CODE OF BUSINESS CONDUCT

The Hospital’s Code of Business Conduct reflects The Baptist Way core values of respect, ownership, superior service, and excellence. To help us understand what is expected in the workplace, the Hospital has adopted a Code of Business Conduct and established a Corporate Compliance Program. Under the program, each of us is responsible for complying with all applicable Federal and State laws, regulations and professional standard governing our operations.

This brochure summarizes the Code, which provides guidance on privacy and confidentiality, conflicts of interest, gifts, billing and claims, and the work environment.

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PRIVACY AND CONFIDENTIALITY

The Hospital is committed to safeguarding our medical and business information. We will comply with the provisions of the Health Insurance Portability and Accountability Act (HIPAA) and the Hospital’s privacy and security policies and procedures. We will protect confidential business information which may include personnel and financial information.

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CONFLICT OF INTEREST

As a tax-exempt organization, the Hospital has a legal obligation to engage in activities and allocate resources to further its charitable purpose. We are committed to providing high quality patient care that is in the best interest of the patient and not influenced by outside interests. If you have been identified as a “decisionmaker,” as defined in the Hospital’s Disclosure of Material Interest Policy, you must complete an annual Disclosure of Material Interest Statement. The Compliance Officer may be consulted for guidance.

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VENDOR GIFTS

Employees and professional staff may not accept or give gifts or other forms of remuneration such as discounts to induce patient referrals. Employees may not accept personal gifts or entertainment whose value exceeds $50. Vendors may not provide or pay for meals on hospital premises.

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PATIENT GIFTS

Gifts from patients are permissible provided the gift is a token of gratitude, is not meant to influence the care given, is not solicited, and is valued at less than $50. Gifts in excess of $50 should be directed to the entire department. The Compliance Officer may be consulted for guidance. Persons wishing to give cash gifts should be referred to the Office of Philanthropy.

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ETHICS AND CLINICAL ETHICS

We are committed to providing high quality health care to our patients and to delivering health care services in an ethical, professional and compassionate manner. We are committed to complying with laws and regulations that govern patient quality of care and safety, such as the Centers for Medicare and Medicaid Conditions of Participation, Massachusetts Department of Public Health Regulations and The Joint Commission accreditation requirements.

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BILLING AND CLAIMS

Only services that are medically necessary, actually rendered and appropriately documented may be billed. Medical coding must accurately reflect the service rendered. A false claim will never knowingly be submitted. Fraud, waste and abuse are violations of federal and state false claims laws. Employees must report suspected violations.

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HUMAN RESOURCES

We do not discriminate against an employee, patient or vendor on the basis of age, sex, race, creed, handicap, disability, sexual orientation or veteran status. We recognize diversity in our staff, employees and patients.

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ETHICS AND INTEGRITY

You do your best to care for our patients with sensitivity and integrity, but your job doesn’t stop there. You are also responsible to:

Commit to the highest standards of patient care.

Be familiar with important Hospital policies such as:

• Code of Business Conduct
• Privacy and Confidentiality Policy
• Ethics Policy
• Compliance Program Policy Manual

Ensure that only services that are actually performed are billed.

Report to your supervisor, manager or the Compliance and Privacy Office:

• Any HIPAA privacy incident, even if it is an accidental breach
• Any suspected theft or fraud, especially Medicare or Medicaid fraud, waste or abuse
• Any violations or suspected violations of Hospital policy, rule regulation or law

Violations of the Code of Business Conduct, Hospital policy, applicable law or regulation may lead to disciplinary action up to and including termination of employment or revocation of staff privileges as applicable. If you are aware of a problem but do not report it and it is later discovered, you could also be disciplined.

All reports are treated as confidential. The Hospital will take no adverse action against anyone who reports in good faith any violation, actual or threatened, regardless of how the issue is ultimately resolved.

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ETHICS, INTEGRITY, AND PRIVACY ALERTLINE

To assist and encourage reporting of suspected violations without fear of retaliation, you may contact the Alertline by telephone at 800-294-3653 or submit a report online.

You may give your name if you choose; you are not required to identify yourself. If you decide to report anonymously, please provide enough detail so that the matter may be investigated. All reports made to the Alertline are addressed promptly by the Compliance and Privacy Office.

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COMPLIANCE AND PRIVACY OFFICE

Contact us at 617-754-6575.