1. Compliance Program and Code of Conduct
The Code of Conduct is a summary of the Compliance Program. It details the fundamental principles, values, and standards that guide our hospital and is intended to deter wrongdoing and promote:
Honest and ethical conduct
Compliance with applicable governmental laws, rules, and regulations
Prompt internal reporting of violations and compliance concerns
Methodist Hospital for Surgery is committed to following the highest ethical standards for individual and corporate conduct.

2. Workforce Member DEFINITION
Workforce members include employees, Medical Staff members, members of the Board of Managers, independent contractors, volunteers, healthcare students, and others performing services on behalf of the hospital.

3. Workforce Member Responsibilities
Comply with all applicable legal and ethical obligations in the performance of your job duties.
Take an active role in detecting and correcting activities that potentially violate applicable laws and regulations and ethical standards. You are responsible to:
LEARN: Participate fully in compliance educational programs.
ASK: Ask a question if you have a compliance-related issue.
REPORT: Report actual or potential wrongdoing promptly.
COOPERATE: Cooperate fully with internal investigations.
Methodist Hospital for Surgery will not retaliate or tolerate any retaliation against any workforce member who reports a suspected ethical or compliance violation.

4. Principle 1 – Patient Care and Treatment
We are committed to providing competent, compassionate care and treating all patients with respect and dignity. We will always act in the best interest of the patient. Clinical care will be medically necessary and appropriate. Patients will have access to all of the information necessary to make decisions about their care.
Nondiscrimination: Patients will be treated without regard to race, color, national origin, religion, sex, sexual orientation, gender identity, age, disability, or any other classification protected by law.
Medical Necessity: We will respect and maintain the dignity of each patient and provide appropriate care in compliance with the Medicare Conditions of Participation, pertinent accreditation standards, and based upon the patient's needs.

5. Principle 1 – Patient Care and Treatment
Medical Records: We will strive to ensure patient medical records are accurate. Medical records will provide information that documents the treatment provided and supports the claims submitted. Tampering with or falsifying medical records, financial documents, or other business records of the hospital will not be tolerated, and in some cases, may result in criminal charges.
Communication and Patient Decision-Making: Patients (or their authorized representatives) will be allowed and encouraged to participate in decisions regarding their care. We will communicate medical information to patients in a manner that allows them to understand the status of their condition and make informed decisions regarding their care and treatment.
Licensure and Credentials: We will maintain professional licenses, certifications, and other credentials in accordance with applicable laws, regulations, and professional standards.

6. Principle 2 – compliance with laws & REGULATIONS
We will conduct our operations in compliance with state and federal laws and regulations specific to our operations.
The False Claims Act and Whistleblower Protections: We will comply with the federal False Claims Act ("FCA") that fights fraud and abuse in government healthcare programs. All billing practices, as well as the preparation and filing of cost reports, will comply with all federal and state laws and regulations, and any overpayments made by a federal healthcare program or other payers will be refunded in accordance with applicable law and regulations. Retaliation against whistleblowers is strictly prohibited under both the FCA and similar state laws.
Stark Law and Anti-Kickback Statute: We will comply with the:
Physician Self-Referral Law (Stark Law) which prohibits healthcare entities from submitting any claim for designated health services if the referral comes from a physician with whom the healthcare entity has a prohibited financial relationship.
Federal Anti-Kickback Statute which prohibits payments (direct or indirect) made to induce or reward the referral or generation of government healthcare program business.

7. Principle 2 – compliance with laws & REGULATIONS
We will conduct our operations in compliance with state and federal laws and regulations specific to our operations.
EMTALA: We will follow the Emergency Medical Treatment and Active Labor Act ("EMTALA") in providing emergency medical screening examinations and stabilizing medical care to all patients who present to our hospital campus with an emergency medical condition or who are in active labor, regardless of their ability to pay.
Ineligible Persons, Excluded Individuals and Entities: We will not do business with, hire, or bill for services rendered by excluded individuals or entities.
Antitrust: We will not discuss with any competitor market allocation or refusals to deal with certain suppliers. This also includes any online communication, social media, or similar forms of communication.
Health, Safety, and Environmental Requirements: We will be familiar with all applicable federal, state, and local health and safety laws and regulations, and will act in compliance with the letter and spirit of those requirements.

8. Principle 2 – compliance with laws & REGULATIONS
We will conduct our operations in compliance with state and federal laws and regulations specific to our operations.
Equal Employment Opportunity, Nondiscrimination and Anti-Harassment: We will promote diversity and provide a workplace environment that complies with applicable employment-related laws, as well as the hospital's policies and procedures. We will provide equal employment opportunities to all workforce members, prospective and current, without regard to race, color, religion, sex, age, sexual orientation, national origin, disability, pregnancy, genetic information, veteran status, or any other classification protected by law. We will do our best to make reasonable accommodations for known disabilities. We will prohibit workplace violence, threats of harm, and harassment of any kind of our workforce members.
Sarbanes-Oxley: In order to protect our investors, we will comply with the requirements set forth in the Sarbanes-Oxley Act.

9. Principle 3 – CONFIDENTIALITY & Protected Health Information
We will actively protect and safeguard confidential, sensitive, and proprietary information.
Patient Information (HIPAA Privacy and Security): We will maintain the confidentiality and security of protected health information (PHI) according to the Health Insurance Portability and Accountability Act ("HIPAA") and applicable laws, regulations, and hospital policies. We will not reveal any personal or confidential information concerning patients unless permitted or required by law for legitimate business or patient care purposes. We will never disclose confidential patient information to any unauthorized person.
Proprietary Information: Information, ideas, and intellectual property assets of our hospital are important to our success. Information relating to the hospital's competitive positon or business strategies, payment and reimbursement information and information relating to negotiations with workforce members or other organizations will be protected and shared only with those with a need to know such information.

10. Principle 4 – BUSINESS ETHICS & protection of assets
We will accurately and honestly represent the hospital and will not engage in any activity or scheme intended to defraud anyone of money, property, or services. We will take all reasonable steps to preserve and protect the hospital's assets by making prudent and effective use of its resources and to properly and accurately report its financial condition.
Honest Communication: We will communicate with candor and honesty in performing our job responsibilities and in dealing with one another, patients, families and significant others, and other individuals.

11. Principle 4 – BUSINESS ETHICS & protection of assets
Accuracy of Records: We will maintain the integrity and accuracy of hospital documents and records, not only to comply with regulatory and legal requirements, but to ensure that records are available to defend business practices and actions. We will not improperly alter, falsify, or purposefully omit information on any record or document. Corrections to any record or document will be made pursuant to established policies and procedures.
Internal Controls and Financial Reporting: We will maintain financial books and records in accordance with all applicable legal requirements. All financial information will conform to generally accepted accounting principles.
Business Expenses: Our business expenditures will be in accordance with applicable policies.
Personal Use of Corporate Assets: We will refrain from using the hospital's assets for personal use.

12. Principle 5 – CONFLICTS OF INTEREST
We owe a duty of undivided and unqualified loyalty to act in a manner that is in the best interest of our hospital. We will not use our positions to profit personally or to assist others in profiting at the expense of the hospital.
Disclosing Conflicts of Interest: We will disclose any actual or potential conflicts of interest.
Gifts and Gratuities: We will preserve and protect our reputation and avoid the appearance of impropriety. We will not solicit money, personal gratuities, or gifts from patients. We will not accept money, personal gratuities, or gifts from patients of more than a nominal value. We will not solicit or accept money, gifts, entertainment, or other favors from vendors, contractors, or suppliers unless specifically allowed by the hospital's policy or written authorization from the President.
Participation on Outside Boards of Directors: Prior to serving as a member of the board of directors of any organization that may have an interest conflicting with those of the hospital, we will disclose such potential service to the President for review.

13. Principle 6 – REPORTING SUSPECTED WRONGDOING
We will promptly report actual or potential wrongdoing or violation of laws, regulations, ethics and safety requirements, or the hospital's Code of Conduct, policies, and procedures.
Reporting Methods
Anonymous Compliance Hotline ( )
Hospital's Variance/Incident Reporting System (accessed from the Intranet)
Personal contact to a supervisor, Chief Nursing Officer, Chief Financial Officer, or President at
U.S. Mail at Nueterra Compliance Officer
∙1221 Roe Avenue, Leawood, KS 66211
Nueterra Compliance Officer at
Other Nueterra representatives

14. Principle 6 – REPORTING SUSPECTED WRONGDOING
We are committed to complying with all applicable laws and regulations, including those designed to prevent and deter fraud, waste, and abuse.
Non-Retaliation: We will report concerns in good faith knowing that we are protected from retaliation, retribution, harassment, or any type of discrimination or adverse action.
Self-reporting Noncompliance: Self-reporting is encouraged. Anyone who reports their own wrongdoing or violation of laws, regulations, ethics and safety requirements, or the hospital's Code of Conduct, policies, and procedures, will be given due consideration in potential mitigation of any disciplinary action.

15. Compliance Program AND CODE OF CONDUCT
YOU are an important member of the MHfS family and are expected to act in an ethical manner and to use good judgment at all times.
If you have concerns about actual or suspected misconduct, don’t hesitate to ask questions.