Standards of Conduct
 Training today will give you talking
points
 You need to read through the book
and get comfortable with the
information
 This replaces two page Standard
 Acknowledgement must be signed
and sent to HR when all meetings
complete
Standards of Conduct
 Purpose – All MHCC Board memebers,
employees, physicians, volunteers,
contractors following the same guidelines
 Governing board supports
 Leadership must support and lead by
example
 Standards are the outward/public sign of
BRMC compliance to legal and ethical
behavior
Standards of Conduct
 Education the most critical element of
the compliance program
 Standards do not address all the
complexity of the issues, rules and
regulations
 Outlines what’s expected of all who
have dealings with us
Standards of Conduct
 A Commitment to Providing Patient
Care
 Document all care and services given
 Individual professionalism – being
responsible for your actions and taking
pride in your work
 Effective communication – using plain
language, making eye contact, using proper
phone etiquette, smiling and greeting
patients and family members
 Exceeding the expectations of patients,
patient family members, and co-workers
Standards of Conduct
 A Commitment to Our Community
 You are identified with BRMC when in
public
 DO nothing to embarrass yourself or
BRMC
Standards of Conduct
 A Commitment to Environmental Health and
Safety
 Follow all governing rules and regulations, i.e.OSHA,
FDA. CDC, etc.
 A Commitment to Environmental Health and Safety
 Workforce members will:
 • Wear appropriately displayed name badges at all
times and be familiar with others that work in their
areas
 • Report suspicious persons or situations immediately
 • Remain calm, listen, and diffuse verbally hostile
situations
Standards of Conduct
 A Commitment to Proper Employment Practices
 McLaren Health Care takes reasonable precautions to
ensure the work environment is free of discrimination
or harassment
 To maintain public trust,
 Employees may not solicit or accept anything of more
than de minimus value, including a loan, reward,
material or property, from a patient or a patient’s
family, visitor, contractor, supplier or competitor.
 Employees may not use their employment, or any
information received through MHC, to obtain financial
gain (direct or indirect) for themselves, a member of
their family or a business with which they or a
member of their family, is associated.
Standards of Conduct
 A Commitment to Ethical Business
Conduct
 Outside employment or business activities
must be limited to off-work time
 Report any situation that may be
considered a conflict of interest
 Staff and physicians may not share pricing
information, internal reports,
communications, procedure schedules
 Honest, accurate, and complete reporting
of financial transactions
Standards of Conduct
 A Commitment to MHC Assets and Financial
Transactions
 Honest, accurate, and complete reporting of financial
transactions
 • Appropriately representing productivity
 • Accurately recording travel expenses and mileage
 • Securing money, equipment, or supplies from theft
 • Complying with business expense reimbursement
policies
Standards of Conduct
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A Commitment to Accurate Coding and Billing
Transactions
Providing and billing only for services that were reasonable
and necessary
Billing for services at levels that are supported by medical
record documentation
Waiving of co-pays or deductibles only in accordance with
policy and procedure
Bundling or unbundling charges appropriately
Attempting to collect outstanding balances from a Medicare
or Medicaid patients only when Advance Beneficiary Notices
were provided prior to service
Preventing duplicate billing
Ensuring the accuracy of diagnostic and procedure codes
Standards of Conduct
 A Commitment to Physician Relations
 The organization will maintain
positive working relationships and
respect the legal rights of physicians.
 provides a uniformly-applied
privileging process
 teaching facilities and practices to
assist in advancing the field of
medicine.
Standards of Conduct
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A Commitment to Confidentiality and Electronic Security
Right to confidential communication of PHI
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Right to receive a notice of uses/disclosures of PHI
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Right to access or receive a copy of their medical records
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Right to request a restriction to how PHI is used
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Right to request changes (amendments) to their records
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Right to receive a listing (accounting of disclosures) if requested
the same safeguards used to protect confidential patient
information should be used to protect our business and financial
information.
Standards of Conduct
 A Commitment to Laws and
Regulations
 Anti-Kickback
 Stark Laws (Physician Self-Referral
Law)
 Federal False Claims Act
 State False Claims Act
 EMTALA (Emergency Medical
Treatment and Active Labor Act)
Standards of Conduct
 A Commitment to Ongoing Monitoring
 The MHC and BRMC compliance
program
 BRMC Hot Line 989-894-3945
 BRMC Privacy Line 989-894-3970
 BRMC Compliance Officer 989-8943849