CODE OF CONDUCT 2013

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1 CODE OF CONDUCT 2013

2 Table of Contents Vision, Mission, and Values Introduction to the Code of Conduct.. 4 Non-retaliation Policy... 6 L.A. Care Health Plan s Compliance Officer 6 Responsibilities of Employees 7 Conduct Standard No.1: Quality of Care... 8 Conduct Standard No. 2: Compliance with Laws & Regulations. 10 Conduct Standard No. 3: Fraud, Waste and Abuse. 12 Conduct Standard No. 4: Health & Safety.. 15 Conduct Standard No. 5: Protection of Property & Proprietary Information.. 17 Conduct Standard No. 6: Documentation & Records Integrity 20 Conduct Standard No. 7: Conflicts of Interest 22 Conduct Standard No. 8: Human Resources Considerations. 25 All Employees are Urged to Report Concerns.. 27 Confidential Toll-free Compliance Helpline 27 The Regulatory Affairs & Compliance Department.. 28 Certification of Receipt and Understanding 29 L.A. Care Toll-Free Compliance Helpline: (800) Page 2 of 29

3 Our Vision Vision, Mission & Values A healthy community in which all have access to the health care they need. Our Mission To provide access to quality health care for Los Angeles County s vulnerable and low income communities and residents and to support the safety net required to achieve that purpose. Our Values We are committed to the promotion of accessible, high quality health care that: Is accountable and responsive to the communities we serve and focuses on making a difference; Fosters and honors strong relationships with our health care providers and the safety net; Is driven by continuous improvement and innovation and aims for excellence and integrity; Reflects a commitment to cultural diversity and the knowledge necessary to serve our members with respect and competence; Empowers our members, by providing health care choices and education and by encouraging their input as partners in improving their health; Demonstrates L.A. Care s leadership by active engagement in community, statewide and national collaborations and initiatives aimed at improving the lives of vulnerable low income individuals and families; and Puts people first, recognizing the centrality of our members and the staff who serve them. L.A. Care Toll-Free Compliance Helpline: (800) Page 3 of 29

4 Introduction to the Code of Conduct This Code of Conduct ( Code ) is intended to provide general ethical conduct standards to follow and to assist L.A. Care Health Plan ( L.A. Care ) in meeting its compliance goals. The Code is intended to complement, but not replace existing policies and procedures. If there is no existing policy on a particular subject matter, this Code shall become the applicable policy. Any questions regarding the Code should be directed to the Compliance Officer. The Code of Conduct Standards, as well as all statutes, regulations, contractual obligations and L.A. Care policies and procedures must be supported by all employees, contractors, consultants, the Board of Governors, the Public Advisory Committees, the Regional Community Advisory Committees, the Executive Community Advisory Committee and anyone else engaged in our work environment or acting on behalf of the organization. No one, regardless of position, will be allowed to compromise adherence to the Code, statutes, regulations, contractual obligations, professional and ethical standards, policies or procedures. When seeking additional guidance and direction concerning operational policies and procedures, employees and other L.A. Care designated individuals are encouraged to refer to L.A. Care s policies, or contact any member of the management team, or the Human Resources or Legal Services departments. The Code was designed to serve several purposes: To assure that all employees, contractors and consultants in the work environment share in the responsibility for keeping L.A. Care in compliance with all applicable laws, regulations, policies, procedures, L.A. Care Toll-Free Compliance Helpline: (800) Page 4 of 29

5 medical and business practices; To communicate the commitment of L.A. Care s management to compliance with laws, regulations, contractual obligations and business standards of care; and To familiarize all employees, contractors, consultants, the Board of Governors and its committees, the Public Advisory Committees, the Regional Community Advisory Committees, the Executive Community Advisory Committee and anyone else engaged in our work environment or acting on behalf of the organization with the basic legal principles and ethical standards of behavior expected throughout this organization. The Code is a living document that will be updated periodically to respond to changing conditions. Therefore, L.A. Care reserves the right to modify any or all of the Code at any time. L.A. Care Toll-Free Compliance Helpline: (800) Page 5 of 29

6 Non-retaliation Policy The L.A. Care management team is responsible for the creation of a work environment in which employee concerns can be raised and openly discussed and resolved. No disciplinary action or other form of retaliation shall be taken against any person who reports a perceived issue, problem, concern or violation to supervisors, management, Human Resources, the Compliance Officer, the Compliance Helpline (800) ), or a regulatory agency in good faith. The in good faith requirement means a person actually believes or perceives the issue or problem to be true. Reporting an infraction does not protect individuals from appropriate disciplinary action regarding their own improper performance or conduct. Any employee, regardless of status, who engages in a retaliatory activity is subject to corrective and/or disciplinary action(s), up to and including termination of employment. L.A. Care Health Plan s Compliance Officer L.A. Care has appointed a Compliance Officer who is responsible for the daily oversight of the Compliance Program. Some responsibilities of the Compliance Officer include: Establishing and maintaining the Code and compliance policies and procedures, and monitoring the operation of the Compliance Helpline; Receiving, investigating, and resolving problems, concerns, questions and issues raised by members, employees or others related to the Compliance Program, including potential violations of the Code of Conduct, policies and procedures, laws and regulations; L.A. Care Toll-Free Compliance Helpline: (800) Page 6 of 29

7 Establishing auditing and monitoring mechanisms to ensure compliance; and Providing oversight of ongoing compliance education for all employees and other designated individuals to ensure understanding and compliance with the mission of L.A. Care. Responsibilities of Employees All employees are expected to follow the Code, L.A. Care policies and procedures, contractual obligations, as well as applicable laws and regulations. Anyone with knowledge of a potential or perceived violation must report such violation. Failure to report a known violation may subject an employee to disciplinary action even if the employee was not involved in the violation itself. When considering reporting a perceived violation, an employee should determine: Do I have all of the facts? Is the perceived action inconsistent with L.A. Care s values as defined by its mission, vision, and the Code? Does the perceived action violate Conduct Standards set out in the L.A. Care Code? Does the perceived action violate any known law, rule, regulation, or policy and procedure? If an employee has any questions or wishes to report a problem, that employee should talk to a supervisor or other member of the management team, and/or speak to a Human Resources representative. If the problem cannot be resolved through normal communication channels, or, for any other reason the employee does not wish to use these channels, the problem should be reported to the Compliance Officer, or to the Compliance Helpline at (800) or online at L.A. Care Toll-Free Compliance Helpline: (800) Page 7 of 29

8 CONDUCT STANDARD NO. 1 Quality of Care L.A. Care s first responsibility is to our members, their families and the communities we serve. We strive to provide quality services and benefits in a responsible, reliable, and appropriate manner. Guidelines for appropriate conduct include, but are not limited to, the following: We endeavor to ensure that the delivery of benefits for medical care and related services to our members is safe and complies with all applicable laws, regulations, and professional standards. We are committed to open and honest communication with all members, recognizing and respecting their right to quality care and services. We are also committed to safeguarding our members confidentiality when dealing with protected health information, including medical records. Employees shall refer all matters outside of their expertise and/or job responsibility to the attention of those who can properly assess and resolve the situation. Periodically, we shall assess and evaluate our operations to ensure our health care delivery system utilizes professional standards, as well as meets our customers needs. Our members shall have access to properly credentialed providers possessing expertise and experience to care for their health care needs. The rendering of clinical decisions involving the delivery of health care to our members shall be made by licensed and qualified L.A. Care Toll-Free Compliance Helpline: (800) Page 8 of 29

9 employees, according to their health care needs, and shall not be improperly influenced by financial incentives. Utilization management decisions are based only on appropriateness of care and service and the existence of coverage. There are no rewards or incentives for practitioners or other individuals for issuing denials of coverage, service, or care. We strive to provide every member with quality health care without discrimination due to race, color, creed, religion, gender, ancestry, sexual orientation, gender identity, national origin, age, marital status, disability, or source of income or payment. See policies under: MEMBER SERVICES BOARD SERVICES UTILIZATION MANAGEMENT QUALITY IMPROVEMENT CREDENTIALING L.A. Care Toll-Free Compliance Helpline: (800) Page 9 of 29

10 CONDUCT STANDARD NO. 2 Compliance with Laws & Regulations L.A. Care strives to operate in accordance with all applicable laws, regulations, contractual obligations and ethical and professional standards needed to maintain a compliant organization. Guidelines for appropriate conduct include, but are not limited to, the following: We strive to maintain complete and accurate member records and keep all such information confidential and available only to those legally authorized to review member information. To ensure their conformity with all applicable laws and regulations, contracts shall be reviewed and approved by L.A. Care s legal counsel in accordance with our organization s policies and procedures before being signed by an authorized representative. We shall market our services in a truthful and accurate way, relying on the merit of our services. Our marketing efforts shall be in accordance with all required laws and regulations. We will not provide or accept kickbacks, bribes, or any other illegal form of compensation to increase our membership or receive favorable treatment from providers. All employees, temporary staff, contractors, consultants, members of L.A. Care's Board of Governors and its committees, and members of Public Advisory Committees, the Regional Community Advisory Committees, and the Executive Community Advisory Committee shall familiarize themselves with applicable laws, policies, rules and L.A. Care Toll-Free Compliance Helpline: (800) Page 10 of 29

11 regulations governing their activities on behalf of L.A. Care. L.A. Care will review and modify its policies and procedures on a regular basis to maintain compliance with laws and regulations. We shall strive to prepare and maintain business data, records, and reports in a timely, accurate and truthful manner. Such actions will be in accordance with internal policies and applicable laws, rules and regulations. All accounting books and records shall also comply with established accounting and internal control policies. See policies under: UTILIZATION MANAGEMENT QUALITY IMPROVEMENT LEGAL SERVICES REGULATORY AFFAIRS & COMPLIANCE SALES AND OUTREACH HUMAN RESOURCES ACCOUNTING & FINANCIAL SERVICES I S BUSINESS SOLUTIONS CREDENTIALING L.A. Care Toll-Free Compliance Helpline: (800) Page 11 of 29

12 CONDUCT STANDARD NO. 3 Fraud, Waste and Abuse L.A. Care has responsibilities to investigate, and take corrective action in response to suspected Fraud, Waste or Abuse incidents perpetrated by employees, members, providers, and contractors/subcontractors, and to report to State and Federal regulatory agencies as applicable. Guidelines for appropriate conduct include, but are not limited to, the following: We will not commit fraud, defined as intentionally deceiving or misrepresenting information with the knowledge that such deception could result in an unauthorized benefit to ourselves or some other person. We will not commit abuse, defined as practices that are inconsistent with sound fiscal or business practices and result in unnecessary cost to the federal Medicaid and Medicare programs. We will not condone waste which is generally defined as an overutilization of services, or careless practices that result in unnecessary costs. Waste is generally not considered a criminally negligent action, but rather the misuse of resources. We provide mandatory training annually on Fraud, Waste and Abuse, the Code of Conduct and other compliance-related issues to all employees, temporary employees, contractors and others subject to this Code. In this training we encourage employees to report suspected Fraud, Waste and Abuse cases and Code of Conduct violations to the Compliance Officer or through the Compliance Helpline. L.A. Care Toll-Free Compliance Helpline: (800) Page 12 of 29

13 We require our providers, on an annual basis, to take our Fraud, Waste and Abuse Awareness Training Program or an equivalent, approved course, submit an attestation that they have done so or provide proof of Medicare certification. We will not engage in practices that are inconsistent with sound medical practices and result in reimbursement by the federal Medicaid and Medicare programs for services that are unnecessary or for substandard items or services that fail to meet professionally recognized standards for health care. We will not do business with any provider, consultant or vendor if it or any of its officers, directors or employees is, or becomes excluded by, debarred from, or ineligible to participate in any federal health care program, or is convicted of a criminal offense in relation to the provision of health care. We will support the Federal and California False Claims Acts, which prohibit filing false claims and statements, and permit a person who learns of fraud against the United States Government or State of California to file a lawsuit on behalf of the government against the person or business that committed the fraud (also known as a qui tam relator). Any employee who participates in good faith in a qui tam action under the False Claims Act is protected against retaliation by L.A. Care management. L.A. Care Toll-Free Compliance Helpline: (800) Page 13 of 29

14 We encourage all L.A. Care employees to report suspected Fraud, Waste and Abuse to their immediate supervisor or anonymously to the Compliance Helpline at (this line is available 24 hours a day, 7 days a week), or call the Compliance Officer at ext Employees may also report online at See policies under: REGULATORY AFFAIRS & COMPLIANCE L.A. Care Toll-Free Compliance Helpline: (800) Page 14 of 29

15 CONDUCT STANDARD NO. 4 Health & Safety L.A. Care follows professional standards and practices to protect the health and safety of employees and visitors, and create a professional work environment for our employees and others in our facilities. Guidelines for appropriate conduct include, but are not limited to, the following: All employees shall perform their work in a manner that is safe and does not pose a hazard to themselves or others. All accidents involving injury to an employee or visitor must be promptly and appropriately reported. Departmental supervisors shall be responsible for ensuring that all employees are properly trained in a healthy and safe work environment. They shall also develop programs to eliminate or minimize, as much as possible, any hazards to the health and safety of employees in accordance with applicable laws and regulations. We strive to provide a work environment that is free from violence. L.A. Care has established a policy that provides zero tolerance for actual or threatened violence by or against employees, visitors or any other persons who are either on our premises or have contact with employees in the course of their duties. Every verbal or physical threat of violence must be treated seriously and reported immediately to the appropriate supervisor/manager and Human Resources. Possession of unauthorized weapons of any kind is strictly prohibited on L.A. Care premises. L.A. Care Toll-Free Compliance Helpline: (800) Page 15 of 29

16 Possession or consumption of alcohol and/or illegal drugs on L.A. Care premises is strictly prohibited. Any employee reporting to, or discovered at work, to be under the influence of alcohol, narcotics, or improperly used prescription drugs will not be permitted to remain on the job. This does not apply to persons taking over-the-counter and physicianprescribed medication according to direction. Exceptions include cases in which such medication causes inefficient performance of duties that may cause harm to the employee or others. Management, in consultation with Human Resources, may take further action as necessary, including possible drug screening in accordance with applicable laws and L.A. Care policies and procedures. This policy against the use of alcohol on L.A. Care premises shall not prohibit the use of alcohol at social and/or business functions sponsored by the organization following approval by the Senior Management team. However, employees are required to conduct themselves properly at all times during such company-sponsored functions. See policies under: HUMAN RESOURCES L.A. Care Toll-Free Compliance Helpline: (800) Page 16 of 29

17 CONDUCT STANDARD NO. 5 Protection of Property & Proprietary Information L.A. Care is committed to protecting confidential information of members from improper disclosure, and to protecting L.A. Care property, physical assets, and proprietary information from loss, theft, destruction, misappropriation and misuse. Guidelines for appropriate conduct include, but are not limited to, the following: The term confidential Information shall include all attorney-client communications, communications deemed to be attorney workproduct, and closed session materials and/or documents. We strive to protect confidential information affecting our members, including information related to the course of treatment, medical history, current health status, and other information contained in member records. Member records may be released only in accordance with L.A. Care s release of information policies and procedures, and applicable laws and regulations. We strive to respect and safeguard the property of employees and others while they are on the premises of L.A. Care. We strive to protect confidential and proprietary L.A. Care information from disclosure and will not use or reveal such information unless deemed necessary to perform certain work. No employee may use or reveal any confidential or proprietary information outside the context of his or her job duties. L.A. Care Toll-Free Compliance Helpline: (800) Page 17 of 29

18 Employees shall not disclose or use, directly or indirectly, confidential information for personal gain. Under no circumstances shall business information or documents be communicated or transferred to unauthorized persons. We strive to dispose of all surplus or obsolete property, records and equipment according to applicable L.A. Care policies and procedures, and applicable laws and regulations. Unauthorized disposal of property is considered a misuse of assets. L.A. Care is committed to developing and maintaining a system of internal controls to adequately protect L.A. Care property and proprietary information. We are also committed to protecting our members and contractors information against fraud, waste or abuse as specified by laws, regulations and contractual obligations. We strive to safeguard L.A. Care computer systems and shall only permit authorized individuals to have access to computer systems, information and software. While working, employees are prohibited from using L.A. Care computer systems or software for any non workrelated purpose, unlawful activities, or in a manner that is inconsistent with L.A. Care policies. Employees who participate in online communication such as social network sites, blogs, chat rooms, Facebook, Twitter and Wikipedia sites must not disclose L.A. Care s confidential information. Postings related to, affecting or impacting L.A. Care-related information or business, whether performed inside or outside of the workplace, may only be done in accordance with applicable L.A. Care policies and procedures. L.A. Care Toll-Free Compliance Helpline: (800) Page 18 of 29

19 Also, employees must make it clear that the views they express are theirs alone and not L.A. Care s views. Content may not be harassing or discriminatory toward any person or entity. See policies under: QUALITY IMPROVEMENT HUMAN RESOURCES I S TECHNOLOGY & SECURITY COMMUNICATIONS & MARKETING I S BUSINESS SOLUTIONS LEGAL SERVICES REGULATORY AFFAIRS & COMPLIANCE/HIPAA L.A. Care Toll-Free Compliance Helpline: (800) Page 19 of 29

20 CONDUCT STANDARD NO. 6 Documentation & Records Integrity L.A. Care is committed to keeping fair and accurate records in accordance with all federal and state laws and regulations. Guidelines for appropriate conduct include, but are not limited to, the following: All employees shall maintain privileged and confidential records in a secure location for the period of time required by law. The premature destruction or alteration of any document in response to, or in anticipation of, a request for those documents by any authorized government, regulatory or law enforcement entity is strictly prohibited. Before destroying records, employees should check to determine if the applicable retention period has expired. In addition, employees should always check with their manager and/or the Legal Services Department to determine if the records are the subject of a Legal Hold Notice before destroying any records. Records that are the subject of a Legal Hold Notice must continue to be preserved and shall not be altered or destroyed without approval from Legal Services, even if the regular retention period has expired. L.A. Care records shall not be altered for any improper purpose, including the unauthorized payment or diversion of government funds. All cost and reimbursement information provided to the government and the public must be current, complete and accurate, and not intentionally false or misleading. L.A. Care Toll-Free Compliance Helpline: (800) Page 20 of 29

21 Under no circumstances shall we make misleading statements to government auditors or investigators during any investigation. L.A. Care employees are strictly prohibited from hiding or providing false or misleading information to governmental investigators or regulators. L.A. Care will not, in any manner, retaliate against any person for cooperating in good faith with appropriate government auditors or investigators during an investigation. Automated time and attendance and other cost records and reports shall be complete and reflect accurate information. See policies under: REGULATORY AFFAIRS & COMPLIANCE LEGAL SERVICES ACCOUNTING & FINANCIAL SERVICES HUMAN RESOURCES BOARD SERVICES I S TECHNOLOGY & SECURITY L.A. Care Toll-Free Compliance Helpline: (800) Page 21 of 29

22 CONDUCT STANDARD NO. 7 Conflicts of Interest L.A. Care does not condone situations where a conflict of interest may occur, exist or appear to exist between an employee s financial interests and those of the organization. Guidelines for appropriate conduct include, but are not limited to, the following: All employees are strongly encouraged to avoid acquiring or maintaining financial interests that can cause a conflict-of-interest in the performance of their duties at L.A. Care. To the extent permitted by law, employees may be terminated if they have financial interests that prevent them from performing a substantial portion of their duties. L.A. Care strongly discourages outside activities by employees that interfere with regular work duties and work time, adversely affect the quality of work or could harm the organization s reputation. Employees shall not use their knowledge of L.A. Care s proprietary or confidential information for their own or others personal profit or advantage. All employees shall avoid engaging in actual favoritism or creating the appearance of favoritism toward a supplier, contractor, consultant, vendor, health care provider or other business associates. We shall do so by complying with all applicable laws, policies and procedures governing the acceptance of gifts, gratuities, honoraria, or any other personal benefits or favors. Please be reminded that in some circumstances gifts to spouses and dependent children could be considered as a gift to the individual. L.A. Care Toll-Free Compliance Helpline: (800) Page 22 of 29

23 Employees are strongly encouraged to contact and consult with L.A. Care s Legal Services Department regarding the applicable laws and regulations. Employees are prohibited from making, or participating in making, any decisions on behalf of L.A. Care that would have an effect upon their personal financial interests or the personal financial interests of their immediate family member, economic dependent or household member. Such individuals may include without limitation the employee s spouse, parent, child, sibling, and domestic partner. California s conflict of interest laws may preclude L.A. Care from entering into any contracts with any vendor, consultant or other business entity in which L.A. Care s employee or employee s immediate family member is either an owner, employee or is otherwise involved. Accordingly, all employees are encouraged to contact the Legal Services Department as soon as possible and to the extent possible before moving forward with the contracting process to conduct a conflict of interest analysis. All employees, temporary agency staff or contracted workers are encouraged to disclose their external employment to their immediate supervisor to prevent potential conflicts of interest. In addition, all employees, temporary agency staff or contracted workers shall adhere to all requirements indicated in relevant policies and procedures governing outside employment, as well as all applicable laws, regulations, policies and procedures governing conflicts of interest and acceptance of gifts, honoraria and other personal benefits. All positions designated in L.A. Care's Conflict of Interest Code are required to file a Form 700 Statement of Economic Interest within thirty (30) days of hire or promotion into the designated position, on an annual basis L.A. Care Toll-Free Compliance Helpline: (800) Page 23 of 29

24 (no later than April 1 of every year) and within thirty (30) days of leaving from or changing the designated position. Such individuals shall also review their conflict of interest status and consult with L.A. Care s legal counsel whenever a change in their personal circumstances may affect any of the responses made in their most recent Form 700. All employees are strongly encouraged to review L.A. Care s Conflict of Interest Code and L.A. Care s applicable policies and procedures related to acceptance of gifts and honoraria. Gifts include, without limitation, payments for meals and beverages, fruit or other gift baskets, and tickets to sporting or entertainment events. See policies under: BOARD SERVICES HUMAN RESOURCES LEGAL SERVICES L.A. CARE HEALTH PLAN'S CONFLICT OF INTEREST CODE L.A. Care Toll-Free Compliance Helpline: (800) Page 24 of 29

25 CONDUCT STANDARD NO. 8 Human Resources Considerations L.A. Care strives to protect, support and develop its workforce to the extent reasonable in a fair and equitable manner. It is recognized that our employees create our success and determine our reputation. Guidelines for appropriate conduct include, but are not limited to, the following: We show proper respect and consideration for one another, regardless of status or position, and are culturally sensitive to everyone at all times. We strive to hire, train, promote and compensate employees on the basis of qualifications, competence, experience, and performance. We shall do so without regard to race, color, creed, religion, gender, ancestry, sexual orientation, gender identity, national origin, age, marital status, or disability, as well as any other characteristics protected by law. We strive to provide a work environment free from unlawful harassment, discrimination and intimidation. Such harassment is defined as verbal, physical or visual conduct that creates an intimidating, offensive or hostile work environment or that interferes with the work performance of any person. We encourage and support individuals seeking to develop their competencies, skills and knowledge. We require employees to conduct themselves appropriately and professionally when representing or attending off-site activities related to L.A. Care business. This includes, but is not limited to, educational, vendor-sponsored, or business partner meetings. L.A. Care Toll-Free Compliance Helpline: (800) Page 25 of 29

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