New Orleans, Louisiana
(Updated September 2010)
CODE OF BUSINESS ETHICS AND CONDUCT
Children's Hospital's mission is to provide comprehensive pediatric health care, which recognizes the special needs of children through excellence and the continuous improvement of patient care, education, research, child advocacy and management.
Children's Hospital's Guiding Values
In pursuing its mission, Children's Hospital's actions will be guided by its values of honesty, integrity, fairness, and adherence to the rights of patients and the laws and regulations of this land. The purpose of this Code of Business Ethics and Conduct is to provide guidance to our employees and medical staff in the application of these values to our daily activities and interactions with our patients, third party payors, fellow employees, vendors, competitors, and government agencies.
Children's Hospital has historically applied its values in all of its patient care and business activities. However, in recent years the health care environment has become so cold, so complex and confrontational that it is now beneficial to establish a formal Code of Business Ethics and Conduct.
Conflicts of Interest
The first element of the Code of Business Ethics is putting the interests of the Hospital above our personal and individual interests. It is in the best interests of Children's Hospital to avoid conflicts of interests between the Hospital and its trustees, officers, employees, and members of its medical staff. The Board of Trustees and the Management of Children's Hospital have adopted conflicts of interests policies and these policies will be complied with in all business transactions and relationships affecting Children's Hospital. Members of the Board will be asked to periodically sign conflicts of interest statements. Any questions regarding the conflicts of interests policies of Children's Hospital should be directed first to your immediate supervisor and then, if necessary, to the Compliance Officer. (See Administrative Policy No.2, Conflict of Interest)
Applying Values to Business Activities:
Management's Responsibilities for Compliance
The Board of Trustees and the President and CEO of Children's Hospital are committed to assuring Children's Hospital's values are applied in all the various relationships of Children's Hospital. They are specifically committed to assuring that Children's Hospital complies with all applicable laws and regulations and have adopted this Code of Business Ethics in an effort to prevent and detect unethical as well as illegal conduct on the part of employees, agents and contractors of Children's Hospital. This commitment to ethical behavior and compliance is to extend to all levels of the hospital including vice presidents, department heads, managers, supervisors and line employees. The Hospital recognizes that the trustees, officers and employees of Children's Hospital have a moral and legal obligation to use all reasonable efforts to assure the Hospital acts in compliance with applicable laws, rules and regulations. Employees have an obligation to report any instances of suspected violations to their immediate supervisor and to make good faith reports of suspected violations to the Corporate Compliance Officer. Managers are to be held accountable not only for their own actions, but also for the actions of the employees they supervise. Managers must take affirmative steps to implement this Compliance Program. The Hospital will devote the resources reasonably necessary to develop, implement and maintain an effective compliance program.
Corporate Compliance Plan
The Hospital has developed this corporate compliance program for several purposes. First, to assure its core values are implemented in its business affairs. This plan is intended to supplement and reinforce the hospital's existing policies and procedures, not replace them. Second, to emphasize that it is, has been, and will continue to be the policy of Children's Hospital to comply with all laws, rules and regulations of the United States, the State of Louisiana and all other states and political subdivisions with which Children's Hospital does business. Third, to provide a mechanism by which Children's Hospital's employees become active and responsible participants in the Hospital's efforts to act ethically, legally and to prevent and detect unethical or illegal conduct.
The Compliance Plan includes: the adoption of this Code of Business Ethics and Conduct; the appointment of a Compliance Officer who reports to the President and CEO and the Patient Safety, Legal and Insurance Committee of the Board of Trustees; the establishment of a Compliance Committee to assist the Compliance Officer; the establishment of a mechanism for the reporting and investigation of suspected violations; the commitment of the resources reasonably necessary to educate Children's Hospital's employees on compliance matters; and the commitment of the resources reasonably necessary to enforce the Compliance Plan through employee evaluations and the Hospital's established disciplinary procedures.
The Compliance Officer
The President and CEO has designated the Vice President of Legal Affairs as the Corporate Compliance Officer of Children's Hospital. The Corporate Compliance Officer shall report directly to the President and CEO and to the Patient Safety, Legal and Insurance Committee of the Children's Hospital Board of Trustees. The Corporate Compliance Officer has the primary responsibility for developing, overseeing and monitoring the implementation of the policies and procedures adopted and enforced as part of the Compliance Program. These responsibilities may include:
- reporting on a regular basis to the President and CEO and the Patient Safety, Legal and Insurance Committee of the Board of Trustees on the progress of implementation of the Corporate Compliance Plan;
- developing, coordinating and participating in educational and training programs that address corporate compliance issues;
- continuously improving and revising the corporate compliance program to address the changes in the laws, rules, regulations of the government, both state and federal and the policies and procedures of private payors;
- conducting investigations of suspected violations of compliance policies and developing, implementing, and monitoring corrective measures;
- monitoring human resources and medical staff functions to assure that the National Practitioner Data Bank and the Cumulative Sanction Report have been checked with respect to employees holding positions of substantial authority, medical staff members and significant independent contractors;
- monitoring internal and external audits of compliance policies to reasonably test the effectiveness of departments in the performance of their various functions;
- monitoring internal and external audits of compliance policies to reasonably assure compliance with applicable laws, rules and regulations; and
- developing, implementing, and maintaining policies and procedures for encouraging managers and employees to report suspected fraud or questionable activities without fear of reprisals or retaliations for good faith reporting.
Corporate Compliance Committee
The Corporate Compliance Officer shall assemble a Corporate Compliance Committee consisting of individuals having the knowledge, expertise, and skills the Corporate Compliance Officer deems necessary to assist in the implementation, application and enforcement of the Code of Business Ethics and the Corporate Compliance Plan of Children's Hospital.
The members of the Corporate Compliance Committee shall act as liaisons with the various departments of the Hospital and its subsidiaries. All hospital officers, vice presidents, department heads, managers, supervisors and employees shall cooperate with and, upon request, assist the Corporate Compliance Officer and/or the members of the Corporate Compliance Committee in the performance of their respective duties. The Corporate Compliance Officer has the authority to review any and all documents, data, information or other material relevant to compliance activities including, but not limited to patient records, billing records, accounts payable, accounts receivable, cost reports, working papers, marketing activities and any and all contracts with officers, directors, employees, agents, independent contractors and any other persons or entities with whom the Hospital or its subsidiaries do business.
The current members of the Compliance Committee are:
Rick Guevara, Vice President, Legal Affairs Corporate Compliance Officer and Chair
Birgit Haylock, Office Manager, CHMPC
Greg Feirn, Senior Vice President, Chief Financial Officer
Wendy Huval, Director of Medical Records and Privacy Officer
Hope Williams, Director, Training & Education
Susan Knowles, Director of Compiance
Mike McSweeney, Computer Services and Security Officer
Shannon Seput, Director, Quality Assessment and Improvement
Doug Mittelstaedt, Vice President, Human Resources
Lisa Miranda, Director, Laboratory
Tammy Reites, Vice President, Patient Financial Services
I. RELATIONSHIP WITH PATIENTS
A. Advocacy for Patients
Children's Hospital fosters an environment that recognizes and upholds the basic rights of those entrusted in our care. (See Administrative Policy No.1, Rights and Responsibilities of Patients; Administrative Policy No. 51 Receiving and Responding to Patient Complaints; Grievance Process, and Administrative Policy No. 59 Ethics Committee,)
1. Children's Hospital recognizes the importance of caring for and protecting our patients who are or may be the victims of neglect and/or abuse. Whenever there is a reasonable belief that an incident of physical, sexual, or mental child abuse and/or neglect has occurred it shall be reported to the appropriate agency for follow up in accordance with Hospital policies. (See Administrative Policy No. 18, Protocol for Reporting Child Abuse and/or Neglect, and Administrative Policy No. 19, Release of Information to the Media and Film Producers)
2. Children's Hospital treats all patients with dignity and respect and provides care that is necessary and appropriate for each individual patient. Clinical care decisions are based on patient needs and not on the patient's race, color, creed, religion, sex, age, health insurance or ability to pay. Children's Hospital will comply with all applicable laws rules and regulations relative to access to care.
3. Children's Hospital adheres to the Emergency Medical Treatment and Active Labor Act (EMTALA) and Louisiana laws LSA-R.S. 40:2113.4 with regard to emergency medical treatment for all patients. All patients with emergency medical conditions are treated and admitted based on medical necessity. Patients will only be transferred to another facility if the patient's medical needs cannot be met at Children's Hospital or the patient requests a transfer. Unless a physician certifies that the benefits of treatment at another facility outweigh the risks of transfer, a patient transfer will occur after the patient is stabilized and has been accepted by another health care facility. Children's Hospital shall accept transfers of pediatric patients from other hospitals whenever it has the necessary staff, beds and services available and shall not condition such acceptance on the basis of ability to pay. (See Administrative Policy No. 54, Compliance with Medicare Obligations in Emergency Cases)
B. Quality of Patient Care
Children's Hospital is committed to the provision of quality care to all of our patients and their families at all times. In order to ensure consistent delivery of quality patient care, quality indicators and continuous quality improvement team activities are monitored on an ongoing basis through the Quality Assessment and Improvement Plan. The goal of the quality review process is to provide the highest standard of comprehensive health care to our patients.
C. Patient Privacy, Confidentiality and Security
Information about the patient's medical condition, history, medication, and family illnesses is required to provide optimal care to our patients. Children's Hospital recognizes this Protected Health Information (PHI) and Electronic Protected Health Information (EPHI) must be held securely and in confidence. It is a policy of Children's Hospital that patient specific information is not to be released to anyone outside of Children's Hospital without a court order, express written authorization, or as otherwise authorized by law (the Health Insurance Portability and Accountability Act (HIPAA) and implementing regulations). It is the policy of Children's Hospital that EPHI be used and maintained in accordance with the applicable security standards.
Even among authorized individuals, patient information should only be discussed on a need to know basis. Children's Hospital counsels its employees not to abuse their access to confidential information or their position to obtain confidential patient information that their job does not require. Any violations of the Privacy Standards and Policies are to be reported to the Privacy Officer and violations of the Security Standards and Policies to the Security Officer.
D. Patient Billing
Patients shall be informed of their right to receive an itemized statement of billed services prior to their discharge from the hospital. Itemized statements of billed services shall be provided to patients within ten (10) days of discharge. Such itemized statements shall include a brief description of the service, the date of service and the amount charged for each service itemized in the statement. See LSA-R.S. 40:2010.
E. Admitting and Discharge
The decision to admit, discharge or transfer a patient shall be based upon the patient's medical condition and the best medical interests of the patient. Decisions to admit, discharge or transfer shall not be based on the patient's ability to pay or the financial interests of the hospital.
Marketing materials, regardless of medium, shall accurately describe the services, facilities and resources of Children's Hospital. Marketing materials shall not misrepresent the services, facilities or resources available at Children's Hospital. Children's Hospital shall not sell any personal health information of its patients to third parties for their marketing purposes.
G. Patient Safety
In the event any of our patients or their legal guardians have concerns regarding patient care and/or safety, Children's Hospital encourages them to contact the Director of Guest Services or the Administrator on Call to request assistance. If their concerns cannot be adequately addressed through the grievance process, they are encouraged to contact the applicable regulatory and/or accrediting organizations such as the Joint Commission on Accreditation of Health Care Organizations.
II. RELATIONSHIP WITH PAYORS
A. Children's Hospital makes a good faith effort to abide by the terms agreed upon when an agreement is entered into with an insurance carrier, health maintenance organization, government health care program and/or managed care company.
Children's Hospital shall take all steps reasonably necessary to meet all established certification standards for Medicare participation through the Joint Commission on Accreditation of Health Care Organizations (JCAHO). It is the policy of Children's Hospital to comply with the Medicare laws, rules and regulations applicable to prospective payment system exempt specialty hospitals such as Children's Hospital.
Children's Hospital has entered into an agreement with the State of Louisiana Department of Health and Hospitals to provide services under the state Medicaid Program. It is the policy of Children's Hospital to take all steps reasonably necessary to comply with the Medicaid laws, rules and regulations applicable to hospitals and physician practices.
Children's Hospital has entered into an agreement to provide services for individuals eligible for Champus benefits according to the plan in which the insured participates. It is the policy of Children's Hospital to take all steps reasonably necessary to comply with terms and conditions of Champus provider agreements.
4. Insurance Companies
Children's Hospital has entered into agreements with insurance companies to provide services to their insureds. Children's Hospital's policy is to take all steps reasonably necessary to provide services according to the terms of each contract and consistent with the medical needs of the patients.
B. Possible Violations of Commitments
1. Fraudulent and False Billing/Billing Errors
Children's Hospital intends to comply with all applicable billing and reimbursement guidelines. There are specific departmental policies and procedures to address the appropriate means for submitting bills and to avoid potential areas of fraud and abuse. Once an issue is detected, it shall be determined whether the offense was a billing error or fraudulent billing practice. The following are examples of fraudulent activities:
· Knowingly billing for services not rendered or equipment not used;
· Knowingly billing for services that are not medically necessary;
· Knowingly submitting duplicate billing with the intent to obtain multiple or inappropriate payments;
· Inappropriate assignment of procedural or diagnostic codes with
intent to increase reimbursement or be paid for services which are not covered;
· Unbundling claims for services with the intent to be paid more than is allowable;
· Billing for services independently rendered by residents (PATH);
· Outpatient services billed separately when performed one day prior to admission rather than consolidated with the inpatient day; and
· Admission and discharge information inaccurately reflected according to the medical record.
"Upcoding” reflects the practice of using a billing code that provides a higher payment rate than the billing code which best reflects the services provided. Children's Hospital is committed to assigning codes based on physician documentation. Audits are conducted to validate coding assignment and accuracy.
Both HCFA Form 1500 and the U.B. 92 contain statements by which the provider of service affirms that the services provided to the patient were medically necessary. Thus ordering a battery of tests when only two or three are necessary may give rise to a false certification.
Also, certifying that cost reports were prepared in accordance with Medicare/
Medicaid regulations when one knows or should know such statement is not true gives rise to a claim of false certification.
2. Cost Reports
A substantial portion of Children's Hospital's business involves reimbursement by government programs (Medicaid, Medicare, Tricare, etc.) which require reports that summarize the Hospital's reimbursable costs of providing patient care related services. Children's Hospital maintains departmental policies and procedures to reasonably assure costs claimed in these reports adhere to the following:
· Only allowable and reasonable costs related to patient care are claimed;
· Costs are appropriately apportioned between program beneficiaries and other patients so that the share borne by the program is based upon actual services received by program beneficiaries;
· Costs will be based on accurate documentation;
· Costs will be properly classified and allocations of costs will be accurate and supportable; and
· Errors discovered subsequent to submission of the cost report will be documented and communicated to the applicable government program.
As the applicable regulations related to cost reports are very complex, issues related to potential cost reimbursable items or the final settlement of cost reports must be coordinated with our reimbursement advisor.
Children's Hospital will use all reasonable efforts to assure compliance with the Stark II physician self-referral law (as amended in the Omnibus Budget Reconciliation Act of 1993) which provides a physician with ownership interest or investment interest in, or a compensation agreement with, an entity is prohibited from making referrals to that entity for the following designated health services [Soc. Sec. Act §1877(h)(6)]:
· Clinical Laboratory Services
· Physical Therapy Services
· Occupational Therapy Services
· Radiology or other Diagnostic Services
· Durable Medical Equipment
· Parental and enteral nutrients
· Prosthetics and orthotics
· Home Health Services
· Outpatient Prescription Drugs
· Inpatient and Outpatient Services
Physician arrangements will be structured to comply with all applicable statues and regulations and Children's Hospital will not knowingly enter into financial arrangements that are designed to provide inappropriate remuneration to hospital-based physicians.
Because prohibition against referrals is so broadly worded, there are a number of exceptions or "Safe Harbors.” Questions or concerns regarding physician referrals not specifically addressed in Hospital or departmental policies and procedures are to be brought to the attention of the Compliance Officer. (See Administrative Policy No. 61, Affiliations/ Agreements/Contract Preparation/Review Process)
4. Clinical Trials
Children's Hospital will use reasonable efforts to assure that any costs reimbursed by sponsors of clinical research protocols are not passed on to the patients or their third party payors such as Medicaid, Medicare and managed care companies. C. Billing Questions and Disputes
Children's Hospital will work in good faith to resolve any questions raised by payors (including patients families) regarding charges imposed or bills rendered by Children's Hospital. Payors may audit Children's Hospital's charges and records in accordance with applicable Louisiana law.D. Federal and State False Claims Acts
The Deficit Reduction Act of 2005 requires health care providers annually receiving five million ($5,000,000) dollars or more in Medicaid reimbursement to provide detailed education to their employees and contractors on the federal and state false claims acts, civil and criminal penalties, and whistleblower protections.
1. False Claims Act
The federal Civil False Claims Act (FCA) Title 31 of the United States Code (USC) §3729 et seq. and its Qui Tam provisions (i.e., a party who sues for and on behalf of another, in this case the Federal Government) is the government's most effective tool in combating fraud, waste and abuse of federal tax dollars spent on health care. The federal government and private citizens suing on behalf of the government annually collect hundreds of millions of dollars from health care providers who commit fraud or abuse of the reimbursement system.
The FCA prohibits any person, including any company or corporation, from knowingly submitting a false or fraudulent claim for payment or approval from any federal or federally funded program, including, by way of example, Medicare, Medicaid, LACHIP, TRISPAN or NIH Grants. The FCA provides a civil penalty of not less than $5,000 and not more than $10,000, plus up to 3 times the amount of damages plus costs of litigation.
The FCA defines the terms "knowing” and "knowingly” to mean that a person: i) has actual knowledge of the information; ii) acts in deliberate ignorance of the truth or falsity of the information; or iii) acts in reckless disregard of the truth or falsity of the information. Specific intent to defraud is not required.
A lawsuit to enforce the FCA may be filed against the health care provider. Any such suit must be filed by a private citizen within six years after a violation. If suit is filed by the federal government it must be filed within three years of when the government knew or should have known of the violation, but in any event no more than 10 years after the violation.
2. Qui Tam and Whistleblower Protection Provisions
Under 31 USC §3730 a private person (called a Qui Tam Relator and also known as a whistleblower) may file suit for and on behalf of the United States Government for a violation of the FCA. A copy of the lawsuit and written disclosure of substantially all the material evidence and information the Qui Tam Relator possesses must be served on the Government when the suit is filed in federal court. The Government then has 60 days to join in the suit or decide not to join. If the Government decides to join in the suit it takes control of the lawsuit and the Qui Tam Relator may be awarded from 15% to 25% of the proceeds from the suit or any settlement depending on how much the Qui Tam Relator substantially contributed to the prosecution of the lawsuit. If the Government decides not to join the lawsuit the Qui Tam Relator may be awarded not less than 25% nor more than 30% of the proceeds of the suit or any settlement. In addition, the Qui Tam Relator is entitled to recover his or her reasonable expenses, including reasonable attorneys fees, if the suit is successful.
In order to bring a Qui Tam action under the FCA, the Qui Tam Relator must be an "original source” of the information regarding the violation of the FCA. "Original source” means an individual who has direct and independent knowledge of the information on which the allegations are based and has voluntarily provided the information to the Government before filing the Qui Tam action.
The FCA provides protection for whistleblowers. It provides that any employee who is discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in the terms and conditions of employment by his or her employer because of lawful acts done by the employee on behalf of the employee or others in furtherance of an action under the FCA, including investigation for, initiation of, testimony for, or assistance of an FCA action filed or to be filed under the FCA, shall be entitled to all relief necessary to make the employee whole. Such relief shall include reinstatement with the same seniority status the employee would have had absent discrimination, two times the amount of back pay, interest on the back pay, and compensation for any special damages sustained as a result of the discrimination, including litigation costs and reasonable attorneys fees.
3. Administrative Remedies
Chapter 38 of Title 31 of the United States Code 31 USC §3801 et seq. also provides administrative remedies for false claims and statements. This legislation prohibits the making of any false claims or false, fictitious or fraudulent written statements to a federal authority. A written statement is false if it contains a false material fact or if it omits a material fact. Federal authorities include, but are not limited to, the United States Department of Health and Human Services (DHHS).
Violations of this act are investigated and prosecuted by the Office of the Inspector General (OIG) of DHHS. The OIG may bring an action before an administrative law judge to enforce this act. This act is used to recover smaller amounts of money, typically under $150,000 and permits DHHS to withhold such funds from any reimbursement amounts lawfully owed to a health care provider.
4. Related State Law Provisions
In 1997, the Louisiana Legislature enacted the Medical Assistance Programs Integrity Law, Louisiana Statutes Annotated-Revised Statute (R.S.) 46:437.1 et seq. to combat and prevent fraud and abuse committed by some health care providers participating in the medical assistance programs. This state law contains many provisions that are similar to the Federal False Claims Act and related statutes.
R.S. 46:438.2 entitled Illegal Remuneration states that no person shall solicit, receive, offer or pay any remuneration (i.e., kickbacks, bribes, rebates or bed hold payments) directly or indirectly, overtly or covertly, in cash or in kind: i) in return for referring an individual to a health care provider or to another person for the purpose of referring an individual to a health care provider; ii) in return for purchasing, leasing, or ordering or arranging the purchase, lease or order of any good, supply, service or facility for which payment may be made in whole or part by Medicaid; iii) to a recipient of goods, services or supplies, or his representative for which payment may be made in whole or part by Medicaid; or iv) to obtain a recipient list, number or name. The illegal remuneration statute includes several "safe harbors” including federal safe harbors permitting certain practices such as discounts and group purchasing arrangements.
R.S. 46:438.3 entitled False or Fraudulent Claim Misrepresentation generally provides no person shall knowingly present or cause to be presented a false or fraudulent claim, knowingly engaged in misrepresentation to obtain payment or knowingly submit a claim for goods, services or supplies which were medically unnecessary, or which were of substandard quality or quantity. Services of substandard quality means services which fall below the applicable standard of care.
R.S. 46:438.4, Illegal Acts Regarding Eligibility and Recipient Lists, prohibits a person from knowingly making a false, fictitious or misleading statement on a form used for qualifying a person for Medicaid. It also forbids unauthorized persons from obtaining lists of persons who are Medicaid recipients.
R.S. 46:438.5 establishes civil money penalties which may be levied against health care providers who engage in false, fraudulent or abusive practices in violation of state or federal laws. The Secretary of the Louisiana Department of Health and Hospitals and/or the Louisiana Attorney General may seek such civil money penalties from the health care provider.
R.S. 46:439.7 et seq. permits a private person (Qui Tam Plaintiff) to institute a civil suit for and on behalf of the Louisiana Medicaid Program seeking recovery of actual damages and fines of not more than $10,000 per claim or three times the value of the illegal remuneration, whichever is greater from the health care provider for violations of the illegal remuneration law, the false claims law or the illegal acts related to eligibility or recipient lists.
As with federal law, the state Qui Tam Plaintiff must be an original source of the information which serves as the basis for the alleged fraud and must notify the Secretary of DHH or the State Attorney General before filing the Qui Tam action in state court.
The state law [R.S. 46:439.1(G) and R.S. 46:440.3] also has protection for whistleblowers and prohibits employers from retaliating against an employee or other person who files a Qui Tam action. An employee may recover all relief he is entitled to under state or federal law, including punitive damages. However, this protection does not apply to any employee or person who files and action the court determines is frivolous, vexatious, or harassing. In state Qui Tam actions, if the Secretary or Attorney General join in the suit, the Qui Tam Plaintiff may recover from 10% to 20% of the recovery depending on how much the Qui Tam Plaintiff substantially contributed to the lawsuit. If the Secretary of DHH or the Attorney General do not join in the suit, the Qui Tam Plaintiff shall receive an amount not to exceed 30% of the recovery as the court determines reasonable. The Qui Tam Plaintiff may recover litigation costs and reasonable attorneys fees as well. However, if the Secretary of DHH or the Attorney General do not join in the lawsuit and the court determines the Qui Tam Plaintiff's allegations were meritless or harassing, the court shall award costs, expenses, fees and attorneys fees to the defendant health care provider.
R.S. 46:440.2, Rewards for Information, states Secretary of DHH may provide a reward of up to $2,000 to individuals providing information leading to a recovery provided the individual is not himself subject to recovery.
5) Criminal Law Provisions
In addition to the civil provisions discussed above, the Louisiana Criminal Code, R.S. 14:1 et seq. also contains provisions related to Medicaid Fraud, Illegal Remuneration and Computer Fraud.
R.S. 14:70.1, Medicaid Fraud, makes it a crime punishable by imprisonment, with or without hard labor, for up to five years and/or a fine of $20,000 for knowingly submitting false claims, false information or statements to obtain payment or authorization from Medicaid.
R.S. 14:70.5 makes it a crime punishable by imprisonment, with or without hard labor, for up to five years and/or a fine of $20,000 for soliciting, receiving, offering or paying any kickback, bribe, rebate or bed hold payments in return for the referring of any patient to a health care provider, the purchasing, leasing or ordering or arranging or recommending for purchasing, leasing or ordering any good, supply, service or facility payable by Medicaid.
R.S. 14:73.5, Computer Fraud, makes it a crime punishable by imprisonment, with or without hard labor, for up to five years and/or a fine of up to $10,000 for accessing or causing to be accessed any computer, computer system or network with the intent to defraud or obtain money, property or services by means of false or fraudulent conduct, practices or representations. The computer fraud law becomes applicable whenever someone uses a computer to fraudulently bill the Medicaid program or any private payor.
Children's Hospital has many policies and conducts many activities to comply with the state and federal False Claims Acts. These policies and activities include this Code of Business Ethics and Conduct, our Quality Assurance Programs, our Patient Safety initiatives, our billing policies and our nurse auditor reviews. However, our employees are the most effective means of compliance and each employee has an obligation to inform management, the Compliance Officer or any member of the Compliance Committee of any suspected violations of the laws related to false claims or false statements.
III. RELATIONSHIP WITH EMPLOYEES
A. Use of Children's Hospital Property
1. Children's Hospital's assets and resources including time, materials, personnel, equipment, supplies and proprietary information are to be used, preserved and maintained for business related purposes. The personal use of any Children's Hospital asset without the prior approval of your supervisor is prohibited. Any authorized personal use of Children's Hospital assets shall be limited to non-commercial purposes and shall not be for personal financial gain.
2. Information regarding Children's Hospital's operations, including patient information, payor information, managed care contracts, vendor contracts, financial reports and other business information is to be preserved, protected and used solely for purposes related to the business of Children's Hospital. Such proprietary information shall be disclosed only on a need to know basis and as authorized by Children's Hospital's policies or as required by law.
B. Commitment to Civil Rights
1. To maintain high standards of performance, Children's Hospital employs only those individuals it believes are most qualified without regard to race, color, religion, sex, age, national origin, handicap or disability in compliance with all federal and state laws regarding discrimination. All employees are given equal consideration with respect to hiring, compensation, benefits, promotions, upgrading, training, transfers, and termination.
2. Sexual Harassment
Children's Hospital is committed to maintaining a work place environment in which employees are free from sexual harassment. Sexual harassment includes requests for sexual favors, receipt of unwelcome sexual advances and other verbal or physical conduct of a sexual nature:
a. as a condition of employment;
b. as a condition or basis for the making of employment conditions affecting the employee; or
c. for the purpose of unreasonably interfering in the employee's performance of his or her job functions or with the effect of creating an intimidating, hostile or offensive working environment.
It is a violation of Children's Hospital's policy for any employee to engage in sexual harassment in the work place or work related situations. Employees who believe they have been sexually harassed by any Children's Hospital employee should report the incident promptly to their supervisor, department head or the Human Resources Department. Any employee who makes a report of suspected misconduct truthfully and in good faith has the Hospital's assurance there will be no retaliation or retribution tolerated, regardless of the final outcome of the investigation. Supervisory personnel should take appropriate steps to prevent sexual harassment and to take prompt action in response to inappropriate behavior which may constitute sexual harassment or create a hostile work environment even in the absence of a complaint about such inappropriate behavior.
C. Commitment to Employee Safety and Welfare
Children's Hospital recognizes that its employees and medical staff are its most valuable assets and is committed to protecting their safety and welfare.
1. Children's Hospital is committed to compliance with the Occupational Safety and Health Act including the provision of appropriate personal protection devices and training in the correct use of personal protection devices. Children's Hospital has established policies and procedures relative to hazardous materials and employees' right to know in compliance with federal regulations. Children's Hospital will provide periodic training to employees in an effort to promote safe work practices, mitigate any personal or property damages as a result of an environmental or work place mishap and provide for the prompt and proper reporting of each incident to the appropriate authorities.
2. Children's Hospital is committed to fair and reasonable compensation practices, including payment of appropriate minimum wage compensation, overtime compensation, unemployment compensation taxes and social security taxes. Supervisors are to review time cards to verify hours worked and not worked so employees are paid appropriately. Employees having concerns regarding Children's Hospital's compliance with federal wage and hour laws are encouraged to bring those concerns to the attention of their supervisor or the Human Resources Department.
3. Children's Hospital has established a retirement plan and self insured health benefits plan for its employees. Children's Hospital is committed to operating these plans in accordance with applicable federal laws including the Employee Retirement Income Security Act and the Internal Revenue Code.
4. Drug Free Workplace
Children's Hospital's policies prohibit the use or possession of illegal drugs on Children's Hospital's property. All personnel are prohibited from being on Children's Hospital's property in an intoxicated condition whether such condition is caused by alcohol or drugs.
D. Commitment to Employee Education on Compliance
Children's Hospital is committed to providing initial and ongoing education for all employees regarding their responsibilities concerning the Code of Business Ethics and Children's Hospital's Corporate Compliance Plan. New employees will receive information and training about the plan during Core Orientation. During the initial training, all employees will receive a copy of the Plan and information and guidance in reviewing the Plan. All employees will sign an acknowledgment of receiving the Plan and the acknowledgment will be maintained in each employee's personnel file. All employees will receive training at least annually. All training will be documented and documentation will be maintained in the Training & Education or Nursing Education departments.
IV. RELATIONSHIP WITH COMPETITORS AND VENDORS
Children's Hospital has relationships and from time to time will enter into new relationships with other hospitals and health care institutions, including competing hospitals. It is the policy of Children's Hospital that these relationships and future relationships are to comply with all applicable federal and state antitrust laws.
Relationships with competitors must be for Children's Hospital's valid business and strategic purposes and must not unreasonably restrain trade or competition. Such relationships may never seek or have the purpose of fixing prices, boycotting other competitors or customers or dividing geographic or product markets. For example, it would not be legal for two or more competing hospitals to agree on the minimum or maximum prices they will charge or the amount of discounts they will agree to accept. Two or more competing hospitals may not agree to refuse to do business with or refer patients to a third hospital. Also it would be illegal for two or more competing hospitals to agree as to which hospital will serve a particular geographic area or provide a particular type of health service such as neonatal services. It should be noted that such illegal agreement need not be in writing, indeed they rarely are. Also such agreements can be inferred from the actions of the competing hospitals. For these reasons, it is important to avoid discussions with employees of other hospitals regarding: the prices we or they charge; the services we or they offer; the customers (patients and/or health insurance plans) we or they serve; or the geographic areas from where we or they get patients. Remember, these conversations or communications should be avoided even if they occur between friends and relatives.
The laws related to antitrust, unfair competition and deceptive trade practices apply to our relationships with our patients and vendors. It is important that we are honest, straight forward and above board in our dealings with our patients and vendors. Customers, suppliers and contractors deserve to be and will be treated fairly and honestly at all times without deception or discrimination and in a manner which complies with all applicable laws and good business practices. Employees should not make false, misleading or deceptive statements about other companies. Whenever selling or buying on behalf of the Hospital, make certain that such decisions are based solely on the quality, price, service, reliability and reputation of the product or service and the needs of Children's Hospital.
Because Children's Hospital and its subsidiaries are nonprofit corporations we are able to purchase pharmaceuticals at very favorable prices. However, the pharmaceuticals must be for use by the Hospital's inpatients, employees and employed physician practices. These pharmaceuticals are not for resale to the general public or to for-profit health care providers. Any questions concerning resale of pharmaceuticals should be directed to the Corporate Compliance Officer.
Children's Hospital will inform agents and independent contractors performing substantial services or work for or on behalf of Children's Hospital of the Code of Business Ethics and Conduct and will require such agents and independent contractors to comply with the Code of Business Ethics and Conduct.
V. RELATIONSHIP WITH THE GOVERNMENT
A. Nonprofit Tax Exempt Status
Children's Hospital is organized and operated as a nonprofit organization exempt from federal taxation under Section 501(c)(3) of the Internal Revenue Code. Tax exempt status is a privilege which comes with certain attendant qualifications and requirements.
1. Private Benefit
These qualifications and requirements include that the hospital serve the interests of the community as a whole and not to benefit the private interests of interested parties including trustees, officers, and members of the medical staff. For this reason the Board of Trustees has adopted a conflict of interest policy to assure that the interest of trustees, officers, employees and insiders are not served at the expense of the Hospital or the community it serves.
2. Private Inurement
Another requirement of tax exempt status is that no part of the Hospital's net earnings inures or goes to private individuals. The Hospital may not pay dividends as a for-profit stock corporation might. All financial transactions must be carefully reviewed by the Corporate Compliance Officer and, if necessary, outside legal counsel to assure the Hospital's funds are expended for commercially reasonable purposes and at fair market rates for the benefits the Hospital receives.
3. Community Benefit
The Hospital is required to serve the interests of the community. To accomplish this the Hospital is guided by a Board of Trustees of civic minded community and business leaders, including physicians, who have adopted a substantial conflict of interest policy. Also, the Hospital maintains an open medical staff and a full service emergency room which provides emergency care to patients regardless of ability to pay.
4. Political Activities
Children's Hospital refrains from participation in political campaigns and elections. It does not and will not make contributions in cash or in kind to political parties or political candidates. Children's Hospital recognizes the rights of employees to engage in political activities; however, the employees must always do so solely as individuals and never represent that their actions are supported by or are on behalf of Children's Hospital.
Children's Hospital will be an advocate for the children it serves. It will advocate for and support, to the extent permitted by law, social policies which improve the health and welfare of children.
B. Regulatory Agencies
Hospitals and health care organizations are subject to myriad regulations issued by various regulatory agencies such as the Food and Drug Administration, the Occupational Safety and Health Administration, the Environmental Protection Agency, the Department of Labor and the Department of Health and Human Services as well as their counterparts in state government. It is the policy of Children's Hospital to take all steps reasonably necessary to comply with all laws, rules and regulations applicable to activities conducted by Children's Hospital.
1. Food and Drug Administration
a. Approved Drugs and Services
In providing patient care, Children's Hospital will take all steps reasonably necessary to assure the use of only approved drugs and devices. Unapproved drugs or adulterated or misbranded drugs will not be knowingly used or distributed by Children's Hospital. Children's Hospital employees are prohibited from bringing unapproved drugs or devices into the United States unless they do so in compliance with applicable import regulations and tariffs.
b. Safe Medical Devices
Children's Hospital will take all steps reasonably necessary to assure that only safe medical devices are used in the provision of patient care. Any substantial failure of devices to perform as intended and any injuries caused by device failures shall be promptly reported to the Director of Quality Assessment and the Director of Biomedical Services. Such device failures shall be investigated and reported in accordance with the Safe Medical Devices Act and applicable regulations.
c. Medical Research
Children's Hospital's activities in medical research are continuously expanding. These research activities shall be conducted in accordance with the Hospital's policies and procedures and all applicable rules and regulations.
(i) Institutional Review Board
Children's Hospital for many years has had an Institutional Review Board (IRB) to review and monitor all research activities conducted at Children's Hospital. Before engaging in any research activity at Children's Hospital, a researcher employed by Children's Hospital must first submit the research protocol and all related materials to the Office of Research and Technology for Review by the Institutional Review Board. All LSUHSC Faculty members must first submit to the LSUHSC Institutional Review Board for approval. If the researcher chooses to use Children's Hospital Patients, the faculty member must then submit LSUHSC IRB approval, the protocol, and all related materials to Children's Hospital Administrative Review Committee, located in the Office of Research and Technology.
(ii) Institutional Animal Care and Use Committee
Any research activities using animals as research subjects must first be reviewed and approved by the Institutional Animal Use and Care Committee to assure humane treatment of all research subjects.
(iii) Scientific Research Integrity
Children's Hospital shall take all reasonable measures necessary to assure all research activities are conducted in accordance with research protocols, applicable requirements of the granting agencies including but not limited to the National Health Institute and ethical principles of scientific inquiry and empirical analysis. Scientific researchers shall avoid conflicts of interests between themselves, Children's Hospital, the sponsors, and granting agencies. Any unethical or improper conduct in research activities should be promptly reported to the Vice President of Research and Technology and the Corporate Compliance Officer.
(iv) Institutional Biosafety Committee
Any research activity involving recombinant DNA or biohazardous material must be reviewed and approved in advance by the Institutional Biosafety Committee.
2. Environmental Protection Agency
Children's Hospital is committed to take all measures reasonably necessary to comply with all applicable environmental regulations and to educating its employees in the proper handling of hazardous materials and substances. Any environmental or medical waste disposal mishaps shall be reported and disclosed promptly to appropriate local, state and federal authorities so as to facilitate prompt and safe responses.
a. Hazardous Materials
Children's Hospital has established policies and procedures for the proper handling, storage and disposal of hazardous substances and materials. The Hazardous Materials Plan has been developed to comply with all applicable rules and regulations. It should be consulted if any questions arise. It is Children's Hospital's policy to comply with federal and state environmental laws, rules and regulations.
b. Medical Wastes
An unavoidable result of providing patient care is the generation of medical wastes, including infectious and biohazardous wastes. The medical waste shall be handled, processed, stored, transported and disposed of consistent with applicable rules and regulations.
VI. DOCUMENTATION, RECORDS AND RECORDS RETENTION
Children's Hospital has established policies and procedures which address the accuracy of documents and records and apply to all employees. Employees must record and report information accurately and honestly. This includes accurate reporting of time worked, business expenses incurred, research test results, laboratory results, patient charts, revenues and cost and other associated business activities. Hospital records are subject to audit. Hospital financial records should be maintained in accordance with generally accepted accounting practices.
Intentionally dishonest reporting, both internal and external, will not be tolerated. This includes reporting or organizing information in an attempt to deceive the recipient. No entry shall be made on the Hospital's books and records which intentionally disguises or hides the true nature of any event or transaction. Additionally, all of Children's Hospital's business shall be reported and accounted for. No undisclosed or unrecorded fund or account may be maintained for any reason. No false or misleading statement or entries may be made in the documents and records of Children's Hospital.
Medical and business records are retained in accordance with the law and our record retention policy. Medical and business records include paper documents such as letters and memos, electronic information on disk or tape, and any other medium that contains information regarding business activities.
VII. REPORTING POSSIBLE VIOLATIONS
Children's Hospital has an established user friendly, accessible mechanism in place to aid employees in reporting possible violations of the Code of Business Ethics and Conduct of its Corporate Compliance Plan.
· Completion and submission of a Compliance Form through the MAGIC boxes
· Corporate Compliance Telephone Line (504/896-9845)
Any employee having or obtaining knowledge of behavior which is in conflict with Children's Hospital's Code of Business Ethics and Conduct is encouraged to report such knowledge to first their superior and then directly to the Corporate Compliance Officer. This includes such behavior by any Hospital employee, physician, independent contractor, outside vendor or any entity with which the Hospital conducts business. Any employee needing guidance on or clarification of the Code of Business Ethics and Conduct is encouraged to call the Compliance Officer.
A. Reports to Superiors
Any employee who may suspect unethical or illegal behavior in any area is encouraged to discuss their concerns with their superiors so that such issues may be forwarded to the Compliance Officer. It is recommended that employees report to their immediate supervisors, providing the nature of their suspicions allow for this. Should the employee feel more comfortable reporting to another manager or directly to the Compliance Officer, this is certainly acceptable. The detailed information will then be provided to the Corporate Compliance Officer who will conduct an investigation.
B. Report to Compliance Office
Any manager receiving a report of suspected misconduct should forward the information directly to the Compliance Office to be handled appropriately. Employees have the option of reporting suspected violations directly to the Compliance Office through the use of the MAGIC boxes or the compliance telephone line. A detailed account of the suspected misconduct will be taken. The Compliance Office will then proceed with an investigation into the reported situation. Upon completion of this investigation, the reporting employee, if identified, will be informed of the findings.
C. Confidentiality of Reports
While every effort will be made to maintain confidentiality of any person reporting a situation to the Compliance Office, such confidentiality cannot be guaranteed. The identity of the reporter may have to be disclosed to appropriate authorities. Children's Hospital employees have a duty to report any potential misbehavior, whether this report is to their superior or directly to the Compliance Office.
D. Non-retaliation for Good Faith Reports
Any employee who makes a report of suspected misconduct truthfully and in good faith has the Hospital's assurance there will be no retaliation or retribution tolerated, regardless of the final outcome of the investigation.E. Quality of Care Concerns
All members of the Medical Staff and Employees are encouraged to bring any issues regarding quality of care rendered such as medication errors, missed or omitted treatments or therapies and any substandard practice (i.e. a breach of JCAHO or College of American Pathologist standards) to the attention of supervisors or department managers. If the member of the Medical Staff or Employee believes these issues are not being adequately addressed by the Hospital, they should report the matter to the appropriate agency (i.e. JCAHO, CARF, CAP, etc). Members of the Medical Staff and/or employees making any such reports in good faith will not be subject to retaliatory treatment or discipline by Children's Hospital.
VIII. RESPONDING TO GOVERNMENT AUDITS AND INVESTIGATIONS
Periodically Children's Hospital receives requests for information from governmental agencies and departments relating to the services the Hospital provides and to whom such services are provided. These inquiries may take several forms, i.e. subpoenas, records requests, correspondence, telephone calls and personal interviews. It is the policy of Children's Hospital to comply with all applicable laws and to cooperate with lawful and reasonable requests from state and federal authorities. However, the legal rights of Children's Hospital, its employees and patients must be protected and preserved.
A. Internal Investigations
Normally, legal counsel will lead any internal investigation to give the Hospital benefit of attorney-client privilege. If an accountant or consultant is needed, normally legal counsel will arrange for one to extend the attorney-client privilege to other professionals.
B. Investigations by Government Agencies
Any communication by a government agency should immediately be reported to the employee's supervisor, who will evaluate the report to determine if it was in the ordinary course of business or if it necessitates intervention by management or legal counsel. If communication is investigative, it shall also immediately be reported to the Corporate Compliance Officer and the President and CEO.
Employees should always treat any investigation seriously, ask to see identification if not offered, be business-like, courteous and not solicitous, and attempt to find out in specific detail what the investigator is seeking and how the employee fits in. Do not speculate or guess about information you do not personally know. Get all information you reasonably can as to what the investigator seeks, and take as detailed notes as possible.
Do not destroy, lose or alter any document at any time. Always maintain copies of all documents taken from your possession, and for a search warrant, an inventory of all items or documents seized.
C. Responding to Government Attempts to Interview Employees
It is Children's Hospital's policy to cooperate as much as possible with governmental investigations of suspected wrongdoing by employees, officers, or agents of the Hospital. However, the Hospital also desires to protect its attorney-client privilege as much as possible unless and until it becomes advisable to waive it. Accordingly, when employees are approached regarding activities involving their work with the Hospital, the Hospital would prefer to be notified of all such contact to the extent practical and prudent.
Employees, officers, or agents should be advised that they may decline to provide voluntary interviews. They may also specify the circumstances under which they are willing to be interviewed, such as during business hours, in the office, with or without an attorney present, etc. The decision to either agree or decline to be interviewed is one to be made solely by each individual.
Employees being requested for interview by government investigators may be entitled to representation by either the Hospital's or their own individual legal counsel. If the Hospital's interest should become adverse to the employee, the Hospital's attorney may advise the employee that they need to obtain independent representation.
D. Miscellaneous Considerations
An entity which fails to grant immediate access to a facility, or to records or documents, upon "reasonable request” by the Secretary of Health and Human Services, Medicaid state agencies, the Office of the Inspector General, or state Fraud Control Units may be excluded from participation in the Medicaid Program pursuant to 42 USC 1320a-7(b)(12).
A "reasonable request” is defined as a written request made by a properly identified agent.
"Immediate access” means within twenty-four hours. However, the Office of the Inspector General of HHS or a Medicare/Medicaid Fraud Control Unit can demand access at the time of the request if there is "reason to believe” that documents are about to be altered or destroyed (42 CFR 1001.1301).
All Children's Hospital employees, officers and agents shall be informed of and familiarize themselves with the foregoing Code of Business Ethics and Conduct of Children's Hospital and shall so signify by executing the following acknowledgment.