Hometown Health

Standards of Conduct

What are the Standards of Conduct?

The Standards of Conduct, sometimes referred to as the Code of Conduct, are foundational to the Compliance Program. It is a core element to Hometown’s culture. Staff, Board Members, and vendors/contractors are bound by Hometown’s Standards of Conduct. The Standards are based on Federal Law, New York Social Services Law, 18 NYCRR Part 521, and best practices.

The Standards highlight some (but not all) of recurring situations at HHC that may occur requiring an ethical response by Staff, volunteers, Board Members, interns/students, and/or vendors/contractors/consultants. The Standards apply to interactions with consumers, government reporting agencies and those who do business with HHC. Each individual must strive to be a model manager, employee, or Board Member. The Standards define staff job performance and Board Director behavior.

Complementary to the Standards of Conduct, yet distinct from them, is ethics. Ethics, as explained further below, is an outlook, attitude, or way of looking at things so that equity, fairness, justice, and transparency is front and center.

Ethics is part of Hometown’s Standards for staff, volunteers, Board Directors, interns/students, and vendors/contractors/consultants to behave ethically. Directors, managers, and supervisors must take responsibility to create and maintain an ethical work environment of mutual respect where concerns are raised without fear of retaliation. It is the Board’s responsibility to support them and be an example to uphold them. It is everyone’s responsibility to make sure employees understand their responsibility to report ethical or legal breaches. Employees, Board Members, and vendors/contractors have a duty to report wrongdoing.

The Standards are how everyone, staff, Board Members, interns/students, and vendors/contractors/consultants, must behave or respond to specific situations when they occur. Always respect patients, for example, who are customers. Coworkers must always respect and be courteous to one another, and Board Members must show respect and courtesy to Staff. This is part of the Standards of Conduct.

Staff, volunteers, Board Members, interns/students, and vendors/contractors/consultants reporting compliance breaches is another element of the Standards of Conduct. Requirements of the Standards include, but are not limited to:

Following State and Federal law and Presidential Executive Orders;
Active participation in the Compliance Program which, as required by the New York Social Services Law, includes: 1) reporting suspected problems; 2) not participating in non-compliant behavior; or 3) not encouraging, directing, facilitating or permitting non-compliant behavior. And realizing disciplinary policies will be enforced;
Respecting co-workers;
Not taking photos/pictures at Hometown;
Maintaining a positive workplace attitude;
Identifying and stopping fraud, waste, and abuse;
Clean, well-groomed, and professional appearance;
Providers locking Medical Notes in a timely manner;
Not gossiping about co-workers and especially patients;
Never share your password, not even with a Supervisor;
Never contacting patients about their care on a personal cell or email;
Board Members holding one another accountable in upholding ethical and legal conduct;
Board Members must disclose to the entire Board when he or she recommends a vendor or contractor in providing a product or service and any affiliation to either;
No one dates patients. If dating a patient before hire or Board Membership, you must notify HR and your supervisor immediately. Failure to do so in either case may result in termination or removal from the Board;
Reading the monthly Compliance Newsletter and checking Hometown emails regularly;
Abiding by Hometown’s Values and Mission at all times, including when not at work (see Appendix A);
Not facetiming in a patient area or where PHI, co-worker, intern/student, or Board Member could be seen;
Coming to work on time, not leaving before your shift is over, and not taking prolonged breaks or lunch periods;
Using proper language (no cursing) at all times which includes showing courtesy to customers and co-workers including when not at work;
Focusing on work and customer needs first, never making personal calls a priority or misusing the office computer for personal use. Remember, if using a company phone or email you have no right or expectation to personal privacy;
Not looking at anyone’s patient record or information, if it is not directly related to performing your job duties at the time the access is done. No exceptions. You should not be looking at the record of a family member or significant other;
Never using social media to discuss patient matters no matter how generic and even if the patient is a friend outside the office;
Always respecting patient privacy both in and out of the office. This includes not misusing, mishandling, or engaging in unauthorized access to PHI;
Board Members respecting staff and supporting them in their work, taking the time to understand the difference between Board Governance and Operations and Management;
Realizing patient trust is key and conduct on your own time that is improper could compromise this trust and hurt Hometown’s reputation. This could result in disciplinary action for the employee. Hometown has a duty to act as an exemplary member of the community and this is defined, in part, by staff behavior. Immediately notify Human Resources of an arrest. Hometown will assess an arrest based on the facts and the magnitude of the alleged crime in conjunction with the employee handbook. If a Board Member or Staff person are arrested, it is their responsibility to report it to the CEO, Human Resources, and Compliance Officer;
Although staff may wish to participate in the democratic process by working on political or social justice campaigns, commentating, public speaking, donating to candidates, and writing blogs, books, or editorials, this may never be done on Hometown time. Nor may Hometown’s name be used, except if required to list your employer when making a campaign donation or other requirements of State or Federal law; and
Understanding the distinction of and maintaining a clear boundary with a friend or social acquaintance who is also a patient. You must always keep separate your role at Hometown and social or personal relationships. Someone you know as a friend or social acquaintance is always a patient first. HIPAA always will be strictly enforced. No exceptions.

This is not an exhaustive list. It highlights professional duties, protocols, expectations, and responsibilities.

The Standards give definition to Ethics for the benefit of staff, volunteers, Board Members, interns/students and vendors/contractors, and most important Hometown’s patients.

Hometown’s Standards are universal.

Vendors and consultants are not only expected to obey the law, but to abide by standards of ethical conduct at all times. Those who may have access to PHI will be expected to sign a Business Associate Agreement (BAA).

What Is the Difference Between Ethics, Standards of Conduct, Conflict of Interest, and the Corporate Compliance Manual?

Ethics, the Standards, Conflicts, and Compliance Manual overlap and complement one another. They have similarities and must be integrated yet have important distinctions. They also complement and further the Values of the organization.

Ethics are the values or philosophy of a person or organization. These values include fairness, honesty, and duty to share concerns or information about what goes on (transparency). Ethics is an attitude in how you live or how an organization acts.

Act fairly and honestly at all times. Approach what you do with integrity. Try to do the right thing in every situation, not just because the law may require it, but because it is the fair and honest thing to do. Ethics goes above and beyond the law.

Risk Assessments/Risk Mitigation are part of the Standards of Conduct. Departments are obligated to identify risks and mitigate them. Risk Assessments/Risk Mitigation serve patients and demonstrate Hometown is good stewards of resources to identify and stop fraud, waste, and abuse.

Standards of Conduct are detail driven. It highlights some, though not all of the issues that may arise. HHC has expectations for professionalism. In addition, it does not, as another example, bill for services it doesn’t provide. It does not up code for any service. HHC does not bill for an improperly documented service by a healthcare provider.

These are specific examples outlined in the Standards. Because every situation cannot be foreseen, it is HHC’s organizational ethics, also noted above, that should guide staff, vendors, employees, consultants, and Board Members.

Conflict of Interest falls under Standards of Conduct but is important enough to discuss separately. An issue may arise, regarding personal or family interests, involving some kind of gain, if it occurs in a manner that can harm or undermine HHC. The Standards of Conduct requires you to report actual or possible conflicts to the Corporate Ethics and Compliance Officer. Even the appearance or perception, though not an actual conflict, can be problematic. Ask the Corporate Ethics and Compliance Officer. A conflict can also arise if outside employment would be injurious in any way to the Hometown or its patients.

Corporate Compliance Manual includes the Standards of Conduct, addresses ethical values and highlights the elements of an effective compliance program as outlined by the New York State Office of Medicaid Inspector General, reflecting, in part, Federal standards.

Risk Areas as identified by New York State Social Services Law and 18 NYCRR Part 521 include, but are not limited to, billings; payments; governance; credentialing; ordered services; medical necessity; mandatory reporting; quality of care; contractor, subcontractor, agent/independent contract oversight; and other risk areas.

Furthermore, the following shall be followed:

Customer service and the highest professional standards for patients

HHC is committed to providing its customers with the highest quality care and excellent service.

These high standards must apply to interactions with everyone with whom HHC representatives interact. This is achieved in several ways including an overall ethics and compliance program and its quality assurance initiatives.

Everyone must remember on a daily basis that patients, though they can be difficult at times, are not an inconvenience to our workday. They are customers who are the reason for the workday. Put yourself in the shoes of a patient and think how you would want to be treated.

Professional standards also demand that patients come first. Patients can be emotionally vulnerable. Hence, it is inappropriate and grounds for immediate termination to date a patient after you start employment at Hometown. If you are dating a patient before starting work at Hometown, you must notify Human Resources and your supervisor at once.

Confidentiality

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) must be followed at all times. It provides safeguards for patient privacy. It is an extremely important means to ensure consumer confidentiality.

HIPAA is always enforced even if a patient is a friend, neighbor, social acquaintance, or relative by blood, marriage, or adoption. Anyone seeking care or treatment at Hometown is always a patient first. No exceptions.

Avoidable HIPAA Breaches include, but are not limited to:

Not gossiping within Hometown or at the family dinner table about a patient’s condition.
NEVER use white out on a document like a records release form. You have two options: start over or cross out and initial.
Do not “friend” patients on Social Media. Never respond to criticism.
If a celebrity (local or otherwise) or co-worker is a patient, you still need written authorization and must follow standard office protocol. If you have a relative who is a patient, you still need written authorization, and you must still follow standard office protocol.
Never text a patient, even to confirm an appointment, from a personal cell phone, or personal email.
Do not share anything that happens here at the dinner table, especially if it is about a relative, neighbor, acquaintance, or local celebrity.
Do not look in a friend, neighbor, co-worker, acquaintance, or partner/family member’s patient record. You risk being terminated.
If a provider asks you to send a letter on their behalf, do not sign their name. You may send a letter on their behalf and sign your name. You may draft a letter for them to sign. You may, if the provider gives clear permission it is OK, sign their name so long as you place a “/” at the end and your initials notifying the world it is signed on the provider’s behalf.
Never sign a patient’s name.
Use a locked HIPAA bin to dispose of PHI, not a recycling bin.
Never use scrap paper with PHI.
Transferring PHI by eCW is always the safest, preferred approach. If you must fax, double check the number before hitting send.
Double check what you are handing or mailing to a patient. Is it the right PHI?
Never let an outside vendor into a secure area without telling IT.
Failing to provide patient information when requested in a timely manner is a HIPAA breach.
Report all HIPAA breaches to the Compliance Officer or HIPAA Officer immediately.
Never mail a letter with PHI on the label. Sometimes labels can be printed with DOB, insurance number, etc. Look before mailing.
If you write something on an envelope intended for patient pick-up at the front desk, but then decide to mail the information instead, address a new envelope.

It is vital all staff be on alert for phishing, ransomware, and other potential cybersecurity breaches. Pay attention to all directives from IT.

All personnel will keep patient information, even appointments, in the strictest of confidence. Information will not be disclosed to anyone unless authorized by the patient or otherwise permitted by law. Because you may know someone well and they ask does not legally permit you to access someone’s Protected Health Information. Nor should you discuss something like a patient’s appointment with a significant other, family member or friend.

Confidential information acquired by personnel about the business of HHC must also be held in confidence and may not be used as a basis for personal gain by personnel, their families, or others. Confidential information includes, but is not limited to customer lists, development plans, and information about pending or contemplated business deals.

Never post information related to your job or patients (even if not named) on social media. Although it may not be your intent, you can innocently violate a patient’s privacy, or the confidentiality required by HHC to be an effective organization.

Information relating to something about to happen with HHC is not to be released to any person unless this information has been published or otherwise made available to the public. Similarly, if HHC is considering buying, leasing, or selling any property, item, or interest, HHC employees and affiliates who are knowledgeable of it must not attempt to buy, lease, or sell for their own benefit or that of their family the item under consideration, until HHC’s decision on the matter has been executed. Finally, other than in connection with the personnel’s discharge of their official responsibilities with HHC, all personnel must also refrain from disclosing information that may be prejudicial to the interest of HHC.

In protecting patient privacy talk with your supervisor, the Corporate Ethics and Compliance Officer, or refer to the many online resources to help answer questions. Do not take pictures because it may be a privacy breach. Be proactive in safeguarding patient privacy. Tell patients they cannot take photos on Hometown property. For further information on Confidentiality and privacy of patient information, please consult the HHS Office for Civil Rights HIPAA FAQ.

HIPAA Breach Reporting

HIPAA is privacy, security, and timely, efficient patient access to their records.

If there is a privacy or security breach and depending on the size and nature of the breach, notifications shall be made to some or all the following:

Patient(s)
Local Media Outlets
NYS Attorney General
NYS Department of Health
NYS Division of State Police
NYS Department of State’s Division of Consumer Protection
Health and Human Services (HHS) – Office of Civil Rights (OCR)

Risk Assessments

It is mandatory departments do audits and self-initiated Risk Assessments on an ongoing basis. Assessments help identify opportunities for improvement ranging from better customer service to improved quality of care, to ensuring HHC is a good steward of the resources provided to it.

Risk Assessments along with work plans developed and implemented to address any shortcomings identified must be shared with the Corporate Ethics and Compliance Officer. It is critical that HHC show a good faith effort during its annual certification with the New York State Office of Medicaid Inspector that it is proactive in its audits and Risk Assessments.

It is the responsibility of Managers, Supervisors and Department Heads to identify areas for improvement and act on them on an ongoing basis.

The Board of Directors has underscored the importance of Assessments and will monitor them. Raises and promotions may be contingent on them.

Persons directly involved with risk management and quality assurance must keep the Corporate Ethics and Compliance Officer apprised in a timely manner of any matters that may compromise the organization or patient care.

Serving families and individuals regardless of their ability to pay

In 2014, HHC began operating a second federally qualified health center (FQHC). It is committed, as reflected in its mission statement, to provide quality, progressive, comprehensive, and cost-effective care to its customers with a focus on low-income residents in the area. It provides these services using a fee schedule approved by the Board of Directors, which may include a sliding fee program.

Transparency, best practices, and quality improvement initiatives

Openness (transparency) about its operations through information sharing is vital to HHC’s mission and ethical culture. Information sharing of detailed and accurate information with staff and especially with the Board of Directors by senior management empowers everyone at HHC to promote quality care, customer satisfaction, an ethical culture, and good stewardship of resources.

Transparency helps identify areas for improvement while fostering a culture of best practices in finance, administration, and patient care. Remember, patients, like you, are consumers and deserve respect, courtesy, and our best efforts to help solve their problems.

Distinguishing a legal right to do things and doing what is right or ethical at all times

Part of HHC’s culture is to go above and beyond what is required by state and federal law. It attempts to promote an environment when doing the right thing and always trying to do better is second nature. There does not have to be a law or policy on a specific matter to act with truth, fairness, and honesty. Act with integrity at all times.

Meeting all legal and ethical requirements, obligating vendors, contractors and consultants to do so as well

It is HHC’s expectation that everyone must adhere both to the spirit and the language of the Standards of Conduct.

Strictly following these standards is a condition of employment, serving on its Board, or doing business with HHC. Any violation or perceived violation will be investigated, and corrective action taken.

Reporting and Complaint Procedures

All staff, vendors, contractors, consultants, and Board Members have an obligation to report wrongdoing. Everyone should raise questions they have about potentially unethical or illegal conduct with the Corporate Ethics and Compliance Officer.

Call the Corporate Ethics and Compliance Officer directly: Ext. 4195,
Call the 24/7 Hotline: *67-518-688-3460, or
Leave an anonymous message in a locked Compliance Box in the Amsterdam or Schenectady facility.

Staff must follow the directives in the Standards of Conduct and work to ensure those standards are followed. All departments, personnel and Board Members must cooperate as appropriate with inquiries concerning possible improper business, documentation, coding or billing practices, respond to any reviews or inquiries, and actively work to correct improper practices that are identified.

If employees have a general question about the propriety of conduct, they should still reach out to the Corporate Ethics and Compliance Officer for guidance. When in doubt, say something.

It is preferred that questions about a potentially troublesome issue be raised before the issue becomes an actual problem.

A report or question may be raised anonymously or confidentially. If concerns are raised in person or by email, such information will be held in the strictest confidence, consistent with the need to investigate any allegations of wrongdoing. A 24/7 Hotline may be used (*67-518-688-3460) or Locked Compliance Box in Amsterdam or Schenectady.

To the extent possible, the Corporate Ethics and Compliance Officer will not disclose the identity of anyone who reports a suspected violation of law or who participates in an investigation.

The Corporate Ethics and Compliance Officer and any legal counsel he or she may consult are obligated to act in accordance with the law, policies, and regulations.

Ethics and Compliance Officer

Paul P. Jesep is HHC’s Chief Ethics and Compliance Officer (Ext. 4195) and HIPAA Privacy Officer. He is responsible for overseeing the daily compliance activities of the program. Paul is the “point person” to whom all employees, contractors, and Board Members can contact to express concerns about compliance matters. Anyone affiliated with Hometown is expected to be engaged in the Compliance Program and help identify and fight fraud, waste, and abuse.

The Corporate Ethics and Compliance Officer is appointed by the CEO in consultation with the Board Chair and shall report to the CEO and Board of Directors.

Investigation by the Corporate Ethics and Compliance Officer

Upon receiving a report of possible unethical or illegal conduct, or of a pattern of possible improper billing, the Corporate Ethics and Compliance Officer will investigate the report and take all necessary and appropriate actions. The Board Compliance Committee will be notified.

The objective of the investigation is to determine whether, first, a compliance issue exists or there has been a violation of the Standards of Conduct or applicable legal rules.

Your information will be kept confidential. If an issue or violation does exist, then the investigation will attempt to determine its cause, so appropriate and effective corrective action can be instituted.

Vendors, employees, and Board Members must cooperate with any such investigations.

Corrective Action and Responses to Suspected Violations

Whenever a compliance problem or billing error is uncovered, regardless of the source, the Corporate Ethics and Compliance Officer will ensure that appropriate and effective corrective action must be implemented by the Billing Manager. Any corrective action and response implemented must be designed to ensure that the violation or problem does not re-occur (or reduce the likelihood that it will reoccur).

Corrective actions are based on an analysis of the root cause of the problem.

A corrective action plan includes a follow-up review of the effectiveness of the corrective action following implementation.

Remedial education both formal and informal is also a part of the corrective action plan.

Bullying and Harassment

Bullying and harassment is not tolerated and may lead to immediate dismissal. Bullying and harassment (sexual or otherwise) includes, but is not limited to: inappropriate contact, lewd jokes, emotional abuse by undermining a coworker’s performance, character abuse like lying and gossiping about a colleague, and professional abuse such as repeatedly finding fault and failing to respect the personhood and basic dignity of another.

EEOC Policy

Hometown and its vendors/contractors and their agents, employees, representatives, subcontractors, sub-contractors, or corporate or business affiliates (domestic or foreign) providing a service to Hometown shall not deny employment, services or harass or discriminate against a Hometown patient or employee based on their age, sex, race, creed, color, disability, marital status, military status, national origin, familial status, sexual orientation, gender identity or expression, predisposing genetic characteristics, status as a victim of domestic violence, sexual and reproductive health decisions, arrest record or conviction record, or sincerely held religious practice. Any such harassment or discrimination will, at Hometown’s sole discretion, result in an immediate termination of this Agreement without any financial consequences to Hometown to complete this contract.

General Business Practices

HHC will forego any business transaction or opportunity that can only be obtained by improper or illegal means and will not make any unethical or illegal payments to anyone to induce the use of its services. Business transactions and joint ventures with other health care providers will be aimed at enhancing the quality or continuity of care provided to patients.

Financial investments in such transactions and ventures, and any return on investments, will be based on the bona fide financial value of the investment and its positive impact on HHC’s ability to deliver medical services. Such investments will not be based on intent to induce or reward referrals to or from another provider.

In the course of HHC’s business practices, personnel must deal with a variety of individuals, companies, organizations, and governmental agencies. In those dealings, all personnel must never make any misrepresentations, dishonest statements, or statements intended to mislead or misinform. If it appears that anything you have said has been misunderstood, it is your responsibility to correct it promptly.

In addition, management must ensure that all business records are accurate and truthful, with no material omissions including that the assets and liabilities of HHC are accounted for in full compliance with all tax and financial reporting requirements, and that no false records are made. Similarly, all reports submitted to governmental agencies, insurance carriers, or other entities will be accurately and honestly made.

Purchasing and Competitive Bidding Policy

All purchasing decisions whether for a product or service must be made with the purpose of obtaining the highest quality product or service for HHC or its patients at the most reasonable price. No purchasing decision may be made based on any consideration that any employee, officer, or trustee – or any family member or friend of any of them – will benefit by the transaction.

Rather, the sole criteria behind all purchasing decisions must be only the best interests of HHC. Nor can any service or item be purchased in return for a referral of patients from another or with a view towards inducing another to refer patients (see also the rules governing Marketing Activities and Patient Referrals set forth below).

The institutional cost report will be prepared in accordance with all applicable state and federal regulations. Costs will be claimed when based on appropriate and accurate documentation; unallowable costs will not be claimed for reimbursement; and all costs will be properly allocated to the appropriate cost centers based on verifiable information and data.

Contractors

All persons and entities with which HHC contracts will be asked to cooperate with HHC’s Compliance program. This includes individual physicians, physician groups, vendors, contractors, and other healthcare providers.

Vendors/Contractors shall be vetted, in part, by using State and Federal Exclusion Lists.

Honest and Lawful Conduct In and Out of the Office

HHC does not tolerate any form of unlawful or unethical behavior by anyone associated with it – staff, vendors, or individuals who serve on the Board of Directors. It expects and requires everyone to be law abiding, honest, trustworthy, and fair in personal and professional dealings. To ensure that these expectations are met, the compliance program has become an integral part of the corporate mission and business operations.

HHC expects ethical and appropriate behavior not only at the worksite, but also outside the office. Patients expect that those who provide care and have access to sensitive Protected Health Information (PHI) are ethical and law abiding at all times. Hence, vendors, employees, and Board Members always must be conscious of their actions. This includes the perception by patients of outside, potentially inappropriate behavior.

Discipline

All personnel and Board Members are expected to adhere to the Standards of Conduct. If the Corporate Ethics and Compliance Officer concludes, after an investigation, that the Standards has been violated, then appropriate discipline, including discharge or termination of employment contracts may be imposed.

The imposition of discipline can be based on the person’s unlawful or unethical actions, condoning or failing to report unlawful actions by others, retaliation against those who report suspected wrongdoing, or other violations of the Standards of Conduct.

In recommending discipline of a manager, supervisor, department director, physician or mid-level provider, the Corporate Ethics and Compliance Officer will do so to the CEO or, in the Officer’s discretion, the Board of Directors.

In recommending discipline of a non-physician employee, the Corporate Ethics and Compliance Officer will refer the matter to the appropriate staff and the employee’s supervisor for disciplinary action.

A manager, supervisor, or department director, in coordination with Human Resources, may initiate his or her own investigation, independent of the Ethics and Compliance Officer, regarding personnel issues and take appropriate action which includes possible suspension or termination in accordance with policies or binding contracts.

Educating and re-educating anyone affiliated with HHC about Conflicts of Interest

Educating new employees and re-educating all employees and Board members will be done on an ongoing basis.

All members of HHC’s Board of Directors and personnel who are in a position to influence any substantive business decision by HHC will, at least annually, file a Conflict of Interest Disclosure Statement with the Corporate Ethics and Compliance Officer. This shall include all Members of Senior Management.

In addition, all Board of Directors and personnel must also immediately disclose to the Corporate Ethics and Compliance Officer any possible conflicts of interests as they arise. The Compliance Officer shall give his/her Annual Conflict of Interest Disclosure Statement to the Chief Executive Officer and Chief of Human Resources.

Use of HHC’s assets for personal gains is not permitted.

Conflict of Interest Rules

The relationship between HHC and all of its personnel and Members of the Board of Directors is one that carries with it a duty of honesty. All personnel and Members of the Board of Directors must exercise good faith in all transactions that touch upon their duties and responsibilities for, or on behalf of, HHC. Even the appearance of illegality, impropriety, or conflict of interest or duality of interest can be detrimental to HHC, and therefore must be avoided.

All members of the Board of Directors and all HHC personnel who are in a position to influence any purchasing decision or business transaction, as determined by the Compliance Officer, must complete an annual conflict of interest form in which they are required to disclose all direct and familial business interests which may or does compete with HHC.

In addition, all personnel and Members of the Board of Directors must examine their own and their immediate family’s activities, and promptly report to the Compliance Officer the existence of any enterprises in which either they or their immediate family has an “interest,” and which the person knows is engaged, or is reasonably likely to engage, in transactions with HHC. A person’s immediate family includes his or her spouse, partner, siblings, children, grandchildren, parents, grandparents, parents-in-law, adoptive parents, or adopted children.

A person is deemed to have an “interest” in an enterprise when he or she, or a member of his or her immediate family, is an employee, member, owner, director, or officer of – or has financial interest in – an enterprise; from which HHC purchases or leases equipment, services, or supplies, or that provides services that compete with HHC; with which HHC negotiates real estate transactions (such as the leasing of space), and which either benefits from the real estate transaction or competes with HHC in the leasing or purchase of real estate; or which renders directive, managerial, or consulting services to any organization that does business with, or competes with, HHC in providing services.

If the financial interest is the ownership of securities which are publicly traded, such interest does not have to be disclosed, unless the combined holdings of the securities of both the person and his or her immediate family constitute 5% or more of the outstanding securities of the entity concerned.

All personnel who have an interest in an enterprise, as outlined above, must disclose their interest in writing to the Corporate Ethics and Compliance Officer; take no part in the consideration or determination of the matter on the part of HHC; and to the extent reasonable given the circumstances, should take no part in, and should have no financial participation in, the transaction between the enterprise and HHC. If HHC is considering engaging in a transaction with an enterprise in which personnel have an interest, that interest must first be brought to the attention of the Corporate Ethics and Compliance Officer, who will then consult with counsel to review the matter. A recommendation will then be made about the propriety of the transaction.

Compliance Committee of the Board of Directors (BOD)

The Board of Directors has overall responsibility, through the CEO and Compliance Officer, for ensuring that HHC conducts its activities with the highest integrity and complies with the law. A Compliance Committee of the Board of Directors was developed to oversee the compliance program. This Committee is distinct from the Internal Staff Compliance Committee.

Gifts and Payments

No personnel will engage, either directly or indirectly, in any corrupt business practice, including bribery, kickbacks, or payoffs, intended to influence or reward favorable decisions of any vendor, patient, physician, government representative, contractor, vendor, or any other person in a position to benefit HHC or the employee or family member in any way.

No employee will make or offer to make any payment or provide any other thing of value to another person with the understanding or intention that such payment is to be used for an unlawful or improper purpose.

Personnel may accept items of very nominal value (e.g. pens, mugs, or calendars used for marketing gimmicks). No gift, no matter how nominal, may be accepted if given for the purpose of influencing the business behavior of the recipient. Cash gifts to physicians or other referral sources are strictly prohibited.

Gifts of even nominal value may not be offered to any governmental official. Such gifts can be misinterpreted as an attempt to improperly influence the official and are to be avoided.

It is prohibited for any personnel to accept gifts, gratuities, loans, or other favors from any patient, client, vendor, contractor, individual or concern that does (or is seeking to do) business with, or is a competitor of, HHC under circumstances from which it could be inferred that the personnel’s action was for their own benefit, and not solely for the benefit of HHC. This does not preclude the acceptance of items of nominal value that are clearly tokens of friendship or business hospitality.

Any questions regarding whether or not an item or situation falls within the scope of the Standards of Conduct must be raised immediately with the Corporate Ethics and Compliance Officer, who, in conjunction with legal counsel, will assess the propriety of the particular situation.

Patient Referrals/Patient Choice

HHC does not pay physicians, or anyone else, either directly or indirectly, for patient referrals. The decision to refer patients is a separate and independent clinical decision made by the referring physician or health care provider. He or she must not benefit from such a referral. Federal and state law makes it unlawful to pay any individual on the basis of the value or volume of referral of patients. This includes the giving of any form of remuneration, including virtually anything of value, in return for referral.

Other Conflicts

If HHC is considering buying, leasing, or selling any property, item, or interest, HHC employees and affiliates who are knowledgeable of it must not attempt to buy, lease, or sell for their own benefit or that of their family the item under consideration, until HHC’s decision on the matter has been executed. One possible exception is when senior management determines to sell old, outdated equipment at a fair market value to staff.

Finally, other than in connection with the personnel’s discharge of their official responsibilities with HHC, all personnel must also refrain from disclosing information about any HHC consideration or decision, or any other information which might be prejudicial to the interest of HHC.

The governing principle about confidential information is that if personnel receive any confidential information pertaining to HHC, they must not use such information for their own or their family’s benefit, nor should they disclose it to others for their personal use.

Any questions regarding whether an item or situation falls within the scope of this section must be immediately raised with the Corporate Ethics and Compliance Officer who will assess the particular situation.

Departmental Compliance Protocols

In addition to the Standards of Conduct and Compliance Procedures set forth in this Manual, many of HHC’s departments have department-specific compliance policies, procedures, and protocols. These additional policies, procedures, and protocols are an integral part of the Compliance Program and are designed to complement the procedures and standards set forth in this Manual.

Marketing services honestly and accurately

HHC’s best advertisement is in the quality of medical services it provides.

HHC relies on the quality of its care and customer service to market services to patients, physicians, and other health care providers who might refer patients. All marketing activities and advertising by personnel must be truthful and not misleading and must be supported by evidence to substantiate any claims made.

No personnel may disparage HHC, or the service or business of another competitor, through the use of false or misleading representations.

In addition, only those persons designated by the CEO may market and communicate with the media, public, trade associations, and government officials on behalf of the organization.

Only senior management may designate personnel to solicit appropriate grant funding.

Being good stewards of all fiscal and administrative resources

HHC has a legal and ethical responsibility to use fiscal and administrative gifts and grants wisely and for their intended purposes. Otherwise, it risks engaging in waste, fraud and abuse, which is against the law and contrary to the philosophy of HHC. HHC must be good stewards of all resources while assuring and placing paramount importance that the organization’s assets must never be used for personal gain.

According to the US Department of Health and Human Services – Health Resources and Services Administration (HRSA):

Fraud is the “deliberate deception to secure an unfair gain.”
Waste is the “unnecessary incurring of costs as a result of inefficient practices, systems or controls.”
Abuse is the “intentional misuse of authority, position, funds, or resources for personal financial interests.”

Source: HRSA Program Integrity Webcast on Fraud, Waste, and Abuse, http://78449.choruscall.com/hrsa/hrsa120717.pdf.

Billing

Billing is a major component of the Corporate Compliance Program. It is HHC’s policy to bill only for the actual services rendered, and only when those services are consistent with accepted standards of medical care.

Billing procedures must always be based on adequate documentation of the medical justification for the service provided and for the bill submitted.

In addition, this medical documentation must comply with all applicable regulations.

It is also strict HHC policy that no “default” or “generic” code be applied for a specific service. Services must be properly documented, and the appropriate code must be identified. No bill should be submitted for reimbursement without proper coding.

While the use of defaults or billing on the basis of unclear documentation can sometimes result in under-billing, these practices can also result in over-billing on other occasions. Do not use them. Occasionally, HHC may need to bill unlisted procedure codes based on insurance guidelines. This should not be construed as “default” or “generic coding.”

No individual associated with HHC may knowingly or carelessly engage in any form of upcoding or under coding of any services in violation of law, rule, or regulation. No one may ever misrepresent charges to, or on behalf of, a patient or third-party payor. Coding for services rendered are performed by dentists, physicians, mid-levels, and behavioral health professionals at HHC. In conformity with HHC’s basic mission and values, only those medical services to patients that are consistent with acceptable standards of medical care may be administered.

In this regard, HHC’s billing procedures must always be based on adequate documentation of the medical justification for the service provided and for the bill submitted, and this medical documentation must comport with all applicable regulations. In addition, all documentation, regardless of any legal requirements, must also be sufficient to satisfy HHC’s own internal standards for quality assurance as to the actual services rendered.

In addition, Current Procedural Terminology (CPTs), International Classification of Diseases (ICDs), Healthcare Common Procedure Coding System (HCPCS) should never be selected on the basis of whether the given code guarantees or enhances payment; rather, only those codes that correspond to the service rendered and documented should be selected. The service only will be billed when the responsible medical personnel provide sufficient documentation.

All federal and state regulations governing billing procedures will be meticulously followed and HHC personnel responsible for coding and billing will be trained in the appropriate rules governing billing, coding, and documentation.

Whenever HHC has learned or knows that it has received payments for which it was not entitled from a government or private payor, the payments will be refunded to the appropriate payor as soon as possible.

All billing must be accurate and truthful; and no personnel should ever misrepresent charges to, or on behalf of, a patient or third-party payor. Making false statements or intentional omissions of material information by any personnel to a government agency or other payor is unacceptable.

Deliberate misstatements to government agencies or other payors will likely cause an individual’s termination and may result in potential criminal penalties.

It is also illegal to supply false information with either a deliberate ignorance or a reckless disregard of its falsity or truth. Thus, if you have any question as to the truth or accuracy of the documentation for billing purposes, or if there is material information that is missing, the bill for the services in question must be held until the uncertainties are resolved. Anything less can result in over billing and is strictly prohibited.

Billing Rules for Clinical Laboratory and Other Diagnostic Testing

HHC performs laboratory tests and diagnostic procedures. As a result, a separate and detailed set of protocols and standards of conduct and compliance procedures specific for laboratory and other diagnostic testing has been developed. It is critical staff be aware and follow them. Documentation, medical justification, correct billing practices and quality assurance apply.

Bill Only for Tests Actually Ordered and Conducted

HHC will bill only for tests that were ordered by a Provider and actually conducted. If a test is ordered, but is not performed for any reason, then no bill for the test may be submitted to any third-party payor. Tests should be performed only when there is a clear order from the patient’s Provider and there is reason to believe that the test is medically necessary.

Medical Necessity for Tests

Although it is ultimately the ordering dentists, mid-levels and Provider’s responsibility to determine whether a test is medically necessary, claims should never be submitted to Medicare or Medicaid (or any other federally funded health care program), if an employee believes the test was medically unnecessary. All HHC ordering procedures – from requisition design to our interactions with the ordering Providers – must be designed to encourage ordering providers to order only medically necessary tests for which reimbursement will be sought from the government.

Diagnostic Codes

The best way that the medical necessity for a given test can be clearly demonstrated is to ensure that the appropriate International Classification of Diseases (ICD)-10 diagnosis code is included on the claim form that is submitted to the government. The ICD codes assigned must be accurate and as specific as possible, based on the information available to the physician ordering the test, based on the patient’s actual condition, and based on information that is otherwise in the patient’s chart.

Only diagnostic information obtained from the provider who ordered or interpreted the test should be placed on any claim/billing form. If the diagnosis is unclear or has not been provided, technical or billing personnel must contact the ordering provider to obtain the necessary information and cannot create diagnostic information based on their own interaction with the customer, from information provided from an earlier date of service, or based on what appears to be the probable or most likely diagnosis.

When an encounter form is submitted with inadequate diagnostic information, HHC will not submit a bill until the appropriate information has been obtained.

Relationships with Physicians and Other Providers

All contracts, leases, and other financial relationships with providers (and with any other medical provider who has a referral relationship with HHC) will be based on the fair market value of the services or items being provided or exchanged, and not on the basis of the volume or value of referrals of Medicare or Medicaid business between the parties. Nor will free services or items be accepted or provided in return for referrals.

Thus, for instance, HHC will not provide excessive payments for medical directorships; free services to physicians who otherwise have a financial relationship with HHC; free or below market rents or fees for administrative services; interest-free loans; or excessive payment for intangible assets in a physician practice acquisition. Similarly, all recruiting arrangements with physicians will not require the physician to refer patients to HHC or compensate the physician, directly or indirectly, for the volume or value of referrals generated by the physician.

All contracts, leases, and other financial relationships with providers with whom HHC has a referral relationship will be reviewed to ensure compliance with the federal and state Anti-Kickback and Stark Laws, and compliance with any applicable Safe Harbor or exception under those laws.

All personnel must strive to avoid even the appearance of impropriety and must never act in a dishonest or misleading manner when dealing with others, both within and outside HHC.

As noted earlier, Providers are required to read and understand before starting employment A Road Map for New Physicians: Avoiding Medicare and Medicaid Fraud and Abuse, issued by the US Department of Health and Human Services – Office of Inspector General. See the OIG physician education Road Map. This “Road Map” and any updated versions must be followed at all times. Once they have started employment they have affirmed they read and understood this publication.

340B Pharmacy Program

HHC’s mission to serve its patients includes participation in the federal 340B Pharmacy Program. The Program, overseen by Finance, is a safety-net to complement medical services for those in need of assistance. It provides individuals an option to purchase needed medications at significant discounts.

HHC has a separate set of policies and protocols to ensure program integrity.

As outlined in the Federal Register/Vol.75, No.43, March 5, 2010: “use of a contract pharmacy arrangement … does not lessen [Hometown’s] duty to ensure that the 340B program is being administered in compliance with the statute and HRSA guidelines. [Hometown] has, and continues to bear, full responsibility and accountability for compliance with all requirements to prevent diversion of covered drugs …”

Grants

HHC receives grants from government agencies, private industry, and various philanthropies. Grants must be subject to adequate safeguards to ensure that an appearance of impropriety, or actual impropriety, is not created. HHC must always be a good steward of any resources.

The receipt and use of all grant money must be pre-approved by senior management. As part of this pre-approval process, the appropriateness of the proposed project will be reviewed, and a system of tracking the use and allocation of the grant money will be put into place. This system will ensure money is used in conformity with the requirements of the grant and in a manner consistent with HHC policies, the needs of patient-consumers, and the scope of an individual’s employment with HHC.

The receipt, or continued receipt, of the grant money must occur under conditions which do not create an appearance that the judgment of HHC personnel will be adversely affected, so as to place their own interest, or that of an outside concern, above that of HHC and its patients.

Grant money should not be accepted in return for the promise or expectation that HHC or anyone affiliated with it will purchase specific services or supplies from a particular company. HHC does not accept compensation in any form as an inducement to purchase products or services. Even the appearance that a grant is accepted for the purpose to purchase a specific service or product must be avoided.

If a grant is provided in order to test, develop, or use equipment or supplies from a particular manufacturer or supplier, the terms and conditions of that grant will be subjected to close scrutiny during the pre-approval process.

Any subsequent purchase of such equipment or supplies must also be subjected to close review to ensure the judgment of HHC personnel involved with the grant has not been compromised and the purchase is otherwise in the best interest of HHC and its patients. In such instances, those personnel directly involved in the receipt and use of the grant money will take no part in the final determination as to the proposed purchase.

Urging vendors, patients, employees, volunteers, and Board Members to report illegal or unethical conduct

Responsibility of Employees and Board Members

Vendors, interns, students, employees, Board Members, and Business Associates are expected to comply and be familiar with all federal and state laws, rules, and regulations that govern their job within HHC. They are also expected to comply with the standards set forth in the Standards of Conduct and with any applicable departmental compliance protocols. Strict compliance with these legal and compliance standards is a condition of employment, Board Membership, and doing business with Hometown. Violation of any of these standards of conduct may result in removal from the Board, contract termination, or termination from employment.

Board Directors, as Members of the Governing Body of Hometown, have an especially important role in setting a standard of conduct. The Values, Policies, and Standards of Conduct apply to Board Members. They should be examples of exemplary behavior while serving an organization dealing with life and death issues. This includes but is not limited to dating staff and attempting to leverage their Board position for direct or indirect financial benefit, including contracts, consulting, or employment at Hometown for themselves or family members. Nor may they secure a benefit for an employer or a colleague with a shared employer. Hometown is an all-volunteer Board and those who serve on it are expected to do so because he or she believes in public service and puts the best interests of the community above self-interest.

Responsibilities of Department Heads, Supervisors and Managers

All department heads, supervisors and managers have the responsibility to help create and maintain a work environment in which ethical concerns can be raised and openly discussed. They are also responsible to ensure that the personnel they supervise understand the importance of the Standards of Conduct and the compliance program; that these personnel are aware of its provisions and of the procedures for reporting suspected unlawful activity; and that all personnel are protected from retaliation if they come forward with information about suspected wrongdoing.

Government Inquiries

While personnel may speak voluntarily with government agents, it is recommended that, before doing so, they contact their supervisors and the Corporate Ethics and Compliance Officer first. In no event, however, may any personnel respond to a request to disclose HHC documents or privileged information without first speaking with their supervisor.

As a general matter, any personnel who receive a governmental request for information, a subpoena, or any other inquiry or legal document regarding HHC’s business should notify his or her supervisor before attempting to make a reply. The supervisor should then contact the Corporate Ethics and Compliance Officer, who will notify legal counsel if necessary.

If a response is given to a request for information from the government regulatory agencies, the response must be accurate and complete. It is HHC’s policy to comply with the law and to cooperate with reasonable demands made during the course of a legitimate governmental investigation or inquiry.

Boxes and Corporate Compliance Hotline

Locked compliance boxes are available at the Schenectady and Amsterdam centers and a 24/7 reporting hotline (*67-518-688-3460) are among the ways those working for or affiliated with HHC can anonymously report a compliance concern. They have been established to raise questions directly with the Corporate Ethics and Compliance Officer and to report possible violations, ask questions or raise compliance concerns.

Only the Corporate Ethics and Compliance Officer has access to both the hotline and locked boxes.

The internal extension for the Corporate Ethics and Compliance Officer is 4195.

Protecting anyone from retaliation when reporting wrongful conduct or afterwards

Retaliation in any form against an individual who in good faith reports or plans to report possible illegal or unethical conduct is strictly prohibited and is itself a serious violation of the Standards and State and Federal law.

It is against the law for anyone to harass or retaliate against you for being proactive and reporting a potential problem. It is also illegal to discourage anyone from reporting a compliance concern. Acts of retaliation against employees should be reported to the Corporate Ethics and Compliance Officer immediately.

Appendix A – Mission and Values

“Hometown Health Centers helps people live healthier lives by improving health outcomes and health equity through quality primary care and preventative services. Anyone seeking care, regardless of income, will be helped and treated with respect by people who are mindful of cultural uniqueness and dedicated to continuous improvement.”