Why we have standards of conduct.
Our Code of Conduct provides guidance to all MyHealth First Network board members, employees, participants and providers/suppliers and assists us in carrying out our daily activities with appropriate ethical, behavioral and legal standards. The requirements apply to our relationships with patients, providers, third-party payors, independent contractors, subcontractors, vendors, consultants, volunteers and each other. The Code guidelines contained herein are considered standards that are mandatory and must be followed.
The Code of Conduct is a critical component of our overall Compliance Program. We have developed the Code of Conduct as a companion document to policies and procedures to ensure we meet our ethical standards and comply with applicable laws and regulations.
This overarching Code of Conduct does not replace professional codes or other statements of similar context. Its intended use is to compliment these existing codes while establishing our ethical, behavioral and legal standards of conduct
How would I use this Code of Conduct in my role or relationship with a MyHealth First Network initiative?
The standards set forth in the Code help to further guide you through the answers to the following questions:
• Whom should I contact if I believe there is a potential non-compliance or fraud, waste and abuse concern?
• What do I do if I believe retaliation has occurred after a concern has been raised?
• How do I contact MyHealth First Network’s compliance representatives?
• What are the ramifications if a MyHealth First Network employee, board member, participant, provider, supplier or other entity performing functions on behalf of MyHealth First Network fails to meet compliance expectations?
All employees, board members, volunteers, participants, providers/suppliers, and other entities performing functions on behalf of MyHealth First Network must read and comply with the Code of Conduct. Furthermore, anyone acting on behalf of MyHealth First Network must:
• Perform job duties in accordance with all federal and state laws or regulations that apply.
• Participate in integrity, compliance and anti-fraud program training and job-specific compliance education or departmental training as necessary for your job duties.
• Report all concerns or alleged violations promptly.
• Keep information obtained through MyHealth First Network confidential.
• Whenever in doubt about something, ask questions.
Fraud, Waste and Abuse
MyHealth First Network negotiates provider and payor-specific contracts on behalf of its participants from which it is obligated by law to correctly bill and submit claims for its services. A variety of federal and state laws and regulations govern MyHealth First Network in this regard. These laws and regulations cover areas such as fraud and abuse, provider self-referrals and medically unnecessary services. MyHealth First Network is committed to prevention, detection, correction and full compliance with laws and regulations that support proper business dealings.
Providers and suppliers have an obligation, under law, to conform to the requirements of the Centers for Medicare and Medicaid Services (CMS) and applicable state regulations. Fraud and abuse committed against these requirements may be prosecuted under various provisions of the United States Code and could result in the imposition of restitution, fines, and in some instances, imprisonment. In addition, there also are a range of administrative sanctions such as exclusion from participation in government-sponsored programs (e.g., Medicare, Medicaid, Tricare) and civil liability resulting in monetary penalties that may be imposed upon the provider. Therefore, it is the expectation that MyHealth First Network employees, board members, participants, providers, and suppliers who create, or cause to create, claims for payment from network-negotiated payor contracts will do so in a manner that is an accurate representation of the services actually provided in accordance with the conditions under which the patient received services.
It is expected that employees, board members, participants, providers, suppliers, and other entities performing functions on behalf of MyHealth First Network will report potential fraud, waste and abuse concerns.
MyHealth First Network will refer potential fraud or unlawful activities to the appropriate government or law enforcement agency, when deemed appropriate and consistent with network policy. MyHealth First Network will provide reports on fraudulent activity and misconduct as required by law.
Inducements and Referrals
It is the expectation that all MyHealth First Network employees, board members, participants, providers/suppliers, and other entities performing functions on behalf of MyHealth First Network will not engage in activities inconsistent with applicable federal regulations, specifically Stark Law and the Anti-Kickback statute. These prohibitions include providing gifts or other forms of payment to any individual in exchange for receiving or giving items and/or services from or to the network. Furthermore, financial arrangements with providers of MyHealth First Network will be in writing and reviewed by our network to ensure that the requirements of applicable laws, regulations and policies are met.
Unless otherwise indicated, MyHealth First Network, at its sole discretion, reserves the right to approve, disapprove, suspend, terminate or take whatever means necessary to assure any and all arrangements meet with regulatory compliance.
Federal and state laws prohibit MyHealth First Network from employing, retaining or conducting business with anyone who is currently excluded from participation in government programs. Background checks are conducted for new hires and published information is reviewed on a regular basis for excluded individuals. When individuals are excluded, they will not be allowed to continue as a MyHealth First Network employee, board member, participant or provider/supplier.
MyHealth First Network will not employ, contract with or bill for services ordered, rendered or supervised by an individual – or entity – who is excluded, suspended, debarred or ineligible to participate in a federal health program, or has been convicted of a criminal offense relating to the provision of health care items or services and has not been reinstated in a federal health care program.
Employees or associated persons are required to notify the MyHealth First Network Compliance Officer if any action is taken that impacts or limits their eligibility to participate in government programs.
Conflict of Interest
A conflict of interest occurs when one’s personal interests or activities are inconsistent with the best interests of the network’s operations, mission and vision.
A conflict of interest may be:
• Actual: a direct and immediate conflict between the individual’s and organization’s interest
• Potential: no immediate conflict, but possibility exists for a conflict in the future
• Appearance of: appearance of an actual or potential conflict of interest to people unfamiliar with all the facts and circumstances
• Indirect: conflicts involving family members or friends of the individual
Conflicts of interest may arise from many sources including, but not limited to: personal financial interests or those of a family member, service, employment or consulting arrangements with a network competitor, the receipt of gifts from vendors or others with whom we do business; or use of network resources to benefit an outside interest or our own personal interest.
Conflicts of interest are concerning not only because of potential legal exposure, but also the disservice it may cause the organization through its harm to the organization’s reputation and public image.
MyHealth First Network has an annual conflict of interest process for all members of the Board of Managers, committee members, and others as deemed necessary from time to time.
It is the expectation that all MyHealth First Network employees, board members, volunteers, participants, providers/suppliers, and other entities performing functions on behalf of the network report any potential conflict of interest to the MyHealth First Network Compliance Office.
MyHealth First Network provides medically necessary care without regard to ethnicity, race, color, national origin, sex, age, disability, sexual orientation or ability to pay. Decisions about medical care are based on medical appropriateness.
MyHealth First Network employees, board members, volunteers, participants, providers/suppliers, and other entities performing functions on behalf of the network are expected to respect the rights of patients, including:
• Respect and dignity
• Privacy and confidentiality
• Personal safety
• Access to care
• Information on treatment, care, and identity of those providing the care
Research with Human Participants
MyHealth First Network supports the highest ethical standards for compliance with laws and regulations applicable to research. First priority is always to protect the patients or human subjects and respect their rights during the course of treatment and research. If you are involved in human participation research, you must have training in the policies protecting rights and welfare of human participants.
MyHealth First Network will not tolerate research misconduct, including, but not limited to: falsifying data, plagiarizing other research studies, failing to properly inform participants (informed consent), or proceeding without Institutional Review Committee (IRC) approval. Any network employee or provider member engaging in human subject research must do so in conjunction with IRC approval and consistent with regulations regarding human subject research and IRC policy.
Use of property
All supplies, equipment, materials, information systems and the like, bought and owned by members of MyHealth First Network, are the property of those respective organizations and shall only be used in accordance with law, regulations and licenses in the normal course of business and for business purposes only.
MyHealth First Network and its affiliated providers shall maintain a drug-free work environment. No employee or associate should report to work or work while under the influence of controlled or illegal substances or substances of abuse. Moreover, to use, own, make, sell, provide, distribute or cause to distribute any substance of abuse or associated item illegally within the network is strictly prohibited.
Health Insurance Portability and Accountability Act (HIPAA) regulations, which protect the privacy and security of patient information, apply to all interactions with patient information. Patients have the right to expect their medical information will remain confidential. Anyone with access to MyHealth First Network patient information must have an awareness and understanding of and obey HIPAA regulations and network privacy policies.
MyHealth First Network employees, board members, volunteers, participants, providers/suppliers, and other entities performing functions on behalf of the network must not access or disclose any personal or confidential patient information unless there is a legitimate business or patient care purpose. Reasonable safeguards to protect the confidentiality of patient information must be used at all times.
In addition, confidentiality of business and proprietary information is of the utmost importance to MyHealth First Network. Sharing of confidential information with other employees or others outside the network is strictly forbidden, unless the person requesting the information has a legitimate reason to know it for MyHealth First Network business-related purposes.
Reporting a Compliance Concern
MyHealth First Network employees, board members, volunteers, participants, providers/suppliers, and other entities performing functions on behalf of the network are required to report potential compliance concerns. There are several ways to report your concerns that are designed to ensure non-retaliation and confidentiality (to the extent allowed by law) of the reporting individual.
MyHealth First Network employees, board members, volunteers, participants, providers/suppliers, and other entities performing functions on behalf of the network can report potential compliance issues or concerns using any of the following communication mechanisms:
• Report your concern to your immediate supervisor or human resource representative.
• Call the MyHealth First Network Compliance Line at 1-855-252-7606.
• Call the MyHealth First Network Compliance Office at 864-797-7726.
• Mail a letter to:
MyHealth First Network
Office of Corporate Integrity
300 E. McBee Avenue, Suite 302
Greenville, SC 29601
The Compliance Line provides a mechanism to report concerns confidentially or anonymously. Callers do not need to give their names or other identifying information when reporting a concern. The Compliance Line is operated by an independent outside firm to further protect anonymity.
No matter how the concern is reported, the MyHealth First Network Compliance Office will research and conduct a timely investigation on the matter and provide a prompt response for each report received.
MyHealth First Network has a non-retaliation policy for good faith participation in the compliance program including, but not limited to, the reporting of potential issues, investigating issues, conducting self-evaluations, audits and remedial actions, and reporting to appropriate compliance officials.
If you feel that there has been retaliation after reporting a concern, please notify the Compliance Officer directly at 864-797-7726.