Code of Conduct
Table of Contents Health Plus is a not-for-profit health care plan committed to quality health care and dedicated to the health and well-being of our culturally diverse communities through partnerships with members, providers, and community-based organizations. We strive for excellence through our commitment to: I. MESSAGE FROM THE HEALTH PLUS EXECUTIVE DIRECTOR AND THE CHAIRMAN OF THE BOARD A. COMPLIANCE WITH LAWS AND REGULATIONS B. Failure to Follow the Code Health Plus takes the Code seriously. An employee’s failure to follow the Code, Health Plus policies and procedures, or applicable laws and regulations may result in serious consequences, up to and including termination, and/or criminal charges, reimbursement for losses or damages, and, where appropriate, reporting to a governmental authority. The following are some examples of actions that could result in disciplinary action: C. GUIDELINES FOR ETHICAL DECISION MAKING Health care is governed by complex, demanding, and changing laws, rules, and regulations. Sometimes the application of these rules and regulations can create uncertainty and questions. The Code of Ethics and Business Conduct helps us to resolve any concerns or questions about business ethics, integrity, and Health Plus’s expectations. D. REPORTING A POTENTIAL VIOLATION If you are not sure about a situation, or if you believe your own conduct or that of another employee may have violated Health Plus’s Code or any law or regulation, you must report the suspected violation. Your identity will be kept confidential, subject to legal limitations. E. ETHICS AND COMPLIANCE HOTLINE The Ethics and Compliance Hotline is available any time, 24 hours per day, 365 days per year. The toll-free number is: F. NON-RELATION POLOCY Health Plus has a non-retaliation policy to protect individuals who report ethical or legal issues in good faith. “In good faith” means an employee actually believes or perceives the information reported is true. Any person who, in good faith, raises concerns or allegations of possible violations of the Code, policies, procedures, laws, or regulations will not be discharged, demoted, suspended, threatened, harassed or in any other manner discriminated against in the terms and conditions of their employment. We want you to raise issues and concerns, and you may do so without any fear of retaliation or punishment. G. AT-WILL EMPLOYMENT The Code does not create a contract of employment either expressly or implied. Nothing contained in the Code is intended to alter a person’s status of “employment-at-will” or other status with Health Plus. lll. OBLIGATIONS TO OUR MEMBERS Our members are the reason we are in business. Health Plus is committed to providing access to quality, cost-effective health care services that respond to individual, family, and community needs. All contracted providers and vendors that provide services for Health Plus must conduct business consistent with the Code. lV. MARKETING PRACTICES We are committed to promoting Health Plus and educating consumers ethically. We will provide sufficient information about health insurance options, and help members make informed choices. V. PROTECTION OF CONFIDENTIAL AND PROPRIETARY INFORMATION We will protect the company’s confidential and proprietary information, as well as nonpublic information entrusted to us by employees, members, providers, and other business partners. A. MEMBER INFORMATION Confidential information also includes protected health information, or PHI. This means all individually identifiable health information or demographic information that is maintained or transmitted in any form or medium. PHI is information that: PHI includes information collected for member applications, claims information, medical information, personal information (such as address, telephone number, and birth date), and eligibility information for public programs. B. EMPLOYEE INFORMATION We will not share other employees’ personal information with other persons or entities, unless required for business operations. This includes an employee’s salary, Social Security Number, age, status, type of leave, or banking information. C. INTELLECTUAL PROPERTY AND TRADE SECRETS Intellectual property and trade secrets include all ideas, inventions, discoveries, improvements, and innovations. Health Plus owns all intellectual property that we make, create, develop, write, or conceive, on our own or with another person, while employed by Health Plus or contracted with Health Plus, if it relates or pertains in any way to Health Plus’s business. We will not disclose information about Health Plus’s intellectual property and trade secrets to people outside Health Plus. D. HEALTH PLUS BUSINESS AND “INSIDER” INFORMATION We will not give confidential or non-public Health Plus information to people outside Health Plus, including competitors, suppliers, or outside contractors, without proper authorization. This includes financial information, member lists, computer data and computer programs, and descriptions of Health Plus’s processes, policies, or operations. We will not discuss Health Plus’s potential business relationships, purchases, mergers or acquisitions, or other organizational changes with people outside Health Plus unless authorized. E. PASSWORDS We will protect and maintain the confidentiality and integrity of passwords and other personal security codes used to access our computer systems. We recognize that we are responsible for actions resulting from the use of our passwords. F. PHYSICAL SAFEGUARDS In accordance with HIPAA privacy and security regulations, state law, and our policies and procedures, we will maintain confidential business documents and information under strict control at secure work-site locations, and will store them in locked file cabinets or offices. We will protect confidential materials from disclosure when copying, faxing, mailing, e-mailing, or speaking to others. Vl. CONFLICTS OF INTEREST Whenever an employee’s personal interests, or the interests of immediate family members or close relatives, could conflict or appear to conflict with his or her job or Health Plus’s interests, the employee must report such interests to management. We will avoid any conflicts with the best interests of Health Plus and its members. Here are some examples of potential conflicts of interest that must be disclosed to management: VlI. GIFTS, GRATUITIES, AND FAVORS Employees should avoid any actions that could create a perception that favorable treatment of outside entities was sought, received, or given in exchange for a gift, gratuity, or favor. The following guidelines apply to business courtesies from vendors and other business associates: VlII. FRAUD AND ABUSE Health Plus’s reputation for integrity and our continued success depends on each of us being honest and following all laws and regulations. Fraud, dishonesty, or criminal conduct on the part of any employee, officer or director or anyone doing business with the company will not be tolerated. Fraud is knowingly lying, cheating, or withholding truth that results in an unauthorized benefit. Fraud includes but is not limited to: Abuse refers to practices that cheat or “game the system” and result in unnecessary cost to the state or federal government or to Health Plus. These include:
lX. ACCURACY OF BOOKS, RECORDS, AND PUBLIC DISCLOSURES We will ensure that all statements, communications, and representations to government agencies are accurate, complete, truthful, timely, and comply with applicable laws and regulations. A. FALSE CLAIMS ACT Under both the Federal and New York State False Claims Acts, it is illegal to knowingly present, or cause to be presented, a false or fraudulent claim or statement to the government. The term “knowingly” means acting not only with actual knowledge but also with deliberate ignorance or reckless disregard of the truth. Individuals or organizations violating the False Claims Act may be subject to large fines and possible exclusion from the right to participate in federal programs. Physicians and other providers are also subject to the False Claims Act. Health Plus has an obligation to monitor physician billing and follow-up on identified cases of potential fraud and abuse by providers. Some examples of conduct that violates the False Claims Act are: X. USE OF COMPANY RESOURCES We will use and maintain Health Plus’s assets with care and respect, guarding against misuse, waste, abuse, loss, and theft. Health Plus’s assets include, but are not limited to, corporate data, business strategies and plans, financial data, and other trade secrets or confidential information about Health Plus business or its employees. A. USE OF THE INTERNET AND OTHER ELECTRONIC SYSTEMS Health Plus’s communication systems, including electronic mail, telephones, voice-mail, fax, and the Health Plus Intranet are the property of Health Plus and are provided for the company’s business use. However, occasional personal use is permissible as long as it does not affect job performance, cause a disruption to the workplace, or otherwise violate a company rule. B. UNAUTHORIZED SOFTWARE We will follow state and federal laws pertaining to copyright protection. This includes the duplication of print materials or licensed computer software. The unauthorized copying or use of software may violate of federal copyright laws and could result in civil and/or criminal liability. Also, we must not take any of Health Plus’s commercial software products home for personal use. . Xl. CONTACTS WITH THE PUBLIC We will avoid unauthorized communications with the public or press regarding company business. If you receive an inquiry from a newspaper or television or radio reporter, refer him or her to the Director of Marketing Communications and External Affairs. Xll. POLITICAL AND CIVIC ACTIVITIES Employees are encouraged to vote and actively participate in the political affairs of their communities. These activities, however, must take place on your own time and at your own expense. Xlll. LOBBYING Health Plus’s corporate funds may not be used to support or oppose any political candidate or political party. Health Plus will not pay any person to influence or attempt to influence an officer or employee of a public agency or a member of Congress or a state, city, or other legislature (or his or her employee) in connection with the award of a federal, state, or other government contract, grant, loan, or agreement. XlV. RESPECTING OUR FELLOW EMPLOYEES Health Plus is committed to maintaining a work environment where we treat each other with honesty, dignity, and respect. Health Plus values diversity and the cultural contributions of all employees, regardless of their position, ethnicity, family status, age, race, sex, disability, religion, sexual orientation, or national origin. All employment practices are based on ability and performance.
XV. CODE OF ETHICS AND BUSINESS CONDUCT ACKNOWLEDGMENT When you begin working for Health Plus, and each year after that, you must certify that: XVl. REFERENCES FOR MORE INFORMATION Ethics and Compliance Department 1-718-840-4592
Compliance Program Code of Conduct - Doing the Right Thing!
Health Plus is committed to providing quality services, fully complying with the law, and meeting the highest ethical practices for business conduct. This commitment to our employees, members, and other business partners is consistent with the values and standards of our parent organization, Lutheran Medical Center. The ethics and compliance program adopted by the Board of Directors supports and demonstrates Health Plus’s mission and sets the norm for how we do business. Our Code of Ethics and Business Conduct is the cornerstone of our ethics and compliance program. All Health Plus employees, officers, members of the Board of Directors, volunteers, and other individuals working at or on behalf of Health Plus are responsible for following the standards of behavior outlined in the Code. No list of standards or rules can cover every possible circumstance. If you run into a situation that is not specifically addressed in this document, you should apply the overall philosophy and concepts of the Code. If you ever have a question or a concern about anything in the Code, or its applicability to a specific circumstance, please discuss it with your supervisor or the Ethics and Compliance staff, or call the Ethics and Compliance Hotline. We expect our staff to be aware of and comply with our business ethics policies. If you suspect a violation of our policies, report it to your supervisor or to the Ethics and Compliance staff. You do not have to fear retaliation or negative actions if your report was made in good faith. Whether you are a new employee or have been with Health Plus for many years, we urge you to review the Code. Our ethics and compliance program depends upon everyone’s participation and support for its continued success. .
Do the right thing!
Sincerely,
II. ABOUT THE CODE OF ETHICS AND BUSINESS CONDUCT
Health Plus is committed to providing access to quality health care in the communities we serve. To succeed in our mission, we must maintain our members’ trust as well as the trust and respect of our employees and our business partners. This trust rests on our commitment to the highest ethical standards in every aspect of our business. To preserve this trust, we must devote ourselves to maintaining high ethical standards in our relationships with our members, providers, vendors, consultants, business partners, and one another. We must live the values of integrity, honesty, fairness, and responsibility in all of our daily work activities, and, ultimately, in our provision of high quality health care services. Health Plus relies upon the integrity of its employees to comply not only with the letter of the Code of Ethics and Business Conduct (Code) but also with its spirit — and to ask questions if they are uncertain about any aspect of the Code. All Health Plus employees, officers, members of the Board of Directors, and other individuals working at or on behalf of Health Plus must comply with the Code and all federal, state, and local laws, rules, and regulations that relate to our business activities. We depend upon each employee at all times to rely upon his or her good judgment to do the right thing! The Code informs employees and those who do business with us of the conduct expected of them. Further, it enables us to identify, address, resolve, and prevent potential problems. .
Health Plus employees must know and follow the laws, regulations, and Health Plus policies that apply to their job responsibilities. Health Plus provides training to its employees on these policies, rules and regulations on regular basis. Employees are required to participate in such training and are evaluated based on that training.
This Code will be enforced at all levels, fairly and without prejudice.
If you are not sure about an action or decision, ask yourself:
If you are not sure whether an activity is wrong, speak to your immediate supervisor, or another member of management. You may also call the Ethics and Compliance Hotline or Department.
Discuss the issue with your immediate supervisor who knows you and the issues in your workplace. Your supervisor is in a good position to understand your concerns. Give your supervisor an opportunity to resolve the issue.
If you still have concerns after talking with your supervisor or if you are not comfortable discussing the matter with your supervisor, you may discuss it with the next management level.
If you still have concerns, or if you are not comfortable discussing the matter with a member of the management team, contact the Ethics and Compliance Hotline or Department.
1-800-826-6762
Calls to the hotline may be made anonymously and without fear of retaliation. The calls are not traced and the information is treated in a confidential manner, subject to the limits imposed by law. If you call, please provide as much information as you can.
The hotline is intended to supplement – not replace – our management team or other corporate resources. It is best used when you believe that you have exhausted the normal channels of reporting problems. No employee is ever discouraged from reporting an issue through the Ethics and Compliance Hotline.
You should report deficiencies, errors, or any incidents of inferior health care services provided to members to your supervisor.
We must comply with all laws, government regulations, and contractual requirements on marketing practices and consumer protection. All marketing materials must be approved internally and then by the appropriate state and city agencies prior to use. Health Plus provides trainings to its employees on policies, rules and regulations specific to their job responsibilities on regular basis. Employees are required to participate in such training and are evaluated based on that training.
We must be careful and honest in marketing. We will not engage in any of the following activities:
We are committed to using and disclosing information only for its intended purposes. Confidential and proprietary information will be accessed, used, or disclosed by employees only as needed to perform specific job responsibilities.
Confidential information includes financial data, strategic plans, policies and procedures, and employee records. If you are not sure whether or not something is confidential, ask! .
We will access and use only the minimum PHI necessary to process a claim, handle an inquiry, or otherwise perform our jobs.
We will not disclose PHI to persons outside of Health Plus unless allowed under the Health Insurance Portability and Accountability Act (HIPAA) and other applicable federal and state laws, or we have the member’s written authorization to do so. We will follow Health Plus’s policies and procedures for the handling of PHI. These requirements continue to apply even after we leave Health Plus employment.
Employees who are also our members should be given the same protections as other members.
When we deal with persons or business entities on behalf of Health Plus, we will act in the best interests of Health Plus. We must award business solely on merit, getting the best value for Health Plus, and, wherever practical, on a competitive basis. .
Employees who date other employees should be sensitive to potential conflicts of interest caused by the dating relationship, particularly if their job responsibilities involve working together or if one member of the relationship works with any information prepared or transmitted by the other. Such potential conflicts should be brought to the attention of the employees’ managers so that the managers may reassign work or modify procedures to avoid any possible conflicts. Also, managerial employees should not date employees who work in their departments. Determining whether a conflict of interest exists is not always easy to do. If you have a question regarding a possible conflict of interest, you should seek advice from your supervisor or from the Ethics and Compliance Department
For this reason, we should not give or accept gifts, payments, fees, services, discounts, valued privileges, or favors, beyond common business courtesies of nominal value.
Under no circumstances will we accept or give kickbacks when obtaining or awarding contracts, services, referrals, goods, or business. A kickback means a willful offer to receive, request, or pay anything of value, including goods or services, in order to encourage or reward referrals of business. We must never offer to or accept gifts or other items of value from government employees.
Gifts to members, potential members, and applicants must be of nominal value, approved by Health Plus, and consistent with government regulations.
If you are not sure about the appropriateness of a gift, contact the Ethics and Compliance Department.
If you are not sure about the appropriateness of a gift, contact the Ethics and Compliance Department.
We must avoid situations or conduct that involves actual or potential fraud or abuse in our internal operations.
We must ensure that payments or other benefits to providers are supported by proper documentation that the services were, in fact, provided or, in the case of capitated agreements, available.
We will ensure that all time records, expense reports, and other reports that we prepare or submit are accurate. We will establish, maintain, support, and follow internal controls designed to reasonably ensure that transactions are authorized and that data are recorded and presented in a manner that is accurate, complete, current, and reliable.
We will retain and destroy records consistent with applicable laws, regulations, contracts, company policies, and business needs. We must never misrepresent facts or falsify or suppress records that may be relevant to a legal action or governmental investigation or audit. We will consult with and follow the instructions of management and the Ethics and Compliance Department.
We will not tolerate known false statements to a government agency or other payor. Any employee who makes a deliberate misstatement to a government agency or other payor risks criminal penalties and termination of employment.
We will cooperate with all reasonable requests for information from government and regulatory agencies. In so doing, it is essential that the legal rights of Health Plus and of our personnel involved are protected. Any governmental or regulatory inquiry, subpoena, or other legal document regarding our business, whether received at home or at the work place, must be forwarded immediately to the Legal Department.
The penalty for filing a false claim, statement or concealing a material fact ranges from $5,000 to $12,000 per violation. The recoverable damages are between two and three times the value of the amount falsely received. In addition, the false claim filer may have to pay the government’s legal fees.
Individuals with knowledge of fraudulent or improper activity may file a lawsuit on behalf of the government, called Qui Tam. The Federal and New York state law prohibits retaliation against “whistleblowers” who file such lawsuits or otherwise assist the government in the prosecution of a violation of the False Claims Act. Whistleblowers may share in a percentage of the proceeds from such action or settlement. Health Plus adheres to a non-retaliation policy
Health Plus’s property also includes all equipment, furniture, vehicles, office supplies, corporate funds, credit cards, employee time, and computer supplies and software.
Company systems may not be used to send chain letters or personal broadcast messages or for viewing, sending, or receiving offensive or inappropriate materials. They also may not be used to conduct outside business or in support of any religious, political, or other outside activity not related to Health Plus’s business.
No communications using Health Plus’s communication systems are private. All such communications, and information contained on an employee’s company-issued computer or other electronic device, are subject to review by Health Plus management.
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You should not offer any information or attempt to respond to any questions posed by a reporter, no matter how innocent the question may appear. A reporter can distort even the most casual comment, however well intentioned.
Health Plus will not participate in or support any political campaign on behalf of (or in opposition to) any candidate for public office. Employees must not associate Health Plus with or imply Health Plus’s endorsement of any personal political activity.
We count on you to do the right thing!
Ethics and Compliance Officer 1-718-491-8386
Human Resources 1-718-491-8326
Marketing Communications and External Affairs (for media inquiries and contacts) 1-718-491-7493
Ethics and Compliance Hotline 1-800-826-6762
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