We insist on full compliance with all laws and regulations in the conduct of our business; we prohibit improper payments from vendors; we are dedicated to patient privacy and the confidentiality of patient medical records. Baptist Health’s Code of Ethics must be followed by all employees, contractors and agents. No one is exempt, no matter their position. Employees annually receive information about the Code, and are encouraged to report violations of the Code.

Code of Ethics PDF

Our Code of Ethics

  • The mission of Baptist Health is to improve the health and well-being of individuals and to promote the sanctity and preservation of life in the communities we serve. We are committed to maintaining the highest standards of clinical and service excellence with the utmost integrity and moral practice. All activities carried out on behalf of Baptist Health will follow all applicable laws, rules and regulations. They will be performed according to the highest ethical and moral standards.

  • People — It’s our people who make us special, and it’s our diverse and empathetic teams that patients trust with their care.

    Belief — We are built on a faith-based heritage and mission, and this spirit inspires our support for the communities we serve.

    Compassion — We prioritize caring above all – for each other, our patients, their families and the communities we serve.

    Excellence — We set a high bar for clinical quality, service and experience across every part of our organization.

    Integrity & Transparency — In everything, we do what’s right – for our patients, for our colleagues, for our industry and for the world around us.

  • Baptist Health’s Code of Ethics is a key part of the Corporate Compliance Program. It reflects the core values and principles that guide Baptist Health operations. The purpose and objective of the Code is to:

    • Establish a code of ethical standards to be followed by all employees, medical staff, Board members, contractors and vendors;
    • Communicate to them the standards they are expected to follow;
    • Communicate to stakeholders the ethical standards we have adopted;
    • Communicate methods of reporting issues and concerns so that we can prevent, detect and correct activities that are not consistent with our ethical standards; and
    • Document Baptist Health’s commitment to the highest professional standards.

    The Code is the cornerstone of our anti-fraud initiatives, designed to prevent and identify potential occurrences of unethical activities such as theft or fraud.

  • All Baptist Health employees, medical staff members, Board members, contractors and vendors must follow our Code of Ethics. No one, no matter what position they hold, is exempt from the standards set forth by the Code. Failure to comply is a serious matter that may lead to disciplinary action. Disciplinary action could include termination. In addition, employees who violate a specific law may be subject to legal prosecution.

    We also expect our vendors and contractors to follow the highest ethical standards and to report any suspected violation of the Code. The reporting mechanisms available to our employees are also available to them.

    Quick Tip

    • The Code of Ethics is available on Pineapple Connect — just search for Code of Ethics. On the internet, click on Fulfilling our Mission.
    • All employees, medical staff members, Board members, contractors and vendors must follow the Code.
    • See BHSF Policy 819 Code of Ethics.

  • Employees, Medical Staff Members, Board Members, Contractors and Vendors

    All employees, medical staff members, Board members, contractors and vendors must be familiar with and follow the standards in the Code of Ethics. Annually, you should review the Code of Ethics and complete compliance training. If you are an employee, you must acknowledge that you have received a copy of the Code at your annual performance review. You must also attest that you are aware of the principles it holds and your responsibility to report anything that may violate those principles.

    Special Responsibilities of Leaders

    With leadership comes added responsibility. While all employees are expected to follow our Code of Ethics, a leader sets an example for employees to follow. Leaders must create an environment that encourages discussion of our ethical standards and values. As a leader, make sure that:

    • Your conduct is consistent with the highest ethical and legal standards.
    • Your employees are aware of our ethical standards.
    • Your employees are aware of the laws, rules, regulations and policies that apply to their jobs.
    • Your employees are aware of their obligation to report suspected violations of our standards.
    • You create a work environment that is open and receptive to discussion and reports of possible ethical violations.
    • You take the appropriate action when a potential violation is reported to you.
    • You prohibit retaliation against anyone who reports a potential violation to you.

  • Nonretaliation

    Baptist Health employees are encouraged to discuss and report ethical and legal issues that come up as they perform their job functions. You must report any suspected violations of the Code of Ethics. We do not tolerate any form of retaliation against anyone who reports a suspected violation of our Code of Ethics. Retaliation for reporting is a violation of our Code. Failure to report a potential violation may lead to disciplinary actions. The discipline could result in termination.

    Whose Responsibility?

    The Code of Ethics promotes honesty and fairness in all our interactions. It is your responsibility to ensure that all your associations with patients and the community are honest and that you follow the Code and all Baptist Health standards and procedures. Our reputation depends upon you doing your part to report any questionable ethical actions or violations you suspect. You must report anything that may be illegal or unethical, so it can be investigated. We want to know so we can correct the problem.

    Sometimes it is difficult to decide whether a specific situation violates our Code of Ethics. If there is any doubt, you should discuss the situation with your leader or one of the compliance contacts listed on the following pages.

    Communicating Issues

    Talk to your leader about your concerns. Your leader is an excellent resource who will listen to you and understand the concerns you have. Give your leader an opportunity to resolve the issue.

    If you think an issue is not getting proper attention or is not properly resolved, talk to your next management level. All leaders have a responsibility to listen to your concerns and take the proper actions to resolve them.

    If your leader or next-level leader is unable to resolve the issue, or you are not comfortable talking to them, contact any of the following: the Audit and Compliance Department, the Legal Department, Human Resources, a compliance liaison, any vice president or any chief executive officer.

    Contact numbers are listed on the next page. Remember, retaliation is forbidden.

    Quick Tip

    • Are your actions in compliance with laws, regulations, policies and the Code of Ethics?
    • How would the issue appear to someone outside Baptist Health?
    • How would your family and friends view the situation?

  • The Audit and Compliance Department directs the Corporate Compliance Program. The staff is available to you to answer questions and give advice. For information on demand, the department has a website on Pineapple Connect. Search for Corporate Compliance on the home page. It has valuable information about our Corporate Compliance Program, our policies and procedures, and contacts available to you.

    Quick Tip

    • Our values include integrity and transparency.
    • Your responsibility is to follow the Code and speak about your concerns.
    • Never retaliate against anyone who reports a suspected violation of the Code.
    • See our non-retaliation policy, BHSF Policy 822.

  • Audit and Compliance...............786-662-7352


    Specialized Resources 

    HIPAA Privacy Hotline...............786-596-8850

    Laboratory Compliance...............786-662-5478

    Legal Department...............786-662-7022

    Research Compliance...............786-527-9026

    Human Resources

    Baptist Health Enterprises...............786-527-9587

    Baptist Health Hospital Doral...............786-527-9795

    Baptist Health Medical Group...............786-595-1131

    Baptist Health Medical Group North...............786-595-1131

    Baptist Hospital...............786-596-1017

    Baptist Outpatient Services...............786-595-9795

    Bethesda Hospital East & West................561-737-7733, Ext. 84666

    Boca Raton Regional Hospital...............561-765-3283

    Corporate Offices...............786-527-9587

    Doctors Hospital...............786-308-3205

    Fishermen’s Community Hospital..............305-434-3657

    Homestead Hospital...............786-243-8552

    Mariners Hospital...............305-434-3657

    Miami Cancer Institute...............786-527-8474

    South Miami Hospital...............786-662-8888

    West Kendall Baptist Hospital...............786-467-2022


    Compliance Hotline...............888-492-9329

    Compliance Liaisons — Located in Risk Management

    Baptist Health Enterprises...............786-308-2718

    Baptist Health Hospital Doral...............786-308-2706

    Baptist Health Medical Group & Medical Group North...............786-308-2716

    Baptist Hospital...............786-596-6150

    Baptist Outpatient Services...............786-308-2706

    Bethesda Hospital East & West...............561-737-7733, Ext. 84104

    Boca Raton Regional Hospital...............561-955-3217

    Doctors Hospital...............786-308-3181

    Fishermen’s Community Hospital................305-434-3671

    Homestead Hospital...............786-243-8440

    Mariners Hospital...............305-434-3671

    Miami Cancer Institute...............786-527-7953

    South Miami Hospital...............786-662-5018

    West Kendall Baptist Hospital...............786-467-2088

  • If you do not feel comfortable discussing your concerns directly with your leader or one of the compliance contacts we have listed, call the Compliance Hotline, toll-free. We will protect your anonymity to the extent possible. The number is 888-492-9329.

    This line does not replace your normal reporting process. It is another resource available to you. Calls are handled confidentially, and you are protected from any form of retaliation for reporting a violation. If anyone tries to retaliate against someone who reports an ethical or legal concern, and the report was made in good faith, that person will be subject to disciplinary action. Disciplinary action could include termination.

    Compliance reports also can be made online at MyComplianceReport.com (enter Access ID BHS). You can access it using your computer or your mobile phone. The app gives you the option to make an anonymous report. These reports are handled in the same confidential manner as calls. Anyone making an online report in good faith is protected from retaliation.

  • Anyone who violates the Code of Ethics may be subject to disciplinary action. The chief compliance officer works with Human Resources to recommend the type of discipline to take. A range of factors and various levels of discipline are considered. All disciplinary actions are taken on a fair and equitable basis.

    When the property or information of Baptist Health or its patients or customers is used to make improper financial gain, it is a serious violation. This may lead to prosecution and/or disciplinary action, which can include termination.

  • Q: Are calls placed to the Compliance Hotline traced?
    A: Calls to the Compliance Hotline are not traced in any way. A third-party vendor answers the calls and does not track the phone number.

    Q: Is it true I can remain anonymous when calling the Hotline?
    A: Yes, if you are not comfortable giving your name, tell the operator that you wish to remain anonymous.

    Q: How can I follow up on my Hotline call?
    A: You will receive a report number and a follow-up date. On or after the follow-up date, you can call the Hotline and obtain a status report about your call.

    Q: If I file a report online through MyComplianceReport.com, will my computer ID be traced?
    A: Just as calls to the telephone line are not traced, reports placed online are not traced in any way. You also will be given a follow-up date for online reports.

    Q: What protects me from being retaliated against for making a report?
    A: Retaliation for making a report is prohibited. Anyone who retaliates against someone for making a Hotline report can be subject to disciplinary action. When you call the Hotline, you will be given the name of a contact you can call. You can also call the Hotline to report retaliation. When making a report, you may remain anonymous, and calls are not traced.

  • The healthcare industry is one of the most highly regulated industries in the United States. Regulations range from those dealing with patient care to those dealing with submission of claims. When you add to this the laws, rules and regulations that apply to any business, the number of guidelines Baptist Health must follow is staggering.

    The fact that there are so many guidelines does not change our commitment to follow them according to our ethical standards. It is impossible to discuss every law, rule and regulation that applies to the healthcare industry in our Code. In the following sections, we discuss topics that are especially important to our commitment to always do the right thing. Our discussion is a summary of our policies. For detailed information, refer to the policy related to the topic.

  • It is the policy of Baptist Health to comply with all federal and state laws, regulations, standards and other compliance requirements that apply to us. Our ethical standards are built upon this principle. We will not pursue any business opportunity that results in unethical or illegal activity. It is your duty to be aware of these requirements and to comply with them.

  • Our policies and procedures define acceptable practices. You are expected to be aware of and follow them. Compliance with Baptist Health policies and procedures is an element in evaluating the performance of all employees. Review policies regularly. Make updates when changes to regulations or processes occur.

    Value Link

    • Integrity and Transparency — In everything, we do what’s right — for our patients, for our colleagues, for our industry and for the world around us.
    • Belief — We are built on a faith-based heritage and mission, and this spirit inspires our support for the communities we serve.

  • Baptist Health is committed to providing consistently high-quality patient care services. We do so without regard to 1) race; 2) color; 3) religion; 4) gender; 5) sexual preference; 6) national origin or 7) disability. Clinical decisions are based on patient healthcare needs. They are not based on financial circumstances. We provide services with skill, concern and compassion. They are evidence-based and compassionately provided. We do so to ensure patient safety, superior clinical outcomes and the highest levels of satisfaction, with a focus on patients and their families.

    Value Link

    • Excellence — We set a high bar for clinical quality, service and experience throughout Baptist Health.

  • Our community benefit initiatives are based upon our mission to care for people and improve the quality of life in the communities we serve. In addition to our high-quality patient care services, we provide a wide range of services that impact the well-being of our entire community. We also provide numerous programs to our employees that help them to achieve success and stay healthy.

    We give respectful treatment and care to all patients coming to our facilities in an emergency. This is regardless of ability to pay or the source of payment. Baptist Health recognizes its responsibility to our community. We provide charity care to those meeting established criteria.

    Value Link

    • Compassion — We prioritize caring above all. This applies to each other, our patients, their families and the communities we serve.

  • Baptist Health ensures that employees are provided nondiscriminatory terms and conditions of employment according to the law. This is regardless of 1) race; 2) color; 3) religion; 4) national origin; 5) gender; 6) sexual preference; 7) age; 8) disability or 9) any other factor protected by applicable law. Our leaders are excellent resources to discuss and help resolve any concerns employees may have. Human Resources representatives are also available to help resolve issues such as these. We put a high emphasis on the value of our employees. Our values’ statement clearly sets forth our Human Resources philosophy.

    Value Link

    • People — It’s our people who make us special, and it’s our diverse and empathetic teams that patients trust with their care.

  • A culture of belonging is the focus of Baptist Health’s diversity, equity and inclusion efforts. We work to create an inclusive atmosphere. Our goal is for everyone to feel acknowledged, accepted, valued, respected and safe. Cultural differences have the potential to affect healthcare delivery. We work to provide effective, culturally competent care to all patients. That means delivering effective, quality care to patients with diverse beliefs, attitudes, values and behaviors.

  • Baptist Health works to provide an environment in which employees are treated with dignity and respect. An environment free from all forms of harassment or discrimination helps our employees work effectively. It also helps them gain personal and professional satisfaction from their work. We do not allow harassment or discrimination based upon classifications or characteristics protected by federal, state or local laws. We do not tolerate it. The protected factors include: 1) race; 2) color; 3) religion; 4) ancestry; 5) sex; 6) gender identity; 7) gender expression; 8) pregnancy; 9) national origin; 10) age; 11) marital status; 12) familial status; 13) military/ veteran status; 14) disability status; 15) genetic information or 16) sexual orientation. Anyone who reports discrimination or harassment is protected from retaliation for making the report. Any leader who sees an incident or receives a report of an incident must report the information at once to Human Resources.

  • We provide our employees a safe workplace and a safe environment. Threats, threatening language or any other acts of aggression or violence are not tolerated. All potentially dangerous situations should be reported at once to your leader. If your leader is unavailable, Security or Human Resources should be contacted.

    We also work to reduce and prevent work-related musculoskeletal disorders. Information about the Occupational Health Department is available on Pineapple Connect. Worksite assessments and remediation plans help to prevent injury.

  • Only licensed and credentialed individuals provide medical care at our facilities. We do not hire, employ or contract with people or entities that have been excluded from participation in federal or state healthcare programs. If a current employee, medical staff member, contractor, vendor or Board member becomes excluded, they must at once notify Audit and Compliance. Audit and Compliance works with the proper departments to decide what action to take. This could include Human Resources, Medical Staff Office, Supply Chain or Board leadership. Actions could include termination of employment, medical staff privileges, contractual arrangements and/or Board membership.

  • All charitable contributions from vendors must directly help a Baptist Health entity or Foundation. The vendor must directly pay the Foundation. Under no circumstances may a check be made payable to an individual within Baptist Health. We do not accept any donations that are in conjunction with a marketing effort or sales promotion. Requests for charitable contributions from vendors may be made only by the Foundation. Individual employees or departments may not ask vendors for gifts or contributions. All offers of charitable contributions should be referred to the proper Foundation representative.

  • A potential conflict of interest exists when you could benefit personally, beyond your paycheck, from an action you are taking as part of your job duties. Potential conflicts of interest come in many forms. For example, let’s assume you are in charge of ordering medical supplies and that you can order those supplies from one of three suppliers. If your spouse sells medical supplies for one of those suppliers and is paid on commission, then you have a potential conflict of interest. You may benefit personally by ordering the medical supplies from that supplier. You must complete a conflict-of-interest disclosure form. The form is available electronically through Employee Self Service. Both your leader and the Audit and Compliance Department will review the information to decide whether an actual conflict of interest exists. A decision will then be made on whether you may order from that supplier.

    To avoid conflicts of interest, you are expected to:

    • Serve Baptist Health with undivided loyalty and never use your position for personal gain.
    • Devote your time and ability to your duties during your working hours.
    • Not accept other employment or engage in business activities outside regular working hours if these would interfere with your ability to meet your regular job responsibilities. Do not accept them if they would conflict or compete with services provided by Baptist Health.
    • Submit a conflict-of-interest disclosure form as soon as an actual or potential conflict of interest occurs. Disclosures must be updated as soon as a change in the situation occurs.

    Refer to BHSF Policy 827 Employee Conflict of Interest. Log on to Employee Self Service to complete the online form.

    Employed physicians are required to submit conflict-of-interest disclosures. Policy BHS 830 Employed Physicians’ Outside Financial Relationships with Industry provides information regarding disclosure requirements.

  • Q: Does the conflict-of-interest policy apply to all employees?
    A: Yes, the conflict-of-interest policy applies to all employees. An employee must disclose his or her employment, contractual relationship or financial relationship, other than his or her employment with Baptist Health.

    Q: I have a job outside Baptist Health. Do you mean that I am not allowed to have a second job?
    A: Our conflict-of-interest policy means only that you must disclose your second job. Once you have done that, a determination will be made as to whether your second job presents a conflict with your duties and responsibilities at Baptist Health.

    Q: I disclosed my second job last year. Do I have to do it every year?
    A: Our policy requires that you disclose potential conflicts of interest as soon as they arise and when there is a change in circumstances.

    Q: My husband just got a new job with a competing hospital. Do I need to complete the form now or can I wait until next year?
    A: A potential conflict of interest must be disclosed as soon as it arises. Complete a form now to report your husband’s employment with a competitor.

  • Baptist Health representatives will not ask for or accept improper payments. Improper payments are receiving or paying bribes, kickbacks or other illegal incentives. This could be for personal gain, developing business or any other purpose.

  • A vendor is defined as any person or company doing business with or looking to do business with Baptist Health. Except in limited circumstances, you may not give or receive gifts, other than gifts of nominal value, to or from a vendor. This prohibition extends to family members as well. Cash gifts, including gift certificates and gift cards, may never be accepted, no matter what the value.

    Noncash gifts of nominal value may be accepted. The guideline used to decide if a gift is of nominal value is $150. If the value of a gift is $150 or more, it is not considered nominal and the gift must not be accepted. In addition, you should consider whether you have received more than one gift from the same source. Annually, the value of gifts received from the same source must not exceed $300.

    Gifts can be in the form of favors, gratuities or other things of value. Discounts for personal items from vendors could be considered a gift and should not be accepted if they are outside of a prearranged Baptist Health discount or if they are of more than nominal value. Remember, cash or cash equivalents such as gift certificates or gift cards may never be accepted.

    Quick Tip:

  • Services to patients are given promptly and graciously. No patient should ever feel it necessary to offer tips or gratuities in order to receive the care they are entitled to receive. If a patient offers a cash gift or tip, you should tactfully decline such an offer. If the patient or family member would like to make a cash contribution, direct them to the appropriate Foundation office. Unsolicited non-cash gifts may be permissible. Check with your leader.

  • Attending business lunches or meals occasionally as a guest of a vendor, sales representative or other person who does business with Baptist Health is allowed. Meals with vendors or potential vendors should be infrequent, and the meals should be of nominal value. You should consider appearances, too. For example, the meal should be in an appropriate setting, at an appropriate time.

  • A vendor or potential vendor might offer to pay for an employee or a family member to attend a meeting. Examples are an educational program, seminar, user group, speaking engagement, promotional program, meeting or site visit. Baptist Health does not allow vendorsponsored travel. If the travel has a legitimate business purpose, and follows our policy on travel expenses, we will pay for employees’ travel.

    An employee may attend a social event, meal or other entertainment as a guest of a vendor while traveling. The cost must meet our definition of nominal and the other guidelines outlined for entertainment.

  • An honorarium is a payment to speak at a meeting or conference. Management staff may not accept honorariums for speaking engagements. Nonmanagement staff may accept honorariums in some situations. If you are not a manager, your leader must preapprove the payment. The organization offering an honorarium may donate it to the Foundation, instead of paying the employee.

    Quick Tip:

    • Cash, gift cards and gift certificates may not be accepted from a patient, other than contributions made to the Foundation.

  • We do not pay employees, physicians, other healthcare professionals or anyone else for referrals of patients. Bribes and kickbacks or any kind of benefits meant to induce patient referrals are not allowed. We do not accept payment as a reward for supplying patient referrals.

    You are expected to conduct business with all parties following high moral and ethical standards. All decisions about patient care are made solely on the best interests of the patient.

    Anyone involved in the negotiation of contracts for Baptist Health must make sure that all statements, communications and representations are open, accurate, appropriate and truthful. They must also be compliant with applicable laws and regulations.

    Regulatory and legal restrictions about referral incentives are complex. Do not complete transactions involving referral sources (e.g., physicians) without the involvement of the Legal Department.

  • All arrangements with clinicians, physicians and other referral sources must be in writing. They must show the specific service the professional is paid to provide. Agreements must include specific and realistic time commitments. Payment rates for services must be at fair market value. The payment rate cannot be based on the volume or value of business referred to Baptist Health. All decisions about patient care are made based on what is best for the patient, not on the value of a business arrangement.

    All payments or other benefits provided to physicians must be supported with documentation to justify the legal business purpose for the payment. Documentation must also confirm that the services contracted were provided.

    The Anti-kickback Statute forbids payments or other consideration to physicians for referrals for services. When dealing with a physician, do not take anything from or offer to give anything to the physician in exchange for the referral of patients or patient-related services. This includes referrals to or from the physician. The Internal Revenue Service (IRS) forbids private individuals, including physicians, from receiving an undue private benefit as the result of their relationship with a tax-exempt healthcare organization. An undue private benefit could be any amount more than the fair market value related to the arrangement.

    The Legal Department must approve all contracts with physicians. This is to ensure that any contractual arrangements do not violate the Anti-kickback Statute, Stark Laws, IRS regulations or any other law or internal policy.

    Quick Tip

    • There are many complex laws that govern our transactions with physicians.
    • The Legal Department has standards for these transactions.
    • Prior to making an arrangement with a physician or other healthcare provider, contact the Legal Department at 786-662-7022.

  • We must not knowingly submit a bill for certain services when the referring physician has a financial relationship with Baptist Health, unless certain exceptions are met. This also applies when a physician’s immediate family member has a financial relationship.

    These laws are complex. Approval from the Legal Department must be obtained prior to setting up a financial relationship with any physician.

  • Charge entry is one the first steps toward creating a bill to send to a payer. Only enter charges that are supported by the medical record documentation. Charges entered are for services rendered, rather than services ordered. Charges must also be entered within reasonable time frames and according to policy.

  • Baptist Health reports diagnosis and procedure codes to various regulators and payers. These codes are assigned during the medical record coding process or via charge entry. A payer may use the codes to decide coverage and payment. Assign all medical recordrelated codes to a patient account based upon the medical record documentation. Do not assign an unsupported code. If you do so intentionally, disciplinary action may be taken. This action may include termination of employment.

  • Intentionally submitting any claim for payment that is false, fraudulent, inaccurate, incomplete or fictitious is not tolerated. There are federal and state laws and regulations governing health insurance billing. Baptist Health and you can be prosecuted for intentionally filing inaccurate claims. This can lead to extremely large civil fines, criminal penalties or both.

    Our Code of Ethics requires:

    • Employees who bill and code take every reasonable precaution to ensure their work is accurate, timely and in compliance with policies and federal and state laws and regulations;
    • Baptist Health makes appropriate corrections if inaccuracies are discovered in bills that have been submitted;
    • Baptist Health only bills for services actually rendered and that are appropriately documented in patients’ medical records, using only billing codes that accurately describe the services provided; and
    • Baptist Health ensures, as much as possible, that all claims to Medicare, Medicaid and other federal and state programs are for services that are medically necessary and properly documented.

    Examples of unacceptable billing practices include:

    • Knowingly and willfully making or causing any false statement or representation of material fact on any claim or report submitted to a payer;
    • Concealing or not disclosing an event affecting the right to payment or the amount of a payment, when the intention is to obtain payment greater than what is due;
    • Presenting or causing a false or fraudulent claim; and
    • Submitting requests for payment in violation of the terms of an assignment or an agreement with the payer.

    You are obligated to notify your leader, or the Audit and Compliance Department, if you are asked to deviate from accepted billing practices or if you have any questions in this area.

  • The False Claims Act (FCA) was enacted to prohibit the knowing submission of false or fraudulent claims to the federal government. This includes the Medicare program. Penalties for violating the FCA can be up to three times the amount of the payment received on the claim, and added amounts that can be over $20,000 per claim. False claims can also result in exclusion from the Medicare and/or Medicaid programs. The state of Florida has enacted a similar law, which also includes penalties for individuals or entities that file false or fraudulent claims to the state or to Medicaid.

    We have policies and procedures that support our commitment to the highest ethical standards for filing claims to any payer. These policies and procedures are available on Pineapple Connect. Our Code of Ethics summarizes them. We require you to report to us suspected improper conduct. We protect from retaliation anyone who reports a suspected violation to Baptist Health. Potential violations may be reported directly to any leader or anonymously via the Compliance Hotline or online at MyComplianceReport.com (enter Access ID BHS).

    Quick Tip

    The Audit and Compliance Department is the department primarily responsible for investigating allegations of misconduct. The department charter sets out the mission for the department. It describes the responsibility to assist in the prevention and detection of fraud, waste and abuse. The department performs proactive audits, provides training and performs investigations. This is done under the guidance of the Audit and Compliance Committee of the Baptist Health Board of Trustees.

    The policies and procedures addressing Baptist Health’s prevention and detection of fraud, waste and abuse are available on Pineapple Connect. They also describe the Audit and Compliance Department’s role in prevention and detection.

  • All Baptist Health records must be accurate, timely, reliable and safely stored. This applies to financial, clinical and employee records. All assets, liabilities, revenue and expenses must be recorded in the books of the health system. All transactions must be appropriately documented and all assets must be used for the purpose approved. An employee’s time card must accurately reflect the time worked and other benefits payable, such as PTO (Paid Time Off) or call time.

    An employee’s signature means that the documentation accurately reflects the data it represents. For example, a leader’s signature on a timecard or expense report means the data was reviewed and steps were taken to verify its validity. This includes the cost center allocation of those expenses. The Code of Ethics emphasizes the need for honesty, integrity and accuracy in our conduct and in our transactions. The accuracy and thoroughness of Baptist Health’s records are an essential element of sustaining high ethical, professional and legal business practices.

    Policy Link

  • Baptist Health policy supports routine and orderly maintenance of records needed for legal, financial or operational purposes. The policy includes a record retention schedule. The types of records kept and the retention periods are outlined. Documents related to an actual or threatened lawsuit or investigation are safeguarded and not destroyed.

    Quick Tip

    • Be aware of patient privacy — avoid unintended disclosures.
    • Safeguard computer passwords and user IDs — do not share.
    • Dispose of documents properly, keeping in mind privacy laws.

  • We gather a lot of personal and health information about patients. The Health Insurance Portability and Accountability Act (HIPAA) gives patients specific rights to privacy. It also limits the use of information that can identify the individual. We must respect the patient’s right to privacy. The inappropriate release of patient information in any form may be harmful to the patient and to Baptist Health. We must also protect patient information that could be used illegally to obtain goods, services or cash. This could be health or contact information or data such as a Social Security Number or credit card number. The inappropriate release of patient information may make you subject to prosecution. It could also result in your termination from Baptist Health.

    In order to protect patient information from inappropriate disclosure, you are expected to:

    • Limit access and use of patient information to that needed to do your job, as allowed by law and authorized by Baptist Health;
    • Use only legitimate and authorized processes to collect patient information. Whenever practical, obtain it directly from the patient;
    • Release information about patients in drug and alcohol treatment programs and information about a patient’s HIV (Human Immunodeficiency Virus) status following the special confidentiality rules and laws that apply;
    • Refrain from revealing any patient information unless supported by legitimate business or patient care purposes defined by Baptist Health;
    • Refrain from discussing health information with anyone inside or outside Baptist Health unless it is in connection with your work, allowed by law and authorized by Baptist Health;
    • Be aware of your surroundings. Guard against visitors and third parties needlessly overhearing patient health information; and
    • Refrain from removing, sending or electronically transmitting a patient medical record, or a copy, without the authorization of a leader or other designated official.

    The Privacy Office has developed policies and procedures that define our privacy practices. Patient and employee complaints of privacy violations may be reported through the HIPAA Privacy Hotline at 786-596-8850 or email Privacy@BaptistHealth.net

  • All business records of Baptist Health are proprietary and confidential. Federal and state laws require Baptist Health to keep certain business records for specific periods of time. We often need to find business and corporate records on short notice. For these reasons, limit your access, use and disclosure of business information and corporate records to what is needed to perform your job duties. Do not remove or electronically send business or corporate records from any department without authorization of the proper leader. This applies to copies of records, too.

  • As part of our commitment to our patients, Baptist Health takes patient privacy very seriously. Everyone is responsible for protecting patient information. You can access patient information if you are involved in the patient’s treatment or in work that supports payment activities or healthcare operations. You are not allowed to access or share patient information for any other reason. Workforce members who access or share patient information when they should not may be subject to immediate termination of employment, loss of privileges or removal of access to electronic systems containing ePHI.

  • Passwords issued to an employee are for that employee’s use only to complete duties assigned to them. Due care must be taken to protect the confidentiality of passwords assigned to you. You must take reasonable precautions to protect against unauthorized access to work areas where confidential information may be available or displayed.

  • When working remotely, it is important to safeguard confidential information. All work-related information must be kept confidential. Do not take proprietary or confidential information from your remote work location without the prior approval of your leader. If you are working at a non-Baptist Health worksite outside of your home, you must ensure you have a private space where conversations cannot be overheard. Make sure others cannot see your computer screen.

  • Social media is the use of technology for social interaction, including words and pictures. Some examples of social media are Facebook, LinkedIn, Wikipedia, chat rooms and blogs. Through your duties at Baptist Health, you have access to all kinds of confidential information. Examples are business records, patient information and expansion plans. You may not use social media to disclose confidential patient or business information. If you disclose on social media that you are associated with Baptist Health, you must clearly specify that any opinions expressed are your own and not those of Baptist Health. All external representations of Baptist Health must first be authorized by the Marketing and Communications Department.

  • Baptist Health’s marketing and communications information is truthful and is not intended to mislead. Claims about Baptist Health services are based on facts.

  • Baptist Health follows all applicable laws about antitrust and competition. These laws generally forbid any kind of understanding or agreement to restrain competition. The agreement could be written or oral. Examples include agreements between competitors to fix or control fees for services or conditions for treatment.

    You must not discuss proprietary or confidential information with anyone outside of the organization. For example, pricing policy, terms and conditions, costs, inventories, marketing and product plans, and market surveys and studies, should not be discussed.

    Baptist Health competes fairly in the market. We will not agree with a competitor about what prices to charge, whom to call on for sales and what services to offer. The following are examples of prohibited activities:

    • Attempts to unlawfully monopolize the provision of medical services;
    • Setting fees at unreasonably low levels to drive out or keep competitors out of the market;
    • Telling a supplier that Baptist Health’s decision to purchase goods or services is dependent upon the supplier’s seeking medical services from Baptist Health;
    • Tying arrangements that condition the purchase or sale of one product on an agreement to do other business with Baptist Health; or
    • Paying an unaffiliated healthcare provider cash or giving gifts as an incentive to promote Baptist Health’s services.

  • Federal law says that tax-exempt organizations may not take part in or intervene in any political campaign related to a candidate for public office. This includes local, state and federal elections. It also includes statements either in support of or against political candidates. Many of our business entities are tax-exempt. You may not donate any Baptist Health funds, products, services or resources to any political cause, party or candidate. This includes use of such things as Baptist Health email or mailing lists. The use of social media is also included. For example, if you are on social media presenting your personal donation to a political candidate and you are wearing your Baptist Health ID badge, it could look like you are making the donation on behalf of Baptist Health. An email from a Baptist Health email account urging votes against a particular candidate would be wrong because the email account belongs to Baptist Health. You, as an individual, may voluntarily make personal contributions to any lawful political cause, party, or candidate. Your personal contribution must not be represented as coming from Baptist Health. You must not ask for or obtain the money from Baptist Health for the specific purpose of making a political contribution.

  • You are personally responsible and accountable for the proper use of our funds and property. This includes taking steps to protect computer systems and networks from unauthorized use, access or modification of software. Baptist Health also requires you to protect patient and other’s property and information.

    You are expected to:

    • Be personally responsible and accountable for the proper expenditure of Baptist Health’s funds and the proper use of its property.
    • Use Baptist Health supplies, equipment and property bought and owned by Baptist Health for business purposes only. Unauthorized use of Baptist Health property is considered theft.
    • Use computer systems’ software and hardware that Baptist Health owns or uses only to conduct business.
    • Follow software copyright licenses and corporate policies on software usage.
    • Dispose of surplus, obsolete or junked property following our policies and procedures. Unauthorized disposal of property is a misuse of assets.

    Use of a Baptist Health computer does not guarantee personal privacy.

  • There are laws about conducting business outside the United States. The Foreign Corrupt Practices Act (FCPA) is one of those laws. It applies to any agent or U.S. citizen transacting business with a foreign official. All employees or agents of Baptist Health must conduct international transactions following our Code of Ethics and the standards of the FCPA. If you do not know what those standards are, contact Audit and Compliance or the Legal Department.

  • Regulatory or government agencies sometimes request information from Baptist Health. Requests for information from these agencies must be responded to in an accurate and timely manner, according to the laws and regulations that apply. Sometimes requests are routine. That could be a request for medical records in order to pay a claim, for example. Routine requests may be responded to as part of the normal business cycle. A non-routine request could be a subpoena, affidavit, warrant or letter from an agency. If you receive notification of a violation or citation from an agency and it relates to topics covered by our Code, contact the Legal Department or Audit and Compliance for immediate attention. This applies especially to non-routine requests.

    We cooperate with all valid and appropriate government inquiries or investigations. You should not obstruct any government request for information, audit or investigation of Baptist Health.

    You must fully cooperate with all internal and external audits. This includes Audit and Compliance Department audits and investigations.

  • Refer requests for information made by a news or media source to the Marketing and Communications Department.

    Policy Link

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