AHC Code of Conduct
Mission and Values Statement of AHC
The purpose of Alcona Citizens for Health, Inc. (Alcona Health Center), shall be to promote, develop and operate such facilities and programs as are necessary to provide quality health care to all residents of Alcona County and the surrounding areas, regardless of ability to pay.
Alcona Health Center believes that dedication to high ethical standards and compliance with all applicable laws and regulations is essential to its mission as stated in the AHC Code of Ethics: “As a health care corporation, AHC believes it has a responsibility to its patients and the community to conduct business and provide care within an ethical framework and to promote an organizational culture that protects human rights and dignity.” (For more info click here- Alcona Health Center – Caring for a Diverse Community) Our Code of Conduct provides guidance to our colleagues and assists us in carrying out our daily activities within appropriate ethical and legal standards. These obligations apply to our relationship with patients, affiliated physicians, third-party payors, subcontractors, independent contractors, vendors, consultants, and one another.
The Code of Conduct is a critical component of our overall Compliance Program. We have developed the Code as an ongoing process to ensure that we meet our ethical standards and comply with all applicable laws and regulations.
Quality Patient Care
AHC has standards of patient care that reflect federal and state laws and regulations, respective medical, professional and clinical practice guidelines, professional standards and accrediting body standards. These standards include specific policies pertaining to the appropriate credentialing and privileging of licensed independent practitioners. The standards are approved by AHC’s Board of Directors.
AHC’s patients deserve care with concern for their personal dignity and independence, and AHC views these as important factors in the healing and wellness process. It is the responsibility of the AHC professional and nonprofessional staff at all of the AHC health centers to respect and preserve these rights for those who come to AHC for health care. The confidentiality of patient records will be maintained as required by law.
Fraud and Abuse, Anti-Kickback, and Self-Referral
AHC, along with the entire health care industry, is subject to numerous federal and state laws regulating practices and relationships within the health care industry. These laws are designed to prevent fraud in the Medicare and Medicaid programs and abuse of the public funds supporting the programs, to regulate patient referrals, and to prohibit false statements to the government. AHC is committed to compliance with the Medicare and Medicaid laws and rules. All employees should be aware of these laws and rules and notify the Compliance Officer of any potential or actual violations within AHC.
Contracting for Services
All business relations with vendors, contractors and other third parties, including physicians and other clinicians, are to be conducted at arm’s length. AHC shall not participate in “gain-sharing” arrangements with hospitals, whereby an AHC physician would receive direct or indirect compensation as an inducement to reduce or limit services to federal program beneficiaries under their care.
Financial Accounting Records, Integrity, and Accuracy
All financial reports, cost reports, accounting records, research reports, expense accounts, time sheets, and other financial documents including tax records shall accurately represent the performance of operations. AHC’s employees shall be trained, and their work shall be monitored to assure proper maintenance of information to comply with AHC’s policy, accreditation standards, and any other such laws, statutes, or regulations.
AHC shall establish procedures to assure a system of internal controls which provides reasonable assurance that financial records are executed and retained consistent with local, state, and federal regulatory requirement and accounting industry guidelines, and AHC shall ensure that all records are prepared timely and are properly supported.
Claims Development and Submission: Billing and Collections
AHC has an obligation to its patients, third party payors, and federal and state governments to exercise diligence, care, and integrity when submitting claims for payment for services rendered. To uphold this obligation, AHC shall maintain honest, fair, and accurate billing practices. All individuals involved in the billing functions of AHC, most importantly its physicians, dentists, and the Accounts Receivable Manager, shall have experience and knowledge and shall be trained to perform all billing functions in accordance with federal, state, and local law.
AHC shall develop and maintain detailed written billing policies and procedures manuals to provide guidance to billing and coding staff under the direction of the Accounts Receivable Manager. These should include job descriptions of the duties and minimum experience and educational requirements for each position in the billing department. With respect to reimbursement claims, AHC’s written policies and procedures should reflect and reinforce current federal and state statutes and regulations regarding the submission of claims. These policies must create a mechanism for the billing or reimbursement staff to communicate effectively and accurately with the clinical staff.
To avoid potential criminal and civil liability, AHC’s billing policies and procedures shall particularly emphasize the following:
- Bill third-party payors only for those services provided as supported by medical record documentation;
- Avoid any duplicate billing;
- Provide for proper and timely documentation of the services of health care providers;
- Emphasize that claims should be submitted only when appropriate documentation supports the claims and only when such documentation is maintained and available for review;
- Provide that the compensation for any employee or contractors including the billing coders and billing consultants shall not provide any financial incentive to improperly up-code claims; and
- Provide written policies and procedures concerning proper coding that shall reflect the current reimbursement principles set forth in the applicable regulations and be developed in tandem with private payor and Corporation standards. Particular attention should be paid to issues of medical necessity and appropriate diagnosis.
- Bill for services of resident physicians only where permissible and in accordance with applicable regulations pertaining to such.
Medical Necessity: Reasonable and Necessary Services Only
Physicians and other licensed health care professionals have the ability to order any services that are appropriate for the treatment of their patients; however, Medicare and other government and private health care plans will only pay for those services that meet appropriate medical necessity standards (as in the case of Medicare, “reasonable and necessary services”). Providers may not bill for services that do not meet the applicable standards.
Therefore, AHC should ensure that claims are submitted only for services that AHC believes are medically necessary and that were ordered by a physician or other appropriately licensed individual. Upon request, AHC should be able to provide documentation to support the medical necessity of a service that AHC has provided.
Conflicts of Interest to be Avoided
AHC recognizes that conflicts of interest often arise in the course of normal business activities; however, employees of AHC should make every effort to avoid all potential conflicts of interest. To achieve our goals and to maintain the integrity of AHC’s business, any individual associated with AHC who can potentially benefit from a contract or other arrangement shall not participate in AHC’s decision-making process relative to that contract or arrangement. Employees of AHC shall not be employed by act as consultants to or have independent business relationships with any of AHC’s physicians or other health care service providers, competitors, third party payors, or hospitals (or their affiliates) where any physician employed by AHC maintains medical staff or similar privileges, nor may the employees invest in any of the above entities without first obtaining written permission from the Compliance Committee.
- Conflict of Interest Disclosure Statement.
All AHC employees in professional or executive positions shall complete conflict of interest disclosure statements as part of the initial employment application. These forms shall be updated on a regular basis.
- Gifts. Bribes, and Gratuities Forbidden.
Acceptance of gifts, gratuities, favors or other benefits from persons or entities that do business with AHC or to whom AHC or its physicians make referrals shall not be permitted. Solicitation of such gifts, favors, or other benefits, regardless of value, shall likewise be prohibited. Not withstanding the foregoing, the acceptance of common business hospitality such as occasional meals, entertainment, or nominal gifts with a retail value of no more than $10.00 per individual AND, a retail value of no more than $50.00 in the aggregate per patient shall not be considered a violation of this section.
- Kickbacks and Rebates.
Improper payments and practices of kickbacks or rebates are unethical and, in many cases, illegal. AHC physicians and other AHC health care providers and their families are prohibited from receiving personal gains or remuneration from any person or entity that might receive a patient referral from AHC. Kickbacks and/or rebates can take many forms and are not limited to direct cash payment or credit.
Antitrust and Trade Regulation
It is the policy of AHC to avoid any activities that unfairly or illegally reduce or eliminate competition, control prices, allocate markets, or exclude competitors.
- All AHC employees or contractors shall comply with the letter and spirit of all federal and state antitrust laws. No AHC employee or contractor shall have any authority to engage in conduct that does not comply with this policy or to authorize, direct, approve, or condone such conduct by any other person.
- Employees or contractors shall not enter into understandings or agreements (whether written or oral) that could unfairly or illegally reduce or eliminate competition, control prices, allocate markets, or exclude competitors. This includes agreements or information sharing with other practices or carriers that affect prices, charges, profits, and service or supplier selection.
- Employees or contractors who negotiate or enter into contracts with competitors, potential competitors, contractors or suppliers shall do so on a competitive basis based upon such factors as price, quality, and service. This policy is especially important for employees or contractors having purchased, planning or marketing responsibilities.
- Employees or contractors who attend association or professional association meetings or who otherwise come in contact with competitors should avoid discussions at those meetings regarding pricing or any other topic which could be interpreted as collusion or cooperation between competitors.
- Any employee or contractor who suspects that a violation of the antitrust and trade regulation laws has occurred shall disclose that information to the Compliance Officer.
It is the intent of AHC to comply with all other laws and regulations pertaining to employers as well as specific AHC guidelines. These include, but are not limited to, the areas of employment practice, lobbying, and marketing/public relations.