Compliance & Ethics Code of Conduct Policy 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 must adhere 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 View All Access to Care Access to CareCoxHealth is committed to providing and supporting health care excellence in partnership with the communities we serve. Patient care and service is provided without regard to race, color, religion, national origin, handicap or disability, financial status, age, sex or ability to pay. Any person who needs emergency treatment at a facility in our system will be treated in compliance with EMTALA (Emergency Medical Treatment and Active Labor Act.). We make every attempt to provide high quality care with respect and dignity for all patients in our clinics, hospitals, long-term care, and assisted living facilities. Accuracy of Records Accuracy of RecordsAll documents, financial reports or records, which include the patient’s medical record, are to be filled out in a clear manner. False or misleading wording in any record is not allowed. A signature that cannot be read must have a printed name below the signature. Any corrections or changes must be done according to our policies. Contact the Health Information Management Department for assistance if you are unsure about correction of medical records. Antitrust Laws Antitrust Laws were created to promote free and open competition. Sharing price, cost, or profit information with our competitors or from one vendor to another is an example of a violation. Likewise, agreements to fix prices, or boycotting another competitor are illegal. Billing, Charging and Coding for Services All staff must be careful to properly charge, code and bill for services in accordance with Federal and State health care program requirements and CoxHealth Policy. Billing for services not documented or provided could be considered a “false claim” and could result in financial penalties. Employees should never charge, code or bill solely to be paid if the service was not provided or documented. An employee who has concerns or questions should notify their Supervisor or the Corporate Integrity Department right away. Compliance Program The Corporate Compliance Program provides a framework which helps CoxHealth ensure that it conducts business in an honest and ethical manner in accordance with state and federal rules and regulations. The Program alsoestablishes a mechanism to detect, correct and prevent errors that result in violations of the laws and regulations governing health care and violations of CoxHealth policies. Ongoing training, education, auditing, and monitoring projects are completed to assess compliance with all laws and regulations. Open communication of possible violations of our own policies and procedures or the federal and state regulations governing health care is an important part of the success of CoxHealth’s Compliance Program. Employees who report a possible concern in good faith will not be punished or retaliated against for making that report. Compliance Hotline An internal Compliance Hotline has been set up as part of the Corporate Compliance Program. The Hotline gives members of CoxHealth a confidential and anonymous reporting system. Members of CoxHealth are required to report known violations of federal or state health care laws or regulations, or violations of CoxHealth’s internal policies, and may use the Hotline to make such reports. In addition, anyone may report a practice or incident they believe violates any policy, federal or state laws or regulations. All employees should feel free to report any concerns they have. The Compliance Hot Line is: (417) COX-LAWS / 417-269-5297 -or- Toll Free (888) 340-5297. Confidentiality Members of CoxHealth may have access to information about our patients in the course and scope of doing their jobs. We have a duty to protect patient health records and our organization’s business records from, theft, fraud, loss and inappropriate use. Patient information and financial or business information is to be released only according to policy. We cannot talk about a patient or their condition in the elevator, hallway or in areas where visitors or other patients could overhear or with another employee who does not have a “need to know.” An Employee may not look up information regarding their own family members. Employees should not seek paper, printed, or electronic access to any confidential information out of curiosity, for malicious purposes or for financial gain. Access to patientinformation, or employee information that is not appropriate, will result in disciplinary action. Please know that electronic access to confidential information can and will be monitored. Contracting Due to the complexity of the laws and regulations governing health care, CoxHealth must carefully monitor existing agreements, and must examine proposed agreements for compliance with those laws. In addition, members of CoxHealth must not violate the Anti-kickback Statute, the Stark Law or CoxHealth policies relating to contractual relationships with outside entities. Corporate Assets All employees are charged with protecting and preserving CoxHealth's assets by following procedures to prevent their loss, theft or unauthorized use. Using corporate assets for unlawful purpose or unauthorized personal benefit and failing to keep accurate and complete records of all assets, liabilities, revenues, expenses or financial transactions is prohibited. Travel and entertainment expenses shall be consistent with the needs of business. An employee should not gain financially as a result of business travel and entertainment. Reports filed reflecting the nature and extent of expenses incurred for travel and entertainment should be accurate. It is the responsibility of those who approve such reports to take reasonable steps to ensure their accuracy. 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. Disruptive Behavior 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 EmploymentMembers of Cox are expected to respect and cooperate with all personnel in each department and facility within the system. We are committed to equal opportunity for hiring, recruitment, retention, transfers, promotion, and education. In addition, we expect employees to treat each other, patients, and customers with respect and compassion and refrain from conduct that may be harmful to employees, patients, and/or customers. 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. Ethical Standards CoxHealth is committed to maintaining its reputation as an organization that is honest in its dealings with others (has integrity), and has respect and compassion for those we serve (patients, family members, fellow employees, physicians, vendors). CoxHealth recognizes and takes seriously its ethical responsibilities to patients, medical staff,the communities, and all others who seek assistance or do business within our healthcare system. Members of CoxHealth are expected to behave in a positive way that demonstrates our organization’s Mission, Vision and Values. Gifts 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. Harassment Our organization is committed to maintaining a work environment that is free of discrimination and harassment. In keeping with this commitment, CoxHealth will not tolerate harassment of those coming in contact with CoxHealth (including employees, students, patients, visitors, physicians, volunteers, and vendors). If you feel you or someone else at CoxHealth is being harassed, please contact your supervisor, the Human Resource Department, the Human Resource Hotline (417-269-6696) or the Compliance Hot Line (417-269-5297 -or- Toll Free 888-340-5297) or Corporate Integrity Department (417-269-7655). Independent Contractors/Vendors Vendors and independent contractors will be given a copy of the CoxHealth Code of Conduct and Procedures forVendor Representatives Doing Business with CoxHealth. All are expected to follow these policies. These policies include a Vendor/Physician Financial Disclosure Statement for Participation in Product Evaluation Process. Additionally, all Vendors shall be responsible to verify that their employees have not been excluded from participation in Medicare/Medicaid or other government programs. The Vendor should become familiar with the government listings whereby they can verify their employees are not excluded. CoxHealth receives federal funds in the form of grants, and payments through Medicare, Medicaid, Champus/Tricare and other government programs. Additionally, all Pharmaceutical Representatives shall receive a copy of the Pharmaceutical Representative Code of Conduct and must agree to abide by such. 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. Intellectual Property In the course of their duties, members of CoxHealth may have access to the proprietary information of CoxHealth. Proprietary information is information that is confidential, privileged or of a competitive value to CoxHealth (for example, management reports, marketing studies, marketing plans, financial statements, internal memoranda, reports of patient records, or patients lists). Members of CoxHealth must respect the confidential nature of this information. CoxHealth is committed to respecting the intellectual property rights of others. All software used in connection with CoxHealth’s business must be properly licensed and used in accordance with the license. Members of CoxHealth must respect patents, trademarks and copyrights. Marketing The CoxHealth trademark, trade names and service marks can only be used with permission of the Planning and Marketing Department or Corporate Communications in accordance with the policy governing their use. Cox has a policy to maintain the quality, value and reputation of service and to insure our trade name is not misused. All marketing and advertising is intended to be truthful so not to mislead, deceive or omit pertinent or significant information, nor to create unrealistic expectations in the consumer’s mind. No Retaliation Retaliation against any person who in good faith reports a concern, potential violation of the Code of Conduct, Corporate Compliance Program, Cox policy or applicable laws is strictly prohibited. Additionally, members of Cox should be aware that the Federal False Claims Act protects whistleblowers from retaliation. Anyone initiating a qui tam case or a concern through the CoxHealth Corporate Compliance Hotline, or the CoxHealth Human Resources Hotline, or the Patient Safety Hotline or a report to the Joint Commission or any government agency may not be discriminated or retaliated against in any manner by their immediate supervisor, or anyone at CoxHealth for filing the lawsuit or complaint. Anyone who believes they have been, or are being, retaliated against they should immediately contact the Corporate Compliance Department (417-269-7655) or the Legal Department (417-269-6577). Patient Rights 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. Performance Evaluations 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 CoxHealth encourages all employees to vote and be active in politics if they so choose; however, the activity must be on personal time and without any financial expense to CoxHealth. Employees should consult with the Corporate Integrity Department, Corporate Communications or Legal Department before agreeing to participate in a political activity that could involve our organization. Product Endorsement Members of CoxHealth are not permitted to endorse or recommend any particular product or service that is allied with or connected to the health care industry, as a representative of CoxHealth without the prior approval of the Vice President of Corporate Communications. 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. Reporting Responsibility 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. Research 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. Violations 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.