Standards of Professional and Business Conduct
Quality of Care
Major Health Partners (MHP) is dedicated to maintaining excellence and integrity in all aspects of its operation and its professional and business conduct. As members of the MHP staff, we are committed to “Do The RIGHT Thing” in all our affairs. This Code of Conduct is our strategy to “Do The RIGHT Thing”. It provides the guiding standards for our decisions and actions as members of the MHP team. Although the Code of Conduct can neither cover every situation in the daily conduct of MHP’s many varied activities nor substitute for commonsense, individual judgment or personal integrity, it is the duty of each member of our staff to adhere, without exception, to the principles set forth herein.
The Standards of Professional and Business Conduct have been designed to be consistent with the MHP Mission Statement and Vision that are summarized as follows:
Major Health Partners exists to create and deliver superior health care solutions by providing our patients and other customers with optimal clinical and economic outcomes. We will attain these goals by combining the following attributes:
- Attracting and retaining a professional, adaptable, caring staff dedicated to lifelong learning using a continuous quality improvement process. Our staff will be measured and rewarded using these same principals.
- Combining innovation, existing clinical technologies, disease prevention, and management and information technologies to meet customer needs.
As a public entity, we must make best use of our financial and human resources so we can care for patients without regard for their ability to pay. We must also function as the community’s leader in upgrading the level of health and wellness in the community.
We will be the best health care resource in central Indiana by recognizing all persons as individuals of value who deserve impeccable facilities and quality service beyond compare.
MHP Shall Comply With All Applicable Laws and Regulations
It is the duty of MHP and each member of its staff to uphold all applicable laws and regulations. All members of the MHP team must be aware of the legal requirements and restrictions applicable to their respective positions and duties. MHP expects each of its employees to refrain from engaging in activity, which may jeopardize the tax-exempt status of the organization, including inappropriate lobbying and political activities.
MHP shall implement programs necessary to further such awareness and to monitor and promote compliance with such laws and regulations.
Any questions about the legality or propriety of any actions undertaken by or on behalf of MHP should be referred immediately to one’s supervisor, or the MHP Corporate Compliance Officer (CCO). To provide further assistance, MHP has implemented the Corporate Compliance (CC) Hotline, a confidential telephone service that can be reached by dialing 1-855-290-0999, should a member of the MHP staff feel uncomfortable reporting violations or ethical concerns to any of the above.
MHP Shall Conduct Its Affairs in Accordance with the Highest Ethical Standards Regarding Patient and Community Communication
MHP and all of its employees and other members of the MHP staff shall conduct all activities in accordance with the highest ethical standards of the community and their respective professions at all times and in a manner which shall uphold MHP’s reputation and standing. No member of the MHP staff shall make false or misleading statements to any patient, person or entity doing business with MHP.
- Patients have the right to know the identity and qualifications of all MHP personnel who provide services for them, and the right to considerate, respectful and safe care.
- In all circumstances, we will attempt to treat patients with a manner in which we give reasonable thought to their background, culture, religion and heritage.
- All questions from patients will be answered promptly and courteously, or referred to the proper source.
- Patients have the right to participate in decision making regarding their healthcare, including refusing treatment to the extent permitted by law, and the patients should be informed of the consequences of such action.
- The patient has the right to personal and medical privacy. Medical records and treatment are confidential. Those not directly involved in the patient’s care must have patient permission to be present or obtain such information.
- Patients have the right to voice their complaints about care and services provided.
- We will seek to inform all patients about the therapeutic alternative and risks associated with the care they are seeking. We will constantly seek to understand and respect their objectives for care.
MHP will foster an environment which encourages open and honest communication between patients and their caregivers, family members, and employees and supervisors.
All MHP employees have a responsibility to report any significant communication problem, breach of confidentiality or other related concern to their supervisor, the CCO, or the CC Hotline.
All MHP Employees Shall Support MHP’s Goals and Avoid Conflicts of Interest
MHP is a non-profit organization dedicated to the provision of health care, education of health professionals and performance of health-related services. All members of the MHP staff must faithfully conduct their duties, in their assigned roles and tasks, for the purpose, benefit and interest of MHP and those that it serves.
All MHP staff members have a duty to avoid conflicts with the interests of MHP and may not use their positions and affiliations with MHP for personal benefit. Members of the MHP community must consider and avoid not only actual conflicts but also the appearance of conflicts of interest.
All agreements with an actual or potential patient referral source must be in writing and approved by management to ensure compliance with applicable laws, regulations, agreements with lenders and MHP policies.
MHP team members shall not solicit, receive, give or offer to give, anything of value to physicians or other healthcare professionals for the referral of patients or services. Kickbacks, bribes, rebates or flow of any kind of benefits intended to induce referrals are strictly prohibited.
Physicians will not refer Medicare or Medicaid patients to an entity with which the physician or an immediate family member has a financial relationship.
Contract payments or other benefits provided to clinicians and referral sources must be for the services provided and at the fair market value rates called for in the contract. They must also be specifically approved by management. Every payment must be supported by proper documentation that the services contracted for were provided.
Joint Venture with Physicians
Management must provide prior review and approval of any joint venture, partnership or other risk-sharing arrangement with any potential or actual referral source.
MHP staff shall avoid agreements or practices “in restraint of trade” such as price fixing; boycotting suppliers or customers; pricing intended to run a competitor out of business; disparaging, misrepresenting or harassing a competitor; stealing trade secrets, bribery and kickbacks.
MHP Shall Strive to Attain the Highest Standards for all Aspects of Patient Care and Services to the Community
All members of the MHP team must support its mission to provide health services of the highest quality that respond to the needs of our patients, their families and the community as a whole. The care provided must be reasonable and necessary to the care of each patient, as appropriate to the situation, and, properly qualified individuals must provide such care. All such care must be properly documented as required by law and regulation, payor requirements and professional standards.
- MHP staff will provide patients with high quality services without discrimination due to gender, age, disability, race, color, religion, national origin or ability to pay.
- MHP staff will treat patients with dignity, respect and courtesy.
- Only personnel with proper credentials, experience, license and expertise shall be employed in meeting the needs of our patient population.
MHP Shall Provide Equal Opportunity and Shall Respect the Dignity of all Members of the MHP Staff
MHP is committed to providing educational and employment opportunities for all persons, without regard to race, color, national or ethnic origin, religion, gender, sexual orientation, disability or veteran’s status.
MHP is committed to providing an academic, patient care and workplace environment that respects the dignity of each individual in the community. Therefore, sexual harassment and any other types of prohibited discrimination in any form or context will not be tolerated.
MHP will ensure that everyone is afforded equal pay for equal work regardless of gender, age, disability, race, color, religion, or national origin.
MHP is committed to protecting and supporting all personnel as well as assisting them to achieve their fullest potential in a fair and equitable manner.
The MHP staff have a duty to report any mistreatment, discrimination, safety issue, hostile activity, legal violation or other non-compliance issue occurring in the workplace to their supervisor, the CCO or the CC Hotline.
- The MHP team will give proper respect and consideration to everyone. Harassment of any type will not be tolerated.
- All MHP staff will conform to the standards of our professions and exercise reasonable judgment and objectivity in the performance or our duties.
MHP Shall Maintain the Appropriate Levels of Confidentiality for Information and Documents Entrusted to It
MHP, its employees and other members of the MHP staff possess and have access to a variety of sensitive and proprietary information the confidentiality of which they are obligated to protect. All members of the MHP community must adhere to the appropriate laws, regulations, policies and procedures to ensure that confidential information is properly maintained and to prevent inappropriate or unauthorized release. MHP and its staff members shall create and keep records and documentation that conform to the legal, professional and ethical standards.
- MHP staff shall maintain complete and accurate patient medical records. Legal and regulatory requirements will be recognized and followed in documenting and maintaining medical records.
- MHP staff shall only sign a form for a physician with physician’s authorization and a cosigner signature.
- MHP staff will make no unauthorized alterations to medical records.
- MHP staff shall prescribe medication and perform procedures only with proper authorization.
The patient has the right to access information contained in his/her clinical records within a reasonable time frame.
MHP Shall Maintain a Relationship of Integrity with Each Payor Source
MHP and the members of its staff shall ensure that all of its requests for payment are for services that are reasonable, necessary and appropriate, are provided by properly qualified persons, and the claims for such services are billed in the correct amount, coded correctly, and supported by appropriate documentation.
- MHP employees will only submit payment or reimbursement claims for services actually rendered that are fully documented in patient’s medical records, using billing codes that accurately describe the services provided.
- Submission of any claim for payment or reimbursement that is false, fraudulent, inaccurate or fictitious is strictly prohibited.
- When an overpayment is identified and confirmed, a refund shall be promptly processed returning any money received that is not due to MHP.
- A claim for physician services will not be submitted unless the service was rendered by a physician or credentialed extender.
- MHP shall take immediate steps to alert appropriate hospital or health system authorities if inaccuracies are discovered in claims that have been submitted for reimbursement.
The patient has the right to examine and understand the itemized bill for services, regardless of source of payment. The patient has the right to be informed of the source of the facility’s reimbursement for his/her services, and of any limitations which may be placed upon his/her care.
MHP and Members of the Staff Shall conduct All Business Practices With Honesty and Integrity
All business practices of MHP must be conducted with honesty and integrity and in a manner that promotes MHP’s reputation with patients, payors, vendors, competitors and the academic community. All members of the MHP community must:
MHP staff have a duty to report any loss, theft or misuse of our organization’s property or the assets of others to their supervisor, CCO or CC Hotline.
- Adhere to proper business practices and federal and state fraud and referral prohibitions in dealing with vendors and referral sources;
- Conduct business transactions free from offers of solicitation of any tips, gifts, favors, personal gratuities or other inducements from patients, vendors, or referral sources; however, the acceptance of modest gifts or entertainment of nominal value is allowed. (If an employee questions the appropriateness of a gift, he or she should seek guidance from Management, Human Resources, the CCO or CC Hotline.
- Conform to all applicable antitrust laws and regulations, and ensure that MHP does not violate laws and regulations with respect to pricing or other sale terms or conditions, improper sharing of competitive information, the allocation of territories or the impermissible exclusion of others from the economic activities;
- Maintain and protect the property and assets of MHP and the assets of others entrusted to us, including intellectual property and proprietary information, controlled substances and pharmaceuticals, equipment and supplies, and funds of MHP against loss, theft or misuse and refrain from converting MHP assets to personal use;
- Maintain the confidentiality of proprietary information belonging to other persons or entities doing business with MHP; and
- Prepare accurate financial reports, accounting records, research reports, expense accounts, time sheets and other documents so that they completely and accurately represent the relevant facts and true nature of all MHP business transactions.
- Set forth our best work efforts and use our time productively at all time in the best interest of MHP and our patients.
- Dispose of surplus, or obsolete property in accordance with our organization’s policies and procedures. Unauthorized disposal of property is a misuse of assets.
- MHP staff will be personally responsible and accountable for the proper expenditure of our organization’s funds and for the proper use of our organization’s property.
MHP Shall Have Proper Regard for Safety Within and Without the Community
MHP and members of the MHP staff shall work to ensure a workplace that conforms to regulations regarding occupational health and safety.
- MHP staff will comply with all work and safety rules, regulations and policies.
- MHP staff will take all reasonable precautions to ensure their safety, that of their co-workers, as well as the safety of patients, visitors and other personnel.
- MHP is committed to maintaining a smoke-free and drug-free environment.
MHP is committed to proper maintenance of the earth’s environment; therefore, all medical waste, hazardous waste as well as radioactive materials and other products shall be used and disposed of in accordance with all applicable environmental laws and regulations.
The Standards of Professional and Business Conduct Shall be Integral to the Operation of MHP and the Activities of the Employees and Other Professionals
The Standards of Professional and Business Conduct exist for the benefit of MHP and all members of the MHP team. It is a dynamic document that will grow over time through the contributions of all MHP members. All members of the MHP team are encouraged to suggest changes or additions to the Standards. The Standards of Conduct must be incorporated into the daily activities of MHP employees.
The Standards of Professional and Business Conduct augments, but does not limit, specific policies and procedures of MHP, and MHP staff members must perform their duties in accordance with such policies and procedures.
The MHP commitment to excellence and integrity means more than just doing the best job possible. It is our commitment to “Do The RIGHT Thing.” Our success and future depend on it.
Obligation to Report
As an organization, we are committed to delivering superior healthcare within the appropriate regulatory framework and in compliance with all applicable laws, statutes, regulations and guidance. All members of our health system have a fundamental responsibility to report possible compliance issues.
Any MHP employee who reports suspected misconduct and does so with a reasonable belief that the activity is a violation of state, federal, local law or regulation is protected from retaliation by our whistleblower protections. This policy protects employees from adverse actions or credible threats of adverse actions taken against them as a result of a good faith allegation of misconduct.
Major Health Partners (MHP) will foster an environment which encourages open communication. We have a responsibility to report any significant communication problem to Management, Human Resources or the Hotline.
- We are responsible for sharing ideas, resolving problems or concerns and treating all opinions with respect and consideration.
- We shall raise legitimate questions or concerns in an appropriate and efficient manner.
- We will strive to understand the duties, responsibilities and challenges that face our fellow workers.
- Supervisors and management shall respond, in a timely manner, to all questions raised to them..
Resolution of Problems and Concerns
Positive relations and morale can best be achieved and maintained in a working environment where ongoing and open communication exists among supervisors and personnel. This includes candid discussions of our problems and concerns.
We are encouraged to express our concerns and opinions on any issue regarding potential violation of laws, regulations, ethics, policies or procedures or these Standards of Professional and Business Conduct. Initially, personnel should contact their own supervisor or human resources representative to voice their concerns. If the concerns remain unresolved, personnel are then encouraged to raise the issues with individuals at the next supervisory level, up to and including the highest level of management. If an employee is uncomfortable following this chain of command, or if their concerns are unresolved, they are encouraged to utilize the CC Hotline.
Corporate Compliance Hotline
MHP recognizes that there will be times when concerns cannot be properly addressed through the normal chain of command. Under such circumstances, personnel are encouraged to report their concerns to the Compliance Office. MHP has initiated a Hotline for this purpose. By dialing 1-855-290-0999, you will reach the MHP CC Hotline. The CC Hotline should be used to report serious concerns about suspected or known instances of fraud or violations of law.
Calls to the CC Hotline will not be traced or recorded. All callers to the CC Hotline are encouraged to remain anonymous. If callers choose to identify themselves, their confidentiality will be protected to the extent permitted by law. Any callers who identify themselves will receive a
follow up telephone call regarding the resolution of the stated concern.
MHP has a non-retribution and non-retaliation policy. This means no action of retaliation or reprisal will be taken against anyone for calling the CC Hotline to make a report, complaint or inquiry. The CCO will evaluate and respond to allegations of wrongdoing, concerns and/or inquires made to the CC Hotline in an impartial manner. The CCO will respect and protect the rights of all personnel, including anyone who is the subject of a CC Hotline complaint. To this end, all allegations will be thoroughly investigated and verified before any action is taken. Furthermore, any disciplinary action or other response resulting from a call will be held confidential by the CC Hotline staff.
Please note: Disciplinary action, including termination, may occur if an employee has knowledge of non-compliance and fails to report it.