It is CoxHealth’s policy to conduct all of its business and other practices in compliance with all applicable laws and regulations and to act with Integrity, Respect and Compassion in all of our business dealings.
CoxHealth and its employees, volunteers, medical staff members, students and Board of Directors (collectively referred to herein as “members”) have a reputation in the community of being a quality organization with quality individuals; an organization that operates in an honest manner; an organization that has both respect and compassion for those we serve. CoxHealth will protect this reputation and our integrity through the enforcement of its policies and procedures.
We are called upon to perform our jobs and carry out many responsibilities. Leaders are to set the example by promoting the highest standards of ethics and compliance with the federal and state regulation and CoxHealth policies and procedures. Members of CoxHealth, including Board members, employees, physicians, volunteers, students and vendors, must be familiar with our Code of Conduct and support the Compliance Program, and mustadhere to the requirements set forth therein. In addition, these individuals must comply with all federal health care program requirements. It is imperative that members of CoxHealth adhere to these laws, regulations and policies. The failure to do so may expose CoxHealth and its members to civil or criminal liability, or exclusion from participation in federal health care programs. The failure of a member of CoxHealth to report a known violation will result in disciplinary action up to and including termination.
Code of Conduct
Access to Care
Accuracy of Records
Billing, Charging and Coding for Services
Conflicts of Interest
Members of CoxHealth must avoid all activities, associations or interests that create a conflict of interest. Conflicts of interest for employees must be reported to the Corporate Integrity Department (269-7655). A file will be maintained of all reported conflicts of interest. If you are a medical staff member, the Conflict of Interest process may be accessed through the Medical Staff Office. If you are a Board Member, the Conflict of Interest process is handled through the Executive Office and is defined in the Board Bylaws. For vendors, the policy is distributed at their first contract with CoxHealth. Examples of conflicts of interest include the following: An employee working a second job and/or making business commitments during work time, using your position to get a benefit or to refer a service to a relative or receiving a payment, gift or improper entertainment in exchange for a contract. Please call your Supervisor, department Director, the Corporate Integrity Department (269-7655) or the Human Resources Department (269-6954) if you have concerns or questions.
In order for CoxHealth to provide the highest level of patient care possible, all members of the health care team must treat each other with respect and dignity. The American Medical Association broadly defines disruptive behavior as “a style of interaction with physicians, hospital personnel, patients, family members and others that interfere with patient care.” These behaviors interfere with the effective, efficient delivery of patient care, impact morale negatively, and prevent team members from effectively working with each other. As such, disruptive behaviors exhibited by employees, members of the medical staff vendors or other associates of CoxHealth will not be tolerated. Disruptive behaviors will subject the offender to progressive disciplinary action pursuant to applicable CoxHealth policies or the Medical Staff Bylaws.
Examples of disruptive behaviors include (but are not limited to) the following:
- The use of abusive, offensive or degrading language;
- Intimidating or threatening physical actions;
- Physical abuse/assault, including the striking of another person;
- Criticism of a personal rather than professional nature; Inappropriate touching;
- Throwing, dropping or intimidating use of instruments or equipment;
- Threats of violence of physical harm;
- The use of sexually explicit or suggestive language;
- Examples of desirable behaviors include (but are not limited to) the following:
- Private, constructive criticism directed to correct an individual’s professional, performance-related deficiency;
- Supportive, encouraging comments directed to members of the care team whose performance exceeds expectations;
- The treatment of other care team members with respect, dignity and courtesy;
- The use of clear, concise language in all directions and other communications.
Incidents or patterns of disruptive behavior can be reported to an individual’s direct supervisor, the Human Resource Department (417-269-6954), the Human Resource Hotline (417-269-6696), the Corporate Integrity Department (417-269-7655) or the Compliance Hotline (“COX-LAWS”/ 417-269-5297, or Toll Free 888-340-5297).
Employee Relations and Equal Opportunity
Environmental Health and Safety
Environmental Health and SafetyCox is committed to providing a safe and healthy environment. Procedures for throwing away medical waste, environmentally sensitive and hazardous materials must be followed at each facility. If you have questions or concerns about proper procedure see the Standard's Manual for information or contact Environmental Services or Infection Control. Using alcohol or illegal drugs is not allowed at any worksite. Members of CoxHealth may have access to prescription drugs, controlled substances and other medical supplies as part of their job; however, we have a legal and ethical responsibility to maintain control over these items and report any possible problems and/or missing drugs to your immediate supervisor, Human Resources or the Corporate Integrity Department.
Members of CoxHealth are not to solicit, take or offer any bribe, kickback, gratuity or other payment made to influence a business decision. Doing so is improper and against the law and CoxHealth policies. Members of CoxHealth may not take or ask for anything of value from a third party, patients or patient’s family members for these same reasons.
Providing free services can also create a conflict of interest, a violation of Medicare/Medicaid and Managed Care contracts and is inappropriate. Members of CoxHealth may not offer anything of value to a government official or other third party in an effort to influence business or to gain special treatment as an individual or for CoxHealth.
Inquiries to Government Payors
To avoid burdening governmental payers with questions that may be answered by others at CoxHealth, employees should notify the Compliance Department before contacting government payers about issues that are different than routine claims or payments.
Patients have a right to considerate care that protects their dignity and privacy. A patient’s spiritual and cultural values will affect a patient’s response to care. We will respect each patient’s spiritual and cultural values and beliefs consistent with the law and with ethical behavior. We encourage patients to be involved with their care, and we remain committed to talking to our patients about ethical responsibilities and patient’s rights. Patients shall be treated without regard to race, color, age, sex, religion, disability, or any other classification protected by law.
CoxHealth reviews employees for their work performance on an annual basis. A discussion of compliance matters, following the Corporate Compliance Program and Code of Conduct, will occur during annual performance evaluations and must be documented. Compliance education must be completed annually, and attendance documented. Employees who do not attend mandatory compliance training shall be appropriately counseled.
Physicians, Directors, Supervisors
Physicians and CoxHealth Management serve as role models for day-to-day operations and are expected to be familiar with and carry out all provisions of the Code of Conduct.
Physicians Self-Referral "Stark"
The self-referral, or “Stark”, law prohibits physicians from making referrals for specific health services to any entity or business in which the physician or a family member has a financial relationship unless an exception applies. CoxHealth is committed to complying with the requirements of the physician self-referral law. All members of CoxHealth must comply with both these regulations and CoxHealth policies addressing physician self-referrals. Violations of the Stark Law may result in the imposition of significant penalties against CoxHealth and individual violators, including significant civil monetary penalties or exclusion from participation in Federal health care programs. Do not provide anything of value (cash payment or gift of any kind) to any physician or physician's family member without contacting the Corporate Integrity Department. It is important to ensure that the payment or giving of non-monetary compensation is tracked and falls into a Stark Exception prior to providing it. This includes honorariums for speaking engagements, CME, event tickets, flowers for an event, meals, etc. Questions regarding these referrals should be directed to the Legal Department or the Corporate Integrity Department.
Political Activity and Contributions
Referral for Business “Anti-kickback”
Anti-kickback statutes do not allow payments, gifts, or other compensation to be made or accepted in exchange for the referral of health care business. The Anti-kickback Statute has safe harbors that may apply. CoxHealth will not participate in, and will not permit any of its members to participate in, arrangements that violate the Anti-kickback statute unless an applicable safe harbor is satisfied. Since this is a criminal statute, violations may expose CoxHealth and individual violators to substantial fines, exclusion from participation in Federal health care programs or even prison. Contact the Legal Department or Corporate Integrity Department if you have questions.
Members of CoxHealth will promptly notify their supervisor, a Vice President, President, the Legal Department, the Corporate Integrity Department, or call the Compliance Hotline (417-269-5297 -or- Toll Free 888-340-5297) to report any possible violations of law or any improper activity by employees, physicians, volunteers, vendors or agents of CoxHealth. Any employee, volunteer, physician with staff privileges or other member of CoxHealth that becomes ineligible to participate in any federal health care program, whether by listing in a “disqualifying database”, conviction of a crime under 42 U.S.C §1320a-7(a), or any other reason, shall immediately report their disqualification to their supervisor, Human Resources, or the Corporate Integrity Department. The failure of an individual to immediately report their disqualification to CoxHealth shall be grounds for immediate termination. For purposes of this paragraph, the “disqualifying databases” include the List of Excluded Individuals and Entities, the Excluded Parties List System, and/or Specially Designated Nationals List.
CoxHealth supports human subject research in accordance with all federal regulations. Research may be in the form of new drug research, new device research, evaluation of existing patient related data with the intent to publish, or surveys of our patient with the intent of drawing a conclusion about services or practices. Through research, advances on drug products, methods of treatment and medical devices, we have the potential to improve the lives of people in our community, state and nation. Protecting human subjects, maintaining confidentiality, and providing informed consent are very important. Contact the Corporate Integrity Department at 417-269-7669 for information regarding research at CoxHealth.
The standards contained in this Code of Conduct are important, and therefore any violation will subject the offender to some form of discipline. The CoxHealth discipline policies will be applied to any violations of the Code of Conduct. The failure to report suspected improper activity, including violations of federal or state health care program requirements or CoxHealth policies may also constitute a violation. Possible disciplinary measures may range from a verbal or written warning to termination, removal from the Medical Staff, approved vendor list or Board of Directors. In addition, the matter will be referred to the appropriate government agencies as required by regulation/law. The employee may also be responsible in a civil suit for losses or other damages caused by his or her conduct.