Standards of Conduct

1. Standards of Conduct • Training today will give you talking points • You need to read through the book and get comfortable with the information • This replaces two page Standard • Acknowledgement must be signed and sent to HR when all meetings complete

2. Standards of Conduct • Purpose – All MHCC Board memebers, employees, physicians, volunteers, contractors following the same guidelines • Governing board supports • Leadership must support and lead by example • Standards are the outward/public sign of BRMC compliance to legal and ethical behavior

3. Standards of Conduct • Education the most critical element of the compliance program • Standards do not address all the complexity of the issues, rules and regulations • Outlines what’s expected of all who have dealings with us

4. Standards of Conduct • A Commitment to Providing Patient Care • Document all care and services given • Individual professionalism – being responsible for your actions and taking pride in your work • Effective communication – using plain language, making eye contact, using proper phone etiquette, smiling and greeting patients and family members • Exceeding the expectations of patients, patient family members, and co-workers

5. Standards of Conduct • A Commitment to Our Community • You are identified with BRMC when in public • DO nothing to embarrass yourself or BRMC

6. Standards of Conduct • A Commitment to Environmental Health and Safety • Follow all governing rules and regulations, i.e.OSHA, FDA. CDC, etc. • A Commitment to Environmental Health and Safety • Workforce members will: • • Wear appropriately displayed name badges at all times and be familiar with others that work in their areas • • Report suspicious persons or situations immediately • • Remain calm, listen, and diffuse verbally hostile situations

7. Standards of Conduct • A Commitment to Proper Employment Practices • McLaren Health Care takes reasonable precautions to ensure the work environment is free of discrimination or harassment • To maintain public trust, • Employees may not solicit or accept anything of more than de minimus value, including a loan, reward, material or property, from a patient or a patient’s family, visitor, contractor, supplier or competitor. • Employees may not use their employment, or any information received through MHC, to obtain financial gain (direct or indirect) for themselves, a member of their family or a business with which they or a member of their family, is associated.

8. Standards of Conduct • A Commitment to Ethical Business Conduct • Outside employment or business activities must be limited to off-work time • Report any situation that may be considered a conflict of interest • Staff and physicians may not share pricing information, internal reports, communications, procedure schedules • Honest, accurate, and complete reporting of financial transactions

9. Standards of Conduct • A Commitment to MHC Assets and Financial Transactions • Honest, accurate, and complete reporting of financial transactions • • Appropriately representing productivity • • Accurately recording travel expenses and mileage • • Securing money, equipment, or supplies from theft • • Complying with business expense reimbursement policies

10. Standards of Conduct • A Commitment to Accurate Coding and Billing Transactions • Providing and billing only for services that were reasonable and necessary • Billing for services at levels that are supported by medical record documentation • Waiving of co-pays or deductibles only in accordance with policy and procedure • Bundling or unbundling charges appropriately • Attempting to collect outstanding balances from a Medicare or Medicaid patients only when Advance Beneficiary Notices were provided prior to service • Preventing duplicate billing • Ensuring the accuracy of diagnostic and procedure codes

11. Standards of Conduct • A Commitment to Physician Relations • The organization will maintain positive working relationships and respect the legal rights of physicians. • provides a uniformly-applied privileging process • teaching facilities and practices to assist in advancing the field of medicine.

12. Standards of Conduct • A Commitment to Confidentiality and Electronic Security • Right to confidential communication of PHI • Right to receive a notice of uses/disclosures of PHI • Right to access or receive a copy of their medical records • Right to request a restriction to how PHI is used • Right to request changes (amendments) to their records • Right to receive a listing (accounting of disclosures) if requested • the same safeguards used to protect confidential patient information should be used to protect our business and financial information.

13. Standards of Conduct • A Commitment to Laws and Regulations • Anti-Kickback • Stark Laws (Physician Self-Referral Law) • Federal False Claims Act • State False Claims Act • EMTALA (Emergency Medical Treatment and Active Labor Act)

14. Standards of Conduct • A Commitment to Ongoing Monitoring • The MHC and BRMC compliance program • BRMC Hot Line 989-894-3945 • BRMC Privacy Line 989-894-3970 • BRMC Compliance Officer 989-894-3849