Wellstar Corporate Purchasing - Code of Conduct (2024)

Wellstar has adopted this Code of Conduct as a demonstration of our unwavering commitment to honor all laws and regulations that govern the healthcare industry. The elements of this Code of Conduct that are incorporated into Wellstar's Corporate Compliance program include:

• Our Vision, Mission, Values,
• Basic Principles of Conduct,
• Standards of Service Excellence, and
• Standards of Professional and Business Conduct

This Code of Conduct serves as our guide to enhance and continually develop aculture that values compliance from the top-down and fosters compliance from thebottom-up throughout Wellstar and among all workforce members.

This Code of Conduct is designed to provide overall guidance; however, it is notpossible to address every situation. Guidance that is more specific may be providedin Wellstar’s Policies and Procedures. If there is no specific policy, this Code ofConduct becomes the policy. If a policy and a Code of Conduct provision conflict,the policy governs. This Code of Conduct is a “living document” meaning that it willbe updated periodically to respond to changing conditions. Wellstar policies andprocedures can be found in the PolicyTech link on eSource, and Wellstar’s Code ofConduct is accessed in the Compliance link on eSource.

Questions regarding this Code of Conduct, or any issue, should first be raised byan employee to his or her immediate supervisor, then through the chain of authorityup to, and including, the Chief Compliance Officer, or Wellstar Corporate Officers.Alternatively, issues may be reported to Human Resources or confidentially andanonymously to the Compliance Hotline. Please download the Code of Conduct document for a list of important phone numbers.

Wellstar’s Vision, Mission and Values

VISION: Deliver world-class healthcare to every person, every time.

MISSION: To enhance the health and well-being of every person we serve.

VALUES:

• We serve with compassion.
• We pursue excellence.
• We honor every voice.

Basic Principles of Conduct (H.E.A.R.T.)

At Wellstar, in keeping with our values of compassion, excellence, and honoring ourvoices, we put our “heart” into all that we do and that includes living in a compliantculture as described below.

Honor Confidences

Honor confidences entrusted to you. Organizational and patient information entrusted to you should be held in the highest confidence.

Ethical Behavior

Ethical behavior of the highest standard is expected of every workforce member and is our institutional cornerstone.

Abide By Laws, Regulations, Policies and Procedures

There are many laws, regulations, policies, and procedures that govern events and behaviors within and on behalf of our organization, particularly those related to coding and billing, and relationships with referral sources and vendors. If you are uncertain about these requirements please ask for help. Guidance can be obtained through your supervisor or the Compliance Department at (470) 644-0400.

Report Events

Report events that concern you. If you observe or have information about events or behaviors that you believe to be unethical, illegal, against policy, or against prescribed protocol, you should report your concerns to your supervisor. Reports may also be made anonymously to the Compliance Hotline at 1 (888) 800-5094.

Truthful, Complete and Accurate Communications

Truthful, complete and accurate communications is the standard within our organization and when communicating with outside agencies, including government representatives. Remember—honesty is always the best policy.

Standards of Service Excellence

Corporate Compliance Program

Wellstar’s Corporate Compliance Program is a comprehensive, self-governingprogram designed to proactively minimize the chances that a violation of law orgovernment regulation occurs within Wellstar Health System (“System”). Wellstar’sCompliance Department is responsible for regulatory, privacy, monitoring and auditingissues, and training. It is modeled on the seven basic elements proposed by the federalgovernment’s Office of Inspector General (OIG) for developing effective CompliancePrograms and includes:

1. Policies and Procedures,
2. Designation of a Chief Compliance Officer,
3. Monitoring and Auditing,
4. Training and Education,
5. Open Lines of Communication,
6. Responding to Detected Deficiencies, and
7. Enforcing Disciplinary Standards.

Designation of Chief Compliance Officer & Compliance Committee

The Chief Compliance Officer (CCO) reports directly to the CEO and the Board ofTrustees and is responsible for the administration of Wellstar’s Corporate ComplianceProgram as well as the day-to-day operation of Wellstar’s Compliance Department.

The Chief Compliance Officer chairs the Corporate Compliance Committee, acomplement of multidisciplinary Wellstar leaders. This committee has oversightresponsibilities to ensure system-wide compliance with the fundamental elements ofWellstar’s Corporate Compliance Program. In general, the committee addressesvarious compliance-related issues and other applicable projects, including but not limitedto regulatory developments, internal and external audits, and legal issues. Mostimportantly, the committee seeks to ensure that all compliance objectives areadvanced according to expectations and properly executed. In furthering system-widecompliance, the Corporate Compliance Committee determines the scope of issues thatwarrant further review by the Board of Trustees and makes recommendationsaccordingly.

The Chief Compliance Officer, on behalf of the Corporate Compliance Committee,presents regular compliance reports to the CEO and the Board of Trustees AuditCommittee as well as submitting reports directly to the Board of Trustees from time totime.

Monitoring and Auditing

Wellstar’s Compliance Department performs monitoring and auditing of internalcontrols related to regulatory compliance, clinical standards, and coding assurance.Regulatory Compliance areas are audited continuously to ensure adherence to allfederal, state, and local laws and regulations. Compliance in these areas allowsWellstar to maintain a positive standing with the Centers for Medicare and MedicaidServices (CMS).

Clinical auditing aims to uphold the highest level of patient care and safety, while alsofollowing the guidelines set out by the government and accreditation agencies, like TheJoint Commission. The Coding Assurance team is responsible for internal monitoringand auditing of documentation, coding, and billing patterns across Wellstar physicianoffices and facilities. Coding Assurance audits focus on the early identification ofunderpayments and overpayments, refunding payments when appropriate, anddeveloping action plans to prevent further occurrences.

Each year the Compliance Department develops and executes an internal audit planderived from the federal government’s OIG Annual Work Plan, internal issues ofconcern, and various other issues within the healthcare industry. Additionally, periodicrisk assessments are conducted across all areas of compliance based on industrytrends and/or regulatory changes.

• Wellstar expects employees to fully cooperate with the Compliance departmentin the course of its audit and investigation activities. Wellstar also expects thatemployees will not improperly influence, manipulate, or interfere with anyauditor engaged to perform audits of Wellstar’s books, records, processes, orinternal controls. Wellstar employees should not conduct audits independentlywithout the approval of the Compliance or Legal department.

Training and Education

Wellstar’s Compliance Department team members provide initial orientation and continuing compliance education for all new and existing employees. In addition, all employees are required to complete annual compliance training hosted by the Organizational Learning Department. The Compliance Department utilizes multiple platforms for training, such as online learning modules and in-person training. In-person training includes lunch and learns, attending staff meetings, and periodic rounding throughout Wellstar facilities. The Compliance Department provides education and training when needed or requested by anyone within Wellstar.

(Refer to Policy CO-08 Compliance Training and Education Procedure)

Personal Obligation to Report

Wellstar believes each of its employees has an individual responsibility and duty and rightto report their good faith belief of any violation of this Code of Conduct, Wellstarpolicies, wrongdoing, or applicable law. Compliance is everyone's responsibility.

The following process should be followed:

• Talk to your supervisor, who is most familiar with the laws, regulations, andpolicies that relate to your work area.
• If you are not comfortable contacting your supervisor or if you do not receive anadequate response, talk to another member of the management team or HumanResources.
• If you still have questions, contact the Wellstar Compliance Officer at 1-470-644-0400.
• You may also use the Compliance Hotline to report concerns and complaints.Individuals using the Compliance Hotline are given the option to make a reportanonymously. The toll-free Compliance Hotline is 1-888-800-5094 and isavailable 24 hours a day, 7 days a week to report misconduct or othercompliance-related issues or concerns.
• Wellstar does not discriminate or retaliate against employees who report acompliance concern, based on a good faith belief that Wellstar is not operatingin accordance with applicable federal and state laws and regulations.

Mechanism for Reporting - Compliance Hotline 1-888-800-5094

Wellstar operates an external, independent Compliance Hotline, which is availableanytime. All calls can be anonymous and will be treated confidentially to the extentpermitted by law. However, calls to the hotline do not protect callers from appropriatedisciplinary or legal action regarding their own performance or conduct.

Internal Investigations of Reports

Wellstar is committed to investigating all reported compliance or privacy concernspromptly with confidentially to the extent possible. The Compliance Officer willcoordinate any findings from the investigations and recommend corrective action orchanges that need to be made. We expect all employees to cooperate withinvestigation efforts.

Corrective Action

Wellstar initiates corrective action and appropriate discipline when internalinvestigations reveal violations of this Code of Conduct, Wellstar policies, and federalor state laws, rules, and regulations. Corrective Actions include, but are not limitedto, targeted education, refunding improper payments, notifying regulatory agencies,correcting the source of errors, and implementing internal controls to prevent futureviolations.

(Refer to Policy CO-06 and Job Aid Fraud, Waste & Abuse Reports and Investigations)