Corporate Responsibility - Ascension Health

The following six Standards of Conduct arepractical extensions of Ascension Health’sMission, Vision and Values. They more clearlystate Ascension Health’s expectations forhow associates should conduct themselvesStandards of Conductto promote and protect the integrity ofAscension Health. Each associate is expectedto act in a manner consistent with thestandards on the following pages. As you readthese standards, keep in mind that referencesto “Ascension Health” and “We” include alladministrators, associates, medical staffC O R P O R A T E R E S P O N S I B I L I T Ymembers, leased associates and volunteers ofAscension Health and its Health Ministries.

Q U A L I T Y O F C A R EA central concern of Ascension Health in meeting patient needs isserving the whole person in his or her spiritual, intellectual, emotionaland physical dimensions. Ascension Health is committed to providingcompetent and compassionate care, to respect and safeguard thedignity of the patient and to allow patients access to all the medicaland ethical information necessary to make decisions about their care.We treat the person rather than the disease.We allow patients to participate in decisionsregarding their care by providing them with accessto information about their care in a manner that theycan understand.We provide medically necessary care that is properlydocumented in the patient’s medical record.We maintain competencies related to our jobresponsibilities and exercise appropriate judgmentand objectivity when providing patient care.We respect and maintain the dignity of every patientand strive to provide care in a manner sensitive tocultural differences and individual desires.We report situations that compromise quality throughthe appropriate, established channels and correct suchsituations as soon as possible.We provide appropriate care based on the patient’smedical need, without regard to race, religion, nationalorigin, age, sex, disability, ability to pay or any classificationprotected by law.2 3

L A W S A N D R E G U L A T I O N SAscension Health will operate in accordance with alllaws and regulations. These laws and regulations applyto areas such as patient referrals, employment, physicianrelationships, billing and payment practices, discountarrangements, lobbying, political contributions, theenvironment, health and safety and dealings withpayors and regulatory agencies.We refrain from any conduct that may violate federalor state laws, including those related to federal programfraud, abuse and false claims.We prohibit any type of payment for or receipt ofmoney or benefits for the purpose of inducing referralsin violation of the anti-kickback statute, Stark physicianC O R P O R A T E R E S P O N S I B I L I T Yself-referral law or other federal or state statutesor regulations.We recruit, hire, train, promote, assign, transfer, lay off,recall and terminate associates based on an evaluationof work performance, their own achievements,experience and conduct without regard to race,religion, national origin, age, sex, disability, abilityto pay or any classification protected by law.

We provide associates with the necessary training andeducation to perform their duties in accordance withapplicable laws and regulations.We establish relationships only with those individualsor entities who have not been excluded from participationin federal healthcare programs.We make certain that reports or other informationrequired to be provided to any federal, state orlocal government agency are filed accurately and inconformance with the applicable laws and regulationsto the best of our knowledge and understanding.We do not engage in activities that jeopardize thetax-exempt status of the organization, including certainlobbying and political activities, or activities that furtherthe private or personal interests of an individual ratherthan our charitable purpose. We refrain from activitiesthat violate the antitrust laws.We follow applicable environmental, health andsafety requirements in the planning and operation ofour facilities.We report any practice or condition that we believemay violate laws, rules or regulations, safety standards,internal policies or Standards of Conduct to appropriatelevels of management in a timely manner.We take steps to ensure that our billing and coding arein compliance with our policies and with federal andstate laws and regulations, and are supported by appropriatedocumentation, including the medical record.4 5

L A W S A N D R E G U L A T I O N SWe create accurate and truthful patient bills and submitaccurate claims for payment from any payer, includingMedicare and Medicaid, commercial insurance or ourpatients. Not only is it the right thing to do, but federaland state laws require accuracy in healthcare billing.The False Claims Act is a federal law that makes it acrime for any person or organization to knowingly makea false record or file a false claim with the governmentfor payment. “Knowingly” includes having actualknowledge that a claim is false, or acting in “deliberateignorance” or “reckless disregard” as to whether a claimis false. Examples of possible false claims include billingFinancial penalties to the organization for submitting afalse claim can total as much as three times the amountof the claim plus fines of $5,500 to $11,000 per claim.In addition to fines and penalties, an individual ororganization that violates the False Claims Act issubject to exclusion from participation in federallyfunded healthcare programs.C O R P O R A T E R E S P O N S I B I L I T YMedicare for services that were not provided, billing fora higher-level service than the service actually furnished(upcoding) or billing for services that were not orderedby a physician.The False Claims Act contains provisions that allowindividuals with original information (i.e., information notalready the subject of legal proceedings or activitiesthat have already been publicly disclosed) concerningfraud involving government programs to file a lawsuiton behalf of the government and, if the lawsuit issuccessful, to receive a portion of recoveries obtainedby the government.

The federal False Claims Act protects an employeefrom being fired, demoted, threatened or harassed by hisor her employer for providing information in good faithrelative to a False Claims Act investigation or lawsuit.The Program Fraud Civil Remedies Act (“PFCRA”)provides federal agencies, including the agenciesresponsible for federally funded healthcare programs,with administrative remedies against individuals andorganizations that knowingly submit a false claim forpayment, or knowingly make or use a false record orstatement to get a false claim paid. The PFCRA islimited to situations where a false claim, or a groupof related false claims, does not exceed $150,000.The PFCRA provides civil penalties up to $6,000 perfalse claim, plus an assessment equal to twice theamount of the false claim.In addition to the federal law, certain states haveadopted a similar law that allows individuals or theState to file a lawsuit in state court for false claimsfiled with the state for payment, such as the Medicaidprogram. Your Corporate Responsibility Officer candescribe the False Claims Act provisions applicable toyour state.Our Corporate Responsibility Program supportscompliance with these federal and state laws by:Monitoring and auditing to prevent or detecterrors in coding or billing.Educating our associates that they areresponsible for reporting any concern abouta possible false claim.Investigating all reported concerns and correctingany billing errors discovered.Protecting our associates who report concernsin good faith.6 7

H U M A NR E S O U R C E SAscension Health strives to cultivate a work environment whereassociates are highly regarded; where they are treated honestly andrespectfully; where their health and safety are protected; where they aremotivated to reach their potential; where they are given the opportunityfor personal and career learning and advancement; where they areprovided with opportunities to participate in decisions that affect theirworking conditions; where they are provided with the tools necessaryto do their jobs well; where there are safe and adequate proceduresfor resolving conflicts; and where associates are recognized and rewardedfor their achievements, without prejudice or discrimination.We do not tolerate any form of harassment ordiscrimination.We seek to be a responsible employer by providingopportunities for professional satisfaction, pride ofwork and career growth.We maintain a drug free workplace and will not toleratethe use or possession of illegally acquired drugs and/oralcoholic substances while associates are on duty.We function in an environmentally responsible manner,providing for the health and safety of our associatesC O R P O R A T E R E S P O N S I B I L I T YWe keep associates informed of activities andevents that affect their specific work environmentand performance of their job duties.We provide training opportunities for associatesto assist them in obtaining and maintainingcertifications or licensures necessary for theperformance of their job duties.as well as our patients and the community.We provide a grievance process to report and resolveconflicts without fear of retribution.The information provided above does not encompassall Human Resource Policies and Procedures. A copy ofthe Human Resources Policies and Procedures Manualis available from the Health Ministry’s HumanResources Department.

B U S I N E S S A N D E T H I C A L P R A C T I C E SAscension Health is committed to ethical business conduct and integrity, includingthe Ethical and Religious Directives for Catholic Health Care Services. Associates mustrepresent Ascension Health accurately and honestly and must not do anythingthat purposely defrauds anyone, including other companies or the government,of money, property or services. Record keeping and billing for services provided topatients must be accurate, timely and lawful. Associates must take all reasonablesteps to preserve and protect Ascension Health’s assets by making prudentand effective use of its resources, and properly and accurately reporting itsfinancial condition.We do not engage in unethical or illegal activities inthe pursuit of business opportunities.We act in good faith and in the best interest ofAscension Health at all times in the performance ofour job duties.We do not use “insider” information for any businessactivity conducted by or on behalf of Ascension Healthor its Health Ministries.We do not offer, give, solicit or receive any form ofbribe, kickback or other improper gift or payment.We appropriately document the care that is provided.We submit claims only for medically necessary servicesand supplies ordered by a physician or legally authorizedindividual and provided to the patient.We do not steal or misappropriate confidential or proprietaryinformation belonging to another person or entity.We use resources and assets only to further theMinistry and Mission of Ascension Health.We make certain that payments and other transactionsare properly authorized by management and properlydocumented in the books and records.We prepare all financial documents, including financialstatements, cost reports, accounting records, expensereports and time sheets accurately.We deal with payors and regulatory agencies honestlyand accurately.8 9

C O N F I D E N T I A L I T YIn keeping with the Health Insurance Portability and Accountability Act(HIPAA), professional ethical guidelines and the Ethical and ReligiousDirectives for Catholic Health Care Services, Ascension Health associatesmust maintain the privacy and security of protected health information,including demographic information that can be used to identify thepatient. Associates are also expected to keep confidential informationabout other associates and the proprietary business practices ofthe organization.We protect and respect the confidentiality of ourpatients and their medical information.We only reveal personal or confidential informationconcerning patients for legitimate patient care purposes,unless authorized by the patient or otherwise permittedby law.We only share confidential information regardingthe operations of Ascension Health or its HealthMinistries with associates when they have a legitimateneed to know the information in order to perform theirjob responsibilities.We will take precautions to maintain and manageintellectual property, including patents, trademarks,C O R P O R A T E R E S P O N S I B I L I T Ycopyright and software, to protect its value.We will maintain confidential information, includingfinancial data and associate related information, ina confidential, secure manner according to relevantpolicies and applicable law.

C O N F L I C T S O F I N T E R E S TAscension Health associates are expected to act in a manner that isin the best interest of the organization and the patients it serves.Associates may not use their positions to profit personally or to assistothers in profiting in any way at the expense of the organization.In any situation where an associate’s outside interests conflict withthose of the organization, the associate must disclose the conflict inaccordance with organizational policy.We avoid engaging in any activity, practice oract that appears to conflict with the interests ofAscension Health.We do not solicit or accept money, gifts, favors,services, entertainment or other things of value unlesspermitted by organizational policy.We will avoid any appearance of impropriety whendealing with clinicians and referral sources.We prohibit the disclosure of proprietary and confidentialinformation related to Ascension Health toany unauthorized person or entity, or the use of suchinformation for private benefit.We abstain from any decision or discussion affectingAscension Health that might represent a conflict ofinterest when serving as a member of an outside organizationor board.We avoid outside employment, consulting arrangementsor personal investments if they interfere with our jobresponsibilities or unduly influence the decisions we arerequired to make on behalf of Ascension Health.We do business only with individuals and companiesbased on the best interests of Ascension Health.10 11

We may face circumstances that can leave us wondering which pathto take, which choice to make and how to make it. This is particularlytrue when we are confronted with challenges to our ethical and legalstandards. Who can we ask for help?Values LineA C O N F I D E N T I A L R E S O U R C E F O R C O M M U N I C A T I N G Y O U R E T H I C A L C O N C E R N SAs responsible associates, it is our right and duty to talkwith our supervisors about any situation that we believemay potentially violate laws or the Ascension HealthStandards of Conduct. It isn’t a question of betraying confidence.It’s a question of the continued respect and viabilityof our organization and professional responsibilities.The Corporate Responsibility Officer is an individualin your organization that has overall responsibility forthe Corporate Responsibility Program. If speaking withyour supervisor or the Corporate Responsibility Officeris not the best avenue for you, we have established theValues Line.What is the Values Line? The Values Line is anadditional means of communication available to allAscension Health associates. You can call this toll-freetelephone service 24 hours a day, seven days aweek, or use the internet to report information youmay have regarding a possible violation of laws orour Standards of Conduct.What kinds of violations should I report? In yourwork you may observe actions that appear to be illegal,unethical or violate our Standards of Conduct. Theseactions should be reported because of the potentialconsequences for our organization. The following areexamples of situations that should be reported:Discrimination/HarassmentDishonest CommunicationViolations of Patient/Associate ConfidentialityConflicts of InterestInappropriate Gifts, Entertainment and GratuitiesStealing or Misuse of Assets

Fraud, Abuse or False ClaimsEnvironmental, Health and Safety ViolationsImproper Use of Proprietary InformationInappropriate Use of Ascension Health Resourcesfor Lobbying/Political ActivitiesBusiness arrangements that promote improper referralsWhat happens when I call the Values Line?Your call to the Values Line is answered by a trainedCommunications Specialist who takes hand-writtennotes as you describe your concern. Questions maybe asked of you to gather additional information. Atthe close of the call, you receive a unique identificationnumber and a specific date to call back to check onthe status of your concern.Do I have to give my name? No. The Values Line isa confidential resource provided to you for disclosinginformation about potential ethical and legal violations.However, we encourage you to leave your name as thatoften helps us with our investigation.What if I don’t know all of the details? You can reportanything that concerns you. Even if your information isincomplete, it could help keep a serious situation fromdeveloping.Are calls ever recorded or traced? No. Call tracingWhat happens after I call? The CommunicationsSpecialist prepares a confidential report based onthe information you provide. The report is forwardedto your Corporate Responsibility Officer for review,investigation and, when appropriate, corrective action.The results of the investigation will be provided to theCommunications Specialist so they may be given toyou during your follow-up call.Do I have to call during normal business hours?No. The Values Line is available to take your call any timeof day or night, any day of the week.How do I use the internet to report a concern? The website is www.AscensionHealthValuesLine.org. Once youconnect to the web site, there is a series of screens thatwalk you through the process of preparing and submittinga report. After you submit a report, you will be provided afollow-up date, report number and PIN.Will I suffer any retaliation from my organization orAscension Health for making a report? No. You shouldfeel comfortable providing information about possiblelegal or ethical violations to the Values Line withoutfear of retribution. We can assure you that no adverseaction will be taken against you by our organization orAscension Health based on a good faith complaint.and recording devices are never used.12 13

ConclusionOur Mission, Vision and Values, along withour Standards of Conduct and Values Lineprovide the foundation for our CorporateResponsibility Program. If you need guidanceconcerning any information in this bookletor you believe you are aware of a situationthat may be illegal or unethical, you areexpected to take action. As a first step,you are encouraged to talk to your supervisoror manager. If you are uncomfortable withgoing to your supervisor or if you needadditional advice, then contact theCorporate Responsibility Officer for yourHealth Ministry, call the Values Line or visitour web site to make a confidential report.

As evidence of your commitment to the Ascension Health Standards of Conduct andCorporate Responsibility Program, please detach the Receipt and Acknowledgment format the perforated line and sign and complete the form.Please return this form to your supervisor. This lets us know we are all committed tocarrying out the ministry of Ascension Health in an ethical and legal manner.R E C E I P T A N D A C K N O W L E D G E M E N TAs an associate or agent employed by or associated with an Ascension Health Health Ministry,I am committed to upholding the highest standard of individual ethical and legal businesspractices. I will not tolerate illegal or questionable activity and promise to take whatever stepsare required by the Corporate Responsibility Program to identify, report and prevent such activity.I acknowledge that I have received my personal copy of the Standards of Conduct and agreeto follow them. I understand that compliance with the Standards of Conduct and theCorporate Responsibility Program is a condition of my continued employment or associationwith Ascension Health.SignaturePrint NameAscension Health Health MinistryDate14 15

Values LineA M I S S I O N B A S E D O N V A L U E SPlease remove and save the Values Line wallet card attached to the back cover of thisbooklet. It fits easily into your purse or wallet. Carry it as a reminder of your responsibilityto report any problems or concerns. Call the confidential, toll-free telephone numberanytime, or visit our web site to discuss your ethical concerns or to report a possibleviolation of law or our Standards of Conduct.Call the toll-free, confidentialValues Line 24 hours a day, sevendays a week, or visit the web siteto discuss these and any otherissues concerning you:discrimination/harassment; dishonestcommunication; violations of patient/associate confidentiality; conflictsof interest; inappropriate gifts,entertainment and gratuities; stealingor misuse of assets; fraud, abuseor false claims; environmental, healthand safety issues; improper use ofproprietary information; inappropriateuse of Ascension Health resourcesfor lobbying/political activitiesV A L U E SL I N E800.707. 2198www.AscensionHealthValuesLine.org

4600 Edmundson RoadSt. Louis, Missouri 63134phone 314.733.8000www.ascensionhealth.orgV A L U E S L I N E800.707. 2198www.AscensionHealthValuesLine.org