Eastman Institute for Oral Health Code of Conduct

Letter from Eli Eliav,

The University of Rochester Medical Center (EIOH) leads the way to creating good health. Every employee and professional staff person within EIOH plays a vital role in providing effective, accessible dental care to the communities we serve. The EIOH Compliance Program strives to ensure we reach these goals. By providing guidance and tools, the Compliance Program helps our employees perform their responsibilities ethically and within the bounds of the law of New York State and the United States.

The EIOH Code of Conduct is an important part of our compliance program. It does not replace any policy or procedure, but rather, furnishes a framework for how we deliver care and treatment to our patients. The Code reflects EIOH's character and your character—commitment to respect, honesty and integrity. Let the principles outlined guide your decisions and actions.

For the Code to truly be effective, we need the participation and support of every entity, all departments and each employee. The EIOH Compliance Program and Code of Conduct have the support of the highest levels of leadership and, even more important, they deserve your support. In addition to using sound judgment in following these standards, each of us has the responsibility to report ethical and legal concerns, either to our supervisor, the Compliance Office at 275-1609, or via the confidential Integrity Hot Line at 585-756-8888.

I want to thank you for your commitment to the values and principles that assist EIOH to accomplish its mission. Your support of the program will enable us to continue to be a recognized leader in the health care community.

Sincerely,

Eli Eliav, DMD, PhD

Professor and Director of Eastman Institute for Oral Health

Vice Dean for Oral Health, School of Medicine and Dentistry

Vice President for Oral Health, University of Rochester Medical Center

Code of Conduct Overview

It is the policy of EIOH that all employees and affiliated professional staff will comply fully with all state and federal laws and will conduct themselves in accord with the highest ethical standards.

To help achieve that end, EIOH has created a policy manual that describes EIOH policy concerning certain laws affecting many of our business operations. EIOH offers this Code of Conduct to help its personnel understand some specific laws they are bound to obey. The Compliance web site (this web site) contains all compliance plans and policies.

This Code of Conduct will be distributed to all employees, affiliated professionals, contractors, volunteers, students, and members of the governing body upon hire or engagement, and annually thereafter.

EIOH policy is to provide services to patients professionally, ethically and legally. EIOH personnel that fail to do so will be subject to discipline, which may include termination of employment or privileges.  Any person who learns of or suspects that someone has violated a state or federal law, or has acted unethically or improperly, should report that information to their supervisor or the Compliance Office. Supervisors also are charged with the responsibility of ensuring compliance by their staff.

If you are uncomfortable discussing your concerns with a supervisor or feel those concerns are being ignored, call the hot line to report information about unethical or illegal conduct. You do not have to leave your name, although you may if you wish. The hot line is an external number (585-756-8888); your telephone number will not be identified in any message.

Individual Responsibility

Each employee is personally responsible to act in accordance with the policies of EIOH as set forth in this document and otherwise. Violating these policies or failing to report violations could subject an employee to disciplinary action, up to and including termination. Employees are required by New York State law to report any actual or suspected violations involving Medicaid claims, fraud, waste, or abuse to the Compliance Officer or through the Integrity Hotline. EIOH strictly prohibits retaliation for good faith reporting.

All individuals are required to review this Code of Conduct during onboarding and annually as part of the EIOH Compliance Program training.

Integrity Hotline

Any employee or professional associated with EIOH can report suspected ethical or legal violations to the EIOH Integrity Hot Line, 756-8888. Reports may be made anonymously, if desired, although all reasonable attempts will be made to preserve the confidentiality of those who give their names when reporting. The Integrity Hot Line will be answered by Compliance Office staff during normal business hours. Calls after hours are handled by a voice mail system that does not record the caller's extension.

All calls are taken seriously and, if warranted, investigated by Compliance. Where feasible, the investigation results will be relayed to the person who reported the violation.

Non-Retaliation

EIOH will not tolerate retaliation against employees and professional staff who report suspected violations in good faith. Any person who attempts to retaliate will be subject to discipline, up to and including termination.

Certain additional protections are provided by State and Federal Law. The New York State and Federal False Claims Acts protect employees who are discharged, demoted, suspended, threatened, harassed or discriminated against by their employer in retaliation for assisting in the investigation, initiation or prosecution of a False Claims Act violation or suit. The protections afforded under the False Claims Acts may include reinstatement with comparable seniority, two times the lost back pay with interest, compensation for special damages, reasonable litigation costs and fees.

The New York State Labor Laws protect employees who are discharged, demoted, suspended or subject to adverse action by their employer for disclosing or threatening to disclose certain kinds of information to their supervisor or to a public official or agency. The disclosures that may be protected under the Labor Laws include (a) disclosures of information about Health Care Fraud under the New York State Penal Law, (b) disclosures of violations of law that create a substantial and specific danger to the public, and (c) disclosures of information about improper quality of patient care. The protections afforded to employees may include an injunction (court order), reinstatement to the same job and seniority, back pay, lost wages, reasonable litigation costs and fees.

Employees should bear in mind that in some cases the Labor Law protections may apply only if the employee disclosed the matter to his or her supervisor and allowed his or her employer a reasonable opportunity to correct the problem.

For more information, see New York State Finance Law section 191, New York Labor Law sections 740 and 741 and the Federal False Claims Act, 31 USC section 3730.

Standards Confidentiality

All patient information (including medical records) must be kept strictly confidential and not released to anyone outside the provider without written patient consent or lawful court order. Laws governing the release of HIV-related information are even stricter. All personnel must avoid discussing confidential information with outsiders, or where others, including family, can overhear them. Internal access to medical records is not appropriate unless there is a legitimate, work-related need to see the information.

Discrimination

It is against the law to discriminate against an employee, student, or patient on the basis of race, color, sex, age, national origin or other protected status. Patients also cannot be discriminated against because of their ability to pay for care. Any person with information that a provider or individual is improperly discriminating or being discriminated against should report that information.

Conflicts of Interest

All personnel associated with EIOH should avoid conflicts of interest and situations that even look like a conflict of interest. This means that personnel should not personally benefit from doing business with EIOH, should not have independent relationships with those who deal with EIOH, should not use their employer's property for their personal benefit and should not compete with EIOH. Any potential for conflict of interest should be disclosed to your supervisor. You should also inform your supervisor if, within a year of your employment, you worked for a Medicare intermediary or carrier.

Record Retention

State and federal laws require that providers and others within EIOH keep certain records for specified periods of time. It is EIOH policy to keep records for as long as the law requires. The legal requirements are many and varied, so before you discard any documentation, it is wise to check with your supervisor, medical records, the Office of Counsel, or the Compliance Office regarding any requirements that might exist. All EIOH personnel should learn and follow the record retention policies of their employer.

For Medicaid claims and related documentation, records must be retained for at least six (6) years from the date the claim is paid or from the date the record is created, whichever is later, unless a longer period is required by law or contract.

Cooperation with Law Enforcement

Federal and State agencies, as well as Medicare carriers and intermediaries, have broad rights to investigate matters involving patient care and billing. EIOH policy is to cooperate with enforcement investigations and activities within the bounds permitted by law. Anyone who is contacted, orally or in writing, at home or at work, by a person stating that he or she is investigating on behalf of the government or an insurer, may refer that person to the Compliance Office or Office of Counsel to the Medical Center. If you are presented with a subpoena, warrant, or court order you have the right to an attorney when speaking with the government agent. The Compliance Office or Office of Counsel to the Medical Center will coordinate the disclosure of documentation. Any person who elects to speak with a law enforcement officer should tell the complete truth.

Payments, Discounts and Gifts

It is generally illegal to pay for patient referrals or to pay for a recommendation that someone lease or buy something (like equipment or drugs) from you, if a government health program (like Medicare) is paying for the patient services or item. It is EIOH policy not to pay for referrals or recommendations or to accept payment for referrals we make. "Payment" does not have to be cash; it can be anything of value, like a discount or a free service or piece of equipment. You should avoid entertaining or giving gifts of more than token value to those who can refer patients or business to a EIOH provider.

Billing

It is against the law and EIOH policy knowingly to submit false claims for payment. Submitting a false claim might be using the wrong billing codes, falsifying the medical record, or billing for services that are not provided or are not medically necessary. Violations of these laws can be punished by fines, prison, or both. Providers can also be excluded from the Medicare or Medicaid program for submitting false claims. EIOH policy is to bill accurately and only for medically necessary services that are provided and documented. Any subcontractors that perform billing services for EIOH providers must ensure compliance with billing requirements as well.

Referrals

It is generally against the law for a doctor to refer patients to providers (such as labs) in which he or she (or a family member) has a financial interest or relationship. An example might be a dentist referring patients to a lab that he owns. Violations can result in fines and exclusion from Medicare or Medicaid. The law is complex; it applies only to certain services and has many exceptions. If you suspect that a dentist is referring patients illegally, it is best to report to your supervisor or the hot line.

Dentist Recruitment and Practice Acquisition

EIOH sometimes recruits dentists to become part of the system. In some cases, EIOH institutions acquire group practices. These actions create the potential for violations of the anti-referral laws mentioned above and are also looked at closely by the IRS. It is EIOH policy only to pay fair market value for group practices and not to offer the dentists anything of value in exchange for referrals to EIOH providers.

Patient Transfers

Federal law requires that an emergency department not transfer a patient who needs emergency treatment (including psychiatric) unless the patient is stable. An emergency department cannot refuse or delay treatment on the basis of the patient's insurance or ability to pay. Transfers can only be done with appropriate medical personnel if the medical benefits of transfer outweigh risk to the patient.

Discussions with Competitors

The antitrust laws prohibit competitors from agreeing on prices or rates. More specifically, it is illegal and against EIOH policy for providers within the system to discuss services, rates, or proposals with competitors.  Any questions about whether it is legal to share business information (prices, contract terms, salaries) with competitors should be raised with the Office of Counsel or your supervisor.

Penalties for antitrust violations are substantial, and can involve fines and prison.

Tax Issues

Many EIOH institutions are tax-exempt because of their charitable missions. The IRS imposes rules on such organizations. In general, a tax-exempt entity may not permit insiders (such as trustees, officers or others who can influence organization decisions) to benefit personally from dealing with the organization. Nor may any private person (insider or not) receive a benefit from the organization beyond what is necessary to let the organization fulfill its mission (e.g. employees may be paid a fair salary).

Issues such as these come up most often with compensation arrangements, contracts, loans, and leases. Those we do business with should not receive more than fair market value for the goods or services they provide. Violations of the tax rules can result in an organization losing its tax exemption, or can cause the IRS to penalize the person receiving an excess benefit, and the institution personnel who approved the payment.

The IRS imposes other limits on tax-exempt organizations. Income from certain activities unrelated to the charitable purpose can be taxed. Also, allowing private persons to use space financed by tax-exempt bonds can result in tax liability. Tax-exempt organizations cannot make political contributions or lobby excessively.

Securities

Some EIOH organizations have issued tax-exempt bonds that are publicly traded. It is illegal for any person with non-public, "inside" information that might affect the value of those bonds to buy or sell those bonds or give information to others who do so. Penalties include fines and prison, and civil liability.

Waste Disposal

The EIOH providers must comply with various environmental laws in the way they dispose of medical waste and other hazardous materials. Individuals should learn and follow their organization's waste disposal policies. Spills or releases must be reported promptly.

Controlled Substances

Federal and state laws affect the handling and dispensing of controlled substances, including narcotics. EIOH will not tolerate unauthorized manufacture, distribution or possession of controlled substances.

Anyone having information about a violation of this policy or the law should report it promptly, or may be subject to discipline.

Scientific Misconduct

Those who receive grants must obey certain federal requirements described in regulations. Some of the regulations apply to "scientific misconduct," such as falsifying data or copying results from other studies. EIOH does not tolerate scientific misconduct and complies fully with governmental requirements for investigating and sanctioning that behavior. Any person who learns of or suspects scientific misconduct should report that to the Office of Research and Project Administration (ORPA).

EIOH Compliance Program

The EIOH Compliance Program was developed in response to the changes in the business and laws of health care. The Program establishes standards of conduct and policies as well as a system for monitoring adherence to those policies and sanctioning noncompliance. The Program also educates and trains EIOH personnel in their responsibilities. The goal of the Program is to ensure that each of us performs our duties ethically, legally and responsibly.

EIOH has designated a Compliance Officer with day-to-day responsibility for the Compliance Program. 

The Compliance Officer has authority to access all information and resources necessary to carry out their responsibilities and reports directly to senior leadership and the governing body.

EIOH maintains a Compliance Committee that supports the Compliance Officer and oversees the implementation and effectiveness of the Compliance Program.

EIOH participates in the New York State Medicaid program and complies with the requirements of Social Services Law § 363-d and 18 NYCRR Part 521. This Code of Conduct forms a key component of the EIOH Compliance Program.