Hospital’s Compliance Program will include:
See Compliance Department Mission Policy No. 012, Compliance Responsibility Development and Management Policy No. 013, Compliance Policy Development and Implementation Policy No. 014, Corporate Compliance Plan Policy No. 015, Compliance Education and Training Policy No. 016, Board Member Training and Certification Form Policy No. 017, Employee Compliance Surveys Policy No. 018.
Compliance is everyone’s business. You are expected to become familiar with and adhere to the Hospital’s Code of Conduct, all relevant laws and regulations that affect the performance of your job, and applicable policies and procedures. Your knowledge or reasonable suspicion of a violation of the Code, law, or regulation should be reported immediately. Failure to report your suspicions or knowledge of a concern is a violation of the Code.
Failure to abide by this Code of Conduct, or the guidelines for behavior that this Code represents, may lead to disciplinary action, up to and including termination. For alleged violations of the Code, the Hospital will weigh all relevant facts and circumstances, including, but not limited to: the extent to which the behavior was contrary to the express language or general intent of the Code, the seriousness of the behavior, the employee’s history with the organization, and other factors that the Hospital deems relevant.
The Hospital intends to employ personnel with proper credentials, experience, licensure and expertise to meet the needs of our patient population, and it shall take reasonable steps to do so. It is the responsibility, therefore, of the employee to maintain the proper credentials, licensure, and expertise necessary to perform the functions for which he or she was hired. Management is obligated to verify credentials on a regular basis.
Nothing in this Code is intended to provide, or shall be construed, as providing any additional employment or contract rights to employees, contractors, or other persons.
The Hospital will generally attempt to communicate changes prior to the implementation of such changes. The Hospital reserves the right to modify, amend, or alter the Code of Conduct without notice to any person or employee.
You should never hesitate to ask a question or raise a legitimate concern. You should also be open and responsive to questions, complaints, and concerns expressed by patients and the employees you supervise.
If you have any questions about the Code, a law, or any the Hospital policy or practice, you are encouraged to talk to your supervisor, another member of management, or your human resources representative. If your concern cannot be resolved at that level, or if you prefer, you may report the matter to the Compliance Officer or call the compliance hotline.
COMPLIANCE HOTLINE: 1-800-601-2144
To ensure an open line of communication, the Hospital has established a compliance hotline, 1-800-601-2144, The compliance hotline is available to you when you have a compliance question or concern and do not feel comfortable discussing the matter with your supervisor. Trained personnel answer calls to the compliance hotline, twenty-four hours a day, seven days a week. Calls are not traced or recorded. The compliance hotline should be used to report serious concerns about suspected or known instances of fraud or violations of law or policy.
All callers to the compliance hotline are encouraged to remain anonymous. If callers choose to identify themselves, their confidentiality will be protected to the extent permitted by law.
The Hospital has a policy of non-retaliation. That is, the Hospital will not take any disciplinary action or allow any other type of retaliation against any employee for reporting in “good faith” a compliance concern. “Good faith” means that you are telling the truth, as you know it.
Furthermore, the False Claims Act prohibits the discharge or harassment of a whistleblower who makes False Claims Act-protected disclosures or files a qui tam suit. Any whistleblower discharged in violation of these provisions of the False Claims Act may file a wrongful discharge suit. In a whistleblower’s claim for wrongful discharge, the whistleblower is eligible for double back pay and other damages. As amended by the Fraud Enforcement and Recovery Act of 2009 (FERA), the class of persons who can serve as whistleblowers includes contractors and agents.
Any employee or contractor who believes that he or she has been retaliated against for making a report should contact the Compliance Officer, Compliance Committee, or call the compliance hotline.
The Hospital will also protect its employees from the intentional misuse of the compliance hotline. Deliberately making a false accusation is a serious violation of this Code and may lead to disciplinary action, up to and including termination of employment.
This means no action of retaliation or reprisal will be taken against anyone for calling the compliance hotline to make a report, complaint, or inquiry. However, calls to the compliance hotline do not protect callers from appropriate disciplinary action regarding their own performance or conduct.
The Compliance Officer will evaluate and respond to all allegations of wrongdoing, concerns, and/or inquiries made to the compliance hotline in an impartial manner. The Compliance Officer will respect and protect the rights of all personnel, including anyone who is the subject of a compliance 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.
See Compliance Hotline Policy No. 002