Code of Conduct
Sheridan Memorial Hospital (SMH) prides itself in providing quality, competent, and excellent patient- centered care. To help achieve our organizational vision, we are committed to holding all members of SMH to the highest legal and ethical standards. Those SMH Members include everyone from the Board of Directors, to senior level administrative staff, physicians, vendors, and all employees.
This Code of Conduct serves as a guide to SMH Members regarding the responsibility we all share to provide quality patient-centered health care and to conduct all patient care and business activities ethically, with integrity, and consistent with applicable laws and regulations. It is also intended to help SMH Members recognize, understand, and fulfill their responsibilities in preventing and detecting violations of SMH policies and procedures, regulations, and the law.
This Code of Conduct provides a summary of the conduct expected of all SMH Members. SMH Members should also consult specific SMH policies and procedures which apply to their duties at SMH. All SMH Members are responsible for being familiar with, and abiding by, this Code of Conduct and other policies/ procedures governing their conduct at SMH.
MISSION OF THE COMPLIANCE DEPARTMENT
The Compliance Department is committed to preventing, detecting, and resolving improper, unethical, and illegal conduct, and violations of law, regulations, and policies and procedures. Through an effective Compliance Program, the Compliance Department will help maintain the integrity of the organization by requiring compliance with applicable regulations and laws and evaluating the effectiveness of the Compliance Program and any policy and procedure through independent investigations and audits.
SMH MEMBER CONDUCT
SMH Members shall adhere to the following conduct:
- Non-retaliation: SMH will not take any adverse action or retribution against any employee due to the good faith reporting of a suspected violation or issue.
- Scope of Practice: Conducting NO activity that is outside of your profession’s scope of practice.
- Duty to Report Illegal and Unethical Activity: SMH Members shall obey and report any suspected violations of the following: a. Federal, state, and local laws and government regulations b. Health system policies and procedures c. Organizational rules and regulations d. Compliance Program e. Code of Conduct
- Clinical Documentation: All clinical professional services will be documented in the medical record, and all documentation will comply with applicable payer regulations. At a minimum, the medical record should establish medical necessity and only reflect treatment for services actually rendered.
- Accurate Coding and Billing: All clinical professional services will be coded to accurately reflect the documentation in the medical record. All claims shall be submitted in compliance with applicable payer regulations or requirements.
- Kickbacks and Bribes: SMH Members will not knowingly and willfully solicit, receive, offer or pay anything of value directly or indirectly, in cash or in kind, in exchange for patient referrals.
- Cooperation in Government Investigations: SMH Members will not knowingly and willfully: a. Falsify, conceal, or cover up a material fact b. Make any false, fictitious, or fraudulent statement or representation, or c. Make or use false writing or documents known to contain false, fictitious, or fraudulent statements in information submitted to the government; this includes submitting claims for services not medically necessary or not actually provided.
- Conspiracy to Commit Fraud: SMH Members will not conspire to defraud any government agency or healthcare benefit program in any manner, for any reason.
- Emergency Medical Treatment and Active Labor Act (EMTALA): No person shall be denied emergency medical treatment or denied medical services when in active labor, regardless of his or her ability to pay.
- Health Insurance Portability and Accountability Act (HIPAA): SMH Members shall not disclose any protected health information without proper consent from the patient, for any purpose outside of treatment, payment, or hospital operations.
- Other Applicable Laws, Regulations, Policies and Procedures: SMH Members shall be familiar with, and abide by, other laws, regulations, policies and procedures governing their conduct at SMH.
REPORTING VIOLATIONS
SMH Members should feel confident in reporting any transaction or conduct which is, or may be a violation of any SMH policies and procedures, this Code of Conduct, or any federal, state or local law. For compliance issues, employees may report concerns to any of the following resources:
- Immediate supervisor
- Compliance Officer at 675-2669, or by email at: compliance@sheridanhospital.org
- Anonymous Reporting Hotline: 307-673-2410
- Mail: Attn: Compliance Officer 1401 W 5th Street Sheridan, WY 82801
Any good faith reports regarding violations of SMH policies and procedures, this Code of conduct, and any federal, state, or local law are subject to SMH’s policy on Non-Retaliation. It is important to note, however, that any abuse of this system to knowingly report false information subjects the employee to disciplinary action. Failure to follow SMH policies and procedures, this Code of Conduct and any federal, state, or local law may be grounds for disciplinary action.
Anyone, including SMH Members, may use the anonymous reporting hotline for any known or perceived violations of this Code of Conduct, or any SMH policy and procedure, or any federal, state or local laws.
CONFIDENTIALITY
At the request of the reporting party, and to the extent we are able, we will maintain the anonymity of the person who reports the violation. However, when the law compels us to do so, we will disclose the identity of the reporting party.
CONCLUSION
This Code of Conduct is about both empowerment to do the right thing, and accountability when errors are found. SMH Members are expected to take the initiative and obtain answers for their questions. No concern is too small or unimportant if it is believed to involve violations of SMH policies and procedures, regulations, or the law.
ATTESTATION / ACKNOWLEDGMENT
My signature below acknowledges that I have read and reviewed this Code of Conduct and that I understand and agree to comply with the standards contained therein and all related policies and procedures. I acknowledge that the Code of Conduct is only a statement of principles for individual and business conduct, and does not constitute an employment contract. I will report any potential violation of which I become aware promptly to my Manager / Supervisor or the Compliance Officer. I understand that any violation of Sheridan Memorial Hospital policies, this Code of conduct, and any federal, state, or local law may be grounds for disciplinary action.
