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While it’s impossible to include every situation that may occur in one place, this Code of Conduct provides guidance about many situations. It will help you know what it means to do the right thing and what to do if you think something isn’t quite right. Our policies and training provide additional details on these and other topics, and should be reviewed carefully. The Code of Conduct highlights the following (click the links below to learn more):

Behavior and Expectations


We are committed to providing a work environment that respects the rights, dignity and cultural differences of its teammates and others with whom we interact. Discrimination, retaliation, harassment or abuse of any form (e.g., physical, mental or verbal) and at any level is inappropriate and will not be tolerated.

Atrium Health is also committed to maintaining an environment that is free of unlawful harassment and intimidation. We do not tolerate behavior or conduct at any level that creates an intimidating, hostile or offensive work environment, including discrimination, retaliation, abuse, sexual harassment, or inappropriate relationships. We take these matters very seriously and will take immediate action against those who engage in such behavior, including termination.

Integrity Tip: Teammates should be treated with respect and dignity. If you have any legitimate, good faith concerns about discrimination, retaliation, harassment or abuse in any form, you should let your supervisor or Human Resources know immediately. If you want to report your concerns anonymously, call the Compliance Hotline. We are all here to help.

Billing and Coding


We are committed to billing for care and services that are properly authorized and documented as medically necessary. We take many reasonable precautions to produce billing and coding that is accurate, timely, relevant and in compliance with our policies, as well as federal and state laws and regulations. Certain government regulations and many insurance payer contracts require patients to pay co-insurance, co-payments and deductibles. We will similarly comply with restrictions on waiving co-insurance, co-payments and deductibles. Those working in areas impacting billing or coding – including teammates, medical staff members, and contractors – are expected to understand and comply with all billing and coding policies, procedures and documentation requirements established by Atrium Health and third-party payers.

Integrity Tip: You have an important role in helping us bill for services that have been properly authorized and documented. If you see a problem, speak up so we can fix it!

Business Conduct


We are committed to conducting ourselves with integrity and making decisions without undue influence. In doing so, we follow the laws that prohibit us from giving or receiving kickbacks, bribes, rebates, or anything of value that could influence, create or induce an improper patient referral, services arrangement, lease, or purchase. We also do not give, promise, offer, or authorize giving anything of value, directly or indirectly, to influence any act or decision in order to improperly advantage or benefit us. These principles of integrity and compliance guide us in how we handle cash, gifts, meals, entertainment, travel, services, and intangible benefits. Even when we are allowed under the law to give or receive items of minimal value, we are careful about who, when, and how much of these are given or received by our teammates, board members, and providers. We also do not solicit, accept or attempt to accept (directly or indirectly) a bribe, kickback, inappropriate gifts, or other improper benefits when we contemplate or enter into transactions or arrangements with others, including with foreign government officials, and we follow anti-corruption standards.

Integrity Tip: You should ask for advice before accepting or giving anything of value from or to an outside party, including foreign government officials, that could interfere with your professional judgment. It is also important to avoid actions or associations that could be perceived as unduly influencing our decisions.

Caring for Patients


Each patient has certain rights, including the right to be treated as an individual and with dignity and respect at all times. Patients will receive prompt and courteous responses to their requests and to their need for treatment and services. Patients also have the right to participate in, and make decisions about, their healthcare, including the right to refuse medical treatment to the extent permitted by law. We will also comply with laws that govern how we care for patients, including the Emergency Medical Treatment and Labor Act (EMTALA) and other applicable laws.

Integrity Tip: We provide patients with information about their rights and responsibilities and strive to protect those rights throughout care and treatment.

Confidentiality and Privacy


Depending on your role with Atrium Health, you may create, access, or maintain confidential and proprietary information, such as confidential business, research, student, and financial information. Confidential and proprietary information belongs to Atrium Health and there are many reasons it must remain confidential, even after your association with Atrium Health ends.

Patient information has additional privacy protections under state and federal laws, including HIPAA, and we all have a duty to protect the confidentiality and security of that patient information. Our Notice of Privacy Practices describes how patients’ medical information may be used and shared and how patients can get access to that information. You are responsible for following our policies on privacy and security matters, including how to appropriately use and share patient information. Accessing patient information for any non-job-related use is strictly prohibited and may result in termination.

Integrity Tip: You are responsible for protecting patient and business-sensitive information and keeping it confidential all the time. If you discover a potential privacy or security incident, report it immediately.

Conflicts of Interest, Commitment and Reputation


You may find yourself with a relationship, commitment or situation that affects (or even appears to affect) your ability to make fair and objective decisions when doing your job or carrying out your duties. This is known as a conflict. You should not place yourself in any situation that might influence or force you to put your personal or financial interests ahead of the interests of our patients or Atrium Health.

Sometimes, conflicts may arise despite your best efforts to avoid them. If that happens at any point during the year, promptly and fully disclose it to your supervisor or to Compliance so they can help you figure out what to do. Remember, having a conflict is not necessarily a problem; not reporting it is. You do not have to wait for the annual disclosure to report a relationship or ask a question about a relationship.

Integrity Tip: You should promptly disclose any potential conflicts and not place yourself in situations that might influence you to put your personal or financial interests ahead of our patients or the enterprise. When in doubt, disclose them and reach out to Compliance for help.

Diversity, Equity and Inclusion


Atrium Health is also committed to responding to patients’ cultural health beliefs, preferences, and communication needs. We work to deliver care in a manner that is culturally and linguistically appropriate, respectful, accessible, inclusive and easy to understand so we can bridge communication gaps between patients and providers and reduce barriers to quality healthcare. We also support and foster cultural competence and make good faith efforts to align with standards and recommendations to support our delivery of accessible and culturally appropriate services, including Limited English Proficient (LEP) requirements and National Standards on Culturally and Linguistically Appropriate Services (CLAS).

Integrity Tip: You should be sensitive to the diverse backgrounds, cultures, and communication needs of your fellow team members and your patients and be respectful and inclusive towards them at all times.

Drug Diversion


Atrium Health maintains a “Drug Free Workplace” as required by the Drug-Free Workplace Act of 1988. Even so, all healthcare settings can be susceptible to drug diversion, which occurs when prescribed medications are obtained, stolen, or used illegally for the personal use or gain of a teammate or staff member. Drug diversion can impact patient care and workplace safety. It is illegal and involves theft of Atrium Health property and could result in loss of licensure for care providers.

Teammates or staff who are suspected of diversion or found to have diverted drugs may be reported to the appropriate authorities, including law enforcement agencies, and their personnel information can be shared with the authorities and as part of any reports. Teammates who are charged with, or convicted of, a drug or alcohol-related offense or other criminal violation, must report the charge or conviction to Human Resources. Because drug diversion may be a symptom of a dependency issue, we encourage anyone with a drug/alcohol problem to contact the Employee Assistance Program at 704-355-5021 for assistance.

Integrity Tip: You should report any suspicious activity or concerns related to the mishandling of controlled substances to your supervisor immediately.

Education and Training


We are committed to providing education and training to help our teams be successful. To do so, we provide education and training in a variety of forms and forums, both at hire and throughout a person’s tenure with us. In addition to job duties, we provide training and education on special areas, such as proper billing and coding compliance, privacy and security safeguards, and complying with applicable laws and our policies. Managers provide additional education about compliance issues affecting specific areas of responsibility. We also use our training and education to encourage reporting of concerns and reiterate our commitment to non-retaliation.

Integrity Tip: Pay close attention to the compliance education you receive throughout the year – it will help you understand the rules that apply to your job, govern our organization, and support our compliance.

Equal Employment Opportunity


We recruit, hire and promote qualified candidates for employment opportunities without regard to race, color, age, religion, gender, sexual orientation, gender identity, national origin, veteran status, disability, genetic information or any factor prohibited by law. We affirm our policy and practice to support and promote the concepts of equal employment opportunity and affirmative action in accordance with all federal, state and municipal laws.

Integrity Tip: You should consistently respect equal rights when making personnel decisions. Human Resources has helpful policies, guidance, and educational resources available.

Fair Competition


We compete in an ethical and legitimate manner. We avoid actions that are anti-competitive or otherwise conflict with laws that govern competitive practices in the marketplace. Unlawful practices include agreements with a competitor to divide territories or customer lists, or any arrangement with a competitor that artificially raises the price of services or improperly reduces competition.

Integrity Tip: You should compete ethically and legitimately.

False Claims Act


Atrium Health is committed to following all laws and regulations, including those from federal and state beneficiary programs, and conducting our business in a legal and ethical manner. We take numerous steps to comply with the law and actively work to prevent the occurrence of any fraudulent or false claims. If we discover inadvertent errors or occurrences of noncompliance, we will promptly correct the issue and take other appropriate actions.

Integrity Tip: We work hard to submit accurate claims and you play a critical role in helping us catch errors. If you find or suspect a billing, coding, or documentation error, report it immediately to your supervisor, Compliance, or the anonymous hotline listed at the end of this Code of Conduct.

Learning Institutions


We are proud to be an academic Learning Health System where we train both our own students and learners, as well as those who come to do clinical rotations with our excellent faculty and providers/preceptors in a variety of disciplines and specialties. To do so, we maintain a professional environment that supports the skills development and success of our trainees and students (also referred to as learners). We will be fair and impartial in grading, evaluations, promotions, and grievances, and follow our policies and procedures for addressing concerns. We will support all learners by demonstrating respect, inclusion, and professionalism in interactions we have with learners. In addition to this Code of Conduct, students and learners are held to the policies, guidelines and resources of their respective institutions and programs.

Integrity Tip: Our education programs will comply with all applicable laws and regulations of our accredited education programs, and we expect our students, learners, and faculty to conduct themselves in a compliant and professional manner that supports effective training.

Marketing and Media Relations


We value the trust our patients and our communities place in us, and we take care to represent ourselves in a truthful and accurate manner. Our advertising will not be misleading, and we represent our services in a manner supported by evidence. We will communicate with respect and integrity whether in person, in print or online.

Integrity Tip: To make sure we speak with one voice, all marketing communications and media requests for information are to be directed to the Communications department.

Patient Care


Each patient has certain rights, including the right to be treated as an individual and with dignity and respect at all times. Patients will receive prompt and courteous responses to their requests and to their need for treatment and services. Patients also have the right to participate in, and make decisions about, their healthcare, including the right to refuse medical treatment to the extent permitted by law. We will also comply with laws that govern how we care for patients, including the Emergency Medical Treatment and Labor Act (EMTALA) and other applicable laws.

Integrity Tip: We provide patients with information about their rights and responsibilities and strive to protect those rights throughout care and treatment.

Political and Community Activities


Our teammates have many passions and interests and we support their right as private citizens to participate in the political process and serve as advocates for religious and charitable organizations, so long as that participation does not:

  • Interfere with the satisfactory performance of our official duties while on work time or our compliance obligations
  • Bring discredit or embarrassment to our fellow teammates or our patients
  • Damage our reputation for providing the highest standards of patient-centered care, education, and research
  • Cause harm to a patient, family member, or member of the public
  • Create a conflict of interest, commitment, reputation, or allegiance that interferes with our professional judgment
  • Violate any Atrium Health policies, including those that prohibit discrimination, harassment, and retaliation
  • The use of Atrium Health funds for political or charitable contributions is subject to restrictions as outlined in our anti-corruption policy

Integrity Tip: You should not express political or religious views in the workplace in a way that conflicts with your ability to do your job. Your personal beliefs and activities should be conducted on your own time and in a way that makes clear you do not represent Atrium Health’s views in those activities or statements.

Record Keeping and Accounting


Our records are prepared accurately, reliably, honestly and in accordance with established finance, accounting and medical record-keeping requirements. Records and documents are not to be destroyed or altered in anticipation of, or in response to, a request for those documents by any government agency or court.

Integrity Tip: You are responsible for accurate and honest record keeping.

Research


Clinical research is an important part of how we advance healthcare for all patients and communities. We take our responsibility seriously to conduct clinical research activities that adhere to legal and ethical standards and in accordance with appropriate regulatory bodies. We respect the right of individuals to refuse to participate in clinical studies without compromising their care. Research applications will be completed honestly and accurately, and research funds will only be utilized for the appropriate purpose. We will also follow all laws, policies and procedures relating to the care, transport and use of animal subjects in research.

Integrity Tip: You should adhere to all legal and ethical standards when conducting clinical research activities. If you have any concerns or questions, contact the Research Office.

Safe Environment


We seek to provide a healthy and safe workplace for our teams, and we continually provide training on health and safety practices and precautions. We also have an obligation to our patients and to the people of our communities to have a workforce that is fit for duty. If you see someone who could cause harm to others because they are impaired or are suspected to be impaired, let your supervisor know immediately.

Integrity Tip: You should do your part to create a safe place for our patients and our teams. Speak up if you see something concerning.

Safeguarding Property and Technology


We take the security of our systems and the confidentiality of information seriously, and it is important that our property and technology be safeguarded from threats, including cyberattacks. Atrium Health assets that are assigned or made available to teammates may be used only for authorized business purposes and not for personal use. You must safeguard all assets, follow applicable policies, and comply with copyright and software licensing laws.

You must return all assets, equipment, credentials, records, confidential information, and technology upon request and/or at the end of your tenure with Atrium Health. If you still have any of these after you leave, we have the right to ask you to return them in person or ship them back to your manager.

Integrity Tip: At all times, you are responsible for protecting any asset, property, information, or technology we give you, including paying attention to what you click on and reporting any unusual activity.

Vendor Relationships


Relationships with external parties are an important aspect of daily business operations. It is our policy to select suppliers based on impartial factors such as price, quality, diversity, performance, customer service, patient safety and reputation. We also follow our conflicts of interest policy when working with vendors. Regardless of where they are located, we expect our vendors and our contractors to have the same sense of integrity and compliance that we do. They are expected to comply with our standards and policies, federal requirements, and the law.

Integrity Tip: Follow the guidelines we have in place to help you appropriately obtain services from vendors and to protect confidential or proprietary information.

Working with Government Officials and Regulatory Agencies


Under the direction of Compliance, Accreditation and Legal, Atrium Health will respond to requests for information from government auditors, investigators, or other officials. We will be truthful in our statements and we will comply with our legal obligations. It is very important that you let your supervisor, Legal, or Compliance know immediately if you are contacted by a government agency administering laws governing billing practices and/or patient care standards in connection with an investigation or request for documents or receive a subpoena, demand or other official request related to your role or to Atrium Health.

Integrity Tip: When working with government agencies, you should provide truthful information and should not destroy or alter any requested records. Do not ignore any legal document or delay in notifying your supervisor! Consult your market contacts and policies for more information about response procedures.

Last Revised Date: October 2021
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