Compliance – SPECTRUM

Code of Conduct Policy

Central Florida Inpatient Medicine – CFIM recognizes that all employees, health care providers, members, affiliates and consultants must conduct ourselves in accordance with our Code of Conduct, policies, procedures, laws and regulations. Failure to do so may result in serious consequences for individual team members, medical staff members and CFIM.

Each team member has an affirmative duty to report a compliance issue and, failure to do so could result in discharge. Adherence to our Code of Conduct and our Compliance Program applies to all CFIM employees and physicians members, as well as board members, providers, volunteers and other individuals authorized to act as representatives of CFIM.

The purpose of the Code of Conduct is to assist all members in our team in maintaining high ethical standards of the corporation in all its business dealings. It will help guide you in making decisions that conform to the ethical and legal standards expected of you. While our Code of Conduct is designed to provide overall guidance, it does not address every situation. For more specific guidance, refer to your supervisor or the Compliance Officer.

The Compliance officer is a CFIM employee who in the capacity as Compliance Officer will report directly to the CFIM Board of Directors. He or she is responsible for directing and coordinating the company efforts to ensure compliance with OIG, CMS and any other governing laws, regulations and policies. The Compliance Officer will promote

Use of Compliance Hot line
Increase awareness of the principles of Integrity and Compliance
Understanding of new and existing compliance issues and related to policies and procedures

The Compliance Officer implements on-going training and education throughout the organization. The Compliance Officer is also responsible for managing the Conflicts of Interest Policy and for addressing and mitigating any conflicts that may arise with CFIM employees and suppliers and notifying and escalating any conflicts of interested to the Board for mitigation.

The Code of Conduct is a “living document” that will be updated periodically to respond to changing conditions. Questions regarding our Code of Conduct, or any issue, should first be raised by the team member to his or her immediate supervisor, then through the chain of authority up to and including the Compliance Officer. Issues can also be reported confidentially and anonymously to the Compliance Hotline as noted in this policy The Code of Conduct is not an employment contract, nor it is intended to provide any expressed or implied rights of continued employment. Conduct contrary to the Code of Conduct will results in an investigation and possible disciplinary action up to an including discharge.

The term “we”, as used in this document, is meant to refer collectively to CFIM team members, board members, providers, affiliates, volunteers, students and other individuals that are authorized to act as representatives of CFIM, both inside and outside CFIM facilities.

Communication Process and Compliance Hotline

Maintaining the ethical standards of Spectrum CFIM is the responsibility of each team member. If you become aware or of suspect a situation that might jeopardize the ethical integrity of our company, it is every person’s obligation to report the circumstances.

It is every person’s responsibility to report possible violations of laws, policies, or the Code of Conduct and is outlined as follows:

Talk to your immediate supervisor
Talk to the manager or director over your area; or
Call the confidential Compliance Hotline

What is Compliance Hotline?

CFIM Compliance Hotline is a simple, confidential way for you to report activities that may involve ethical violations and criminal conduct. The Compliance Hotline is available 24 hours a day, seven days a week.

Why is the Compliance Hotline important?

CFIM is committed to conducting business in compliance with all applicable laws. The Compliance Hotline, with the support of all team members, is an effective way to report activities that may be in violation of the law.

What should I report to the Compliance Hotline?

Call the Compliance Hotline to report violations if you have the believe that any of the following items has been, is being, or is likely to be committed:

Conflicts of Interest
Illegal activities
Medicare/Medicaid fraud and abuse
Patient’s rights
Professional Standards of practice
Fraudulent billing
Individual conduct that puts the health and safety of any individual in danger
Deliberate concealment relating to any of the above items

What are the steps I should take?

First, report your concerns to your immediate supervisor, manager or director over your area. If you suspect that your supervisor, manager or director is involved, or your previous reports have not been acted upon, call the Compliance Hotline

What happens when I make a call?

Your call to the Compliance Hotline is confidential. You will either reach the Compliance officer directly or you will be instructed to leave a message. To protect everyone involved, no disciplinary actions or legal action will be taken based only on Compliance Hotline calls. Only substantiated findings will result in action

Do I have to reveal my name?

No. You are not required to identify yourself and calls that are answered by the Compliance officer are not recorded.

What if I do not have all the facts?

Call the Compliance Hotline even if you are not sure there is a problem. The Compliance officer will investigate the information you provide, attempt to verify it and take appropriate action.

Compliance hotlines reports can be made two ways:
Via telephone:
321.397.2719

In writing, to:
Compliance Officer CFIM
525 Technology Park, Suite 109
Lake Mary, Florida, 32746

Legal Compliance

Government regulation of the healthcare industry is increasingly complex. At the same, federal and state governments have made healthcare fraud and abuse a top law enforcement priority. CFIM takes its responsibility to comply with the law very seriously and has taken steps to prevent, detect and correct legal violations. The following standards are neither exclusive nor complete. We are required to comply with all applicable laws whether they are specifically in this Code of Conduct or in policies and procedures. If you have any questions regarding the existence, interpretation or application of any law, you should contact the Compliance Officer.

Fraud and Abuse

While not an exhaustive list, the following are examples of fraud, waste and abuse:

False documentation of a diagnose or procedure code to obtain a higher rate of reimbursement
Forging or changing patient billing-related items such as making false claims, or billing for services or supplies not rendered, not medically necessary or not documented
Misrepresenting a diagnose or procedure code to obtain payment
Alteration or forgery of checks
Any misuse or theft of funds
Any irregularity in the handling or reporting financials transactions
Any irregularities of or giving or receiving payment in connection with business transactions and the giving or obtaining contracts
Falsifying or altering any record or report, such as an employment application, payroll or time record, expense account, medical record, patient record, research or data collection record
Theft or unauthorized use of furniture, fixtures, equipment, supplies, software or other property
Misleading or falsely reporting financial or operation records or books
Falsely reporting costs

If you know or suspect activity of this nature, report it immediately. If you are uncertain as to whether an activity is fraudulent, contact the Chief Compliance Officer for guidance.
Individuals who lawfully report false claims or other fraudulent conduct or who otherwise assist in an investigation, action or testimony, are protected from retaliation under both federal and state laws. We will not discriminate or retaliate against any whistle blower that files, in good faith, a civil action for false claims or participates in an investigation of CFIM.

Coding and Billing

At CFIM policies, procedures and systems have been put in place to assist with accurate billing to government payors, commercial insurance payors and patients. We ensure that coding and billing are performed accurately, in accordance with nationally recognized standards and rules. It is the responsibility of providers to ensure that the information required for proper coding accurately reflects the care provided and is documented in patients’ medical records and encounter forms.

Accurate and timely documentation also depends on the diligence and attention of physicians who treat patients at the facilities we provide services. We do not destroy any information considered part of the official medical record.We ensure that all payments and other transactions are properly documented and authorized by management. Payors should be notified of payment errors and refunds should be processed promptly and accurately.

Political Activity

If you choose to engage in any political activity, including lobbying, it is important not to give the impression that you are speaking on behalf of or representing CFIM.

Copyrights

We follow the laws regarding intellectual properties, including patents, trademarks, marketing, copyrights and software. We may not make, acquire, or use unauthorized copies of computer software unless it is specifically allowed in the license agreement.

Workplace Conduct and Employment Practices

CFIM provides equal employment opportunities to prospective and current team members, based solely on merit ualifications and abilities. We respect team members and organizational affiliates and do not discriminate in employment opportunities or practices based on race, color, religion, sex, national origin, ancestry, age, physical or mental disability, sexual orientation, veteran status or any other status protected by law.
Any behavior that interferes with a team member’s work performance or creates an intimidating, hostile or offensive work environment will not be tolerated by CFIM. Management is responsible for preventing discrimination and harassment of any kind. Everyone is responsible for respecting the rights of their fellow team members and for reporting inappropriate behavior to the appropriate parties.

Criminal Conduct

We do not tolerate or condone criminal activity with respect to any team member, business practice or service provided. If you become aware of possible criminal activity, you are required to report the circumstances to the Compliance Officer.
Any team member found to be involved in criminal conduct will be reported to the Compliance Officer. Disciplinary action will be appropriate for the offense committed up to and including discharge.
We will refer all instances of suspected criminal conduct to the appropriate governmental authorities for possible criminal prosecution.

Confidentiality

CFIM maintains the privacy and confidentiality of all sensitive information entrusted to us. We are committed to following all federal and state privacy laws and regulations. In addition, our members are responsible for signing the participation agreement that explicitly states confidentiality and records retention rules, or reading and signing CFIM Confidentiality and non-disclosure policy

Privacy of Patient Information

We do not share confidential information with anyone who does not have a legal need to know. We will safeguard patient information from physical harm and protect the privacy of patient health records according to federal, state and accreditation requirements.
We safeguard oral communications that must take place for patient care, including telephone conversations, to avoid disclosures of protected health information to unauthorized individuals.
We safeguard confidential, sensitive and proprietary information in a manner designed to prevent unauthorized disclosures.

Information Security

Information security refers to safeguarding confidential and sensitive information from damage, loss, unauthorized access or unauthorized modification. All types of information, including but not limited to patient data, payroll records, personnel files, passwords and access codes will be maintained and safeguarded to prevent unauthorized disclosures.
We maintain and monitor security systems, data back-up systems and storages capabilities to ensure that all confidential and sensitive information is maintained safely and in accordance with our Policies and Procedures, federal, state and local laws.

Record Retention and Destruction

CFIM has established policies and procedures regarding the storage and destruction of records. All records are kept for the legally required timeframe, including 10 years for Medicare for audits of the Medicare billing and indefinitely for pediatrics records. Once that time is complete, it is important to destroy the records in a timely and appropriate manner. For questions, contact the Compliance Officer.
Any records that you wish to dispose of that may contain patient, financial, or other confidential information regarding CFIM must be discarded in a shred bin. Under no circumstances should these documents be thrown in the trash.

Conflicts of Interest

Applicability

This policy applies to all Board members, healthcare providers, employees and affiliates conducted at or under the auspices of CFIM.

Conflict of Interest

A conflict of interest is defined as an actual or perceived interest by a (Healthcare provider/staff member/ board member) in an action that results in, or has the appearance of resulting in, personal, organizational, or professional gain.
A conflict of interest occurs when a healthcare professional, employee, board member or contractor has a direct or fiduciary interest in another relationship. A conflict of interest could include:

Ownership with a member of the Board of Directors/ Trustees or an employee where one or the other has supervisory authority over the other or with a client who receives services
Employment of or by a member providing services or by a member of the Board of Directors or an employee where one or the other has supervisory authority over the other or which a patient or client who receives services.
Contractual relationship with a member of the Board of Directors or an employee where one or the other has supervisory authority over the other or with a patients or client who receives services.
Creditor or debtor to a member of the Board of Directors or an employee where one or the other has a supervisory authority over the other or with a client or patient who receives services
Consultative or consumer relationship with a member of the Board of Directors or an employee where one or the other has authority over the other

The definition of conflict of interest include any bias or the appearance of bias in a decision-making process that would reflect a dual role played by a member of the organization or group.

Responsibilities

It is the interest of CFIM, its healthcare professionals, individual staff, and Board members to strengthen the trust and confidence in each other, to expedite resolution of problems, to mitigate the effect and minimize organizational and individual stress that can be caused by a conflict of interest.
Healthcare providers, board members, members, employees are to avoid any conflict of interest, even the appearance of ca conflict of interest. This organization services the community rather than only serving a special interest of a group.

The appearance of a conflict of interest can cause embarrassment to the organization and jeopardize the credibility and its ability to promote evidence-based medicine, patient engagement, quality reporting an quality patient-centered care.

Any conflict of interest, potential conflict of interest, or the appearance of a conflict of interest is to be reported to the Compliance Officer immediately.Healthcare providers, employees, and Board members are to maintain independence and objectivity with the community and organization. Every member is called to maintain a sense of fairness, civility, ethics and personal integrity even though law, regulation or custom does not require them.

III. General Policy

Board members, physicians, employees, contractors, subcontractors and any other team members providing services under Central Florida Inpatient Medicine or under the auspices of CFIM have a primary obligation to provide quality, patient-centered healthcare free of any appearance of impropriety or conflict of interest.
A “Conflict of Interest” exists when a provider’s financial interest might reasonably appear to affect or be affected by the design, conduct or reporting of the care or services provided to any of the patients receiving care by CFIM. All potential Conflicts of Interest require disclosure, evaluation and either management or elimination under this Policy.
A Conflict of Interest may exist whenever a physician, provider, employee or contractor has a Financial Interest that is not a Significant Financial Interest, participation in the endeavor will generally be permitted, subject to a conflict of management plan issued by the Office of Compliance and/or reviewed and permission granted by the Board.
Certain Conflicts of Interest are too significant to manage and must be eliminated. When a Physician, healthcare provider, member or employee makes decisions based on financial gains that jeopardize the quality of care, patientcentered decision making or intentionally circumvent patient input that affects the patient’s condition or disregard clinical protocols, the service provider may become ineligible to participate in the Company. As an exception to this policy may only be made when the Board of CFIM determines that Compelling Circumstances exist to merit an
exception and a conflict management plan is adopted to maintain integrity and serve the best interests of the patients.

IV. Disclosure

Board members, physicians, contractors and employees must submit an annual disclosure form upon request of the Office of Compliance and annually thereafter and submit a financial interest disclosure form. Disclosure to the office of Compliance is required for any direct or family ownership, from direct ownership or through an investment and any type and prevalence of financial arrangements between physicians and hospitals or healthcare providers and paid speeches,educational presentations or published articles that are sponsored by pharmaceutical company, hospitals, device makers or any care facility.

Annual Disclosures – All members, physicians, contractors and employees are required under the CFIM Policy on Conflicts of Interest to compete and return an annual disclosure form.
New Financial Interests – All members, physicians, contractors and employees must disclose any new financial interests prior to acquiring such Financial Interests as well as Contractors if required. This is important to ensure that governing decisions are not influenced by conflicting, external Financial interests.
Confidentiality – All disclosures will be kept confidential and disclosed only on a need-to-know basis as required to perform the review and evaluation required by this Policy.

V. Review and Organization

Office of Compliance Review – The office of Compliance is responsible for reviewing each disclosure of a Financial Interest held by members, physicians and employees as well as Contractors if required, and for organizing into the four categories:

(1) Disclosure where no financial interest is disclosed
(2) Initial disclosures which is not significant financial interest
(3) Initial disclosures of a significant financial interest
(4) Disclosures of a financial interest that has previously been reviewed, evaluated, and made subject to a conflict management plan issued under this policy

(1) For disclosures where no financial interest is disclosed, no further notification is required in the absence of known conflicts to serve no any committees or on the Board

(2) For initial disclosures, the Compliance Officer will identify if participation on Committees or the Board or in other capacities where the person can influence decisions should be subject to an appropriate conflict of management plan limiting participation on issues where the person has decision-making capacity that may compromise fiduciary responsibilities

(3) For initial disclosures of a significant financial interest, the Compliance Officer will issue a conflict of management plan to be submitted to the CEO and or to the Board for its review and evaluation.

(4) For disclosures of a financial interests which has been previously been reviewed and evaluated and is subject to a conflict management plan issues under this policy, the Compliance Officer may, in its discretion, approve the continuation of conflict management plan without referral if the nature and amount of the financial interest has not changed or materially increased since the issuance of the conflict management plan

VI. Acceptance of Gifts

Members, physicians, employees, Board members and their immediate family members are prohibited from accepting gifts, money or gratuities over $100.00 (one hundred dollars) within any calendar year from the following:

Persons receiving benefits or services from the organization
Any person or organization performing or seeking to perform services under contract with the organization; and
Persons who are otherwise in a position to benefit from the actions of any employee of the organization
If gifts are received, notify the Compliance Officer upon receipt of the gift stating the sender, the value in USD and the name of the recipient for the Compliance officer to review and to resolve any potential Conflict of Interest.

VII. Enforcement

Violations of this Policy are subject to disciplinary action, up to and including termination of employment or association with CFIM disciplinary Policies and Procedures.

Patient Rights and Responsibilities

A patient has the right to be treated with courtesy and respect, with appreciation of his or her individual dignity, and with protection of his or her need for privacy.
A patient has the right to a prompt and reasonable response to questions and requests.
A patient has the right to know who is providing medical services and who is responsible for his or her care.
A patient has the right to know what patient support services are available, including whether an interpreter is available if he or she does not speak English.
A patient has the right to bring any person or receive visitors of his or her choosing to the patient-accessible areas of the health care facility or provider’s office to accompany the patient while the patient is receiving inpatient or outpatient treatment or is consulting with his or her health care provider, unless doing so would risk the safety or health of the patient, other patients, or staff of the facility or office or cannot be reasonably accommodated by the facility or provider.
A patient has the right to know what rules and regulations apply to his or her conduct.
A patient has the right to be given by the health care provider information concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis.
A patient has the right to be fully informed regarding his or her health status, participate in the development and implementation of his or her plan of care, and make informed decisions regarding care.
A patient has the right to request or refuse any treatment, except as otherwise provided by law.
A patient has the right to refuse treatment and life-prolonging procedures.
A patient has the right to be free from physical or mental abuse, and corporal punishment.
A patient has the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff and to be subjected to restraint or seclusion only to ensure the immediate physical safety of the patient, a staff member, or others and to have it discontinued at the earliest possible time.
A patient has the right to written information concerning the health care facility’s policies respecting advance directives, including a copy of “Health Care Advance Directives – The Patient’s Right to Decide.”
A patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives.
A patient has the right to not have treatment or admission conditioned upon whether or not the individual has executed or waived an advance directive.
A patient has the right to have his or her advanced directive documented in his or her medical record.
A patient has the right to designate a surrogate to make health care decisions on behalf of the patient as specified under chapter.
A patient has the right to personal privacy, to receive care in a safe setting, and to be free from all forms of abuse or harassment.
A patient has the right to participate in the consideration of ethical issues that arise in his or her care.
A patient has the right to have a family member or representative of his or her choice and his or her physician notified promptly of his or her admission to the hospital.
A patient has the right to confidentiality of his or her clinical records and to access information contain in his or her clinical records within a reasonable time frame.
A patient has the right to be given, upon request, full information and necessary counseling on the availability of known financial resources for his or her care.
A patient who is eligible for Medicare has the right to know, upon request and in advance of treatment, whether the health care provider or health care facility accepts the Medicare assignment rate.
A patient has the right to receive, upon request, prior to treatment, a reasonable estimate of charges for medical care.
A patient has the right to receive a copy of a reasonably clear and understandable, itemized bill and, upon request, to have the charges explained.
A patient has the right to impartial access to medical treatment or accommodations, regardless of race, national origin, religion, handicap, or source of payment.
A patient has the right to treatment for any emergency medical condition that will deteriorate from failure to provide treatment.
A patient has the right to know if medical treatment is for purposes of experimental research and to give his or her consent or refusal to participate in such experimental research.
A patient has the right to express grievances regarding any violation of his or her rights, as stated in Florida law, through the grievance procedure of the health care provider or health care facility which served him or her and to the appropriate state licensing agency.
A patient has the right to information about procedures for initiating, reviewing and resolving patient complaints.
A patient is responsible for providing to the health care provider, to the best of his or her knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to his or her health.
A patient is responsible for reporting unexpected changes in his or her condition to the health care provider.
A patient is responsible for reporting to the health care provider whether he or she comprehends a contemplated course of action and what is expected of him or her.
A patient is responsible for following the treatment plan recommended by the health care provider.
A patient is responsible for keeping appointments and, when he or she is unable to do so for any reason, for notifying the health care provider or health care facility.
A patient is responsible for his or her actions if he or she refuses treatment or does not follow the health care provider’s instructions.
A patient is responsible for assuring that the financial obligations of his or her health care are fulfilled as promptly as possible.
A patient is responsible for following health care facility rules and regulations affecting patient care and conduct.

Concerns or Complaints

Your satisfaction is important to us. Please take the survey below to allow the person responsible for your care or their supervisor the opportunity to listen, review, and to assist you with an appropriate resolution. If your complaint is unresolved, please ask to speak to the department’s manager, director or the house supervisor in the comments section. If your concern cannot be resolved by the Spectrum Medical Partners team process indicated, please allow the facility the opportunity to address your grievance.