Thompson Health 

Health Care Compliance Code of Conduct

Standards of conduct are a vital means of ensuring that all Affected Individuals understand their obligation to conduct themselves in a compliant and ethical manner in providing services to an organization. Thompson Health requires that all Affected Individuals1 follow the below standards in this Compliance Code of Conduct in connection with providing services of any kind for Thompson Health.

CONDUCT STANDARD NO. 1: MISSION

Thompson Health is committed to continuously improve the health of the residents and communities of the Finger Lakes and the surrounding region.

In this role, we are committed to providing the highest quality health services while exercising prudent fiscal responsibility. Utilizing the resources entrusted to us, we will follow sound management principles in our goal to attain excellence in healthcare.

At all times we will demonstrate regard for the medical needs of those we serve and promote community wellness. In fulfilling our mission, we will exhibit the highest standards of professionalism.

Our dedication of purpose will foster the creation of a caring environment for all whom we serve, without regard to personal resources or other factors not related to their healthcare status.

A complementary and abbreviated statement of our compliance standards is part of the Thompson Health Code of Ethics and Compliance Code of Conduct, available on the Intranet, under Legal & Regulatory Affairs, and is also attached at LR.01.001.00.01.

CONDUCT STANDARD NO. 2: COMPLIANCE WITH LAWS AND REGULATIONS

Thompson Health strives to operate in accordance with high legal, moral and ethical standards, whichfully recognizes justifiable expectations of the public it serves, including patients, residents, physicians, associates, vendors, contractors, lenders, and governmental entities.

• We will comply with all applicable laws, regulations, standards and other compliance requirements at all levels of government.
• We will actively participate in Thomson Health education on compliance and ethics provided by Thompson Health.
• We will not pursue any business opportunity that requires engagement in unethical or illegal activity.
• We will not tolerate payment or reimbursement practices of any kind that are false, fraudulent, inaccurate, incomplete or fictitious.
• We will maintain and, where appropriate, submit all Thompson Health business data, records, and reports in a complete, accurate and truthful manner.
• We will not tolerate fraud, kickbacks or bribes intended to induce patient or resident referrals or admissions.
• Patients and residents will be admitted, receive treatment and be discharged in accordance with all federal, state and local laws and regulations, and Thompson Health policies, procedures and ethical standards.
• Associates who do not comply with the above requirements will be subject to discipline, under the Thompson Health progressive discipline policy, up to and including termination from employment. See Associate Handbook, Section 3.14.
• All board members, agents, contractors, subcontractors, independent contractors, vendors, medical staff and volunteers are also required to comply with the above requirements, and a failure to do so will result in applicable sanctions given their role at Thompson Health, including but not limited to, termination of any contract.

CONDUCT STANDARD NO. 3: CONFLICTS OF INTEREST

All Thompson Health associates as well as Board of Directors members will refrain from and avoid conflicts or appearance of conflicts between private interests and their responsibilities to the health system. See LR.05.015 Conflict of Interests Policy.

We will avoid engaging in any activity, practice or act which conflicts with the interests of Thompson Health or its patients.

We will not accept gifts, gratuities, compensation, remuneration or entertainment, which might influence, or might reasonably be perceived by others to influence, our judgment or actions as associates of Thompson Health. See LR.05.027 Gifts, Gratuities and Improper Inducement Policy.

Thompson Health will make no corporate contributions, gifts or donations to any political party or candidate for office.

We ensure that any funds provided to support healthcare are provided for bona fide purposes.

CONDUCT STANDARD NO. 4: SAFEGUARDING RESOURCES AND INTERESTS OF THOMPSON HEALTH

Thompson Health will protect its assets, and the assets of others entrusted to it, against loss, theft, destruction, misappropriation and misuse, including physical property and proprietary information.

All Affected Individuals are responsible for protecting Thompson Health's confidential patient and proprietary information.

We will be responsible and accountable for the proper expenditure of funds and for the proper use of property.

We will hold contractual terms, the names of Thompson Health patients and residents and the nature of Thompson Health's dealings as confidential matters.

We will use computer systems, networks and software for only authorized and appropriate purposes.

We will ensure that drugs and other pharmaceuticals are safely stored, secured, and inventoried and that missing supplies are promptly reported.

CONDUCT STANDARD NO. 5: MAINTAINING A SAFE HEALTH CARE ENVIRONMENT

Thompson Health is committed to operating in an environment that provides for the health, safety, privacy and comfort of all patients, residents, medical staff, visitors and associates.

• We will comply with all applicable laws and apply due diligence and care to minimize the general discharge and disposal of medical waste and other hazardous materials.
• We will maintain a drug-free, smoke-free environment.
• We will promote courteous and appropriate behavior toward and from our patients and visitors.
• We will report to our supervisor any practice or condition that may violate any rule, regulation, policy or safety standard.
• We will report all unusual events or accidents, by both verbal and written form, which involve patients, visitors or Affected Individuals in a timely manner.
• We will respect the privacy and confidentiality of everyone.
• We will utilize all required safety equipment, follow all safety procedures and attend all safety training sessions as dictated by Thompson Health policy 

CONDUCT STANDARD NO. 6: CONSIDERATION OF HUMAN RESOURCES

Thompson Health will protect, support and develop its human resources to the fullest of their potential in a fair and equitable manner.

• Appropriate training and education will be provided to all Affected Individuals.
• Proper respect and consideration will be shown for all Affected Individuals.
• We will provide opportunities for professional satisfaction, pride of work, and career growth for our associates.
• We will ensure that Affected Individuals are afforded nondiscriminatory terms, conditions and privileges in accordance with laws, regardless of race, color, sex, age, disability, religion, citizenship, national origin, ancestry, military status or veteran status, marital status, sexual orientation, gender identity, domestic violence victim status, predisposing genetic characteristics and genetic information, and any other status protected by law.
• We will not tolerate discriminatory treatment or unlawful harassment.
• We will comply with all applicable laws and regulations related to human resources.

CONDUCT STANDARD NO. 7: CODING AND BILLING INTEGRITY

Thompson Health is committed to the proposition that all payments and other transactions must be accurate, complete, properly documented and authorized by management. We are committed to ensuring that billing practices comply with all federal and state laws, regulations, guidelines and policies.

• We will not knowingly file a claim or bill for services that were not rendered or were not rendered as described on the claim form or statement.
• We will not file a claim for services that were rendered but were known to be medically unnecessary.
• We will not knowingly submit claims for payment that were not properly coded, documented or billed according to all applicable laws and regulations.
• We will ensure that diagnoses are properly coded and that they are supported by medical necessity documentation.
• We will make reasonable efforts to identify and locate the owner of funds received that are not due Thompson Health and subsequently refund them to the owner.
• We will ensure that any filed cost report accurately reflects appropriate costs incurred while furnishing health care services.

CONDUCT STANDARD NO. 8: COMPLIANCE REPORTING

An important factor in the success of Thompson Health's Corporate Compliance Program is maintaining open channels of communication.

All Affected Individuals must report suspected or identified problems that they recognize to their Thompson Health supervisors, the Thompson Health Chief Compliance Officer (585-396-6714), through the confidential Integrity Helpline (585-756-8888) or online: (https://www.mycompliancereport.com/report?cid=URMC).

Affected Individuals who ignore compliance issues and do not comply with the above requirements will be subject sanctions including but not limited to sanctions, termination of contract or discipline, as appropriate. Discipline for associates will follow the Thompson Health progressive discipline policy. See Associate Handbook, Section 3.14.

The Thompson Health Integrity Helpline allows Affected Individuals, as well as patients and visitors to report concerns confidentially. The Integrity Helpline may be used to report concerns about suspected or known instances of fraud or violations of law, regulations, Thompson Health policies, its Compliance Code of Conduct or Code of Ethics and Professionalism. No one reporting a concern in good faith may be intimidated or retaliated against for reporting such a concern.

The Chief Compliance Officer will promptly and thoroughly investigate all reports to the Integrity Helpline.

CONDUCT STANDARD NO. 9: PHYSICIAN COMPENSATION AND CONTRACTING

Physician agreements will be based on a standard format approved by Thompson Health's General Counsel. As appropriate, payment to contracted physicians and other types of medical providers, will be made based on written invoices, which document actual hours worked and necessary services performed. Compensation amounts to any medical provider will reflect fair market value and any agreements with physicians shall be commercially reasonable.