Code of Conduct

I. Introduction

The policy and desire of McAlester Regional Health Center ("MRHC") is and always has been to follow all laws and regulations. It is important that MRHC's outstanding reputation be maintained. In order to assist employees and people affiliated with MRHC in understanding and complying with the law, MRHC has adopted a Compliance Program. A copy is available on each employee's home page of the Kronos Timekeeper System or from any supervisor or manager of MRHC, and anyone interested is urged to review it. In particular, each person affiliated with MRHC should be familiar with those parts of the Compliance Program relevant to their responsibilities.

This pamphlet will provide an overview of the Compliance Program. The Program is intended to (1) promote legal and ethical behavior, (2) provide a guide for the conduct of each employee, independent contractor or agent of the Hospital as well as those medical professionals who enjoy professional staff membership and/or clinical privileges at the Hospital, and (3) prevent and detect violations of law.

II. Compliance Duties

It is the duty of each person to Comply with all applicable laws. It is the responsibility of each person to be trained or to obtain the training necessary so that his or her duties can be performed in a manner which is effective, competent, professional and in compliance with the law.

In order to assist people in compliance, MRHC has appointed a Compliance Officer and a Compliance Committee. The Compliance Officer is John Gallagher. Mr. Gallagher can be contacted in one of the following manners: telephoned at 918-421-8642 or e-mailed tojdgallagher@mrhcokcompliance@mrhcok orcompliancereporting@mrhcok. In addition, if you wish to remain anonymous you may call the Compliance Report Hotline at 918-421-6853.

The members of the Compliance Committee are as follows: The Chief Executive Officer, The Compliance Officer, the Vice President of Information Systems, the Chief Financial Officer and the Vice President of Human Resources.

Members of the Compliance Committee can address questions about the operation of the Compliance Program and can also address questions about specific operations within the Hospital. People having questions about applicable laws are encouraged to present those questions to their supervisor or a member of the Compliance Committee. Any compliance related suggestions are welcomed.

III. Board of Trustee Oversight

The Board of Trustees of MRHC is also very actively involved in the Compliance Program, giving oversight to the Committee and Compliance Officer, as well as being informed of the Program's effectiveness. Three members of the Board of Trustees serve on a separate committee to receive periodic updates of the Program. These three seats are appointed by the Chairman of the Board of Trustees and are on a rotation cycle.

IV. Reports of Wrongdoing

While it is inevitable that some mistakes will occur in the operations of any hospital, mistakes should be kept to a minimum. Therefore, when a mistake is made, it is important that it be brought to light so it can be corrected. All people spotting mistakes of any sort should bring them to the attention of the appropriate supervisor or a member of the Compliance Committee.

Honesty and accuracy in billing and in the making of claims for payment by a Federal Health Care Program, or payment by any third party payer, is vital. Under the Federal False Claims Act, any person who (a) knowingly presents or causes to be presented, a false or fraudulent claim, record or statement for payment or approval; (b) conspires to defraud the government by getting a false or fraudulent claim allowed or paid; (c) uses a false record or statement to avoid or decrease an obligation to pay the government; or (d) engages in other fraudulent acts enumerated in the Act, is subject to significant penalties. The Oklahoma Medicaid False Claims Act, at 63 Okla Stat. § 5053 et. seq. contains similar penalties relating to the Medicaid program. Full details of this policy can be found in the Employee's Handbook. Employees who lawfully report false claims are protected from retaliation by hospital policy and federal and state law.

V. Audits and Investigations

In today's legal and regulatory environment it is reasonable to anticipate that various government agencies will audit and investigate the Hospital from time to time. The Hospital's policy is to cooperate with all such audits and investigations. It is particularly important to be certain to be truthful at all times with auditors and investigators. Any person having knowledge of an investigation or audit concerning the Hospital must notify a supervisor or a member of the Compliance Committee as soon as possible. This is important so that the Hospital can be certain it is responding accurately and appropriately.

VI. Duties

A. Billing

The Hospital is committed to maintaining the accuracy of every claim it processes and submits. Any false, inaccurate or questionable claim should be reported immediately to a supervisor or a member of the Compliance Committee. All persons shall refrain from any false billing practice, including but not limited to the following:

  • Billing for items or services not provided or rendered
  • Misrepresenting the services actually rendered
  • Filing duplicate claims
  • "Upcoding"
  • "Unbundling"
  • Billing for services not medically necessary

B. Hospital Business

The Hospital's business will be conducted in an ethical, legal manner at all times. Anyone entering contracts or business relationships on behalf of the Hospital must bring all legal issues to the attention of a member of the Compliance Committee.

All financial reports, accounting records and cost reports must accurately represent the true nature of the transaction. No false or artificial financial records shall be made. No hospital records will be destroyed except in accordance with the Hospital's record retention policy. All grants and contracts will be accurately reflected and all expenditures used as intended. Required tax documents will be accurately completed. No one will receive compensation above fair market value for a good or service provided to the Hospital.

C. Patient Referral

Patients are free to select their health care providers as they see fit. The Hospital will not pay anyone anything in order to induce the referral of a patient to the Hospital. No one acting on behalf of the Hospital may offer gifts, loans, rebates, services or payment of any type in order to induce a referral of a patient.

D. Emergency Room

It is the policy of MRHC to provide emergency services to any individual who presents to the Emergency Department regardless of ability to pay. A medical screening examination will not be delayed in order to determine an individual's methods of payment or insurance coverage. Any person who believes that an emergency patient has been transferred or discharged inappropriately must report the incident to a supervisor or a member of the Compliance Committee.

E. Patient Relations

It is imperative that patient relations be maintained at the highest level. At all times, patients and their loved ones will be treated with utmost courtesy and dignity. No confidential information regarding a patient shall be disclosed except to a person with a legal right to know.

F. Political Activity

The Hospital encourages people to participate in political activities on their own behalf. The Hospital's political activities are limited by law. No person should engage in political activity on behalf of the Hospital without first discussing the legal implications of the activity with the Compliance Officer or the CEO.

G. Antitrust

The Hospital will comply with antitrust laws prohibiting anti-competitive practices such as bid rigging or collusion with competitors. Questions in this area should be addressed to a department manager or the Compliance Officer.

H. Relationships with Physicians

MRHC values its relationships with physicians and will work to keep those relationships within the bounds of the law. Agreements with physicians must be approved in advance by the Compliance Officer. Physicians will not receive in excess of fair market value for goods or services sold to or purchased from the Hospital.

I. Conflict of Interest

All employees owe a duty of loyalty to the Hospital. Employees must avoid even the appearance that their other activities might be in conflict with their duties from the Hospital.

J. Open Meetings/Open Records

The Hospital will comply with Oklahoma's Open Meetings Act and Open Records Act to the extent required by law.

K. Personnel Policies

The Hospital will perform appropriate due diligence before hiring someone or allowing a person to join the medical staff. The Hospital will perform background checks as appropriate.

L. Acceptance of Gifts and Gratuities

  • Gifts From Patients: All hospital personnel are prohibited from soliciting tips, monetary gifts or gratuities from patients. However, if the patient wishes to make such a gift, the employee's supervisor should be notified. The patient or family member shall be notified that the gift can be accepted if donated to a charitable event within the hospital, such as the Friends-Helping-Friends account or a similar function. For a list of acceptable functions, please contact your supervisor or a member of the Compliance Committee.
  • Gifts To Patients: The Hospital may give to patients non-monetary gifts (including transportation) having a retail value of no more than $10 for any one item or $50.00 in aggregate value per year. Any other gifts must be reviewed in advance by the Compliance Officer.
  • Gifts From Vendors: Only vendors already doing business with the Hospital may offer non-monetary gifts valued at no more than $300.00 in a calendar year. Vendor sponsored travel or lodging may only be accepted with the advance approval of the CEO. Gifts which will affect a Person's business judgment on behalf of the Hospital must be declined.


MRHC appreciates the efforts made by so many people to make McAlester Regional Health Center the outstanding Hospital it is. Anyone with questions about the Compliance Plan may address them to a supervisor or a member of the Compliance Committee.