Legal & Ethics

Integrity & Compliance

What is Integrity & Compliance?

The Integrity & Compliance department manages the Code of Conduct and enforces its observance through the Integrity & Compliance Program. Integrity & Compliance are guiding principles for conducting business in a proper, ethical and legal way. Through the Code of Conduct, they demonstrate how Stormont Vail Health and its team members should handle difficult situations that can have negative consequences for themselves and the organization.

Integrity & Compliance Program

The Integrity & Compliance Program is the first line of defense to oversee the organization and its business practices. It provides protection against fraud, waste and abuse and other regulatory non-compliance through monitoring, training, policies and procedures.

Code of Conduct

The Code of Conduct provides team members with examples of proper, ethical and lawful business behaviors designed to protect Stormont Vail and team members from legal problems. It ensures everyone complies with the laws, regulations and organizational policies governing health care.

Areas of Compliance Conflicts of Interest

Team members should avoid situations in which personal interests could conflict with the interests of Stormont Vail Health. Examples: A personal or family interest (investment or compensation) in an enterprise that has business relations with Stormont Vail Health or that creates a bias for or against a contractor/vendor; secondary employment at a competing organization; outside activities, such as community board participation, where proprietary or confidential information may be shared.

Emergency Medical Treatment and Active Labor Act

Team members must provide to each person who comes to the Emergency Department an appropriate medical screening exam to determine whether the individual has an emergency medical condition, to stabilize the person or to transfer the individual to an appropriate medical facility regardless of the individual’s ability to pay, race, color, national origin, age, sex, religion or disability.

HIPAA Privacy and Confidentiality of Patient Information

Team members must observe applicable standards of ethical and legal conduct with respect to Protected Health Information or PHI (HITECH) with regard to keeping information confidential and taking appropriate actions for certain types of privacy breaches. Team members must report any known or suspected privacy breach.

Ethical Business Relationships

Conducting business with vendors, including physicians, can pose ethical or even legal problems.

Kickbacks and Rebates (Anti-kickback Law)

The purchase or sale of goods and services, or patient referrals to or from Stormont Vail Health, must not lead to any person or their family members receiving rewards or anything of significant value (monetary or non-monetary) for such activity. Team members must not personally benefit from conducting business on behalf of Stormont Vail Health.

Financial Arrangements with Physicians or Other Patient Referral Sources (Stark Law)
No payments may be made to or by physicians in exchange for referral of any federal health care program patients or business. No inducement in exchange for referral of patients shall be offered to any physician. Penalties apply for noncompliance.

False Claims Act

This is a federal law that prohibits anyone from submitting false or fraudulent claims to the federal government for payment.
Reporting Compliance/Privacy Concerns
The following is available for reporting concerns or asking for guidance:

Integrity Helpline 1-833-SVH-UP2U (1-833-784-8728)

Office for Civil Rights (OCR)
Office of Inspector General (OIG)
1-800-HHS-TIPS (1-800-447-8477)