Code of

Conduct
Guidelines

Rev. 2/22
 Approved by Hospital Sisters Health System
Board of Directors

Dear Fellow Colleagues,

Hospital Sisters Health System (“HSHS”) combines quality medical care with ethical and professional business
practices. Our commitment to act consistently with honesty and integrity, by the ways in which we care for our
patients is a proud tradition.

The enclosed Code of Conduct provides guidance to ensure that we, as colleagues, providers, Board members,
business partners, contractors, and volunteers, continue to work in a manner consistent with our religious
and ethical beliefs, and professional conduct standards. The Code expresses a continuing commitment to our
mission and shared common values. Although it cannot answer every question, it outlines principles that guide
our understanding of some of the most important policies and regulations which we are expected to know and
comply with as healthcare providers. It also identifies resources to help answer questions about appropriate
conduct in the workplace. Please review it thoroughly. Your adherence to its spirit, as well as its specific provisions,
is critical to our ongoing success.

Our HSHS Code of Conduct is not a substitute for our own internal sense of fairness, honesty, and integrity. If,
in your work, you encounter a situation or behavior that goes against our values or that violates our policies
or the law, please discuss this with your leader, the Compliance Department, or submit a concern through our
confidential Compliance Line.

We thank you for your continued commitment to HSHS.

Damond Boatwright Mark A. Novak

President and Chief Vice President,
Executive Officer Corporate Compliance Officer

Table of Contents

Page
Topic Page

Introduction to HSHS ………………………………………………………………………………………………………………………......……. 3

Introduction to Compliance …………………………………………………………………………………………………………………...... 4

Section 1: Personal Accountability ………………………………………………………………………………………………………...... 5

Section 2: Getting Help and Reporting Concerns …………………………………………………………………………………. 6

Section 3: Guidance on Colleague Behavior ……………………………………………………………………………………….…. 9

Section 4: Billing ……………………………………………………………………………………………………………………………….........….. 14

Section 5: Referrals ……………………………………………………………………………………………………………………………........… 16

Section 6: Certificate of Acknowledgement …………………………………………………………………………………….……. 17

Disclaimer …………………………………………………………………………………………………………………………………………..........….. 17

2
 Introduction to HSHS
The foundational mission principles of Hospital Sisters Health System (HSHS) embody the belief that every life is
a sacred gift and every human being is a unity of body, mind and spirit. Our healthcare ministry calls upon us to
foster healing, serve with compassion, and promote wellness for all persons, with special attention to our brothers
and sisters who are poor, underserved and most vulnerable.

These principles are the basis for HSHS to provide high-quality, cost-effective and compassionate healthcare –
committed to continuing the healing ministry of Jesus Christ – in our communities in Illinois and Wisconsin.

Mission
To reveal and embody Christ's healing love for all people through our high quality Franciscan healthcare ministry.

Vision
Rooted in our Franciscan mission, we will be the unique, high-quality health system providing exceptional care,
centered on the whole person.

Core Values
Our four core values will be lived by all who work here and felt by all who use our services:

Care embodies the concern, compassion, and sensitivity with which we care for patients as individuals, on a one-
to-one basis, and one another as fellow colleagues and providers. Often it is thought of as bedside behavior but it
also belongs in business offices, cafeterias and board rooms.

Joy is the manner in which our colleagues and all who join us in our ministry seek to perform their work – the
internal fulfillment of caring for others. It is an essential ingredient in bringing a sense of hope to those who suffer.

Respect is the Franciscan respect for life from conception to death and for the dignity of each individual person. It
is a commitment to freeing and empowering each person to develop to his or her full potential.

Competence means that our work is performed and our institutions are managed with the highest level of skill
and ability. We are committed to recruiting and developing people who are competent in their work and whose
values reflect our own. Our values are an integral part of our system’s strategic plan, which provides the overall
framework for all local activities.

3
Introduction to Compliance
HSHS provides patients with excellent healthcare by combining safe quality care with ethical and professional
business practices. Organizational ethics and compliance with government and industry regulations are
responsibilities we take seriously. Compliance is knowing and following the rules and regulations that govern our
business practices and work conduct. It is vital to the success of our mission. We fundamentally believe that the
community and our patients have a right to expect that we will act within a framework of honesty and integrity. In
recognition of our corporate responsibilities, our commitment to our patients, and in alignment with our vision of
being a values driven health system, HSHS has developed a robust Compliance Program.

The guidance throughout this Code is an important component of our Compliance Program, as it highlights some
of the most important laws and policies that we are expected to know and comply with as healthcare providers.
The Code also provides guidance on what we are expected to do, if we have questions about work activity or
conduct that goes against our values or that violates our policies or the law.

All colleagues, providers, Board members, business partners, contractors and volunteers of HSHS are expected to
reflect behaviors and conduct, consistent with religious sponsorship and the articulated values of the organization.
The HSHS Compliance Program Manual describes what we are to do in certain instances, whereas the Code
of Conduct (“Code”), more generally, governs expected behaviors that guide the application of our Colleague
Handbook, as well as HSHS policies and procedures.

The Code has been approved by the HSHS Board of Directors and applies to HSHS and its affiliated subsidiaries.
Introduction to System Responsibility

HSHS has provided patients with excellent healthcare by combining safe quality care with ethical and professional
business practices. Organizational ethics and compliance with government and industry regulation are
responsibilities we take seriously. System Responsibility is knowing and following the rules and regulations that
govern our business practices and work conduct. It is vital to the success of our mission. We fundamentally
believe that the community and our patients have a right to expect that we will act within a framework of honesty
and integrity. In recognition of our corporate responsibilities, our commitment to our patients and in alignment
with our vision of being a values driven health system, HSHS has developed a System Responsibility Program.

All colleagues, administrative staff, agents, contractors, board members and volunteers of HSHS are expected to
reflect behaviors and conduct consistent with religious sponsorship and articulated values of the organization.
The Colleague Handbook and the HSHS System Responsibility Program Manual describe what we are to do in
certain instances; this Code of Conduct more generally governs expected behaviors, which guide the application
of the Colleague Handbook rules as well as other HSHS policies and procedures.

The key reason for HSHS’s existence is to be a vehicle for sharing Christ’s healing love with others. This is done
in the spirit of St. Francis, with respect for Catholic faith tradition and with regard for the dignity of all persons –
both those who serve and those who are served. Certain values guide us toward the desired behaviors: honesty,
integrity, fairness, justice, responsible stewardship and a genuine concern for others.

The guidelines addressed in this Code of Conduct (Code) are an important component of our System
Responsibility Program and express a continuing commitment to our mission and values. Our Code highlights
some of the most important laws and policies that we are expected to know and comply with as healthcare
providers. The Code also provides guidance on what we are expected to do if we have questions about work
activity or conduct that goes against our values or that violates our policies or the law.

The Code cannot answer every question, but it can serve as a starting point. If you have questions or concerns not
addressed in the Code, contact your Manager or Director. If they are unable to help, or if you feel uncomfortable
talking to your Manager or Director, call the System Responsibility Office or the confidential HSHS Values Line.
(see Section 2- Getting Help and Reporting Problems, Page 6)

The Code has been approved by the HSHS Board of Directors and applies to HSHS and its affiliated subsidiaries.

4
 SECTION 1: YOUR PERSONAL ACCOUNTABILITY
A. Who Should Read This?

- Colleagues - Contracted vendors and business

- Medical Staff Members partners
- Board Members - Volunteers

Collectively referred to (“colleagues”), hereafter, are all expected to read

How do I know if and comply with the Code. Colleagues who have questions regarding
I’m doing the right the Code should direct them to their leader, the Compliance Department
or HSHS Compliance Line. See Section 2 - Getting Help and Reporting
thing? Concerns.

B. Learning the Law

Ask yourself the
following questions: We have faith that all colleagues will perform every aspect of their job
• Is the action legal? with honesty, fairness, and integrity. All colleagues are also required
• Does the action to perform their jobs in accordance with any applicable statutory and
comply with our code regulatory requirements. Consequently, colleagues are expected to
of conduct and core complete compliance training courses, review regulatory updatesand
policies/procedures and ask questions to ensure they are performing
values? their job functions properly and within the law.
• Is the action honest?
• Will the action appear C. The Cost of Breaking the Law
appropriate to
others? Violating the law can greatly harm HSHS’s reputation and ability to
deliver safe, reliable healthcare. Violations in the healthcare industry have
• Will I be proud to tell
resulted in large fines, penalties and even prison terms. HSHS intends to
my family or friends comply with the law and help its colleagues do the same.
about this action?
D. Duty to Report or Detect an Offense
If you answer “no” to
any of the questions All HSHS colleagues have a duty to report conduct that a person should
reasonably know is unlawful, unethical or that violates the Code. Also,
then immediately
leaders have a duty to detect conduct that a person should reasonably
contact management know is unlawful, unethical or that violates the Code.
for guidance before
taking action. If you E. Enforcement and Discipline
feel uncomfortable
talking to management We have faith that no colleague will knowingly violate the law or
our standards of conduct. Intentional violations or failure to report a
please call the HSHS
suspected violation, may result in disciplinary action, up to and including
Values Line. termination.

Our Human Resources policies govern the type and severity of a

colleague’s discipline, which will depend on the exercise of HSHS’s
discretion regarding, among other things, the nature of the violation and
the colleague’s disciplinary history.

HSHS Values Line

866.435.5777 5
F. Annual Compliance Education

All colleagues are required to complete annual compliance education

and review of the Code. Failure to complete the education may result in
disciplinary action.

G. Non-Colleague Sanctions

All independent providers, contractors, and vendors are expected to

comply with the Code. Violations of the Code may result in HSHS ending
its relationship with the offending person or entity. HSHS may also institute
legal action to address resulting losses.

SECTION 2: GETTING HELP AND REPORTING CONCERNS

Most departments within a health system are subject to ever-changing rules,
which can create uncertainties about the correct way to perform our work.
If you are unsure whether your own actions (or another’s actions) are in
compliance with the law or our policies, do not struggle alone. Get help so
the situation can be promptly addressed.

A. Department Leader

Ethical legal concerns in the workplace should be promptly reported to your

leader. They can help you think through the issue and assist with taking the
appropriate action. If you are uncomfortable approaching your leader, you
may also contact the HSHS System Compliance (anonymously) through the
external HSHS Compliance Line or by reporting the matter directly to the
Compliance Department (see Sections B. Compliance Officer and C. HSHS
Compliance Line)

B. System Compliance Department

The HSHS VP, System Compliance Officer and team members are valuable
resources to colleagues seeking help with understanding internal policies
and regulations . The Compliance Department and your leader help alert
and coach colleagues about how to keep behavior and work practices
in compliance with the law. Colleagues are encouraged to contact the
Compliance Department to clarify questions or report ethical or legal
concerns.

C. HSHS Compliance Line

HSHS has established an external Compliance Line to encourage colleagues

to report knowledge of illegal or unethical acts. HSHS will protect, to the
fullest extent permitted by law, the identity of reporters who desire to
remain anonymous. HSHS will not tolerate retaliation against reporters who
act in good faith when reporting concerns or suspected problems. Reporters
will be asked to provide enough details so that their concerns can be
properly investigated. The more details given through the Compliance Line,
the easier it is to investigate concerns or answer questions.

When calling the external HSHS Compliance Line (1-866-435-5777),

colleagues are greeted by a neutral third-party who will ask for detailed
information about their concern. Callers wanting to remain anonymous will
receive a caller I.D. number to be used when calling back, to report more
details or receive a follow-up response. Callers who report anonymously will
not be contacted as their identity will remain unknown to HSHS.

6 hshsvalueline.ethicspoint.com
 To submit a) concern online, visit: http://hshsvalueline.ethicspoint.com. The
website allows for anonymous or non-anonymous reporting 24 hours a day
7 days a week. If you submit an anonymous report online you will be given a
number that you’ll need to keep if you’d like to update your case or check for
messages posted to the website.

System Compliance receives a report of all (non-HR related) concerns and

I need to report an works with the appropriate leader(s) to address.
issue to the HSHS
D. Reporting Retaliation
Values Line but
want to remain If you suspect you or another is being retaliated against for reporting suspected
misconduct, immediately contact the System Compliance Department or call
anonymous. What the Compliance Line.
should I include in
HSHS protects, to the fullest extent permitted by law, the identity of colleagues
my report? who reach out with questions and concerns. HSHS does not allow retaliation
against any colleagues who, in good faith raise concerns, ask questions,
or report suspected misconduct. If a suspected problem turns out to be
Please include as unfounded but was reported in good faith, the reporting colleague(s) will not
be subject to disciplinary action for bringing it to the attention of HSHS.
many details about
your issue as possible. E. Reporting False Information
This includes dates,
Any HSHS colleague who purposely makes a false accusation with the purpose
times, locations,
of harming another colleague or the organization, will be subject to discipline.
colleague names and The consequences of such conduct will be determined in accordance with HR
any other information policies and procedures.
that will assist System
Responsibility in SECTION 3: GUIDANCE ON COLLEAGUE BEHAVIOR
investigating the
issue. Many rules and regulations that colleagues are expected to comply with are
based on common sense notions of right and wrong such as those against
stealing, cheating, and lying. These need no technical explanation. Others,
however, are more technical and require explanation about how they may affect
your work duties.

A. Conflict of Interest

All colleagues are expected to conduct business and personal activities in a

manner that does not conflict with the interests of HSHS. “Conflict of Interest”
is any situation where an individual has an outside interest or activity that may
influence, or appear to influence, his/her ability to be objective or meet his/her
responsibilities to HSHS.

Colleagues are encouraged to be active and involved participants in the

community. The ability to pursue private interests (i.e. social, civic, commercial,
political, religious or professional)-outside of their employment or relationship
with HSHS is respected. Such activities, however, must not interfere with their
duties to HSHS, divide loyalty or allow the possibility of a Conflict of Interest.

Colleagues who work with contractors, suppliers and competitors must not
take advantage of their position to obtain personal benefits. Colleagues must
not take personal advantage of a business opportunity that may be, or appears
to be, of interest to HSHS without the approval of his/her Manager. Colleagues
must not conduct business on behalf of HSHS, with any other company in
which they have an interest, without first disclosing that interest to their leader.
Senior leaders, medical staff leaders, and Board Members are required to
complete an annual conflict of interest survey to ensure appropriate evaluation
and management of potential conflicts.
HSHS Values Line
866.435.5777 7
B. Bribes, Kickbacks, and Illegal Payments

HSHS strives to make business decisions based on sound judgment

alone. Thus, any payment that constitutes a bribe, kickback, or other
illegal payment, in any form, is strictly prohibited. Bribes or kickbacks
may include cash, as well as anything of value, or other gifts for which
the receiver does not pay fair market value or which are offered with the
intent to influence a decision on grounds not related to business merits.

Even the appearance of such dealings, damages our reputation and is

prohibited. Therefore, no colleagues shall offer, give, solicit or accept any
benefits, incentives, gifts, discounts or rewards in return for the business
or confidential information of HSHS. Accepting cash or a cash equivalent,
such as a gift certificate, is not allowed. Generally, colleagues are further
prohibited from accepting anything of value (other than bona fide salary,
wages, fees, or other compensation paid or reimbursed in the usual
course of business) from anyone in connection with the business of HSHS,
either before or after a transaction is discussed or consummated. The
cost of business entertainment must be reasonable and fully documented.
The following are examples of potentially problematic payments and
should not be offered and/or accepted without first consulting with and
obtaining the approval of the Compliance Department:

• Free or discounted services or trips without a clear business

purpose;

• Write-offs, discounts and forgiveness of debt;

• Gratuities, in any form, designed to get favorable treatment or

decisions, including those from government representatives,
patients, suppliers and distributors. (Note: Bribing government
officials is a crime punishable by severe legal penalties, including
prison); and

• Subsidized rent, subsidies for office staff, and special prices for
medical supplies or equipment.

Some payment arrangements that might otherwise violate applicable laws

may be permitted under statutory or regulatory provisions known as “Safe
Harbors.” The interpretation and application of these Safe Harbors are
complex and may lead to potentially problematic arrangements, therefore,
they shall be reviewed by System Compliance or Office of General
Counsel.

8 hshsvalueline.ethicspoint.com
 C. Vendor Gifts and Tokens

Sometimes, small gift offerings to or from vendors and business

associates are acceptable, but these should be of nominal value and not
intended to influence any business, referrals or medical decision. Refer to
the HSHS Vendor Relations Policy (RC-03).

The following examples are permissible within limits defined by HSHS

policy:

• Food, refreshments, flowers or similar perishables;

• Advertising or promotional material such as pens, pencils, note

pads, key chains, calendars and similar items;

• Discounts or rebates on merchandise or services that do not

exceed those available to other colleagues;

• Awards from civic, charitable, educational or religious

organizations for recognition of services and accomplishment; and

• Reasonable offers to attend social events

(i.e., sporting events, golf outings, meals, and charity events)
to further develop HSHS business relationships. The offer shall not
include expenses paid for any travel costs (other than in a vehicle
owned privately or by the host company) or overnight lodging.

Questions about the appropriateness of gifts shall be referred to your

leader or the Compliance Department.

D. Confidential Information

We collect information about patient medical conditions, use of

medications, and family history to provide appropriate care. We
realize the sensitive nature of this information and are committed to
maintaining its confidentiality. We do not release or discuss patient-
specific information with others unless it is necessary to serve the patient
or required by law. We do not disclose confidential information that
violates the HIPAA privacy rights of our patients unless required by law.
No colleague or provider has a right to any patient information other
than that necessary to perform his/her job. Patients can expect that their
privacy will be protected.

Confidential information is not to be shared with any person outside

of HSHS, unless that person is authorized by the law to receive such
information, or the patient has consented in writing to release the
information. Patient information shall not be discussed (in person or over
the phone) in places where unauthorized individuals can overhear it, such
as hallways, elevators, cafeteria, lobbies, restaurants, airplanes, or other
public places.

No financial or other information regarding HSHS, or any of its activities

that could reasonably be expected to affect its position in the community,
is to be disclosed to any unauthorized person until it has been made
available to the general public, in accordance with applicable disclosure
regulations and internal policies.
HSHS Values Line
866.435.5777 9
At the time of employment/contract, colleagues must sign a
confidentiality statement acknowledging HSHS’ expectation and
requirements related to confidential information. Those who end an
employment or contractual relationship with HSHS shall remain legally
responsible to protect patient privileged, confidential, financial or
proprietary information.
Occasionally, a
E. Copyright Laws
family member
Colleagues shall use their best efforts to avoid violations of federal
copyright laws, including but not limited to, laws pertaining to computer will call and ask
software and television-music licenses and use. me to provide
them with
F. Environmental Safety
information in
HSHS is committed to providing an alcohol and drug-free, safe and
positive work environment. All colleagues must follow the HSHS Drug their medical
Free Workplace policy. record. Is this
G. Management of Controlled Substances
allowed?
HSHS colleagues are expected to comply with all regulations governing
the management and distribution of controlled substances. Specifically, no
colleague or provider affiliated with HSHS may illegally divert or distribute
any controlled substances, including prescription drugs. In addition, No. You may only
expired, adulterated or misbranded pharmaceutical drugs may not be access medical
diverted or distributed. records for business
and/or health care
H. Marketing/Public Image related reasons.
The ethical content and moral impact of any advertising made for, or on Please refer your
behalf of HSHS, will be determined in accordance with social values and family member to the
in good-taste. Marketing materials shall accurately represent the services
offered by the organization, and its level of licensure and accreditation.
Health Information
Marketing materials that provide advertising services to an individual Management
physician or physician practice must comply with the HSHS Financial department to obtain
Transactions with Physicians policy. the information.
Inquiries about HSHS or its ministries, by the news media, are to be
referred to Marketing/Public Relations and/or the Administrator on call.

No colleagues will use official HSHS stationery, corporation names, and/or

a position title as endorsement for personal or non-job-related purposes.

I. Use of Social Networking & Media

HSHS respects the rights of colleagues and medical staff appointees,
allied health professionals, contracted staff and volunteers to engage in
online activity on social media sites (i.e., Facebook, Twitter, LinkedIn, etc.),
personal websites, and blogs. Any personal or professional use of Social
Media shall be in accordance with the HSHS Social Networking & Media
Policy.

J. Promote a Positive Work Environment

All HSHS colleagues should promote a workplace in which they have the
opportunity to feel respected, satisfied and appreciated. Colleagues will
be hired, promoted and compensated according to their qualifications,
performance and potential. Harassment or discrimination of any kind,
especially involving race, color, religion, creed, gender, age, national or
unacceptable in the workplace.

10 hshsvalueline.ethicspoint.com
 K. Supplier Relations
HSHS expects its colleagues, medical staff, contractors, vendors and volunteers
to comply fully with the Medicare and Medicaid Antikickback Statute. To achieve
compliance, anyone involved with proposals, bid preparations or contract
negotiations is expected to be certain that all statements, communications and
representations to prospective partners or suppliers are accurate and truthful.

L. Carefully Bid, Negotiate, and Perform Contracts

Leaders involved with the procurement of goods or services for HSHS should
treat all suppliers uniformly and fairly. In deciding among competing suppliers,
the leaders are expected to choose suppliers based on sound judgment and
professional merits such as safety, price, quality, delivery, service and reputation.
Leaders are expected to avoid even the appearance of favoritism. All transactions
and relationships between HSHS and suppliers of healthcare items or services
are to be documented in a formal written contract or purchase order. No
contract is to be signed before it is reviewed and approved in accordance with
HSHS policies and procedures including the HSHS Financial Transactions with
Physicians Policy (D-01) and Financial Transactions with Non-Physicians Policy
(A-13).

M. Patient Relations
Providing patient care includes the following:
• Assessing individuals and determining medical necessity of the care to be
What if someone provided;
asks me to do • Accurately recording patient care;
• Documenting consent and authorization as necessary; and
something I • Properly coding and billing the services and care provided.
think violates the
Code of Conduct The patient’s plan of care, use of services and clinical modalities (including tests,
treatments and other interventions) are determined solely based on appropriate
Guidelines? factors (including an assessment of need) and not determined or influenced
by any financial payments or incentives to providers. Patient care must be
necessary, appropriate and well documented. Patients are to be informed of
Don’t do it. No matter options and alternatives to care based on their needs.
who asks you to do N. Emergency Medical Screening Examination
something, if you
HSHS complies with the Emergency Medical Treatment and Active Labor Act
believe it violates
(EMTALA) (see: HSHS EMTALA Policy & HSHS EMTALA On-Call Policy) in
the Code you should providing emergency medical treatment to all patients, regardless of ability to
refuse to do it and pay. In an emergency situation, financial and demographic information will be
immediately report obtained only after the immediate needs of the patient are met. An appropriate
the request to the screening examination for all individuals who present to the Emergency
Department to identify whether an emergency medical condition exists. When
HSHS Values Line.
such a condition exits, stabilizing treatment is provided before allowing a
medically necessary, or patient requested, transfer to another facility.

O. Acute Care Admission, Transfer and Discharge

All patients are to be afforded access to medical treatment, care and service
regardless of race, color, religion, creed, sex, national origin, disability, source of
payment for care or other classifications protected by law.

A patient may be transferred from a HSHS entity to another healthcare facility

when the patient, or legally responsible person acting on behalf of the patient,
requests care elsewhere, or the services needed by the patient are not available
at HSHS. All transfers must be executed in accordance with EMTALA regulations
and HSHS EMTALA Policy.
HSHS Values Line
866.435.5777 11
P. Competitor Relations – Antitrust
Federal and state antitrust laws protect the integrity of our free enterprise
system. We believe competition must be fair and certain laws must be
followed to keep competition fair. These laws address agreements and
practices resulting in the restraint of competition. Actions that are not lawful
include, but are not limited to:

• “Fixing” or “stabilizing” prices

• “Dividing-up” markets or patient healthcare services
• Boycotting competitors or patients
• Requiring referrals from independent physician contractors

Antitrust laws are vigorously enforced. Violations may result in severe

penalties and significant fines for HSHS. Sanctions can be brought against
colleagues responsible for violating antitrust laws including substantial fines
and prison sentences.

Q. Responding to Routine Requests for Information

HSHS must regularly record, compile, maintain and submit information to
government agencies. These agencies include the Department of Health and
Human Services, Occupational Health and Safety Administration, Food and
Drug Administration, Internal Revenue Service, and other federal, state and
local agencies.

Failure to comply with the requirements of these agencies may result in

fines or imprisonment. HSHS expects all colleagues who prepare or submit
information to government agencies to do so accurately and truthfully. The
duty to provide accurate and truthful information also applies to dealings
with colleagues and others, including suppliers and private insurance
companies.

R. Responding to Non-Routine Requests from Government Agencies

The government closely monitors the healthcare industry and HSHS may
receive unexpected requests for information from local, state and federal
agencies. Requests may come directly to colleagues. If you are presented
with a subpoena, search warrant or similar request by a government official
(or there is reason to believe that the organization may be served with the
same), promptly contact your leader and/or the Compliance Department
who will ensure the request is managed in accordance with procedures
outlined in the HSHS Records Retention and Disposal Policy (RC-07) and
the Government and Regulatory or Private Investigations/Inspections Policy
(RC-20).

S. Taxes
HSHS is a non-profit organization (503c) and most of its subsidiaries and
affiliates are exempt from federal, state, and local taxes. To maintain tax
exemption, no part of an exempt organization’s earnings may benefit private
individuals, among other things. This means that HSHS must negotiate
arrangements “at arm’s length,” and must pay no more than fair market
value for goods and services. Refer all questions about tax matters to your
leader, Chief Financial Officer, Office of General Counsel or the Compliance
Department.

12 hshsvalueline.ethicspoint.com
 SECTION 4: BILLING COMPLIANCE
All HSHS business practices must comply with government regulations and
ethical standards. This can be challenging for claim development and processing,
due to the variety of reimbursement plans and programs. An important goal
of HSHS is to ensure that all claim submission activity accurately reflects the
services rendered and complies with all government regulations, and applicable
third-party-payor contractual requirements.

A. Billing for Professional Medical Services

It is a violation of HSHS policies, including HSHS False Claims Act policy, to
submit false, fictitious, or fraudulent billing claims to any payor. Colleagues
who knowingly do so are subject to HSHS’s established disciplinary policy and
procedures. Violators may also be fined and/or imprisoned.

B. Billing for Hospital/Facility Services

HSHS colleagues who deal with patient bills, claims and records are expected to
accurately report the services and supplies rendered.

While Business Office colleagues are responsible for ensuring all billing claims are
true and accurate, they rely on many other colleagues to contribute and submit
the correct information related to the services provided. . Thus, all colleagues
involved in the claim development process should be sure all information
conveyed or entered within hospital records is complete and accurate.

C. Billing Questions and Inquiries

Colleagues should submit questions about billing policies, procedures, and
requirements to their leader or the Business Office If questions or concerns
continue to exist, colleagues are encouraged to contact the Compliance
Department. D. Medicare/Medicaid Billing Compliance
Certain billing and coding practices are unacceptable because they either are or
may be perceived as, fraudulent. HSHS will not knowingly submit billing data that is
inaccurate or unsupported by proper medical documentation. Medicare and Medicaid
rules and regulations must be followed to avoid submitting false claims. Leaders shall
provide instruction on proper billing rules and procedures for their areas.

The HSHS Chief Financial Officer (or his or her designee), working with the
Compliance Officer (or his or her designee), provides training to relevant Billing
colleagues regarding fraud awareness, and Medicare and Medicaid billing
compliance.

Each colleague is expected to be diligent in handling and issuing bills. This

includes immediately reporting, to the Compliance Department, any known or
suspected submission of an improper, false, fictitious or fraudulent bill. Examples
of fraudulent billing include, but are not limited to:

1. False Claims
· No one may prepare or present claim information they know
to be false or inaccurate.
2. Misrepresenting Services Rendered
· No one may charge a higher rate than that medically justified
for any inpatient or outpatient service or item. This often involves
billing and coding issues. Under the DRG billing system, the
code of a principle diagnosis must always conform to the treating
physician’s description of the diagnosis on the patient record.
An example would be to charge for complex treatment when
simple treatment was rendered.
HSHS Values Line
866.435.5777 13
 3. Unbundling Services
· No one may submit bills resulting in the unbundling of services.
“Unbundling” is the practice of inappropriately charging separately
for services to increase reimbursement.

4. Seeking Reimbursement for Medically Unnecessary Services or

Equipment
· No one may submit any bill for services or equipment that
they know or believe to be medically unnecessary Colleagues must
submit any questions about such bills to their leader.

5. Duplicate Billing
· No one may submit more than one claim for the same service or
submit the bill to more than one primary payor at the same time.

6. Falsifying Cost Reports

· No one may prepare or submit false cost reports to third-party
payors. HSHS’ internal and external auditors are responsible for
guarding against false Cost Reports.

7. Multiple Coverage and Secondary-Payor Fraud

· No one may intentionally bill Medicare or Medicaid as a primary
payor, knowing that another insurer is primary.

8. False Statements
· No one may knowingly or willfully make false statements or My Director asked
representations, or conceal or fail to disclose required information,
to any government official or entity. me to review
medical records
9. Rejected Claims
· No one may alter a rejected claim by putting false or assumed
and fill in missing
information on it for purposes of payment (claims rejected by signatures in
Medicare and Medicaid will be monitored by the Business Office to preparation for an
identify and correct the reason for the rejection).
accreditation visit.
10. Credit Balances Is this wrong?
· No one may fail to refund a credit balance. A credit balance is
an improper or excess payment made to a healthcare provider, as
a result of a patient billing or claims processing error or
overpayment. An example of a credit balance is a scenario where a
provider is inadvertently paid twice for one service. It is absolutely wrong
for you to include a
11. Duty to Report health care provider’s
· Every colleague of HSHS has the responsibility to report any signature in a medical
instance of misconduct to their leader, the Compliance Department
or HSHS Compliance Line, or member of senior leadership.
record when the
physician did not
SECTION 5: ILLEGAL REFERRALS approve it initially.

A. Physician Relationships

All business arrangements with physicians must comply with legal requirements.
In negotiating and entering into business arrangements with physicians, HSHS
adheres to two primary rules:

1. We do not pay for referrals. We accept referrals and admissions based

solely on the patient’s clinical needs and our ability to render the needed
services. We do not pay or offer to pay anyone (colleagues, Physicians,
vendors, or other persons) for referral of patients; and
hshsvalueline.ethicspoint.com
14
 2. We do not accept payments for referrals that we make. No colleague
or any other person acting on behalf of the organization is permitted
to solicit or receive anything of value, directly or indirectly, in exchange
for the referral of patients. Similarly, when making patient referrals to
another healthcare provider we do not take into account the volume or
value of referrals that the provider has made (or may make) to us.

Violation of this policy may have grave consequences for the organization
and the individuals involved, including civil and criminal penalties and possible
exclusion from participation in federally funded healthcare programs.

Physicians are prohibited from referring Medicare patients for the Medicare
reimbursable services listed below, to any entity with which the physician or
their immediate family member has a financial relationship or compensation
arrangement (unless the relationship comes within an exception as defined by
regulation):

· Clinical Laboratory
· Physical Therapy services
· Occupational Therapy services
· Radiation Therapy services
· Radiology services (including magnetic resonance imaging, ultrasound services,
computerized axial tomography scans and positron emission tomography
scans)
· Durable Medical Equipment
· Parenteral and enteral nutrients
· Equipment and supplies
· Prosthetics, orthotics and prosthetic devices
· Home health services
· Outpatient prescription drugs, and
· Inpatient and outpatient hospital services.

HSHS Values Line

866.435.5777 15
SECTION 6: CERTIFICATE OF ACKNOWLEDGEMENT
HSHS colleagues and medical staff members must sign a Certificate of
Acknowledgement certifying that they have received a copy of the Code,
understand they are responsible for adhering to it, acknowledge their duty to
report suspected violations, and understand that non-compliance is grounds
for disciplinary action.

DISCLAIMER

The Code is not intended to and does not create contractual rights upon
any person. It is informational in nature and is used by HSHS to guide in the
exercise of its discretion. It is subject to change or revocation without prior
notice.

Hospital Sisters Health System

Code of Conduct Guidelines
Acknowledgement Form

I acknowledge that I have received a copy of the HSHS “Code of Conduct

Guidelines.” and I agree to comply with them.

I understand that each colleague, provider, volunteer, agent, consultant, or

representative is responsible for knowing and adhering to the principles and
standards of the Code.

I acknowledge that it is my duty to report any suspected violations of the law

or standards of conduct to leader or the Compliance Department.

I understand that the Code does not create contractual rights or alter my
“at will” employment or contractual arrangement with HSHS.

________________________________
Signature

__________________________________
Printed or Typed Name

_________________________________
Colleague Badge #

__________________________________
Date

16 hshsvalueline.ethicspoint.com