New Orleans, Louisiana
(Updated October 2014)
CODE OF BUSINESS ETHICS AND CONDUCT
Children’s Hospital’s mission is to provide comprehensive
pediatric health care, which recognizes the special needs of children through
excellence and the continuous improvement of patient care, education, research,
child advocacy and management.
Hospital’s Guiding Values
In pursuing its mission, Children’s Hospital’s actions
will be guided by its values of honesty, integrity, fairness, and adherence to
the rights of patients and the laws and regulations of this land. The purpose of this Code of Business Ethics
and Conduct is to provide guidance to our employees and medical staff in the
application of these values to our daily activities and interactions with our
patients, third party payors, fellow employees, vendors, competitors, and
Hospital has historically applied its values in all of its patient care and
business activities. However, in recent
years the health care environment has become so complex that it is now
beneficial to establish a formal Code of Business Ethics and Conduct.
The first element of the Code of
Business Ethics is putting the interests of the Hospital above our personal and
individual interests. It is in the best
interests of Children’s Hospital to avoid conflicts of interests between the
Hospital and its trustees, officers, employees, and members of its medical
staff. The Board of Trustees and the
Management of Children’s Hospital have adopted conflicts of interest policies
and these policies will be complied with in all business transactions and
relationships affecting Children’s Hospital.
Members of the Board will be asked to periodically sign conflicts of
interest statements. Any questions
regarding the conflicts of interests policies of Children’s Hospital should be
directed first to your immediate supervisor and then, if necessary, to the
Compliance Officer. (See Administrative
Policy No.2, Conflict of Interest
Values to Business Activities:
Responsibilities for Compliance
Board of Trustees and the President and CEO of Children’s Hospital are
committed to assuring Children’s Hospital’s values are applied in all the
various relationships of Children’s Hospital.
They are specifically committed to assuring that Children’s Hospital
complies with all applicable laws and regulations and have adopted this Code of
Business Ethics in an effort to prevent and detect unethical as well as illegal
conduct on the part of employees, agents and contractors of Children’s
Hospital. This commitment to ethical
behavior and compliance is to extend to all levels of the hospital including
vice presidents, department heads, managers, supervisors and line
employees. The Hospital recognizes that
the trustees, officers and employees of Children’s Hospital have a moral and
legal obligation to use all reasonable efforts to assure the Hospital acts in
compliance with applicable laws, rules and regulations. Employees have an obligation to report any
instances of suspected violations to their immediate supervisor and to make
good faith reports of suspected violations to the Compliance Officer. Managers are to be held accountable not only
for their own actions, but also for the actions of the employees they
supervise. Managers must take
affirmative steps to implement this Compliance Program. The Hospital will devote the resources
reasonably necessary to develop, implement and maintain an effective compliance
Hospital has developed this compliance program for several purposes. First, to assure its core values are
implemented in its business affairs. This plan is intended to supplement and
reinforce the hospital’s existing policies and procedures, not replace
them. Second, to emphasize that it is,
has been, and will continue to be the policy of Children’s Hospital to comply
with all laws, rules and regulations of the United
States, the State of Louisiana and all other states and political
subdivisions with which Children’s Hospital does business. Third, to provide a mechanism by which
Children’s Hospital’s employees become active and responsible participants in
the Hospital’s efforts to act ethically, legally and to prevent and detect
unethical or illegal conduct.
Compliance Plan includes: the adoption
of this Code of Business Ethics and Conduct;
the appointment of a Compliance Officer; the establishment of a
Compliance Committee to assist the Compliance Officer; the establishment of a mechanism for the
reporting and investigation of suspected violations; the commitment of the resources reasonably
necessary to educate Children’s Hospital’s employees on compliance
matters; and the commitment of the
resources reasonably necessary to enforce the Compliance Plan through employee
evaluations and the Hospital’s established disciplinary procedures.
The Compliance Officer
Compliance Officer reports to the Chief Operating Officer and to the Senior
Vice President, General Counsel, Corporate Compliance Officer, for LCMC Health.
The Compliance Officer has the primary
responsibility for developing, overseeing and monitoring the implementation of
the policies and procedures adopted and enforced as part of the Compliance
Program. These responsibilities may
on a regular basis to senior management on the progress of implementation of
the Compliance Plan;
coordinating and participating in educational and training programs that
address compliance issues;
improving and revising the compliance program to address the changes in the
laws, rules, regulations of the government, both state and federal and the
policies and procedures of private payors;
the operation of Children’s Hospital compliance hotline, conducting
investigations of suspected violations of compliance in a timely manner, and
developing, implementing, and monitoring corrective measures;
human resources and medical staff functions to assure that the National
Practitioner Data Bank and the Cumulative Sanction Report have been checked
with respect to employees holding positions of substantial authority, medical
staff members and significant independent contractors;
the internal monitoring and auditing processes to reasonably assure compliance
with applicable laws, rules, regulations, and policies
· responding to all internal and external inquiries and
audit requests regarding compliance
implementing, and maintaining policies and procedures for encouraging managers
and employees to report suspected fraud or questionable activities without fear
of reprisals or retaliations for good faith reporting.
Officer shall assemble a Compliance Committee consisting of individuals having
the knowledge, expertise, and skills the Compliance Officer deems necessary to
assist in the implementation, application and enforcement of the Code of
Business Ethics and the Compliance Plan of Children’s Hospital.
members of the Compliance Committee shall act as liaisons with the various
departments of the Hospital and its subsidiaries. All hospital officers, vice presidents, department
heads, managers, supervisors and employees shall cooperate with and, upon
request, assist the Compliance Officer and/or the members of the Compliance
Committee in the performance of their respective duties. The Compliance Officer has the authority to
review any and all documents, data, information or other material relevant to
compliance activities including, but not limited to patient records, billing
records, accounts payable, accounts receivable, cost reports, working papers,
marketing activities and any and all contracts with officers, directors,
employees, agents, independent contractors and any other persons or entities
with whom the Hospital or its subsidiaries do business.
current members of the Compliance Committee are:
President, General Counsel, LCMC
Susan Knowles - Compliance Officer and Chair
– Chief Operating Officer
- Director, CHMPC
– Director of
- Director of Medical Records and Privacy Officer
Hope Williams - Director, Training & Education
Mike McSweeney - Computer Services and Security Officer
President, Human Resources
Deidre Harris– Director, Laboratory
– Director of
Laurie Bolanos -
Nurse Auditor, Physician Billing
Jessica Cahill -Controller
A. Advocacy for Patients
Hospital fosters an environment that recognizes and upholds the basic rights of
those entrusted in our care. (See
Administrative Policy No.1, Rights and Responsibilities of Patients;
Administrative Policy No. 51 Receiving and Responding to Patient Complaints;
Grievance Process, and Administrative Policy No. 59 Ethics Committee,)
Children’s Hospital recognizes the importance of caring
for and protecting our patients who are or may be the victims of neglect and/or
abuse. Whenever there is a reasonable
belief that an incident of physical, sexual, or mental child abuse and/or
neglect has occurred it shall be reported to the appropriate agency for follow
up in accordance with Hospital policies.
(See Administrative Policy No. 18, Protocol for Reporting Child Abuse
and/or Neglect, See Administrative Policy No. 132Protocol for Preventing and/or Reporting Cases of Abuse or Neglect Which
Occur to Patients While Under the Care of Children's Hospital, and
Administrative Policy No. 19, Release of Information to the Media and Film
Hospital treats all patients with dignity and respect and provides care that is
necessary and appropriate for each individual patient. Clinical care decisions
are based on patient needs and not on the patient’s race, color, creed,
religion, sex, age, health insurance or ability to pay. Children’s Hospital will comply with all
applicable laws rules and regulations relative to access to care.
Hospital adheres to the Emergency Medical Treatment and Active Labor Act
(EMTALA) and Louisiana laws LSA-R.S. 40:2113.4 with regard to emergency medical
treatment for all patients. All patients
with emergency medical conditions are treated and admitted based on medical
necessity. Patients will only be
transferred to another facility if the patient’s medical needs cannot be met at
Children’s Hospital or the patient requests a transfer. Unless a physician certifies that the
benefits of treatment at another facility outweigh the risks of transfer, a
patient transfer will occur after the patient is stabilized and has been
accepted by another health care facility.
Children’s Hospital shall accept transfers of pediatric patients from
other hospitals whenever it has the necessary staff, beds and services
available and shall not condition such acceptance on the basis of ability to
pay. (See Administrative Policy No. 54, Compliance
with Medicare Obligations in Emergency Cases)
B. Quality of Patient Care
Hospital is committed to the provision of quality care to all of our patients
and their families at all times. In
order to ensure consistent delivery of quality patient care, quality indicators
and continuous quality improvement team activities are monitored on an ongoing
basis through the Quality Assessment and Improvement Plan. The goal of the
quality review process is to provide the highest standard of comprehensive
health care to our patients.
C. Patient Privacy, Confidentiality and
about the patient’s medical condition, history, medication, and family
illnesses is required to provide optimal care to our patients. Children’s Hospital recognizes this Protected
Health Information (PHI) and Electronic Protected Health Information (EPHI)
must be held securely and in confidence.
It is a policy of Children’s Hospital that patient specific information
is not to be released to anyone outside of Children’s Hospital without a court
order, express written authorization, or as otherwise authorized by law (including
the Health Insurance Portability and Accountability Act (HIPAA) and
implementing regulations). It is the
policy of Children's Hospital that EPHI be used and maintained in accordance
with the applicable security standards outlined in HIPAA.
among authorized individuals, patient information should only be discussed on a
need to know basis. Children’s Hospital
counsels its employees not to abuse their access to confidential information or
their position to obtain confidential patient information that their job does
not require. Any violations of the
Privacy Standards and Policies are to be reported to the Privacy Officer and
violations of the Security Standards and Policies to the Security Officer.
shall be informed of their right to receive an itemized statement of billed
services prior to their discharge from the hospital. Itemized statements of billed services shall
be provided to patients within ten (10) days of discharge. Such itemized statements shall include a
brief description of the service, the date of service and the amount charged
for each service itemized in the statement.
See LSA-R.S. 40:2010.
Admitting and Discharge
decision to admit, discharge or transfer a patient shall be based upon the patient’s
medical condition and the best medical interests of the patient. Decisions to admit, discharge or transfer
shall not be based on the patient’s ability to pay or the financial interests
of the hospital.
materials, regardless of medium, shall accurately describe the services,
facilities and resources of Children's Hospital. Marketing materials shall not misrepresent
the services, facilities or resources available at Children's Hospital. Children's Hospital shall not sell any personal
health information of its patients to third parties for their marketing
In the event any of our patients or their legal
guardians have concerns regarding patient care and/or safety, Children’s
Hospital encourages them to contact the Department Supervisor or the
Administrator on Call to request assistance.
If their concerns cannot be adequately addressed through the grievance
process, they are encouraged to contact the applicable regulatory and/or
accrediting organizations such as the Joint Commission on Accreditation of
Health Care Organizations or the Department of Health and Hospitals. Contact information for these organizations
are provided on the notice of Patient
Rights and Responsibilities.
Hospital makes a good faith effort to abide by the terms agreed upon when an
agreement is entered into with an insurance carrier, health maintenance
organization, government health care program and/or managed care company.
Hospital shall take all steps reasonably necessary to meet all established
certification standards for Medicare participation through the Joint Commission
on Accreditation of Health Care Organizations (JCAHO). It is the policy of Children’s Hospital to
comply with the Medicare laws, rules and regulations applicable to prospective
payment system exempt specialty hospitals such as Children’s Hospital.
Hospital has entered into an agreement with the State of Louisiana Department
of Health and Hospitals to provide services under the state Medicaid
Program. It is the policy of Children’s
Hospital to take all steps reasonably necessary to comply with the Medicaid
laws, rules and regulations applicable to hospitals and physician practices.
Hospital has entered into an agreement to provide services for individuals
eligible for Tricare/Champus benefits according to the plan in which the
insured participates. It is the policy
of Children’s Hospital to take all steps reasonably necessary to comply with
terms and conditions of Tricare/Champus provider agreements.
4. Insurance Companies
Hospital has entered into agreements with insurance companies to provide
services to their insureds. Children’s
Hospital’s policy is to take all steps reasonably necessary to provide services
according to the terms of each contract and consistent with the medical needs
of the patients.
B. Possible Violations of Commitments
1. Fraudulent and False Billing/Billing
Hospital intends to comply with all applicable billing and reimbursement
guidelines. There are specific
departmental policies and procedures to address the appropriate means for
submitting bills and to avoid potential areas of fraud and abuse. Once an issue is detected, it shall be
determined whether the offense was a billing error or fraudulent billing
practice. The following are examples of
billing for services not rendered or equipment not used;
billing for services that are not medically necessary;
submitting duplicate billing with the intent to obtain multiple or
assignment of procedural or diagnostic codes with
to increase reimbursement or be paid for services which are not covered;
claims for services with the intent to be paid more than is allowable;
for services independently rendered by residents (PATH);
services billed separately when performed one day prior to admission rather
than consolidated with the inpatient day; and
and discharge information inaccurately reflected according to the medical
reflects the practice of using a billing code that provides a higher payment
rate than the billing code which best reflects the services provided. Children’s Hospital is committed to assigning
codes based on physician documentation.
Audits are conducted to validate coding assignment and accuracy.
HCFA Form 1500 and the U.B. contain statements by which the provider of service
affirms that the services provided to the patient were medically necessary. Thus
ordering a battery of tests when only two or three are necessary may give rise
to a false certification.
certifying that cost reports were prepared in accordance with Medicare/
regulations when one knows or should know such statement is not true gives rise
to a claim of false certification.
2. Cost Reports
substantial portion of Children’s Hospital’s business involves reimbursement by
government programs (Medicaid, Medicare, Tricare, etc.) which require reports
that summarize the Hospital’s reimbursable costs of providing patient care
related services. Children’s Hospital
maintains departmental policies and procedures to reasonably assure costs
claimed in these reports adhere to the following:
allowable and reasonable costs related to patient care are claimed;
are appropriately apportioned between program beneficiaries and other patients
so that the share borne by the program is based upon actual services received
by program beneficiaries;
will be based on accurate documentation;
will be properly classified and allocations of costs will be accurate and
discovered subsequent to submission of the cost report will be documented and
communicated to the applicable government program.
As the applicable regulations
related to cost reports are very complex, issues related to potential cost
reimbursable items or the final settlement of cost reports must be coordinated
with the controller or his/her designee.
Hospital will use all reasonable efforts to assure compliance with the Stark II
physician self-referral law (as amended in the Omnibus Budget Reconciliation
Act of 1993) which provides a physician with ownership interest or investment
interest in, or a compensation agreement with, an entity is prohibited from
making referrals to that entity for the following designated health services
[Soc. Sec. Act §1877(h)(6)]:
· Clinical Laboratory Services
· Physical Therapy Services
· Occupational Therapy Services
· Radiology or other Diagnostic Services
· Durable Medical Equipment
· Parenteral and enteral nutrients
· Prosthetics and orthotics
· Home Health Services
· Outpatient Prescription Drugs
· Inpatient and Outpatient Services
arrangements will be structured to comply with all applicable statues and
regulations and Children’s Hospital will not knowingly enter into financial
arrangements that are designed to provide inappropriate remuneration to hospital-based
prohibition against referrals is so broadly worded, there are a number of
exceptions or "Safe Harbors.” Questions
or concerns regarding physician referrals not specifically addressed in
Hospital or departmental policies and procedures are to be brought to the
attention of the Compliance Officer.
(See Administrative Policy No. 61, Affiliations/ Agreements/Contract
Hospital will use reasonable efforts to assure that any costs reimbursed by
sponsors of clinical research protocols are not passed on to the patients or
their third party payors such as Medicaid, Medicare and managed care companies.
Billing Questions and Disputes
Hospital will work in good faith to resolve any questions raised by payors
(including patients families) regarding charges imposed or bills rendered by
Children's Hospital. Payors may audit
Children's Hospital’s charges and records in accordance with applicable
Federal and State False Claims Acts
The Deficit Reduction Act of 2005 requires health
care providers annually receiving five million ($5,000,000) dollars or more in
Medicaid reimbursement to provide detailed education to their employees and
contractors on the federal and state false claims acts, civil and criminal
penalties, and whistleblower protections.
1. False Claims Act
federal Civil False Claims Act (FCA) Title 31 of the United States Code (USC) §3729 etseq. and its Qui Tam provisions (i.e., a
party who sues for and on behalf of another, in this case the Federal
Government) is the government’s most effective tool in combating fraud, waste
and abuse of federal tax dollars spent on health care. The federal government and private citizens
suing on behalf of the government annually collect hundreds of millions of
dollars from health care providers who commit fraud or abuse of the
The FCA prohibits any
person, including any company or corporation, from knowingly submitting a false
or fraudulent claim for payment or approval from any federal or federally
funded program, including, by way of example, Medicare, Medicaid, LACHIP,
TRISPAN or NIH Grants. The FCA provides
a civil penalty of not less than $5,000 and not more than $10,000, plus up to 3
times the amount of damages plus costs of litigation.
FCA defines the terms "knowing” and "knowingly” to mean that a person: i) has actual knowledge of the
information; ii) acts in deliberate ignorance
of the truth or falsity of the information; or
iii) acts in reckless disregard of the truth or falsity of the
information. Specific intent to defraud
is not required.
lawsuit to enforce the FCA may be filed against the health care provider. Any
such suit must be filed by a private citizen within six years after a
violation. If suit is filed by the
federal government it must be filed within three years of when the government
knew or should have known of the violation, but in any event no more than 10
years after the violation.
2. Qui Tam and Whistleblower Protection
31 USC §3730 a private person (called a Qui Tam Relator and also known as a
whistleblower) may file suit for and on behalf of the United States Government
for a violation of the FCA. A copy of
the lawsuit and written disclosure of substantially all the material evidence
and information the Qui Tam Relator possesses must be served on the Government
when the suit is filed in federal court.
The Government then has 60 days to join in the suit or decide not to
join. If the Government decides to join
in the suit it takes control of the lawsuit and the Qui Tam Relator may be
awarded from 15% to 25% of the proceeds from the suit or any settlement
depending on how much the Qui Tam Relator substantially contributed to the
prosecution of the lawsuit. If the Government
decides not to join the lawsuit the Qui Tam Relator may be awarded not less
than 25% nor more than 30% of the proceeds of the suit or any settlement. In addition, the Qui Tam Relator is entitled
to recover his or her reasonable expenses, including reasonable attorney fees,
if the suit is successful.
In order to bring a Qui
Tam action under the FCA, the Qui Tam Relator must be an "original source” of
the information regarding the violation of the FCA. "Original source” means an individual who
either (i) prior to a public disclosure, has voluntarily disclosed to the
Government the information on which allegations or transactions in a claim are
based, or (2) who has knowledge that is independent of and materially adds to
the publicly disclosed allegations or transactions, and who has voluntarily
provided the information to the Government before filing the Qui Tam
FCA provides protection for whistleblowers.
It provides that any employee who is discharged, demoted, suspended,
threatened, harassed, or in any other manner discriminated against in the terms
and conditions of employment by his or her employer because of lawful acts done
by the employee on behalf of the employee or others in furtherance of an action
under the FCA, including investigation for, initiation of, testimony for, or
assistance of an FCA action filed or to be filed under the FCA, shall be
entitled to all relief necessary to make the employee whole. Such relief shall include reinstatement with
the same seniority status the employee would have had absent discrimination,
two times the amount of back pay, interest on the back pay, and compensation
for any special damages sustained as a result of the discrimination, including
litigation costs and reasonable attorney’s fees.
38 of Title 31 of the United States Code 31 USC §3801 etseq. also
provides administrative remedies for false claims and statements. This legislation prohibits the making of any
false claims or false, fictitious or fraudulent written statements to a federal
authority. A written statement is false
if it omits a material fact and is false,
fictitious, or fraudulent as a result of such omission and is a statement in
which the person making, presenting, or submitting such statement has a duty to
include such material fact; a written statement is also false if is for payment
for the provision of property or services which the person has not provided as
Federal authorities include, but are not limited to, the United States
Department of Health and Human Services (DHHS).
of this act are investigated and prosecuted by the Office of the Inspector
General (OIG) of DHHS. The OIG may bring
an action before an administrative law judge to enforce this act. This act is used to recover smaller amounts
of money, typically under $150,000 and permits DHHS to withhold such funds from
any reimbursement amounts lawfully owed to a health care provider.
4. Related State Law Provisions
1997, the Louisiana Legislature enacted the Medical Assistance Programs
Integrity Law, Louisiana Statutes Annotated-Revised Statute (R.S.) 46:437.1 etseq.
to combat and prevent fraud and abuse committed by some health care providers
participating in the medical assistance programs. This state law contains many provisions that
are similar to the Federal False Claims Act and related statutes.
46:438.2 entitled Illegal Remuneration states that no person shall
solicit, receive, offer or pay any remuneration (i.e., kickbacks, bribes, rebates
or bed hold payments) directly or indirectly, overtly or covertly, in cash or
in kind: i) in return for referring an individual to a
health care provider or to another person for the purpose of referring an
individual to a health care provider;
ii) in return for purchasing, leasing, or ordering or arranging the
purchase, lease or order of any good, supply, service or facility for which
payment may be made in whole or part by Medicaid; iii) to a recipient of goods, services or
supplies, or his representative for which payment may be made in whole or part
by Medicaid; or iv) to obtain a recipient list, number or name. The illegal remuneration statute includes
several "safe harbors” including federal safe harbors permitting certain
practices such as discounts and group purchasing arrangements.
46:438.3 entitled False or Fraudulent Claim Misrepresentation provides
no person shall i) knowingly present or cause to be presented a false or
fraudulent claim, ii) knowingly engage in misrepresentation or make, use, or cause to be made or used, a false record or
statement material to a false or fraudulent claim, iii) knowingly make, use, or
cause to be made or used, a false record or statement material to an obligation
to pay or transmit money or property to the medical assistance programs, or to
knowingly conceal, avoid, or decrease an obligation to pay or transmit money or
property to the medical assistance programs, iv) conspire to defraud, or
attempt to defraud, the medical assistance programs through misrepresentation
or by obtaining, or attempting to obtain, payment for a false or fraudulent
claim, v) knowingly submit a claim for
goods, services or supplies which were medically unnecessary, or which were of
substandard quality or quantity.
Services of substandard quality means services which fall below the
applicable standard of care.
46:438.4, Illegal Acts Regarding Eligibility and Recipient Lists, prohibits
a person from knowingly making a false, fictitious or misleading statement on a
form used for qualifying a person for Medicaid or
to receive any good, service, or supply under Medicaid which that person is not
eligible to receive. It also forbids unauthorized persons from
obtaining lists of persons who are Medicaid recipients.
46:438.5 establishes civil money penalties which may be levied against health
care providers who engage in false, fraudulent or abusive practices in
violation of state or federal laws. The
Secretary of the Louisiana Department of Health and Hospitals and/or the
Louisiana Attorney General may seek such civil money penalties from the health
46:439.1 etseq. permits a private person (Qui Tam Plaintiff) to
institute a civil suit for and on behalf of the Louisiana Medicaid Program
seeking recovery of actual damages and fines of not more than $10,000 per claim
or three times the value of the illegal remuneration, whichever is greater from
the health care provider for violations of the illegal remuneration law, the
false claims law or the illegal acts related to eligibility or recipient lists.
with federal law, the state Qui Tam Plaintiff must be an original source of the
information which serves as the basis for the alleged fraud and must serve the
Secretary of DHH or the State Attorney General once the Qui Tam action is filed
in state court.
state law [R.S. 46:439.1(G) and R.S. 46:440.3] also has protection for
whistleblowers and prohibits employers from retaliating against an employee or
other person who files a Qui Tam action.
An employee may recover all relief he is entitled to under state or
federal law, including punitive damages.
However, this protection does not apply to any employee or person who
files and action the court determines is frivolous, vexatious, or
harassing. In state Qui Tam actions, if
the Secretary or Attorney General join in the suit, the Qui Tam Plaintiff may
recover from at least 15%, but not more than 25% of the recovery depending on
how much the Qui Tam Plaintiff substantially contributed to the lawsuit. If the Secretary of DHH or the Attorney
General do not join in the suit, the Qui Tam Plaintiff shall receive an amount
between 25% and 30% of the recovery as the court determines reasonable. The Qui Tam Plaintiff may recover litigation
costs and reasonable attorney fees as well.
However, if the Secretary of DHH or the Attorney General do not join in
the lawsuit and the court determines the Qui Tam Plaintiff’s allegations were
meritless or harassing, the court shall award costs, expenses, fees and
attorney fees to the defendant health care provider.
46:440.2, Rewards for Information, states Secretary of DHH may provide a
reward of up to $2,000 to individuals providing information leading to a
recovery provided the individual is not himself subject to recovery.
5) Criminal Law Provisions
In addition to the civil
provisions discussed above, the Louisiana Criminal Code, R.S. 14:1 et seq. also
contains provisions related to Medicaid Fraud, Illegal Remuneration and
14:70.1, Medicaid Fraud, makes it a crime punishable by imprisonment,
with or without hard labor, for up to five years and/or a fine of $20,000 for
knowingly submitting false claims, false information or statements to obtain
payment or authorization from Medicaid.
14:70.5 makes it a crime punishable by imprisonment, with or without hard
labor, for up to five years and/or a fine of $20,000 for soliciting, receiving,
offering or paying any kickback, bribe, rebate or bed hold payments in return
for the referring of any patient to a health care provider, the purchasing,
leasing or ordering or arranging or recommending for purchasing, leasing or
ordering any good, supply, service or facility payable by Medicaid.
14:73.5, Computer Fraud, makes it a crime punishable by imprisonment,
with or without hard labor, for up to five years and/or a fine of up to $10,000
for accessing or causing to be accessed any computer, computer system or
network with the intent to defraud or obtain money, property or services by
means of false or fraudulent conduct, practices or representations. The computer fraud law becomes applicable
whenever someone uses a computer to fraudulently bill the Medicaid program or
any private payor.
Hospital has many policies and conducts many activities to comply with the
state and federal False Claims Acts.
These policies and activities include this Code of Business Ethics and
Conduct, our Quality Assessment and Improvement Program,utilization
review, our Patient Safety initiatives, our documentation and billing policies,
and our nurse auditor reviews. However,
our employees are the most effective means of compliance and each employee has
an obligation to inform management, the Compliance Officer or any member of the
Compliance Committee of any suspected violations of the laws related to false
claims or false statements.
A. Use of Children’s Hospital Property
Hospital’s assets and resources including time, materials, personnel, equipment,
supplies and proprietary information are to be used, preserved and maintained
for business related purposes. The
personal use of any Children’s Hospital asset without the prior approval of
your supervisor is prohibited. Any
authorized personal use of Children’s Hospital assets shall be limited to
non-commercial purposes and shall not be for personal financial gain.
regarding Children’s Hospital’s operations, including patient information,
payor information, managed care contracts, vendor contracts, financial reports
and other business information is to be preserved, protected and used solely
for purposes related to the business of Children’s Hospital. Such proprietary information shall be
disclosed only on a need to know basis and as authorized by Children’s
Hospital’s policies or as required by law.
B. Commitment to Civil Rights
maintain high standards of performance, Children’s Hospital employs only those
individuals it believes are most qualified without regard to race, color,
religion, sex, sexual orientation, gender identity, age, national origin,
handicap or disability in compliance with all federal and state laws regarding
discrimination. All employees are given
equal consideration with respect to hiring, compensation, benefits, promotions,
upgrading, training, transfers, and termination.
Hospital is committed to maintaining a work place environment in which
employees are free from sexual harassment.
Sexual harassment includes requests for sexual favors, receipt of
unwelcome sexual advances and other verbal or physical conduct of a sexual
a. as a condition of employment;
b. as a
condition or basis for the making of employment conditions affecting the
the purpose of unreasonably interfering in the employee’s performance of his or
her job functions or with the effect of creating an intimidating, hostile or
offensive working environment.
is a violation of Children’s Hospital’s policy for any employee to engage in
sexual harassment in the work place or work related situations. Employees who believe they have been sexually
harassed by any Children’s Hospital employee should report the incident
promptly to their supervisor, department head, the Human Resources Department,
or the compliance officer. Any employee
who makes a report of suspected misconduct truthfully and in good faith has the
Hospital’s assurance there will be no retaliation or retribution tolerated,
regardless of the final outcome of the investigation. Supervisory personnel should take appropriate
steps to prevent sexual harassment and to take prompt action in response to
inappropriate behavior which may constitute sexual harassment or create a
hostile work environment even in the absence of a complaint about such
C. Commitment to Employee Safety and
Hospital recognizes that its employees and medical staff are its most valuable
assets and is committed to protecting their safety and welfare.
Hospital is committed to compliance with the Occupational Safety and Health Act
including the provision of appropriate personal protection devices and training
in the correct use of personal protection devices. Children’s Hospital has established policies
and procedures relative to hazardous materials and employees’ right to know in
compliance with federal regulations.
Children’s Hospital will provide periodic training to employees in an
effort to promote safe work practices, mitigate any personal or property
damages as a result of an environmental or work place mishap, and provide for
the prompt and proper reporting of each incident to the appropriate
Hospital is committed to fair and reasonable compensation practices, including
payment of appropriate minimum wage compensation, overtime compensation,
unemployment compensation taxes and social security taxes. Supervisors are to review time records to
verify hours worked and not worked so employees are paid appropriately. Employees having concerns regarding
Children’s Hospital’s compliance with federal wage and hour laws are encouraged
to bring those concerns to the attention of their supervisor, the Human
Resources Department, or the Compliance Officer.
Hospital has established a retirement plan and self-insured health benefits
plan for its employees. Children’s
Hospital is committed to operating these plans in accordance with applicable
federal laws including the Employee Retirement Income Security Act and the
Internal Revenue Code.
4. Drug Free Workplace
Hospital’s policies prohibit the use or possession of illegal drugs on
Children’s Hospital’s property. All
personnel are prohibited from being on Children’s Hospital’s property in an
intoxicated condition whether such condition is caused by alcohol or drugs.
D. Commitment to Employee Education on
Children’s Hospital is committed to providing
initial and ongoing education for all employees regarding their responsibilities
concerning Children’s Hospital’s Corporate Compliance Plan and its Code for
Business Ethics and Conduct. New
employees will receive information and training about the plan during Core
Orientation. During the initial
training, all employees will receive a copy of the Plan as well as information
and guidance in reviewing the Plan. All
employees will sign an acknowledgment of receiving the Plan and the
acknowledgment will be maintained in each employee’s personnel file. All employees will receive training at least
annually. All training will be
documented and documentation will be maintained in the Training & Education
or Nursing Education departments.
WITH COMPETITORS AND VENDORS
Hospital has relationships and from time to time will enter into new
relationships with other hospitals and health care institutions, including
competing hospitals. It is the policy of
Children’s Hospital that these relationships and future relationships are to
comply with all applicable federal and state antitrust laws.
with competitors must be for Children’s Hospital’s valid business and strategic
purposes and must not unreasonably restrain trade or competition. Such
relationships may never seek or have the purpose of fixing prices, boycotting
other competitors or customers or dividing geographic or product markets. For example, it would not be legal for two or
more competing hospitals to agree on the minimum or maximum prices they will
charge or the amount of discounts they will agree to accept. Two or more competing hospitals may not agree
to refuse to do business with or refer patients to a third hospital. Also it would be illegal for two or more
competing hospitals to agree as to which hospital will serve a particular
geographic area or provide a particular type of health service such as neonatal
services. It should be noted that such
illegal agreement need not be in writing, indeed they rarely are. Also such agreements can be inferred from the
actions of the competing hospitals. For
these reasons, it is important to avoid discussions with employees of other
hospitals regarding: the prices we or
they charge; the services we or they offer; the customers (patients and/or
health insurance plans) we or they serve; or the geographic areas from where we
or they get patients. Remember, these
conversations or communications should be avoided even if they occur between
friends and relatives.
laws related to antitrust, unfair competition and deceptive trade practices
apply to our relationships with our patients and vendors. It is important that we are honest, straight
forward and above board in our dealings with our patients and vendors. Customers, suppliers and contractors deserve
to be and will be treated fairly and honestly at all times without deception or
discrimination and in a manner which complies with all applicable laws and good
business practices. Employees should not
make false, misleading or deceptive statements about other companies. Whenever selling or buying on behalf of the
Hospital, make certain that such decisions are based solely on the quality,
price, service, reliability and reputation of the product or service and the
needs of Children’s Hospital.
Children’s Hospital and its subsidiaries are nonprofit corporations we are able
to purchase pharmaceuticals at very favorable prices. However, the pharmaceuticals must be for use
by the Hospital’s inpatients, employees and employed physician practices. These pharmaceuticals are not for resale to
the general public or to for-profit health care providers. Any questions concerning resale of
pharmaceuticals should be directed to the Compliance Officer.
Hospital will inform agents and independent contractors performing substantial
services or work for or on behalf of Children’s Hospital of the Code of
Business Ethics and Conduct and will require such agents and independent
contractors to comply with the Code of Business Ethics and Conduct.
WITH THE GOVERNMENT
A. Nonprofit Tax Exempt
Hospital is organized and operated as a nonprofit organization exempt from
federal taxation under Section 501(c)(3) of the Internal Revenue Code. Tax exempt status is a privilege which comes
with certain attendant qualifications and requirements.
qualifications and requirements include that the hospital serve the interests
of the community as a whole and not to benefit the private interests of
interested parties including trustees, officers, and members of the medical
staff. For this reason the Board of
Trustees has adopted a conflict of interest policy to assure that the interest
of trustees, officers, employees and insiders are not served at the expense of
the Hospital or the community it serves.
2. Private Inurement
requirement of tax exempt status is that no part of the Hospital’s net earnings
inures or goes to private individuals.
The Hospital may not pay dividends as a for-profit stock corporation
might. All financial transactions must
be carefully reviewed by the Corporate Compliance Officer and, if necessary,
outside legal counsel to assure the Hospital’s funds are expended for
commercially reasonable purposes and at fair market rates for the benefits the
3. Community Benefit
Hospital is required to serve the interests of the community. To accomplish this the Hospital is guided by
a Board of Trustees of civic minded community and business leaders, including physicians,
who have adopted a substantial conflict of interest policy. Also, the Hospital maintains an open medical
staff and a full service emergency room which provides emergency care to
patients regardless of ability to pay.
4. Political Activities
Hospital refrains from participation in political campaigns and elections. It does not and will not make contributions
in cash or in kind to political parties or political candidates. Children’s Hospital recognizes the rights of
employees to engage in political activities; however, the employees must always
do so solely as individuals and never represent that their actions are
supported by or are on behalf of Children’s Hospital.
Hospital will be an advocate for the children it serves. It will advocate for and support, to the
extent permitted by law, social policies which improve the health and welfare
B. Regulatory Agencies
and health care organizations are subject to myriad regulations issued by
various regulatory agencies such as the Food and Drug Administration, the
Occupational Safety and Health Administration, the Environmental Protection
Agency, the Department of Labor and the Department of Health and Human Services
as well as their counterparts in state government. It is the policy of Children’s Hospital to
take all steps reasonably necessary to comply with all laws, rules and
regulations applicable to activities conducted by Children’s Hospital.
1. Food and Drug Administration
Drugs and Services
providing patient care, Children’s Hospital will take all steps reasonably
necessary to assure the use of only approved drugs and devices. Unapproved drugs or adulterated or misbranded
drugs will not be knowingly used or distributed by Children’s Hospital. Children’s Hospital employees are prohibited
from bringing unapproved drugs or devices into the United States unless they do
so in compliance with applicable import regulations and tariffs.
b. Safe Medical Devices
Hospital will take all steps reasonably necessary to assure that only safe
medical devices are used in the provision of patient care. Any substantial failure of devices to perform
as intended and any injuries caused by device failures shall be promptly reported
to the Director of Quality Assessment and Improvement and the Director of
Biomedical Services. Such device
failures shall be investigated and reported in accordance with the Safe Medical
Devices Act and applicable regulations.
c. Medical Research
Hospital’s activities in medical research are continuously expanding. These research activities shall be conducted
in accordance with the Hospital’s policies and procedures and all applicable
rules and regulations.
Hospital for many years has had an Institutional Review Board (IRB) to review
and monitor all research activities conducted at Children’s Hospital. Before engaging in any research activity at
Children’s Hospital, a researcher employed by Children’s Hospital must first
submit the research protocol and all related materials to the Office of
Research and Technology for Review by the Institutional Review Board. All LSUHSC Faculty members must first submit
to the LSUHSC Institutional Review Board for approval. If the researcher chooses to use Children’s
Hospital Patients, the faculty member must then submit LSUHSC IRB approval, the
protocol, and all related materials to Children’s Hospital Administrative
Review Committee, located in the Office of Research and Technology.
Animal Care and Use Committee
research activities using animals as research subjects must first be reviewed
and approved by the Institutional Animal Use and Care Committee to assure
humane treatment of all research subjects.
Hospital shall take all reasonable measures necessary to assure all research
activities are conducted in accordance with research protocols, applicable
requirements of the granting agencies including but not limited to the National
Health Institute and ethical principles of scientific inquiry and empirical
analysis. Scientific researchers shall
avoid conflicts of interests between themselves, Children’s Hospital, the
sponsors, and granting agencies. Any
unethical or improper conduct in research activities should be promptly
reported to the Assistant Vice President of Hospital Operations who oversees
Research and the Compliance Officer.
(iv) Institutional Biosafety Committee
research activity involving recombinant DNA or biohazardous material must be
reviewed and approved in advance by the Institutional Biosafety Committee.
2. Environmental Protection Agency
Hospital is committed to take all measures reasonably necessary to comply with
all applicable environmental regulations and to educating its employees in the
proper handling of hazardous materials and substances. Any environmental or medical waste disposal
mishaps shall be reported and disclosed promptly to appropriate local, state
and federal authorities so as to facilitate prompt and safe responses.
a. Hazardous Materials
Hospital has established policies and procedures for the proper handling,
storage and disposal of hazardous substances and materials. The Hazardous Materials Plan has been
developed to comply with all applicable rules and regulations. It should be consulted if any questions
arise. It is Children’s Hospital’s
policy to comply with federal and state environmental laws, rules and
b. Medical Wastes
unavoidable result of providing patient care is the generation of medical
wastes, including infectious and biohazardous wastes. The medical waste shall be handled,
processed, stored, transported and disposed of consistent with applicable rules
RECORDS AND RECORDS RETENTION
Hospital has established policies and procedures which address the accuracy of
documents and records and apply to all employees. Employees must record and report information
accurately and honestly. This includes
accurate reporting of time worked, business expenses incurred, research test
results, laboratory results, patient charts, revenues and cost and other
associated business activities. Hospital
records are subject to audit. Hospital
financial records should be maintained in accordance with generally accepted
dishonest reporting, both internal and external, will not be tolerated. This includes reporting or organizing
information in an attempt to deceive the recipient. No entry shall be made on the Hospital’s
books and records which intentionally disguises or hides the true nature of any
event or transaction. Additionally, all
of Children’s Hospital’s business shall be reported and accounted for. No undisclosed or unrecorded fund or account
may be maintained for any reason. No
false or misleading statement or entries may be made in the documents and
records of Children’s Hospital.
Medical and business records are retained in
accordance with the law and our record retention policy. Medical and business records include paper
documents such as letters and memos, electronic information on disk or tape,
and any other medium that contains information regarding business activities.
Hospital has established user friendly, accessible mechanisms in place to aid
employees in reporting possible violations of the Code of Business Ethics and
Conduct of its Corporate Compliance Plan.
Reports of possible violations or concerns can be made anonymously
through the Magic Box located at the information desk in the hospital lobby or
by leaving a message on the Compliance Hotline (504/896-9845). Possible violations or concerns may also be
reported by contacting the Compliance Department at 504/894-5395 or by email at
employee having or obtaining knowledge of behavior which is in conflict with
Children’s Hospital’s Code of Business Ethics and Conduct is encouraged to
report such knowledge to first their superior and then to the Compliance
Officer. This includes such behavior by
any Hospital employee, physician, independent contractor, outside vendor or any
entity with which the Hospital conducts business. Any employee needing guidance on or
clarification of the Code of Business Ethics and Conduct is encouraged to call
the Compliance Officer.
A. Reports to Superiors
employee who may suspect unethical or illegal behavior in any area is
encouraged to discuss their concerns with their superiors so that such issues
may be forwarded to the Compliance Officer.
It is recommended that employees report to their immediate supervisors,
providing the nature of their suspicions allow for this. Should the employee feel more comfortable
reporting to another manager or directly to the Compliance Officer, this is
certainly acceptable. Any manager
receiving a report of suspected misconduct should forward the information
directly to the Compliance Office to be handled appropriately.
B. Report to Compliance Office
have the option of reporting suspected violations to the Compliance Office through
the use of the MAGIC box located at the information desk in the lobby, by
calling the Compliance Officer at (504) 894-5395, by calling the Compliance Hotline
at (504) 896-9845, or by reporting their compliance concerns via email at email@example.com.
A detailed account of the suspected
misconduct will be taken and documented on the form
entitled Notification of Compliance
Concern. The Compliance Officer will
then proceed with an investigation into the reported situation. An investigation will be initiated within two
weeks of receipt of the reported concern. The results of the investigation will
be documented on the form entitled Compliance Investigation Report. Upon
completion of the investigation, the reporting employee, if identified, will be
informed of the findings. An anonymous reporter who wishes to
obtain an update on the matter can contact the Compliance Officer two weeks after
initially reporting the concern. To the extent possible and appropriate, an
update will be provided.
C. Confidentiality of Reports
every effort will be made to maintain confidentiality of any person reporting a
situation to the Compliance Office, such confidentiality cannot be
guaranteed. The identity of the reporter
may have to be disclosed to appropriate authorities if the situation warrants. Children’s Hospital employees have a duty to
report any potential misbehavior, whether this report is to their superior or
directly to the Compliance Officer.
D. Non-retaliation for Good Faith
employee who makes a report of suspected misconduct truthfully and in good
faith has the Hospital’s assurance there will be no retaliation or retribution
tolerated, regardless of the final outcome of the investigation.
of Care Concerns
members of the Medical Staff and Employees are encouraged to bring any issues
regarding quality of care rendered such as medication errors, missed or omitted
treatments or therapies and any substandard practice (i.e. a breach of JCAHO or
College of American Pathologist standards) to the attention of supervisors or
department managers. If the member of
the Medical Staff or Employee believes these issues are not being adequately
addressed by the Hospital, they should report the matter to the appropriate agency
(i.e. JCAHO, CARF, CAP, etc). Members of
the Medical Staff and/or employees making any such reports in good faith will
not be subject to retaliatory treatment or discipline by Children's Hospital.
TO GOVERNMENT AUDITS AND INVESTIGATIONS
Periodically Children’s Hospital receives requests
for information from governmental agencies and departments relating to the
services the Hospital provides and to whom such services are provided. These inquiries may take several forms, i.e.
subpoenas, records requests, correspondence, telephone calls and personal
interviews.The Compliance Department should be
notified of any external audit requests or request for monetaryrecoupments
in order to determine if internal auditing and monitoring is necessary. It is
the policy of Children’s Hospital to comply with all applicable laws and to
cooperate withlawful and reasonable requests from
state and federal authorities. However, the legal rights of Children’s
Hospital, its employees and patients must be protected and preserved.
A. Internal Investigations
legal counsel will lead any internal investigation to give the Hospital benefit
of attorney-client privilege. If an
accountant or consultant is needed, normally legal counsel will arrange for one
to extend the attorney-client privilege to other professionals.
B. Investigations by Government Agencies
communication by a government agency should immediately be reported to the
employee’s supervisor, who will evaluate the report to determine if it was in
the ordinary course of business or if it necessitates intervention by
management or legal counsel. If
communication is investigative, it shall also immediately be reported to the
Compliance Officer and the President and CEO.
should always treat any investigation seriously, ask to see identification if
not offered, be business-like, courteous and not solicitous, and attempt to
find out in specific detail what the investigator is seeking and how the
employee fits in. Do not speculate or
guess about information you do not personally know. Get all information you reasonably can as to
what the investigator seeks, and take as detailed notes as possible.
not destroy, lose or alter any document at any time. Always maintain copies of all documents taken
from your possession, and for a search warrant, an inventory of all items or
to Government Attempts to Interview Employees
is Children’s Hospital’s policy to cooperate as much as possible with
governmental investigations of suspected wrongdoing by employees, officers, or
agents of the Hospital. However, the
Hospital also desires to protect its attorney-client privilege as much as
possible unless and until it becomes advisable to waive it. Accordingly, when employees are approached
regarding activities involving their work with the Hospital, the Hospital would
prefer to be notified of all such contact to the extent practical and prudent.
officers, or agents should be advised that they may decline to provide
voluntary interviews. They may also
specify the circumstances under which they are willing to be interviewed, such
as during business hours, in the office, with or without an attorney present,
etc. The decision to either agree or
decline to be interviewed is one to be made solely by each individual.
being requested for interview by government investigators may be entitled to
representation by either the Hospital’s or their own individual legal
counsel. If the Hospital’s interest
should become adverse to the employee, the Hospital’s attorney may advise the
employee that they need to obtain independent representation.
D. Miscellaneous Considerations
entity which fails to grant immediate access to a facility, or to records or
documents, upon "reasonable request” by the Secretary of Health and Human
Services, Medicaid state agencies, the Office of the Inspector General, or
state Fraud Control Units may be excluded from participation in the Medicaid
Program pursuant to 42 USC 1320a-7(b)(12).
"reasonable request” is defined as a written request made by a properly
access” means within twenty-four hours.
However, the Office of the Inspector General of HHS or a Medicare/Medicaid
Fraud Control Unit can demand access at the time of the request if there is
"reason to believe” that documents are about to be altered or destroyed (42 CFR
Children’s Hospital employees, officers and agents shall be informed of and
familiarize themselves with the foregoing Code of Business Ethics and Conduct
of Children’s Hospital and shall agree to follow this code by signing the Core Orientation Checklist Acknowledgement.