Code of Conduct
Throughout the community we serve, RMCHCS strives to provide exceptional care. RMCHCS' reputation is important and the RMCHCS' goal is integrity, honesty and doing the right thing.RMCHCS' Code of Conduct provides an overview of our commitment to high ethical standards and outlines expectations that are intended to help us make the right choices and do the right thing. This document is meant to be a summary of our policies and practices and intended to reinforce the spirit of our dedication to integrity, performance, innovation and to people.
MY COMMITMENT TO RMCHCS
My Responsibilities
Every employee, provider, volunteer and contractor has the responsibility to read the commitment to principles and live by its values.I am responsible for upholding RMCHCS' values in my everyday work -- speaking up when I have a question or concern and reporting conduct that is inconsistent with those values. In addition to the values-based commitments in the Code of Conduct, RMCHCS' policies and procedures provide additional guidance. I have a responsibility to be aware of and follow the policies and procedures related to my job. If I need assistance finding a specific policy, I can contact my manager, human resources, or the compliance department for assistance.
RMCHCS' Fundamental Commitment
TO OUR PATIENTS: We are committed to providing quality care that is sensitive, compassionate, promptly delivered and cost-effective. We treat all patients with respect, compassion and dignity.TO OUR RMCHCS COLLEAGUES: We are committed to a culture which treats all colleagues with fairness, dignity and respect and affords them an opportunity to grow, develop professionally and to work in a team environment in which all ideas are considered.
TO OUR PROVIDERS: We are committed to providing a work environment, which has excellent facilities, modern equipment and outstanding professional support.
TO OUR THIRD-PARTY PAYERS: We are committed to our contractual obligations and share the concern for quality healthcare and bringing efficiency and cost effectiveness to healthcare.
TO OUR REGULATORS: We are committed to an environment in which compliance with rules, regulations and sound business practices is woven into our corporate culture. We accept the responsibility to aggressively self-govern and monitor compliance with the requirements of law and to the Commitment to Principles.
TO THE COMMUNITY WE SERVE: We are committed to understanding the particular needs of the community we serve and providing our community with quality, cost-effective healthcare. We realize as an organization that we have a responsibility to help those in need. We proudly support charitable contributions and events in an effort to promote good will and promote healthy lifestyle for our community.
TO OUR SUPPLIERS/CONTRACTORS: We are committed to fair competition among prospective suppliers and the sense of responsibility required of a good customer.
TO OUR VOLUNTEERS: The concept of voluntary assistance to the needs of patients and their families, as well as to our RMCHCS colleagues, is an integral part of the culture of RMCHCS. We are committed to ensuring that our volunteers feel a sense of pride in their volunteer work and receive recognition for their volunteer efforts.
PRINCIPLE 1: Quality of Care
As a RMCHCS employee, I am committed to delivering quality care, services and products to our patients in a compassionate, respectful and efficient manner. At RMCHCS, I treat everyone with respect and dignity. I will not compromise quality.RMCHCS is committed to delivering the highest quality of patient care without regard to race, color, religion, gender, national origin, age, disability, sexual orientation, payer source or ability to pay.
Patient Rights
Improved patient outcomes and high standards of medical ethics are maintained by respecting the rights of each patient. RMCHCS provides each patient with information regarding his or her rights and responsibilities at the time care is initiated and endeavors to protect those rights while rendering care and treatment. In addition, the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy regulations created new rights for patients concerning their own health information.
Specifically, the Privacy Regulations grant patients a number of rights over their health information. These new rights include: (1) the right to receive a Notice of Privacy Practices; (2) the right to inspect and obtain a copy of their own health information; (3) the right to request amendments to their health information; (4) the right to request an accounting of disclosures and (5) the right to file a privacy complaint. I accept the responsibility to familiarize myself with RMCHCS' privacy policies.
Confidentiality and Privacy
As a RMCHCS employee, I am required to protect all patients' personal information. Written, verbal and electronic health information is protected by law from unlawful access, use, disclosure, loss, tampering, alteration or destruction. Use and disclosure of a patient's health information is limited to the "minimum amount necessary" to accomplish the intended purpose. Unless authorized by federal or New Mexico law, the disclosure of patient information requires a patient, or the patient's representative, to sign a written Authorization for the Use or Disclosure of Protected Health Information (PHI) for purposes other than treatment, payment of that treatment or healthcare operations. HIPAA Privacy Regulations require safeguards for appropriate access, use and disclosure of PHI to protect patient privacy. Additionally, new security regulations also require protection for the electronic security of medical information.
Emergency Medical Treatment and Active Labor Act (EMTALA)
RMCHCS adheres to the Emergency Medical Treatment and Active Labor Act (EMTALA). RMCHCS provides every patient seeking medical care with an appropriate medical screening examination to determine whether the patient has an emergency medical condition or is in active labor. In addition, if the medical screening examination reveals that an emergency medical condition exists, RMCHCS provides the patient with treatment necessary to stabilize this condition. RMCHCS may transfer a patient with a medical emergency condition to another facility, provided several statutory requirements are first satisfied.
PRINCIPLE 2: Business Ethics
RMCHCS and its employees, providers and contractors will conduct business with honesty, fairness and integrity demonstrated through truthfulness, the absence of deception or fraud, and respect for applicable laws.Gifts and Gratuities
Contractors are selected only on the basis of quality, performance, reputation, price and suitability of products or services. As a RMCHCS employee, I may not accept gifts, bequests, entertainment of excessive value and/or monetary gifts in any amount. I should not accept or solicit any benefit from an existing or potential supplier. If a patient, family member or other individual offers a monetary gift, the individual should promptly be referred to the appropriate foundation office where a donation can be made.
Acceptable items include the following: unsolicited advertising or promotional materials, such as a pen, cup/mug, calendar, paperweight or other traditional marketing item with little to no value other than name recognition.
Questions regarding accepting gifts should be brought to my director or the compliance department.
Anyone representing RMCHCS or acting on its behalf in negotiating agreements has a responsibility to:
1. Obtain clarification regarding questionable issues, and
2. Report efforts by independent contractors to inappropriately influence business relations and activities.
Charting and Documentation
I understand the accuracy and completeness of RMCHCS' medical records are essential to maintaining ethical and professional business practices. I understand medical records must be completed in compliance with all medical staff bylaws, accreditation standards and relevant laws and regulations. All RMCHCS employees, providers and independent contractors who document in a medical record are responsible for accurate, appropriate, legible and timely charting of the care provided to any patient.
Medical Records, Coding and Billing
I recognize that all providers and employees involved in billing and coding are expected to understand and comply with billing-related and coding-related policies and procedures established by RMCHCS and by third-party carriers (including Medicare and Medicaid) to which claims are submitted. I will take every reasonable precaution to ensure that billing and medical record coding are accurate, timely and in compliance with federal and New Mexico laws and regulations.
Record Retention
All records (such as medical, financial and employee) will be stored in a safe and secure location for the period of time required by law. I will organize records in a manner that permits prompt retrieval. Old or unnecessary records, no matter if paper or in an electronic format, will be properly disposed of in accordance with appropriate retention schedules and RMCHCS document destruction/recycling policies. Shredding bins for paper destruction are located for convenience. I understand that employees, providers or independent contractors should never destroy or alter any document (except in a properly appended and dated format) in anticipation of, or in response to, a request for those documents by any government agency or court.
Competition and Antitrust
As a RMCHCS employee, I must avoid all actions that are anti-competitive or otherwise contrary to laws that govern competitive practices in the marketplace.
I will never discuss with or disclose to someone from another company price or market information without consulting RMCHCS Finance Department. Under no circumstances should competitively sensitive information regarding RMCHCS' competitors or contractors be exchanged. If I am uncertain of the sensitivity of information, I will address the issue with my director.
Access to Patient Health and Business Information
RMCHCS employees, providers, volunteers, and contractors are responsible for helping ensure the confidentiality and privacy of corporate information and patient health information. I understand that access to RMCHCS' medical records, billing records, computing environments, data communications and data resources will be limited to the "minimum necessary" to accomplish the intended or specified purpose required by each employee's job duties.
Acceptable Use of Information and Computing Resources
Every person who is eligible and authorized to access information contained on the RMCHCS computer network is responsible for the protection of RMCHCS' confidential and proprietary data assets. My responsibilities include:
Protecting passwords from use by any other person
Protecting passwords from use by any other personAppropriate access to confidential data
Safe practices for virus management
Reasonable and professional use of e-mail
Web and Internet services
Adherence to all laws, regulations and policies which protect information and maintain medical privacy
I understand that any violations will be dealt with in accordance with RMCHCS' Information Security and Human Resources policies.
When I am assigned a unique identification code and/or password in order to access RMCHCS information systems, I will be held responsible for maintaining the integrity of the health information I access. I understand that sharing identification codes or passwords, or unauthorized access or disclosure of confidential information, is prohibited and will result in disciplinary action up to and including termination and/or revocation of access. If a password has been compromised or revealed to anyone other than the authorized user, I should contact the Information Technology Department.
PRINCIPLE 3: Conflicts of Interest
A conflict of interest includes anything that divides my loyalty between the best interests of RMCHCS and those of a patient, supplier, friend, relative, visitor or competitor. Here are some instances in which a conflict of interest may exist:Direct or indirect ownership of or substantial interest in a company or private business that is a competitor of, or a supplier of goods and services, to RMCHCS
Acceptance of gifts, payments or services from those doing business or seeking to do business with RMCHCS
A situation in which financial or other personal considerations may compromise or appear to compromise delivery of patient care
Serving as a director, officer, consultant or other key role with a company or private business that is conducting business, seeking to do business or competing with RMCHCS
Hiring or contracting with a family member or friend to provide goods and/or services to RMCHCS
Customer and Business Associate/Contractor Relations
All business relationships with contractors must be conducted impartially and in a fair manner in compliance with RMCHCS policies. A contractor cannot be required to cease business with RMCHCS competitors, or to purchase RMCHCS products or services in order to gain favorable contracts with RMCHCS. Anyone representing RMCHCS or acting on its behalf in negotiating agreements has a responsibility to: (1) obtain clarification regarding questionable issues and (2) report efforts by independent contractors to inappropriately influence business relations and activities.
RMCHCS leadership must secure written Business Associates Agreement with all person and organization who will receive, use or gain access to protected health information. Business Associate Agreements will do three things. They will: (1) identify the protected health information to be disclosed and used; (2) ensure the appropriate use of that protected health information and (3) impose security, inspection and reporting requirements on the business associate.
Protected health, confidential, proprietary and unclassified information shared by a customer or a representative of a contracting entity should be held confidential. A contractor may not agree to provide special discounts or other favorable treatment to an RMCHCS employee or other affiliate of RMCHCS in an effort to gain favor.
Community and Political Involvement
RMCHCS encourages employees, as private citizens, to participate in the political process and to serve as advocates for community-service organizations. Affiliations and contacts with community officials, religious and charitable organizations, political parties and governmental agencies should be conducted in compliance with applicable law. Participation in such activities should not:
Interfere with the satisfactory performance of job-related duties
Bring discredit, embarrassment or liability to RMCHCS
Jeopardize the tax-exempt status of RMCHCS
Create a conflict of interest
RMCHCS funds, equipment, facilities and/or assets may not be utilized to support a political party, candidate(s), holder of any government position or any community organization without administrative approval.
I may personally participate in and contribute to individuals, organizations or campaigns, but must do so clearly as a private citizen, using my own funds and name.
PRINCIPLE 4: Corporate Assets
Protecting RMCHCS' AssetsAll RMCHCS financial documents must be prepared accurately, reliably, honestly and in accordance with established finance and accounting procedures. Standards and procedures are in place to ensure that RMCHCS' assets are protected and used in accordance with their intended purpose.
Entries of cost, financial or similar business information will be made only to the regularly maintained books and records of RMCHCS. Any resources purchased or leased by RMCHCS are intended to be used solely for business purposes. Private use of RMCHCS' assets and resources for personal benefit or gain is not allowed. The destruction of RMCHCS' property is prohibited.
Safety, Health and Environmental Matters
Every effort is made to prevent accidents by establishing safety procedures and by using proper equipment, instructions and safeguards.
The illegal use, sale or transfer of drugs is prohibited. I understand that I may not possess or drink alcoholic beverages in the workplace or report to work under the influence of any illegal drug or alcohol. I realize that any violations will be dealt with in accordance with RMCHCS' Substance Abuse Policy.
Proprietary Information and System Property
RMCHCS complies with all copyright and software licensing laws. As an employee, I may not make copies of computer software programs for personal use and realize that unauthorized duplication of copyrighted computer software violates the law and RMCHCS' Commitment to Principles. I understand that RMCHCS disapproves of such copying and recognizes the following principles as a basis for preventing its occurrence:
RMCHCS will neither engage in nor tolerate the making or using of unauthorized software copies under any circumstances.
RMCHCS will provide legally acquired software to meet legitimate software needs in a timely fashion and in sufficient quantities for all RMCHCS computers.
RMCHCS will comply with all licenses or purchase terms regulating the use of any software it acquires or uses.
RMCHCS will enforce strong internal controls to prevent the making or use of unauthorized software copies, including effective measures to verify compliance with these standards and appropriate disciplinary measures for violation of these standards.
I commit to workplace excellence by respecting the dignity of those I serve, protecting the property of the RMCHCS system, and promoting creativity, innovation and accountability.
It is my understanding that copyrighted or trademarked materials may not be copied or used without written permission. I am prohibited from using or copying any customer and/or supplier price lists, contracts, documents, publications, computer systems, software information or products in violation of a third party's interest.
Confidential and/or exclusive business information is considered to be an asset of RMCHCS and such information should not be shared with others -- including fellow employees -- without a legitimate business reason. Similarly, it is RMCHCS' policy to respect the trade secrets and intellectual property rights of others. RMCHCS' assets may be used only for authorized business purposes.
PRINCIPLE 5: Regulatory Affairs
Requests from Government Officials and Regulatory AgenciesRMCHCS cooperates fully with requests for information from government auditors, investigators or other regulatory agency officials. If a government investigator contacts me by a phone call, visit or search warrant, this situation should be brought immediately to the attention of my supervisor and the compliance department.
If I am contacted by a government agent in connection with an investigation or request for documents, I should identify the government agency(ies) executing the search warrant and obtain a business card from the individual(s) presenting the warrant. If a search warrant is presented, I will ask to make a photocopy of the search warrant and affidavit. I will then write down the subject that the agent wishes to discuss and immediately contact my supervisor and the compliance department.
If contacted by a government agent in connection with an investigation, I will:
Ask: If contacted in person, I will ask for identification and a business card, and make copies of both. If contacted by phone, I will ask for and write down the agent's name, office address and telephone number.
Call: I will call my director and the compliance department immediately. Alternatively, I may call any member of administration, including the risk management.
Compliance Department: 505.863.7225
Take: I will take notes and write a list of any documentation presented to a government representative.
Tell: I will tell the representative the truth. If I don't know, I will say "I don't know." I will not guess a response. I may be required to answer questions about the location of documents only. I have the right to wait until counsel is present to answer any questions.
Government Business
Special care must be exercised when dealing with government officials and agencies. Laws, regulations and ethical standards that apply to business with federal, New Mexico and local government agencies often differ from those that apply to dealings with non-government customers and suppliers. RMCHCS employees who work with government business divisions are responsible for knowing and complying with applicable laws and regulations. Some of these laws and regulations are described below.
Laws and Regulations
The submission of false information or false claims to the government may violate laws such as the Mail and Wire Fraud Statute, False Claims Act and False Statements Act.
Mail and Wire Fraud Statute
The use of company mail or wire services, such as fax machines, e-mail or telephone systems, to transmit false or misleading information constitutes mail or wire fraud.
False Claims Act
A false claim is any attempt to obtain money from the federal government or the state of New Mexico by knowingly presenting false or misleading information relating to payment from the government. An example of a violation of this law includes, but is not limited to, an associate knowingly recording or processing any information inaccurately, e.g., changing a beneficiary name, changing dollar amounts on claims, filing false time reports or filing false expense reports.
False Statements Acts
The False Statements Acts prohibit a person from making a false or misleading statement or withholding material information in connection with the delivery of services to or payment from the government. If done intentionally and with the intent to mislead the government, examples of potential violations include:
Providing false reports or data
Falsifying conflict-of-interest information
Making a false statement to a government auditor
Presenting false or misleading information in a contractor performance review
Anti-Kickback Statutes
The anti-kickback statutes impose severe criminal, civil and monetary penalties not only on individuals or organizations that offer a "kickback," but also on individuals or organizations accepting such kickbacks. A kickback is considered any money, fee, commission, credit, gift, gratuity, discount, rebate, item of value or compensation of any kind that is provided, directly or indirectly, to improperly obtain or reward favorable treatment.
I understand that RMCHCS prohibits anything other than deminimis payment or acceptance of anything of value in return for, or to induce the referral of any patient for any service that may be payable under Medicare, Medicaid or any other federal or New Mexico health care program. Payments or items of value offered to influence referrals to or from RMCHCS are considered inducements and are prohibited.
Obstruction of a Federal Audit
This law prohibits anyone from intentionally deceiving or defrauding the United States. Also, the law prohibits anyone from attempting to influence, obstruct or impede a federal auditor in the performance of official duties. This law includes, but is not limited to, routine government audits and government investigations.
New Mexico Medical Privacy Statutes
New Mexico requires that healthcare providers preserve the confidentiality of a patient's record. Any negligent treatment of those records shall be subject to remedies and penalties.
Deficit Reduction Act
The Deficit Reduction Act requires that any healthcare provider receiving Medicaid payments of at least $5 million per year must establish internal policies and provide education on whistleblower protections with respect to preventing and detecting fraud, waste and abuse in federal healthcare programs.
Disclosure
RMCHCS is committed to appropriately disclosing violations of law, regulations or requirements under all government or business contracts to applicable governing entities.
Affiliated Organizations/ Individuals
RMCHCS works closely with non-employed individuals and organizations serving as board members, medical professionals, contractors and volunteers.
Each is expected to honor and abide by all applicable portions of the RMCHCS Commitment to Principles and policies while working at RMCHCS or conducting business with, or on behalf of, RMCHCS.
Marketing and Media Inquiries
RMCHCS' advertising must be truthful and not misleading. Any marketing claims about RMCHCS' services must be clearly supported by evidence. All pricing advertisements must accurately reflect the true charges for services. RMCHCS will not use or disclose protected health information for the purposes of marketing communications without a written authorization from the individual.
The release of sensitive information could have a negative impact on patients, providers and employees, as well as RMCHCS' reputation and interests. Requests from the media for information regarding a patient's condition, requests for interviews with staff members, visitors or patients are received frequently. All requests from news media personnel should be referred to management and the development office and communications department.
Tax-Exempt Status
RMCHCS is a nonprofit corporation organized under Section 501(c)(3) of the Internal Revenue Code and other applicable New Mexico laws. As such, RMCHCS must comply with Internal Revenue Service laws and regulations, engage in activities that further tax-exempt purposes and use resources to promote such a purpose. Employees are not allowed to use the tax-exempt status of RMCHCS for personal gain.
Cost Reports
RMCHCS is required by federal and New Mexico laws and regulations to submit reports of its operating costs and statistics. These laws and regulations define what costs are permissible and outline the reimbursement procedures for the cost of services provided to a beneficiary.
RMCHCS is committed to providing appropriate education to staff regarding federal and New Mexico laws, regulations and guidelines. All issues related to the preparation, submission and settlement of cost reports must be performed by, or coordinated with, RMCHCS' finance and compliance departments.
PRINCIPLE 6: Compliance Reporting and Our Shared Responsibility
I am committed to preventing, detecting and reporting violations of RMCHCS policies, statutes, regulations or guidelines applicable to federal and New Mexico healthcare programs.Reporting Compliance Violations
I have an obligation to report any actual or suspected violation of the Code of Conduct. Reporting suspected violations is not an act of disloyalty. Rather, it shows responsibility and fairness to patients and payers as well as protects RMCHCS' reputation and assets.
To report compliance violations, I may do any of the following:
Contact my director to discuss questionable issues
Contact senior management
Contact the RMCHCS compliance department
My report will go directly to the compliance department for appropriate action. If I wish, I can submit my report anonymously. If I choose to identify myself, my identity will be held in confidence as permitted or required by law.
Non-retaliation Policy
RMCHCS understands that an employee's willingness to report potential compliance violations is reduced if the employee believes he/she will be subject to retaliation or retribution. Any employee who reports, in good faith, an alleged act of misconduct will not be subject to retaliation or retribution. Any employee engaging in retaliatory activity is subject to discipline, up to and including termination.
Investigation and Resolution
The RMCHCS compliance department will impartially and thoroughly review, evaluate and respond to allegations of misconduct, concerns and/or inquiries made directly to the compliance department. All allegations will be investigated and verified before any action is taken.
Disciplinary Action
I understand that adhering to the commitment to principles, as well as all RMCHCS policies and procedures, is a condition of employment and of doing business with RMCHCS. Persons who violate any of the compliance principles or any RMCHCS policies are subject to discipline, including potential loss of employment, the inability to continue doing business with RMCHCS or the loss of staff membership privileges.
Disciplinary action may be taken for, but not limited to, any of the following circumstances:
Authorizing or participating in actions that violate the commitment to principles or RMCHCS' policies and procedures
Failing to report a possible violation of the commitment to principles
Refusing to cooperate in the investigation of a potential violation
Disclosing confidential information about an investigation
Retaliating against an individual for reporting a potential violation
Making intentional false reports of misconduct or violation of the commitment to principles
The nature of any disciplinary action will depend on the nature of the violation and the circumstances involved.
COMPLIANCE REPORTING AND OUR SHARED RESPONSIBILITIES
RMCHCS Standards of Excellence:
My actions comply with the intent and purpose of the Code of Conduct.
My actions are honest in every respect.
I strive to be aware of how my actions may be perceived by others.
Resource Guide
The Resource Guide is designed to provide internal resources available to me for reporting and resolving potential violations as outlined in RMCHCS' Code of Conduct. When I have a question or concern about the commitment to principles; a situation or issue not covered in this booklet; need assistance to report or discuss issues related to a possible violation of the Code of Conduct, policies and procedures or any compliance requirement or an ethical dilemma I have several options: discuss the issue with my supervisor/director; discuss the issue with human resources or discuss with the compliance officer.
RMCHCS provides necessary education regarding the RMCHCS Code of Conduct. Some employees will receive specialized education on subjects such as billing, coding, documentation, medical necessity, employment regulations, information security awareness and medical privacy that relate specifically to job responsibilities.
My Resources
My Director
My director is responsible for knowing and demonstrating compliance with the commitment to principles and operational policies and procedures within his or her area of operation.
My director is one of the primary contacts who will answer questions and provide direction regarding compliance concerns. I may consult with my director for information about compliance requirements and operational policies and procedures. If I do not feel comfortable talking with my director about a potential compliance issue, I may use one of the following available resources:
Compliance
The compliance department facilitates investigations and ensures resolution of suspected violations of federal and New Mexico law, the commitment to principles and RMCHCS policies and procedures. The compliance department works collaboratively with management, human resources, and external examiners to ensure fair resolution of ethical and compliance concerns.
Human Resources
The human resources department can assist me in assessing my concerns and directing me to the appropriate resource or remedy. Compliance concerns can include a number of related workplace issues that can be best managed through human resources and management. Human resources is available to assist me.
Compliance / HIPAA Contacts
Compliance Hot Line1-844-984-2754
INSTRUCTIONS FOR COMPLETING CERTIFICATION (SEE ATTACHMENT)
RMCHCS Employee: Complete your certification as part of the orientation new hire process, within 30 days of hire date and annual mandatory compliance education.
