Compliance Program

The purpose of this Code of Conduct is to guide MHHC personnel in ensuring that all aspects of the health center’s operations are in conformance with its mission and with all applicable laws and regulations.

Client’s Rights

1. MHHC will provide every client served with appropriate, high-quality care regardless of race, color, religion, national origin, gender, age, ability to pay for such care, military status, sexual orientation, marital status or sponsor.

2. All care and treatments recommended and provided by MHHC to patients served in its clinics will be medically necessary and consistent with accepted professional standards of care.

3. MHHC clients, where competent, will be involved in and agree to all decisions affecting their services to the fullest extent possible. Informed consent will be obtained from all clients prior to providing clinical services, as appropriate and required by law.

4. Clients and their representatives will be accorded appropriate confidentiality, privacy, security and respect and the opportunity to express concerns and to have their concerns addressed.

6. All MHHC staff will be appropriately qualified, trained and licensed to carry out their job functions. Qualifications and licensure shall be confirmed through the health center’s credentialing process, as discussed below.

Business Conduct

1. MHHC will strive to comply with all federal, state and New York City laws, rules and regulations which affect MHHC’s operations and its relationships with its clients.

2. All decisions by MHHC personnel relating to health center operations must be made in the best interest of MHHC’s clients and the health center, and no considerations may undermine this fundamental commitment.

3. MHHC will not directly or indirectly pay or receive from any person or any entity anything of value in exchange for client referrals or for the arrangement or the purchase or lease of any item or service in violation of state or federal law. No MHHC personnel shall offer any financial inducement or gift (other than of nominal value) to prospective clients or referral

sources in order to encourage them to receive services from MHHC.

4. MHHC will not enter into any financial relationships with any physicians, providers or entities that order services from MHHC, except to the extent permitted by the Medicare and Medicaid Protection Act of 1987, 42 U.S.C. sections 1320a-7b and analogous New York State law.

5. All MHHC records and documents, including medical records will be maintained in accordance with MHHC's records retention program. Documents will be destroyed consistent with this program as well. This applies to all records and documents including both hard copy and electronic formats.

6. All MHHC financial records will be maintained in a complete and accurate manner in accordance with generally accepted accounting principles. It is against MHHC’s policy to knowingly cause the health center’s books and records to be inaccurate.

7. MHHC business and client related records, including medical and billing records, are of a highly confidential nature. Except as authorized or required by law, they shall not be disclosed or discussed with anyone not employed by or affiliated with MHHC without the written permission of MHHC management or the relevant client or his or her authorized representative. In addition, all disclosures of Protected Health Information (PHI) as defined in the Health Insurance Portability and Accountability Act (HIPAA) of 1996, Public Law 104-191, and the regulations promulgated pursuant thereto, shall be made in accordance with that law HIPAA and any and all New York laws regulating privacy of individually identifiable health information.

8. No alteration will be made to a medical or business record unless the alteration is made in a manner consistent with applicable standards of practice and MHHC’s policies and procedures. Complete records including medical records will be stored in a confidential and organized manner and will be readily retrievable and available as needed for legitimate client or health center related purposes.

9. MHHC will be forthright and candid in dealing with any governmental inquiries. Designated staff will respond to any requests for non-privileged information with complete, factual, and accurate information. Requests for privileged materials will be considered on an item-by-item basis in consultation with the health center’s legal counsel and/or Compliance Officer

10. The policy of MHHC is to conduct criminal background checks of all employees. Employment is contingent upon satisfactory results of the background checks. Past conviction does not automatically exclude an employee from employment with MHHC.

11. Any medical staff member, including part-time and per diem providers, hired by MHHC will have to meet the standards and be subject to the medical credentialing policies established by the Medical Director and the Board of Directors, as detailed in the health center’s Medical By-Laws. The Compliance Officer will conduct periodic audits of the credentialing files of MHHC providers. Such audits will include, but not be limited to, a review of the Medicare

List of Excluded Individuals/Entities (LEIE), the National Practitioner Data Bank, the Healthcare Integrity and Protection Data Bank, and the New York State Office of the Medicaid Inspector General’s Banned Provider list, as appropriate.

12. All provider staff must immediately notify the Chief Medical Officer and/or the Compliance Officer if he or she is excluded, suspended or removed, either voluntarily or involuntarily, from any government payor or plan or if there is any change in the status of his or her license to practice in New York State. All provider staff must immediately notify the Chief Medical Officer and/or the Compliance Officer if he or she is excluded, suspended or removed from any commercial payor or plan if such exclusion is related to allegations by the commercial payor of improper or unethical conduct by the provider.

13. All MHHC advertising or promotion of its services, including any appearing on the internet, will comply with federal and state laws and regulations.

Billing Practices

1. All MHHC personnel, to the extent applicable to their job functions, are required to comply with all billing and claims submission requirements promulgated by federal, state, and other payors. As needed, MHHC will provide internal and external training to providers and billing staff regarding coding and billing procedures.

2. MHHC follows the billing and coding rules, regulations and recommendations issued by the Centers for Medicare & Medicaid Services and the New York State Medicaid program as well as all other applicable agencies.

3. Coding and billing procedures are set forth in the MHHC Procedures and Code of Conduct for Provider and Billing Staff to Ensure Billing Accuracy, a copy of which is appended hereto as Attachment 6.

4. MHHC will provide appropriate supervision to all providers to allow the health center to bill for their services. Where services are rendered by non-physician professional providers, supervision will be that required by New York State laws applicable to such providers.

5. The compensation for health center billing staff, or billing consultants engaged by MHHC, will not provide any financial incentives to improperly bill or submit claims.

Conflicts of Interests

1. It is the responsibility of MHHC personnel to avoid situations in which their personal interests or those of a close associate such as a family member could conflict or appear to a reasonable outside observer to conflict with the interests of MHHC. Such a conflict may arise in, but is not limited to, situations where an individual or close associate could gain financially from their association with MHHC apart from their normal compensation. Any individual who believes that he/she may have a potential conflict of interest should communicate his or her concern to MHHC management and/or the Compliance Officer.

2. No employee may accept outside employment if it interferes with the employee’s ability to fulfill his or her responsibility to the health center.

3. Employees are not to accept gifts, gratuities, free trips, personal property or other items of value from an outside person or organization as an inducement to provide services on behalf of MHHC to anyone or any organization or to purchase goods or services from an outside vendor.

4. MHHC’s assets are to be used solely for the benefit of the health center and the clients that it serves. They may not be used by any individual for personal gain. Assets include not only health center funds, equipment, space, and supplies, but also include usage of MHHC-issued cell phones, usage of MHHC computers, and information about MHHC’s future plans and business strategy.

5. No MHHC-related information or property, including, without limitation, documents, files, records, computer files, equipment, office supplies or similar materials (except in the ordinary course of performing duties on behalf of the health center) may, therefore, be removed from the health center’s premises without permission from a supervisor. Violation of this policy is a serious offense and will result in appropriate disciplinary action, up to and including discharge. In addition, when an employee leaves MHHC, the employee must return to MHHC all MHHC-related information and property that the employee has in his or her possession, including without limitation, documents, files, records, manuals, information stored on a personal computer or on a computer disc, cell phones, supplies and equipment and/or office supplies. Violation of this policy may subject the employee to civil or criminal penalties.

6. All purchasing decisions will be based on value to the health center and the preservation of health center assets. Procedures governing purchasing, payment and other fiscally- related activities are detailed in MHHC’s Finance Department Manual. MHHC personnel and/or their families or close associates must not receive personal remuneration, kickbacks or rebates as a result of the purchase or sale or goods or services at MHHC. The terms “kickback” and “rebate” are not limited solely to monetary compensation but include any situation where an individual stands to benefit personally from the purchase or sale of goods and services.

7. Rental rates for space to be occupied by MHHC or for equipment to be leased shall at all times be at fair market value, irrespective of any referral source. MHHC will verify that proposed rentals and equipment leases are at fair market value prior to undertaking those obligations.

8. Any proposals for strategic alliances, joint ventures or other arrangements with any hospital, hospital-affiliated entity, clinic or health care provider or practice that makes referrals to MHHC, or has the potential to direct referrals to MHHC, will be reviewed by the Compliance Officer and the Internal Compliance Committee. The Compliance Officer and the Internal Compliance Committee may ask MHHC's legal counsel to review the arrangement as well.

9. The policy governing Conflicts of Interest with respect to members of the Board and all other personnel appended hereto as Attachment 8.

Political Activity and Contributions

1. MHHC encourages everyone to participate in the political process. However, as a not-for- profit organization, MHHC is prohibited from conducting political activities. Individuals are therefore prohibited from engaging in political activities during work hours or using MHHC’s personnel, resources or supplies to distribute statements supporting or opposing any candidate.

2. Personal political activities should not reference MHHC or an individual’s association with MHHC.

3. Not-for-profit organizations may engage in limited lobbying activities related to issues affecting the organization. As this process is highly regulated employees will consult with the Compliance Officer before participating in any lobbying activity related to the work of MHHC before a government or funding health center.

Click here to view or download a pdf version of the code of conduct.