COMPREHENSIVE HEALTH SYSTEMS, INC.
CODE OF CONDUCT
As adopted by the Board of Directors on August 9, 2001
And modified as approved by the Board of Directors in January 2012
PURPOSE:
This Code of Conduct has been adopted by the Comprehensive Health Systems, Inc. to
provide standards by which employees (including contractors, other providers, and
vendors) of the Center will conduct themselves in order to protect and promote
organization-wide integrity. The Code is a critical component of our overall Compliance
Program. We have developed the Code to ensure we meet our ethical standards and
comply with applicable laws and regulations.
INTRODUCTION:
Statement of Policy: The Code of Conduct sets forth the policy of Comprehensive
Health Systems, Inc, which states that all employees and affiliated professional staff will
comply fully with all state and federal laws and will conduct themselves in accord with
the highest ethical standard. Employees and affiliated professional staff, and where
appropriate, contractors and other agents are expected to abide by this Code of Conduct
and related Policies and Procedures.
Staff working for Comprehensive Health Systems, Inc. who fail to provide services to
people professionally, ethically, and legally will be subject to discipline, which may
include termination of employment. Any person who learns of or suspects that someone
has violated a state or federal law, or has acted unethically or improperly, should report
that information to the Chief Executive Officer. Supervisors are charged with the
responsibility of ensuring compliance by their staff.
In addition to the standards listed below, all employees and subcontractors for
Comprehensive Health Systems Inc. must adhere to anti-kickback and referral statutes,
the False Claims Act as well as Anti-Stark Laws.
STANDARDS:
Ethical Standards – The business conducted by Comprehensive Health Systems will be
delivered in an environment with the highest ethical, legal and professional standards.
Honesty, integrity and impartiality will be demonstrated when dealing with CHS
customers, providers, vendors, regulators, competitors, community and employees. The
Governing Board, employees, and contract providers will make every effort to avoid
even the appearance of illegal, unethical or unprofessional conduct.
Billing - It is against the law and the policy of Comprehensive Health Systems, Inc. to
knowingly submit false claims for payment. Submitting a false claim might be using the
wrong billing codes, falsifying the medical record, or billing for services that were not
provided or are not medically necessary. Violations of these laws can be punished by
fines, prison or both. Providers can also be excluded from the Medicare or Medicaid
program for submitting false claims. Comprehensive Health Systems’ policy is to bill
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accurately and only for medically necessary services that are provided and documented.
Any subcontractors that perform billing services must ensure compliance with billing
requirements as well.
Oversight - We will operate oversight systems designed to verify claims are submitted
only for services actually provided and services are billed as provided. These systems
will emphasize the critical nature of complete and accurate documentation of services
provided. As part of our documentation effort, we will maintain current and accurate
medical records.
Confidentiality - All consumer information (including medical records) must be kept
strictly confidential and not released to anyone outside the Center without written patient
consent or lawful court order. Exceptions to this are noted in the Policy and Procedure
manual regarding Confidentiality. All personnel must avoid discussing confidential
information with outsiders, or where others, including family, can overhear them.
Internal access to medical records is not appropriate unless there is a legitimate, workrelated need to see the information. All staff will make every effort to comply with HIPAA
regulations as outlined in CHS policy, and in the Standards for Privacy of Individually
Identifiable Health Information (45 CFR Parts 160 and 164).
Conflicts of Interest - All personnel associated with Comprehensive Health Systems, Inc.
should avoid conflicts of interest and situations that even look like a conflict of interest.
This means that personnel should not benefit from doing business with Comprehensive
Health Systems, should not have independent relationships with those who deal with
Comprehensive Health Systems, should not use their employer's property for their
personal benefit and should not compete with Comprehensive Health Systems, Inc. Any
potential for conflict of interest should be disclosed to your supervisor.
Gifts and Favors - Gifts of entertainment from vendors should be limited to common
business courtesies which may include an occasional lunch or dinner or gift of limited
value. Monetary gifts or any favors in attempt to gain unfair influence or advantage are
never acceptable. Conversely, employees should not seek to gain influence or
advantage of a customer, potential customer or business by providing inappropriate gifts
or entertainment. Any gift should be limited in value and consistent with common
business courtesies. Giving monetary gifts is never acceptable.
Outside Business and Financial Interests - Employees, or members of their respective
families should not have substantial financial or business interest with a competitor,
customer or supplier of Comprehensive Health Systems, Inc. without first reviewing the
nature of activity with Comprehensive’s Chief Executive Officer. Each employee's
employment should be his/her first business priority. Any other employment or business
activity will be considered secondary and should not interfere with individual employee
job performance and responsibilities.
Compliance – The following are guidelines for compliance with this Code of Conduct:
A. Employees (and contract providers) are committed to complying with all federal
and state laws and regulations with an emphasis on preventing fraud and abuse.
B. Comprehensive Health Systems will conduct audits and other risk evaluation to
monitor compliance and assist in the reduction of identified problem areas
C. Comprehensive Health Systems will maintain processes to:
a. Detect Medicaid/Medicare or other third party payer compliance offenses
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b. Initiate corrective and preventive action
c. Report to appropriate oversight authorities, both professional and
regulatory, when appropriate, and
d. Address consequences for employees (and contract providers) for failure
to comply with standards, policies, and procedures.
Political Activities - Employees must ensure that employee and political activities and
contributions do not appear to represent the opinion of Comprehensive Health Systems,
Inc.
Consumer Focus - Because individuals who receive services at Comprehensive Health
Systems, Inc. are the primary focus of every activity, each employee will be committed to
continually improving our products, services and competitiveness to meet the individual
needs of the people served at Comprehensive Health Systems, Inc. In addition,
employees will seek to treat the people we serve in a manner that preserves their
dignity, autonomy, self-esteem, civil rights and involvement in their own care.
Employee Relations - Each employee is expected to perform assigned tasks in a
responsible, reliable and cooperative manner and treat each other with mutual respect,
dignity and trust.
Harassment - Everyone has the right to work in an environment free of harassment and
disruptive behavior. Harassment by anyone based on the diverse characteristics or
cultural backgrounds of those who work at Comprehensive Health Systems, Inc. will not
be tolerated. Degrading or humiliating jokes, slurs, intimidation or other harassing
conduct is not acceptable in our workplace. Any form of sexual harassment is strictly
prohibited. This includes unwelcome sexual advances, or requests for sexual favors in
conjunction with employment decisions. Moreover, verbal or physical conduct of a
sexual nature that interferes with an individual's work performance or crates an
intimidating, hostile, or offensive work environment has no place at Comprehensive
Health Systems, Inc.
Unauthorized Use or Possession of Licit and Illicit Substances
Comprehensive Health Systems forbids the use, sale, purchase, transfer, or possession
of any illegal substance, and the unauthorized use or possession of licit substances.
These acts are illegal and jeopardize the safety of employees and people served; and
reduce productivity, reliability, and trustworthiness. Consequences, per Center policy
will be adhered to in instances of these actions.
INDIVIDUAL RESPONSIBILITY:
Reporting Violations - In the event you have information about unethical or illegal
conduct, you must report this information to the Chief Executive Officer either by verbal
report or through using a Quality Improvement Form. You do not have to leave your
name, although you may if you wish. Employees may be required to substantiate any
allegations of wrongdoing. Comprehensive Health Systems, Inc. will make every effort to
maintain, within limits of the law, confidentiality of the identity of any individual who
reports possible misconduct.
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Comprehensive Health Systems, Inc. will not tolerate retaliation against staff who reports
suspected violations in good faith. Any person who attempts to retaliate will be subject
to discipline, up to and including termination.
CONCLUSION:
Each employee of Comprehensive Health Systems, Inc. is responsible to act in
accordance with the policies as set forth in this document and otherwise. Each
employee is expected to maintain the highest standards of business ethics. This
includes taking positive action to prevent or correct any improper or inappropriate acts.
Violating these policies or failing to report violations could subject an employee to
disciplinary action, up to and including termination.
Comprehensive Health Systems’ Board of Directors and Management are committed to
providing avenues through which ethical issues may be raised, reviewed and resolved
openly and honestly.
____________________________________
Signature of Employee
_____________________
Date
____________________________________
Signature of Supervisor
_____________________
Date
____________________________________
Signature of Witness
_____________________
Date
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