Central Florida Inpatient Medicine – CFIM recognizes that all employees, health care providers, members, affiliates and consultants must conduct ourselves in accordance with our Code of Conduct, policies, procedures, laws and regulations. Failure to do so may result in serious consequences for individual team members, medical staff members and CFIM.
Each team member has an affirmative duty to report a compliance issue and, failure to do so could result in discharge. Adherence to our Code of Conduct and our Compliance Program applies to all CFIM employees and physicians members, as well as board members, providers, volunteers and other individuals authorized to act as representatives of CFIM.
The purpose of the Code of Conduct is to assist all members in our team in maintaining high ethical standards of the corporation in all its business dealings. It will help guide you in making decisions that conform to the ethical and legal standards expected of you. While our Code of Conduct is designed to provide overall guidance, it does not address every situation. For more specific guidance, refer to your supervisor or the Compliance Officer.
The Compliance officer is a CFIM employee who in the capacity as Compliance Officer will report directly to the CFIM Board of Directors. He or she is responsible for directing and coordinating the company efforts to ensure compliance with OIG, CMS and any other governing laws, regulations and policies. The Compliance Officer will promote
The Compliance Officer implements on-going training and education throughout the organization. The Compliance Officer is also responsible for managing the Conflicts of Interest Policy and for addressing and mitigating any conflicts that may arise with CFIM employees and suppliers and notifying and escalating any conflicts of interested to the Board for mitigation.
The Code of Conduct is a “living document” that will be updated periodically to respond to changing conditions. Questions regarding our Code of Conduct, or any issue, should first be raised by the team member to his or her immediate supervisor, then through the chain of authority up to and including the Compliance Officer. Issues can also be reported confidentially and anonymously to the Compliance Hotline as noted in this policy The Code of Conduct is not an employment contract, nor it is intended to provide any expressed or implied rights of continued employment. Conduct contrary to the Code of Conduct will results in an investigation and possible disciplinary action up to an including discharge.
The term “we”, as used in this document, is meant to refer collectively to CFIM team members, board members, providers, affiliates, volunteers, students and other individuals that are authorized to act as representatives of CFIM, both inside and outside CFIM facilities.
Maintaining the ethical standards of Spectrum CFIM is the responsibility of each team member. If you become aware or of suspect a situation that might jeopardize the ethical integrity of our company, it is every person’s obligation to report the circumstances.
It is every person’s responsibility to report possible violations of laws, policies, or the Code of Conduct and is outlined as follows:
Call the Compliance Hotline to report violations if you have the believe that any of the following items has been, is being, or is likely to be committed:
First, report your concerns to your immediate supervisor, manager or director over your area. If you suspect that your supervisor, manager or director is involved, or your previous reports have not been acted upon, call the Compliance Hotline
Your call to the Compliance Hotline is confidential. You will either reach the Compliance officer directly or you will be instructed to leave a message. To protect everyone involved, no disciplinary actions or legal action will be taken based only on Compliance Hotline calls. Only substantiated findings will result in action
No. You are not required to identify yourself and calls that are answered by the Compliance officer are not recorded.
Call the Compliance Hotline even if you are not sure there is a problem. The Compliance officer will investigate the information you provide, attempt to verify it and take appropriate action.
Compliance hotlines reports can be made two ways:
In writing, to:
Compliance Officer CFIM
525 Technology Park, Suite 109
Lake Mary, Florida, 32746
Government regulation of the healthcare industry is increasingly complex. At the same, federal and state governments have made healthcare fraud and abuse a top law enforcement priority. CFIM takes its responsibility to comply with the law very seriously and has taken steps to prevent, detect and correct legal violations. The following standards are neither exclusive nor complete. We are required to comply with all applicable laws whether they are specifically in this Code of Conduct or in policies and procedures. If you have any questions regarding the existence, interpretation or application of any law, you should contact the Compliance Officer.
While not an exhaustive list, the following are examples of fraud, waste and abuse:
If you know or suspect activity of this nature, report it immediately. If you are uncertain as to whether an activity is fraudulent, contact the Chief Compliance Officer for guidance.
Individuals who lawfully report false claims or other fraudulent conduct or who otherwise assist in an investigation, action or testimony, are protected from retaliation under both federal and state laws. We will not discriminate or retaliate against any whistle blower that files, in good faith, a civil action for false claims or participates in an investigation of CFIM.
At CFIM policies, procedures and systems have been put in place to assist with accurate billing to government payors, commercial insurance payors and patients. We ensure that coding and billing are performed accurately, in accordance with nationally recognized standards and rules. It is the responsibility of providers to ensure that the information required for proper coding accurately reflects the care provided and is documented in patients’ medical records and encounter forms.
Accurate and timely documentation also depends on the diligence and attention of physicians who treat patients at the facilities we provide services. We do not destroy any information considered part of the official medical record.We ensure that all payments and other transactions are properly documented and authorized by management. Payors should be notified of payment errors and refunds should be processed promptly and accurately.
If you choose to engage in any political activity, including lobbying, it is important not to give the impression that you are speaking on behalf of or representing CFIM.
We follow the laws regarding intellectual properties, including patents, trademarks, marketing, copyrights and software. We may not make, acquire, or use unauthorized copies of computer software unless it is specifically allowed in the license agreement.
CFIM provides equal employment opportunities to prospective and current team members, based solely on merit ualifications and abilities. We respect team members and organizational affiliates and do not discriminate in employment opportunities or practices based on race, color, religion, sex, national origin, ancestry, age, physical or mental disability, sexual orientation, veteran status or any other status protected by law.
Any behavior that interferes with a team member’s work performance or creates an intimidating, hostile or offensive work environment will not be tolerated by CFIM. Management is responsible for preventing discrimination and harassment of any kind. Everyone is responsible for respecting the rights of their fellow team members and for reporting inappropriate behavior to the appropriate parties.
We do not tolerate or condone criminal activity with respect to any team member, business practice or service provided. If you become aware of possible criminal activity, you are required to report the circumstances to the Compliance Officer.
Any team member found to be involved in criminal conduct will be reported to the Compliance Officer. Disciplinary action will be appropriate for the offense committed up to and including discharge.
We will refer all instances of suspected criminal conduct to the appropriate governmental authorities for possible criminal prosecution.
CFIM maintains the privacy and confidentiality of all sensitive information entrusted to us. We are committed to following all federal and state privacy laws and regulations. In addition, our members are responsible for signing the participation agreement that explicitly states confidentiality and records retention rules, or reading and signing CFIM Confidentiality and non-disclosure policy
We do not share confidential information with anyone who does not have a legal need to know. We will safeguard patient information from physical harm and protect the privacy of patient health records according to federal, state and accreditation requirements.
We safeguard oral communications that must take place for patient care, including telephone conversations, to avoid disclosures of protected health information to unauthorized individuals.
We safeguard confidential, sensitive and proprietary information in a manner designed to prevent unauthorized disclosures.
Information security refers to safeguarding confidential and sensitive information from damage, loss, unauthorized access or unauthorized modification. All types of information, including but not limited to patient data, payroll records, personnel files, passwords and access codes will be maintained and safeguarded to prevent unauthorized disclosures.
We maintain and monitor security systems, data back-up systems and storages capabilities to ensure that all confidential and sensitive information is maintained safely and in accordance with our Policies and Procedures, federal, state and local laws.
CFIM has established policies and procedures regarding the storage and destruction of records. All records are kept for the legally required timeframe, including 10 years for Medicare for audits of the Medicare billing and indefinitely for pediatrics records. Once that time is complete, it is important to destroy the records in a timely and appropriate manner. For questions, contact the Compliance Officer.
Any records that you wish to dispose of that may contain patient, financial, or other confidential information regarding CFIM must be discarded in a shred bin. Under no circumstances should these documents be thrown in the trash.
This policy applies to all Board members, healthcare providers, employees and affiliates conducted at or under the auspices of CFIM.
A conflict of interest is defined as an actual or perceived interest by a (Healthcare provider/staff member/ board member) in an action that results in, or has the appearance of resulting in, personal, organizational, or professional gain.
A conflict of interest occurs when a healthcare professional, employee, board member or contractor has a direct or fiduciary interest in another relationship. A conflict of interest could include:
The definition of conflict of interest include any bias or the appearance of bias in a decision-making process that would reflect a dual role played by a member of the organization or group.
It is the interest of CFIM, its healthcare professionals, individual staff, and Board members to strengthen the trust and confidence in each other, to expedite resolution of problems, to mitigate the effect and minimize organizational and individual stress that can be caused by a conflict of interest.
Healthcare providers, board members, members, employees are to avoid any conflict of interest, even the appearance of ca conflict of interest. This organization services the community rather than only serving a special interest of a group.
The appearance of a conflict of interest can cause embarrassment to the organization and jeopardize the credibility and its ability to promote evidence-based medicine, patient engagement, quality reporting an quality patient-centered care.
Any conflict of interest, potential conflict of interest, or the appearance of a conflict of interest is to be reported to the Compliance Officer immediately.Healthcare providers, employees, and Board members are to maintain independence and objectivity with the community and organization. Every member is called to maintain a sense of fairness, civility, ethics and personal integrity even though law, regulation or custom does not require them.
Board members, physicians, contractors and employees must submit an annual disclosure form upon request of the Office of Compliance and annually thereafter and submit a financial interest disclosure form. Disclosure to the office of Compliance is required for any direct or family ownership, from direct ownership or through an investment and any type and prevalence of financial arrangements between physicians and hospitals or healthcare providers and paid speeches,educational presentations or published articles that are sponsored by pharmaceutical company, hospitals, device makers or any care facility.
Office of Compliance Review – The office of Compliance is responsible for reviewing each disclosure of a Financial Interest held by members, physicians and employees as well as Contractors if required, and for organizing into the four categories:
(1) Disclosure where no financial interest is disclosed
(2) Initial disclosures which is not significant financial interest
(3) Initial disclosures of a significant financial interest
(4) Disclosures of a financial interest that has previously been reviewed, evaluated, and made subject to a conflict management plan issued under this policy
(1) For disclosures where no financial interest is disclosed, no further notification is required in the absence of known conflicts to serve no any committees or on the Board
(2) For initial disclosures, the Compliance Officer will identify if participation on Committees or the Board or in other capacities where the person can influence decisions should be subject to an appropriate conflict of management plan limiting participation on issues where the person has decision-making capacity that may compromise fiduciary responsibilities
(3) For initial disclosures of a significant financial interest, the Compliance Officer will issue a conflict of management plan to be submitted to the CEO and or to the Board for its review and evaluation.
(4) For disclosures of a financial interests which has been previously been reviewed and evaluated and is subject to a conflict management plan issues under this policy, the Compliance Officer may, in its discretion, approve the continuation of conflict management plan without referral if the nature and amount of the financial interest has not changed or materially increased since the issuance of the conflict management plan
Members, physicians, employees, Board members and their immediate family members are prohibited from accepting gifts, money or gratuities over $100.00 (one hundred dollars) within any calendar year from the following:
Violations of this Policy are subject to disciplinary action, up to and including termination of employment or association with CFIM disciplinary Policies and Procedures.
Your satisfaction is important to us. Please take the survey below to allow the person responsible for your care or their supervisor the opportunity to listen, review, and to assist you with an appropriate resolution. If your complaint is unresolved, please ask to speak to the department’s manager, director or the house supervisor in the comments section. If your concern cannot be resolved by the Spectrum Medical Partners team process indicated, please allow the facility the opportunity to address your grievance.