Corporate Compliance Program and Code of Conduct

Transcription

1 Hope. Care. Cure. M/S S-232 PO Box Seattle, WA Pub. 8/01 Rev. 11/04 10/06 4/09 6/12 Corporate Compliance Program and Code of Conduct We are all responsible.

2 About Seattle Children s i The statements contained in the following pages are guidelines only and do not constitute an express or implied contract for employment nor promise of any specific benefit, procedure, or treatment in any particular situation. Children s is an at-will employer, which means that you may resign at any time, with or without a reason or notice, and Children s may terminate you at any time, with or without cause or notice. Nothing in the following pages and nothing in the work environment at Children s can modify the at-will status of employment. No one at Children s except for the Board of Trustees, and then only in writing, is authorized to alter the at-will status of employment. Hope. Care. Cure. These three simple words capture what we are here to do. They speak to what inspires us now, and to our aspirations for the future. We are a compassionate community where skilled physician-researchers, nurses and staff partner with patients and families to help each child live their best life. We are united by a compelling mission: to prevent, treat and eliminate pediatric disease. Seattle Children s consists of: Seattle Children s Hospital Seattle Children s Research Institute Seattle Children s Hospital Foundation Seattle Children s Hospital Guild Association Together, we deliver superior patient care, advance new discoveries and treatments through pediatric research and serve as the pediatric and adolescent academic medical referral center for Washington, Alaska, Montana and Idaho - the largest region of any children s hospital in the country. For more information visit ii

3 Table of Contents Dear Fellow Children s Staff and Faculty: i Introduction ii About Seattle Children s iii Table of Contents iv Letter From Tom Hansen, M.D., C.E.O. 1 Mission and Vision 2 Seattle Children s Code of Conduct 3 Corporate Compliance Program Laws and Regulations Responsible Conduct of Research Reporting Compliance Concerns Auditing and Monitoring Disciplinary Process/Corrective Action 12 Protecting Confidential Information Protected Health Information Other Confidential Information Information Systems and Data Security More Information 14 Business Standards Billing Practices Conflict of Interest Gifts Antitrust Government Investigations and Legal Actions Copyrights, Intellectual Property and Inventions 17 Patient Care Standards Admission, Transfer and Discharge Patient s Right to Protective Services Patient Care Decision Dilemmas Integrity of Clinical Decision Making Staff Request to Not Participate Staff Right to Notify The Joint Commission Enclosed is your copy of Seattle Children s Compliance Code of Conduct. These materials, developed with input from our employees, senior management and the Board of Trustees, strive to: tell you about the basic laws that govern our daily work and the standards of behavior expected at Children s; communicate our commitment to follow laws, regulations, standards of care and ethical business practices; and help you understand how you can help assure that Children s remains compliant with all the laws and regulations that govern our organization and support our mission. These materials serve as a reference point for compliance standards. We outline a process to follow if you should ever have any questions or concerns. Children s will continue to provide detailed communications and training regarding the laws and regulations that apply to your specific job functions. It is your responsibility to understand, learn and obey these rules. If you ever feel uncertain about the right thing to do, I encourage you to ASK. You will not be penalized for asking a question about your legal or ethical responsibilities. The importance of following the standards in these materials cannot be overestimated. A violation of law or unethical conduct in delivering health care services could reduce the quality of patient care and even harm patients. It could also cause Children s to have to pay fines. Children s provides excellent, safe, quality care to children and families throughout the Washington, Alaska, Montana and Idaho (WAMI) region. Since Children s founding in 1907, our ethical and professional conduct has earned us an unsurpassed reputation. Thank you for your continued support of Children s mission and dedication to excellence. Sincerely yours, Tom Hansen, MD Chief Executive Officer 20 Acknowledgement Form iii EthicsPoint: From CHILD, click on I want to... Report a Compliance Issue iv

4 Mission and Vision Seattle Children s Code of Conduct The Code of Conduct is applicable to the entire Children s workforce, including employees, non-employees, medical staff, volunteers, vendors and others. Seattle Children s has adopted these standards as our Code of Conduct: We strive to deliver excellent quality care to our patients. Integrity, both personal and professional, is and always has been our most important asset. We demand ethical conduct in all our activities. Our Mission: We believe all children have unique needs and should grow up without illness or injury. With the support of the community and through our spirit of inquiry, we will prevent, treat and eliminate pediatric disease. Our Vision: Our founding promise is to care for each child in our region, regardless of their family s ability to pay. Over the next five years we aspire to: Provide the safest, most effective care possible. Control and reduce the cost of providing care. Find cures and educate clinicians and researchers. Grow responsibly and provide access to every child who needs us. We care not only for the end result, but also how we achieve that result. Our relationships with our patients, other professionals and vendors are essential to our business. They must be built upon credibility and mutual respect. When confronted with a choice, we do the right thing. When in doubt about the rules, we ask. We are committed to an environment that fosters communication and partnerships among patients, families and staff. We strive for excellence in family-centered care, quality, responsible research, cultural competency and workplace engagement. We act in accordance with Children s Community Standards of Accountability, Respect and Teamwork (ART). The Code of Conduct applies to the entire Children s workforce and supports Children s mission, policies and procedures. 1 2

5 Corporate Compliance Program Pru Arnquist Corporate Compliance Officer Corporate Compliance is a program designed to ensure that the organization s workforce follow the laws and regulations that govern healthcare. The term workforce includes, but is not limited to the entire Children s workforce. Children s commitment to ethical behavior is reflected in our Compliance Code of Conduct and our business practices. Making sure we understand how to apply the laws and regulations that guide our activities is what the Compliance Code of Conduct and the Corporate Compliance Program are about. Children s Corporate Compliance Program affirms our dedication to excellence. The Corporate Compliance Program encourages and enhances the efforts of everyone to use the highest level of integrity. Ethical behavior will help shield Children s from potential liability under the complex laws and regulations that govern the activities of the healthcare industry. To do this, we will: Provide written standards such as: The Code of Conduct (see page 2). Policies and procedures located on CHILD, Seattle Children s intranet. Conduct education and training programs for employees, volunteers, certain vendors and nonemployees: All new employees are required to take the Corporate Compliance web-based training module. All employees are required to take the web-based training module annually prior to performance evaluations. Volunteers and other non-employees also receive compliance training. Ask your supervisor or sponsor to learn more. Establish methods for employees to provide feedback and convey concerns or complaints without fear of retaliation: How to report (see page 8). Respond to questions about improper or unethical activities and take appropriate disciplinary action when violations occur: Disciplinary process (see page 9). Monitor compliance efforts and help solve problems: Auditing and Monitoring (see page 9). Laws and Regulations The ultimate goals of the Corporate Compliance Program are first and foremost to prevent actions that may violate laws and regulations and to prevent fraud and abuse of healthcare dollars wherever possible. The False Claims Act A false or fraudulent claim is a request for payment for a medical service or item that is not reasonable or necessary for the diagnosis or treatment of a patient. What do you need to know about the False Claims Act? The submission to a federal governmental health care program of a false or fraudulent claim for a medical service or item is prohibited by the federal False Claims Act (FCA) ( of Title 31 U.S.C.) and also prohibited by Washington state law (see page 6). Employees who report the submission of false or fraudulent claims are protected as whistleblowers and may not be retaliated against in their employment. Private citizens may share in the money recovered by the government if a prosecution is successful. Children s Corporate Compliance Program policies and procedures have been developed to further define our plan to prevent and detect fraud, waste and abuse. Go to CHILD to read the Compliance Program policies and procedures. Submitting false or fraudulent claims may result in enforcement action by a government agency. It is important for everyone to understand how serious it is to submit a false claim! 3 4

6 The penalties can be very high, such as: A provider may be fined up to $11,000 for each false claim for certain kinds of fraud in addition to three times the amount of the loss. Providers may be excluded from participating in any federal healthcare program. Providers may face jail time. The Program Fraud and Civil Remedies Act Under the Program Fraud and Civil Remedies Act (PFCRA, 31 U.S.C ), the person submitting the claim may be subject to a penalty of up to $5,000 per claim or statement, plus up to double the amount of each claim falsely made. The Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) is repsonsible for investigating allegations of false claims and statements to HHS. Anti-kickback The primary purpose of this federal law is to protect patients from providers making healthcare decisions based on the influence of anything of value from interested parties. Anyone who knowingly receives or pays anything of value to influence the referral of federal healthcare program business, including Medicare and Medicaid, can be prosecuted for a felony. Washington State also has anti-kickback laws. Patient Protection and Affordable Care Act (also known as healthcare reform) This law makes compliance programs mandatory. Many changes to laws occurred under this statute, including anti-kickback violations can now be prosecuted as false claims. Additionally, if an overpayment is received from a government payer, it must be returned in a specified time or it can be considered a false claim and prosecuted as such. Emergency Medical and Active Labor Act (EMTALA) This law, also known as the anti-dumpting law,, states that anyone presenting to an emergency department asking for treatment for an emergency condition must be provided an emergency medical screening and necessary stabilization measures. This exam and treatment cannot be delayed to inquire about payment status. Conditions of Participation (CoP) or Conditions for Coverage (CfC) These laws are mandated by the Centers for Medicare and Medicaid Services and are focused on minimum standards expected to maintain quality of patient care. Hospitals and other providers must comply with these standards to maintain their Medicare and Medicaid provider status. Applicable State Law Under Washington State Law, it is a felony for any person or institution to knowingly make or cause to be made any false statement or representation of material fact: In application for payment under any state medical care program; or For use in determining rights to such payment. It is also a felony to conceal, cover up or fail to disclose: Any material fact to a state medical care program or any right to payment greater than is due or for which no payment is due. The occurence of any event affecting either the initial or continued right to any payment with the intent to secure payments fraudently either in a greater amount than what is due or when no such payment is authorized. The above crimes may be punishable by up to 5 years in prison and/or a fine not to exceed $25,000. In addition to criminal sanctions and other penalties, a person or institution who obtains or attempts to obtain payment from a state health care benefit program in an amount greater than that to which the person or institution is entitled by means of: Willful false statements; Willful misrepresentation or concealment of any material facts; or Any fraudulent scheme (including billing for items or services not provided, misrepresenting the items billed, or billing for purportedly covered items, which were in fact not covered) Must repay the amounts wrongfully obtained plus interest and subjected to a civil penalty in an amount up to 3 times the amount of the excess payments received. 5 6

7 Did you ever wonder who Children s reports to? See the image below for the federal, state, local and miscellaneous agencies the govern Seattle Children s activities. Responsible Conduct of Research COMPLIANCE IS NOT ONLY IMPORTANT FOR SEATTLE CHILDREN S, IT S MANDATORY! Nicole Jacobs Research Integrity Officer nicole.jacobs@seattlechildrens.org Seattle Children s Research Institute strives for excellence in the responsible conduct of research. This involves: Protection of human research participants Ethical treatment of animal research subjects Assurance of environmental health and workplace safety for researchers Administration and management of research awards Identification and management of financial conflicts of interest Fostering a culture of research compliance and responsible financial stewardship. As a result, all employees and agents of Children s who are engaged in research activities are expected to conduct research in compliance with federal, state and local laws, as well as institutional policies and procedures. The Office of Research Compliance works with the Corporate Compliance Program to encourage and enhance the efforts of employees and agents to achieve the highest level of integrity. It does so by performing compliance research risk assessments, auditing and monitoring research activities, conducting effective education and training programs on responsible conduct of research, developing research policies and procedures, and promptly investigating all reported research compliance concerns (See page 9 How do I report an issue ). For more information on the research compliance program, go to the Research tab on CHILD and click Forms and Policies. Research policies and procedures can be found by clicking on the Policies & Procedures tab and choosing Research in the left hand column. You may direct research compliance questions to the Office of Research Compliance at researchcompliance@seattlechildrens.org 7 8

8 You have a duty to report potential compliance concerns -- we can t fix it if we don t know about it. Reporting What do I report? Compliance issues can be complex and knowing when to report a potential issue is not always easy. Ask yourself these questions when you see a possible violation: Does the action seem illegal? Is it inconsistent with Children s policies and procedures? Does it violate your standard of ethical behavior? If you are still unsure after considering these questions, contact your supervisor, the Corporate Compliance Department, the Compliance Helpline or you can report online through CHILD using Ethics Point. How do I report an issue? \ If an issue arises that you feel may violate the Compliance Code of Conduct or any of the laws described in these materials, please do the following: 1. Start with the chain of command by talking to your immediate supervisor or manager. 2. If that does not seem appropriate, go to the department director or another trusted manager or leader at Children s. 3. You can also call the Compliance Helpline, report using Ethics Point through the CHILD, or contact the Corporate Compliance Officer directly at Reporting a Potential Violation Using the Compliance Helpline When you call the Helpline, you can identify yourself or, if you prefer, just let them know that you would like to provide information anonymously. The representative will create a report based on the information that you provide and send the report to the Children s Corporate Compliance Office. Compliance Helpline: (877) When should I use the Compliance Helpline or submit questions online? Anytime. The Compliance Helpline and Ethics Point (the online source from CHILD) are additional resources available for you to report potential violations or ask questions. Reporting Potential Violation on the Web Ethics Point not only services the Compliance Helpline, but it also provides a Web-based option for reporting compliance concerns. The process is described as follows: 1. You can report online by going to the CHILD homepage or Corporate Compliance Program site. 2. Click on the Compliance Reporting link. 3. This will take you to an external website. This website is not part of the Children s system and cannot be tracked by Children s, so reporters may remain anonymous if desired. 4. You will be directed to set up a password so that those investigating can communicate with you while maintaining your anonymity if so desired. Potential violations and other compliance concerns can be reported anonymously if you desire. Ethics Point is a company completely external to Children s. Those who wish to report a violation can call and talk to a live person or type in their concern through a webbased program. Children s takes seriously the importance of confidentiality in matters involving potential compliance violations. All calls placed to the Compliance Helpline or Ethics Point will be kept confidential as provided by law. When you call the Helpline, you will speak directly with a compliance professional who will ask questions about the issue. This line is staffed on a 24/7 basis. 9 10

9 Protecting Confidential Information You will never be required to provide your name if you do not want to. If you wish to know what follow-up has occurred, you can set up an appointment to call back and ask the Compliance Helpline or use the follow-up function in Ethics Point. What happens after I report a violation? Children s will promptly investigate all reports. Investigations will be as confidential as possible. The Compliance Officer will coordinate findings and, if necessary, recommend changes that need to be made to fix identified problems. Will I get in trouble for reporting a violation? No. Children s policy, as well as federal and state laws, described in these materials, prohibit any retaliation or harm to a person who reports in good faith. In fact, Children s wants to know of all potential violations. Auditing and Monitoring Auditing and monitoring is an important component of an effective compliance program. To help assure Children s compliance with all applicable laws and regulations, we will perform periodic compliance audits. Audits in identified risk areas will be more frequent and detailed. The Compliance Officer and a group of internal staff members, as well as external auditors (as needed), will conduct the audits. When complete, the audit results will be presented to the Compliance Committee and the affected department. Disciplinary Process/Corrective Action Children s will not tolerate behavior that violates the Compliance Code of Conduct. This includes failure to comply with laws, regulations, policies and procedures. Failure to comply is a serious matter and may lead to corrective action, up to and including immediate suspension and even termination. In addition, employees who violate certain laws may be subject to legal prosecution. Management staff may be held accountable for failure to comply with Children s Corporate Compliance Program or for the failure of their reporting staffs to comply. Managers will be evaluated on how well they educate about and enforce the standards of the Corporate Compliance Program. Cris Ewell, Chief Information Security Officer cris.ewell@seattlechildrens.org Sue Stubbs, Director, Health Information and Privacy susan.stubbs@seattlechildrens.org Protected Health Information (PHI) Federal and state laws impose specific requirements and restrictions on the use of protected health information (PHI). Children s requires that all members of its workforce take privacy and security training in order to more clearly understand their responsibilities. Remember, all who work at Children s are responsible for maintaining the privacy and security of PHI in all forms; oral, written and electronic. Other Confidential Information Children s also creates and uses many other kinds of confidential information to conduct business. Examples include strategic plans, contracts, budgets, salaries and personal information about employees. These types of information are to be viewed and used only by the individuals who need them to do their jobs. Information Systems and Data Security Much of Children s PHI is stored in electronic form. Many of Children s large computer applications contain information that is used for patient care and related activities (treatment, payment and hospital operations). Just as with paper or oral communications, you are responsible for making sure that electronic information about patients and research participants is protected from unauthorized access, modification or theft. It is also your responsibility to keep Children s business information confidential. Any attempt to inappropriately access or share confidential information, including PHI, may be subject to disciplinary action, up to and including termination

10 It is a violation of policy to: Share your user ID (login) or password for any Children s system; Seek or share confidential information that is outside the scope of your job responsibilities; Access information for others who are not authorized to obtain that information; Breach or attempt to breach the security of any Children s information system or confidential data; or Leave computers or media containing patient or other confidential information unsecured. All workforce members sign a confidentiality agreement before they receive access to Children s network and information systems. Your access to electronic information may be monitored to assure compliance with Children s privacy and security policies. We Are All Responsible Protecting the privacy and security of PHI and other confidential information is: Everyone s responsibility. The right thing to do! The law. Never access or disclose PHI or any other type of confidential information except as needed to perform your job; share confidential information only with authorized individuals. Business Standards Billing Practices Accurate billing and submission of claims are top priorities for Children s. We must follow billing laws and regulations to be appropriately paid for our services. Clinical records must contain complete and accurate documentation necessary to support all claims. Failure to follow proper procedures can result in improper billing, which may lead to civil and criminal liability for Children s as well as individual employees. We want to know when errors are found, and we encourage you to report them so corrections and education can occur. The deliberate submission of charges or claims for reimbursement that are false, inaccurate, incomplete or duplicate is strictly prohibited. More Information To find more information about Children s Privacy and Security programs, from the CHILD home page, select the People and Places tab; select Programs, and then select the Privacy and Security Program. Privacy and Security policies can be easily found by selecting the Policies and Standards tab at the top of the CHILD home page; then select Policies and Procedures. From this page you may search all policies using key words or select Privacy and Security or Information Services from the categories displayed on the left-hand side of the page. You may direct specific privacy questions to the Privacy Help Line, , or via privacy.questions@seattlechildrens.org. You may direct information systems security questions to the IS Service Desk, If you discover a billing error, you should notify your supervisor or Business Services immediately. It is important for Children s to learn of billing errors and fix them as well as any system problems that may have caused the error. If we do not do so, the government may consider ongoing errors to be false claims. The government may then sue Children s under the False Claims Act (see page 5). If you have concerns about any charges submitted from your department you should contact your supervisor, the Revenue Cycle Director or call the Compliance Helpline at You will not get into trouble for reporting your good faith concerns. You are protected by law and also by Children s non-retaliation policy. See page 9 for how to report

11 Patient Billing and Resolution of Conflicts Children s requires that charges for services shall be standard for all patients and payers. Claims are submitted in accordance with government program regulations, payer contract requirements, and industry standards. Questions from patients or payers are reviewed and responded to. Billing complaints are handled through established procedures. Children s general credit and collection procedures comply with the Fair Debt Collection Practices Act. We prohibit harrassmentin our debt debt collection efforts. Conflict of Interest As an employee of Children s, you are expected to avoid situations that might cause your personal interests to conflict with Children s or to compromise Children s reputation for integrity. A conflict of interest or the appearance of one, occurs when you or your immediate family could use your position for personal benefit. We care not only for the end result, but also how we achieve that result. If you have a question about whether an activity or involvement might create a conflict of interest, contact your supervisor, the General Counsel at or call the Compliance Helpline.at Gifts You are not allowed to receive gifts that may be viewed as a bribe or a kickback. These include gifts with more than a small value, excessive entertainment or anything of any value given to employees, physicians or any other party in a position to influence patient referrals, patient care or Children s business. Government Investigations and Legal Actions If you are approached by any person who identifies himself or herself as a government investigator, you should contact the General Counsel s office immediately at Notify the person taking the call that you are reporting a potential government investigation. If you receive a subpoena or other written request for information related to a government investigation contact the General Counsel s office immediately. Do not respond directly to such requests or subpoenas. Copyrights, Intellectual Property, Patents and Inventions Children s retains the right to all copyrights, intellectual property, discoveries, patents and inventions developed by staff that involve Children s facilities, services, conditions of employment or assignment of duties. The rights to inventions developed by employees of Children s will be assigned by agreement to Children s. You are required to report any inventions conceived or developed in connection with your work or that involve Children s facilities or services to your department director. Your director will work with you to make the appropriate invention disclosure. Antitrust Children s is committed to competing fairly and in compliance with all applicable laws. Antitrust laws prohibit agreements or attempted agreements that limit or restrict competition. This includes sharing information on prices or costs, products or services, dividing geographic markets, boycotting or leading patients or customers to certain facilities. While most business agreements are in the form of a written contract, unwritten or informal agreements also fall under the guidance of antitrust laws. Children s complies with all antitrust laws

12 Patient Care Standards Admission, Transfer and Discharge At Children s, a pediatric patient in need of medical care is admitted without discrimination on the basis of race, gender, creed, ethnicity or disability. Patients who enter our system are carefully assessed at the time of entry and placed in a patient care area that best meets their clinical needs. Transfer to another unit or service is determined by the patient s clinical condition, matched to the admission and discharge criteria of the specific units. Diversion to another health care facility occurs only after a child s condition has been assessed, and we are unable to match their needs based on bed availability, adequate and trained staff, technology or necessary equipment. Patient s Right to Protective Services Under Washington state law, all professional staff are obligated to make a report to the proper authorities if they have reasonable cause to believe that a child has suffered abuse or neglect. Seattle Children s provides resources to help determine the need for these services and, if requested, a list of advocacy groups. Patient Care Decision Dilemmas Individuals with knowledge and training in medical ethics are available for consultation on a 24-hour, 7-day-a-week basis to patients, family, staff or health care providers through the paging operator at Integrity of Clinical Decision Making Clinical decisions are based on identified patient health care needs. The integrity of clinical decision making is maintained, regardless of how leaders, managers, clinical staff or licensed independent practitioners are compensated and/or share financial risk. Staff Request to Not Participate in Aspect of Care Children s respects a staff member s request not to participate in an aspect of patient care that infringes on his or her cultural values, ethics or religious beliefs. The medical needs of patients and their overall well-being take precedence, however, so that care, treatment and services are not negatively affected. Staff Right to Notify the Joint Commission Employees have the right to report to The Joint Commission concerns about the safety or quality of clinical/medical care provided at Children s. Concerns may be reported to The Joint Commission via any of the following: Telephone: Fax : complaint@jointcommission.org Mail: One Renaissance Boulevard, Oak Terrace, IL Children s will take no disciplinary action against the person for good faith reporting. Remember, for further information, see the Corporate Compliance Web page on CHILD: Services/Corporate_Compliance_Program/ 17 18

13 Seattle Children s Corporate Compliance Program and Code of Conduct Acknowledgement Form My signature on this form acknowledges that I have received, read and understand Seattle Children s Corporate Compliance Program and Code of Conduct. Signature Printed Name Employee Number Department Date Please return the completed form to the Corporate Compliance Office. Fax: Mailstop: RC-402 Scan and to: corporatecompliance@seattlechildrens.org If you need any help understanding these standards, please talk with your supervisor