Compliance Reporting Options

Purpose It is the policy of Campbell County Memorial Hospital (CCMH) to fully comply with all the laws and regulations that relate to or affect the delivery of health care services and the billing for those services. These laws and regulations apply to CCMH because the Hospital receives payment for services from Medicare, Medicaid, and other government programs.

CCMH wants all employees to act in ways to protect and strengthen the Hospital’s reputation for honesty. To do so, the Hospital expects all employees to obey all laws that apply to their jobs and to help the Hospital make sure that all laws that apply to the hospital are followed.

Fraud and Abuse Compliance Program CCMH has a fraud and abuse compliance program that will help you understand your obligations and responsibilities with regard to applicable laws. The fraud and abuse compliance program also applies to business arrangements with physicians, vendors, other health care providers and other persons that may be impacted by federal or state laws relating to fraud and abuse.

Chief Compliance Officer

The Board of Trustees of CCMH has appointed Susan Novak to serve as the Compliance Officer for the Hospital. As the Compliance Officer, she is responsible for helping the hospital obey the laws that apply to it. If you have questions or concerns, you should direct them to your supervisor or to the Corporate Compliance Officer.

Code of Conduct CCMH has developed a Code of Conduct to help its employees, volunteers, and medical staff members understand the laws that apply to the Hospital and affect the way in which the Hospital must act. When the word “Hospital” is used, this means every department, service, or unit even if it is not located at the main hospital building.

The Code of Conduct has six “Principles” that explain the most important rules. Each Principle includes a discussion of the rules that employees, volunteers, and medical staff members are expected to follow.

The six Principles deal with the following issues:

1. Legal Compliance: CCMH will make every effort to ensure that all actions by the Hospital or for the Hospital are in compliance with all applicable laws.

2. Business Ethics: CCMH is committed to the highest standards of business ethics and integrity. Therefore, all employees are expected to act honestly and ethically in all business dealings. This means that CCMH employees shall not act in any way that is intended to defraud or cheat anyone of money, property, or honest services.

3. Confidentiality: CCMH employees, volunteers, and medical staff members will make every possible effort to maintain the confidentiality of patient information and other confidential information in accordance with applicable legal and ethical standards.

4. Conflicts of Interest: Hospital Trustees, managers, and employees who are in a position to influence Hospital decision-making have a duty of loyalty to the Hospital. This means that such persons must not use their position and ability to influence, to benefit personally or to help others to benefit at the expense of CCMH.

5. Business Relationships: Any business transaction with vendors, contractors, and other persons must be conducted free from gifts, favors, offers of gifts or favors, solicitation of gifts or favors, or other improper inducements in exchange for influencing or assisting in a business transaction.

6. Protection of Assets: All employees will make every effort to preserve and protect the assets of the Hospital

If you have questions about any part of the Code of Conduct, or the Principles or the rules, you should ask your supervisor or Corporate Compliance Officer (C.C.O.). If you are not comfortable with talking with your supervisor or C.C.O., please call the “Compliance Reporting Line” or fill out a Compliance Reporting form. You will not be punished for telling or asking about anything that may be not legal or that may be wrong so long as you have told the truth or with an honest belief in what you told.

What do individual employees have to do to help the hospital meet the compliance goals? Each employee is expected to read the Code of Conduct. If you have any questions, you are expected to go to your supervisor or the Compliance Officer for further information. Please ask questions, many of the issues and laws are complicated and it helps to ask questions to better understand these matters.

An employee’s failure to read, accept, and follow this Code of Conduct may lead to disciplinary action, including but not limited to termination. If an employee does not understand an issue, that employee should seek help from his or her supervisor or the Compliance Officer.

Every employee has a duty to report violations of the Code of Conduct or violations of laws to Hospital Management. The report may be made by a telephone call to the Compliance Reporting Line at 688-1568; the report may be made in writing on forms available outside Human Resources and the Cafeteria; or the report may be made directly to the Compliance Officer.