Standards for Business Conduct

9th Edition

i | Sutter Health Confidential Message Line 1-800-500-1950

Message from Sutter Healths President and CEO

Dear Colleague,
For more than a decade, Sutter Health has been proud to demonstrate its
commitment to honesty and integrity through our Standards for Business Conduct
which are outlined in this document. This document was created with the goal of
ensuring our employees, aligned physicians, vendors and contractors understand the
importance of their role in conducting business with the highest levels of honesty
and integrity.
The examples found in this document will help guide you through the complex
policies, laws, rules and regulations that you may face in your everyday job. As Sutter
Healths President and CEO, I can assure you that we will continue to treat honesty
and integrity as our highest priorities. It is important to remember that despite the
difficult and ever-changing environment in which we work, each of us has a duty to
uphold the highest ethical standards in the way we deal with our patients, customers
and coworkers.
Please take the time to read through this important information and learn more
about the resources available to you and how you make a difference in Sutter Health.
Thank you for doing your part in continuing to make Sutter Health an organization
of which we can all be proud.

Sarah Krevans
President and CEO
Message from Sutter Healths Chief Compliance Officer

The responsibility for maintaining an ethical and legally compliant Ethics & Compliance - Everyones
environment rests with each and every one of us. We have a duty to make Responsibility
compliance part of our daily operations and to operate with integrity.
If you find yourself asking What is the
The Sutter Health Ethics & Compliance Program and the Standards
right thing to do in this situation?, the
for Business Conduct are designed to foster an environment in which
Standards for Business Conduct is a good
employees, physicians, vendors and contractors are given the tools they
place to begin your search for the answer. The Standards for Business
need to build and maintain a culture of compliance.
Conduct provides an overview of the most significant standards and
We work in one of the most highly regulated industries in the United requirements that apply to your daily work. Remember, each of us has
States. Comprehensive legal and regulatory requirements control an obligation to ask questions and to seek to understand requirements
nearly every aspect of our operations, from protecting the privacy and that apply in our day to day work for Sutter Health. Thank you for taking
security of patient information, to how we provide and bill for services the time to read through and acknowledge Sutter Healths Standards for
to our patients and how we manage our relationships. The burden of Business Conduct and for your commitment to an ethical and compliant
understanding and correctly applying legal and regulatory requirements environment.
in our health care organization is significant. At Sutter Health, our goal
is to maintain a patient care, business and workplace environment that
is consistent with the highest ethical standards and applicable legal and
regulatory requirements.
We all strive to do the right thing. However, working in this complex Ginger Chappell
environment means that making legal and ethical decisions is not always Vice President, Ethics & Compliance Services
easy or intuitive. You may, therefore, become aware of activities or and Chief Compliance Officer
behaviors that appear to be inconsistent with the Standards for Business
Conduct or other Sutter Health policies or legal requirements. If so,
it is your responsibility to report the suspected misconduct to your
manager, another supervisor, or compliance, privacy, or information
security officer. You may reach out to our officers directly, by calling the
Confidential Message Line, or by reporting online. Every Sutter Health
employee has a duty to report suspected illegal or unethical conduct.
Sutter Health has a strict policy prohibiting any form of retaliation against
a person who, in good faith, reports a concern about possible non-
compliance.
Contents
Sutter Health Mission, Vision and Values. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Patient Billing Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Ethical Conduct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Accuracy of Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Confidentiality and Proprietary Information . . . . . . . . . . . . . . . . . . . . . . . . 3 Coding and Billing Practices: Accurately Bill for Services Rendered to
Our Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Conflict of Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Coding and Billing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Gifts, Loans, and Entertainment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Reporting Improper Coding/Billing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Solicitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
False Claims Act (FCA). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Advertising, Marketing and Communications . . . . . . . . . . . . . . . . . . . . . . . . . 6
California FCA: Medi-Cal Fraud . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Advertising . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Financial Relationships with Physicians and Other Providers. . . . . . . . . . . . . 25
Graphic Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
The Anti-kickback Laws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
News Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Physician Financial Relationships: Stark Law Essentials. . . . . . . . . . . . 26
Social Networking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
California Anti-Kickback and Anti-Referral law. . . . . . . . . . . . . . . . . . . . . 27
Third-Party Use of the Sutter Health or Affiliate Names and Logos . . . . . . 8
Payments to Physicians to Reduce or Limit Care . . . . . . . . . . . . . . . . . . 27
Patient Care and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Patient Inducement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Patient Confidentiality and Privacy Rights. . . . . . . . . . . . . . . . . . . . . . . . 10
Tax-Exempt Status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Employee Use of Computer Systems and Equipment . . . . . . . . . . . . . . 11
Prohibition of Private Benefit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Emergency Medical Treatment and Labor Act (EMTALA) . . . . . . . . . . . . 12
Sanctions of Private Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Charity Care: Our Commitment to Low Income Uninsured Patients . . . . 12
Government Investigations/Audits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Patients with Disabilities: Our Commitment to Equal Access. . . . . . . . . . 13
Responding to Government Investigations/Audits . . . . . . . . . . . . . . . . . 32
Caring for Patients with Communication Challenges . . . . . . . . . . . . . . . 13
Obstruction of a Federal Audit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Communicating Patient Care Concerns to Joint Commission . . . . . . . . 14
Exclusion Checks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Workplace Conduct and Employment Practices. . . . . . . . . . . . . . . . . . . . . . 15
Individual Culpability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Prohibition Against Discrimination, Harassment and Retaliation. . . . . . . . 16
Health, Safety and Environmental Concerns. . . . . . . . . . . . . . . . . . . . . . . . . 34
Confidential Employee Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Research and Research Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Financial Integrity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Human Subjects Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Employee Use of Charitable Assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Privacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Political Contributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Research Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Anti-Trust Laws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Acknowledgement of Standards for Business Conduct Handbook. . . . . . . . 40
 Sutter Health Mission, Vision and Values
Mission
We enhance the well-being of people in the
communities we serve through a not-for-profit
commitment to compassion and excellence in
health care services.
Vision
Sutter Health leads the transformation of health
care to achieve the highest levels of quality,
access and affordability.
1 | Sutter Health Confidential Message Line 1-800-500-1950
Values
Honesty and Integrity
We act openly and truthfully in everything we do.
Excellence and Quality
We exceed customer expectations by delivering premier clinical quality and
maintaining the highest levels of safety.
Compassion and Caring
We treat those we serve, and one another, with concern, kindness and respect.
Community
We work to understand and best serve the diverse needs of our community.
Teamwork and Trust
We recognize that the power of our combined efforts exceeds what we can accomplish
individually, and we are accountable to each other and to our customers.
Innovation
We continually create, seek out and adopt new ways of providing value to our
customers, rapidly moving from idea to execution.
Affordability
We deliver health care efficiently by using resources responsibly.
 ETHICAL CONDUCT

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 Ethical Conduct
Conduct business with honesty and integrity.
These qualities are demonstrated through
truthfulness, the absence of deception or
fraud, and respect for the laws that apply to
Sutter Health and Affiliates. Every member of
the Sutter Health workforce is responsible for
acting with integrity.
Being ethical and having integrity is more than
just following laws, regulations and policies.
These qualities require strong moral principles
which govern behavior. The ethical behavior
of each individual at Sutter Health supports the
organizations integrity. If there is any doubt
in the appropriateness of any behavior, stop
and seek guidance from a supervisor or your
Compliance, Privacy or Information Security
Officer.
Q. My supervisor asked me to do something
but I dont feel comfortable doing it. Im not
aware of a policy or law which prohibits the
behavior, but it doesnt feel right. What do
I do?
A. There are many actions and behaviors
which are legal but may not be ethical (i.e.
not doing what you say youll do). Trust your
instincts. If you feel uncomfortable doing
something, talk to your supervisor or another
leader. Remember that Sutter Health prohibits
retaliation and retribution for reporting
concerns in good faith.
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Honesty & Integrity are at the center of Sutter
Healths values. The following situations
demonstrate how ethics ties to each of our
values.
Teamwork: A co-worker asks you for
assistance with a clinical procedure but you are
not qualified to do so. Rather than declining
to assist or violating a policy by assisting, you
find someone else who is qualified to help your
co-worker.
Community: A patient asks if they can leave
the hospital (against medical advice) because
they worry they cannot pay for hospital
expenses. You explain Sutter Healths not-for-
profit mission and offer to put them in contact
with the hospital Community Benefits Liaison
to assist with applying for financial assistance.
Excellence & Quality: The deadline for
a software upgrade project is quickly
approaching. You become aware of a glitch that
may adversely affect some patient records. You
report the concern even though it postpones
project completion and requires rework and
overtime.
Innovation: A patient expresses dissatisfaction
about the response time she experiences when
leaving a message for her doctor. You suggest
that she submit her questions through the
MyHealthOnline mobile app. The patient has
the app on her phone but she doesnt know how
to send a question in a message. You sit next
to her and teach her how to send a message,
lookup results and schedule appointments.
Affordability: You recognize your departments
processes use a considerable amount of
supplies unnecessarily. Although youre not
aware of a policy against the current practices,
you suggest new processes to your supervisor
which minimizes the waste.
Compassion & Caring: You observe someone
struggling to navigate a hospital because they
cant read. Rather than just pointing them in
the right direction, you guide them to their
destination and introduce them to someone
who can help them.
Q. How do I know whether something is
ethical?
A. If a policy, standard or law doesnt answer
your question, consider asking yourself how
you would feel if you saw your words or
actions in social media or in the news. Or,
ask yourself how it would look to your family,
friends, patients or community.
Confidentiality and Proprietary
Information
Employees must not use or share Sutter Health
confidential and proprietary information with
anyone outside the organization (including
friends, relatives, acquaintances, customers
and others). Proprietary information is
any information used in the operation of
Sutter Health and Affiliate business that is
sufficiently valuable and secret to afford an
 actual or potential economic advantage over
others and is not available to the general
public. Confidential information means any
information that is intended strictly for use
within, by or on behalf of, Sutter Health, as
required by law or as required or permitted
by Sutter Health policies, including but not
limited to any information created, received,
maintained, or transmitted by or on behalf
of Sutter Health that identifies, or could
identify, a patient or health plan member.
Unauthorized use or disclosure of confidential
information could seriously adversely impact
the organization, our patients and members,
employees, and business partners.
Without specific authorization, do not disclose
this information to other Sutter Health
employees except on a need-to-know basis
(i.e. the disclosure is necessary to accomplish a
job function) and the recipient agrees to treat
the information as confidential.
Some examples of confidential or proprietary
information include, but are not limited to, the
following:
1. Financial Data/Projected Earnings
2. Provider Contracts
3. Information Systems/Technical Designs
4. Marketing Plans/Strategies
5. Business Forecasts/Strategies
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6. P
 rotected Health Information (PHI) any
information about health status, provision
of care or payment for healthcare about
a patient or member
7. Personally Identifiable Information
All employees are required to abide by the
Workforce Confidentiality and Privacy Policy,
Use of Internet, E-Mail and Instant Messaging
Policy, and all other Privacy, Information
Security Policies and Procedures. All
employees will be asked to sign a Workforce
Confidentiality Agreement annually and to
acknowledge the Privacy and Information
Security Policies and Procedures.
Conflict of Interest
Avoid conflicts of interest and even the
appearance of conflicts of interest.
A conflict of interest occurs if an outside
interest or activity may influence or appear to
influence your ability to exercise objectivity or
meet your job responsibilities to Sutter Health.
Participation in activities that conflict with your
employment responsibilities at Sutter Health is
not acceptable and it is your responsibility to
discuss any suspected conflict of interest with
your supervisor, as discussed below.
A reasonable guideline to follow is that a
potential conflict of interest exists any time
an objective observer of your actions might
wonder whether you are motivated solely by
your responsibilities to Sutter Health or are
influenced, in part or in whole, by your other
interests.
Officers, directors and certain other employees
must complete a Conflict of Interest Disclosure
Statement annually. In any event, if you
are unsure whether you have an actual or
potential conflict of interest, promptly notify
your supervisor so that you may discuss the
circumstances. Generally, a conflict of interest
can be avoided or resolved if it is disclosed
in advance. If there is an actual or potential
conflict of interest, you may be asked to
complete a Conflict of Interest Disclosure
Statement if not already required to do so.
Q. Our hospital is holding a seminar for the
public on womens health. A pharmaceutical
company wishes to help sponsor the event
and to provide educational materials about
its newest drugs. Can we accept its support
and list it as a co-sponsor?
A. Donations from pharmaceutical companies
to support educational forums can be
accepted in some circumstances, but
subject to limits on the type and amount
of donations. See the Conflict of Interest
policy and Attachment A to the Supplier
Registration and Facility Access Policy.
Educational materials produced by a
pharmaceutical firm may be distributed
if they help to inform patients about
a condition or disease and suggest a
 consultation with the patients physician
regarding options for treatment. However,
in these public situations, neither Sutter
Health nor any Affiliated individual should
endorse, or be perceived as endorsing
any particular commercial product. In
any event, no patients protected health
information, including, but not limited
to, a patients picture, and no employees
protected identifiable information,
including, but not limited to, an employees
picture, may be used or disclosed in relation
to the seminar without the express written
authorization of the patient or employee,
as applicable. Consult your local Privacy
Officer if you have questions.
Gifts, Loans, and Entertainment
Sutter Health employees and their families
are prohibited from soliciting or receiving
substantial gifts, loans, entertainment or
anything else of value from a person or
organization that does business, or may want
to do business, with Sutter Health. This applies
to all employees of Sutter Health and its
Affiliates, including senior management. If a
Sutter Health employee receives any substantial
gift, it must be returned and the employees
supervisor notified. Below are some general
examples of gifts that are not permitted. Please
see the Sutter Health Conflict of Interest Policy
for additional guidance on what gifts are and
are not permitted.
Sutter Health employees may not accept a gift
of more than nominal value or any gift of cash
5 | Sutter Health Confidential Message Line 1-800-500-1950
or cash equivalent (such as gift cards) from a Q. My two children attend a private school.
patient or a vendor. The school desperately needs funds for
playground equipment and field trip
Sutter Health employees also may not offer or
activities. They are having a Jog-A-Thon to
give a gift of substantial value that may appear
raise money. Is it okay if I ask my coworkers
to be intended to influence anyone outside of
if they would be willing to support my kids
Sutter Health.
in this event?
Q. A vendor with whom we have done business
in the past offered to pay for an all-inclusive A. E
 mployees are prohibited during work time,
seminar at a resort hotel. Can a Sutter or at any time in an immediate patient care
Health employee accept the offer? area, from soliciting coworkers or patients
relating to a personal, non-Sutter Health
related activity. An employee may engage in
A. No, Sutter Health employees must not
accept gifts, particularly ones that have such activities on an employees own time
outside of immediate patient care areas
substantial value, from individuals or
from companies that do business, or may provided that the employee complies with
want to do business, with Sutter Health Sutter Healths policies regarding solicitation
or any Affiliate. This type of activity and conflict of interest. If you have any
should be reported to your supervisor and questions about the solicitation or conflict
Compliance Officer to resolve the current of interest policies, your supervisor or
gift and assure this does not happen in Human Resources professional are available
the future. to assist you.
Solicitation
Sutter Health employees may not solicit their
co-workers or patients on behalf of their
personal business or any third party during
work time or in any immediate patient care
areas. Limited fundraising or solicitation in
furtherance of Sutter Healths mission and in
support of various health-related not-for-profit
programs may be permitted with management
approval (e.g., United Way, March of Dimes).
 ADVERTISING, MARKETING
AND COMMUNICATIONS

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 Advertising, Marketing and Communications
Sutter Health is viewed as a reliable,
authoritative source of information about
health care and about issues relating to the
delivery of health care. We want to maintain
public trust by providing accurate, balanced
and consistent information.
All advertising, communications and other
promotions should enhance the positive
reputation of Sutter Health and its Affiliates by
communicating a clear, consistent, high-quality
image of the organization and its services.
Advertising
All advertising should be produced by or in
coordination with representatives of the Sutter
Health Marketing Department to ensure it
complies with Sutter Healths brand guidelines
and graphic standards. Advertising that
includes photographs and/or names of patients,
their family members, physicians or employees
must also comply with our policies requiring
signed individual consent.
Graphic Standards
All Sutter Health departments and Affiliates
must conform to Sutter Healths graphic
standards to maintain a consistent and
recognizable image. For information about
our graphic standards, please refer to the
Sutter Health Brand Center at http://brand.
sutterhealth.org. In addition, all logos should
be obtained through the Brand Center. To
request access, please contact brandcenter@
sutterhealth.org.
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News Media
It is Sutter Healths systemwide policy to
identify, train and authorize spokespeople to
talk with representatives of the news media
about official Sutter Health information.
Approved spokespersons of Sutter Health
shall work cooperatively with news media
representatives to provide official news
announcements, releases, statements, reports,
reactions, responses, etc., to requests for
information.
The Communications Department of Sutter
Health and its Affiliates serves as the first
point of contact with representatives of
the news media regarding all inquiries
related to the organization and its services.
Communications will follow established
processes when engaging with the news
media, including the identification of
appropriate subject matter experts and
spokespersons throughout the network.
Employees should refer all media inquiries to
the Communications Department.
online communications. This includes knowing
Q. After I finished work, a reporter and camera
person approached me in the parking lot.
They said they had some questions about
our organization and wanted an employees
perspective. They were just asking for my
opinion, so is it OK to go on camera?
A. Although the media may seem to only be
interested in your personal opinion, your
comments may come across as a response
from Sutter Health, especially if you are still
in uniform, wearing an ID badge or in front
of a company building. Also, they may ask
questions you are not prepared to answer
on camera. If you are ever approached by
a reporter, politely decline the request and
direct him or her to the Communications
Department, where official Sutter Health
spokespeople will respond.
Social Networking
Employees should follow the Sutter Health
Standards for Business Conduct, as well
as Sutter Health or Affiliate Employee
Handbooks, values and applicable laws in all
and adhering to Sutter Healths systemwide
Social Networking Policy.
Never share information in online communities
about a patients identity or health condition
in any way, or Sutter Health or Affiliate
confidential, proprietary or trade-secret
information.
 Q. My friends and family are interested in
seeing what I do at work on a regular basis.
I started a blog to document my days as a
nurse, and I also post a lot on Facebook and
Twitter as a way to stay connected. Today,
I encountered a patient with a very rare
condition that I think my followers will be
interested in learning more about. Can I
write about this experience?
A. Any employee can start his or her own
blog or be active in social networking,
but participation in such activities
requires following Sutter Healths Social
Networking Policy and Commenting
Guidelines. Employees cannot discuss any
patient information in person or in online
communities and forums per Privacy
regulations. This includes videos, text,
photos or any other communication that
identifies a patient or in any way discusses a
patients health condition or an image. Even
if you do not identify a patient by name, a
description of the patients condition might
reveal his or her identity.
Employees are encouraged to follow or
fan official Sutter Health social media
accounts, and share information posted
there to help promote the good works of
our organization.
8 | Sutter Health Confidential Message Line 1-800-500-1950
Q. I was disappointed to see a number of
negative online reviews about my employer.
Theres nothing wrong with posting a positive
review under an anonymous account on Yelp,
right? I just want to create a more accurate
reflection of my organization.
A. There are serious implications for ghost
blogging, which is when an individual
posts an endorsement or review about his
or her company without sharing his or her
connection to, or role in, the organization.
Be transparent and state your connection
to Sutter Health or a Sutter Affiliate in any
online forums or postings from online
comments on news stories to discussion
boards and more.
Third-Party Use of the Sutter Health
or Affiliate Names and Logos
Sutter Health believes that vendor or other
third-party use of our organizations names
and logos requires special scrutiny. It is our
systemwide policy that employees cannot
approve, permit, originate, edit or otherwise
produce communications and marketing
materials related to or referencing Sutter
Health on behalf of a Vendor, Other Third-
Party Vendor or Private Individual without
prior review and approval by the Sutter Health
Marketing/Communications Department
before use or distribution. Never promise,
in writing or in conversation, that our
organization or its employees will endorse a
particular third-party product or service.
 PATIENT CARE
AND TREATMENT

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 Patient Care and Treatment
Deliver appropriate, effective, and quality
care with compassion. Deliver care to patients
without regard to race, creed, gender, age,
illness, disability status, sexual orientation,
national origin or ability to pay.
Patients must always be treated with sensitivity,
respect and professionalism. A patients
care plan must be appropriate to meet the
intended medical and psychological outcomes.
Protective measures must be in place to
safeguard patients from harm.
Patient and Member Confidentiality
and Privacy Rights
Information about our patients and members
is considered Protected Health Information
(PHI) and must only be accessed, used or
disclosed for legitimate business purposes and
as required to perform job related duties. State
and Federal laws govern the use, disclosure
and safeguarding of health information and
give patients and members rights related
to access, restrictions, amendment, and
confidential communication of their health
information. The disclosure of sensitive patient
information such as information regarding
HIV test results, alcohol or drug use, and
mental health treatment is generally subject
to additional restrictions. Unlawful access, use
or disclosure of patient or member information
may be reportable to the patient or member,
government agencies and, in some cases, the
media. Contact your local Privacy Officer to
report a privacy incident or if you have any
questions about privacy.
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All employees are required to abide by the A. No. There are specified procedures and legal
Workforce Confidentiality and Privacy Policy, requirements that must be followed to gain
Use of Internet, E-Mail and Instant Messaging access to records of family members. Your
Policy, and all other Privacy, Information local Privacy Officer can assist you.
Security Policies and Procedures. All
employees will be asked to sign a Workforce Q. I am a clinical assistant and I am
Confidentiality Agreement annually and to often asked to fax confidential patient
acknowledge the Privacy and Information information to a physicians office, per
Security Policies and Procedures. the physicians request, without a signed
authorization form from the patient. I feel
Q. I am concerned about a co-worker who
uncomfortable doing this, and I could not
was recently admitted to the hospital.
find a policy dealing with this issue. Is this
Can I access her information in our
permitted?
electronic medical record system to see
how she is doing?
A. Yes, state and Federal privacy laws and
regulations generally allow for the release of
A. No. While you have the best interests of
health information to a treating physician
your co-worker at heart and assuming you
without the patients authorization for
are not one of the patients caregivers, you
continuing care of the patient. If you feel
may not access her health information
that you need further explanation regarding
without her specific written authorization
the purpose for the release of information,
to do so. This would be a violation of
it is your responsibility to ask the resources
Privacy regulations and Sutter Health and
available to you until you are satisfied that
Affiliate Policy would require disciplinary
you are following correct procedures. Please
action, up to and including termination of
see the Electronic and Fax Transmittal of
employment.
Protected Health Information Policy for
more details.
Q. How can I access records of members of my
immediate family including my childrens
Q. I accidentally faxed a document that
records? I know they are stored in our
contained patient information to the wrong
computer system. Can I just go in and look
person. What should I do?
at them?
 A. If you have accidentally faxed sensitive
or confidential information to the wrong
recipient(s), you should inform your
supervisor, manager or director and the
local Privacy Officer immediately. You
should also follow up with the recipient(s)
to inform them that the fax was sent in
error and, obtain their full name and
contact information, and ask them to retain
the information until the Privacy Officer
contacts them to make arrangements for the
return of the documents.
Q. I had an interesting patient case that I want
to post on my various social media sites,
including my Facebook page. Is it ok to post
information about the case if I dont include
the patient name?
A. Individuals may not use or disclose any
patient identifiable information of any
kind, including patient images, on any
social media platform. Even if an Individual
is not identified by name within the
information at issue, if there is a reasonable
basis to believe that the person could still
be identified from that information, then
its use or disclosure could constitute a
violation of the federal or state privacy
regulations. Information of any kind,
including patient images, on any social
media platform cannot be shared or posted
without the express written authorization
of the patient. Additionally, online activities
11 | Sutter Health Confidential Message Line 1-800-500-1950
regarding patients within the Sutter Health
network of care, that may compromise
a patients personal dignity or otherwise
make them question the confidentiality of
the services provided by the network, are
prohibited.
Q. Im not sure what to do with these
prescription bottles with patient names on
them. Can I just throw them in the trash?
A. No. You should check with your department
to confirm the process for properly
disposing of the bottles. The bottles will
likely be processed by a disposal vendor to
pick up and shred or otherwise destroy the
PHI. Sutter Health is not allowed to dispose
of any PHI in dumpsters or other containers
that are accessible by the public or other
unauthorized persons.
Employee Use of Computer Systems
and Equipment
Sutter Health is expanding its use of
computer systems and portable devices (i.e.,
laptops, smartphones, etc.) to better manage
information about patients, employees and
the organization. Employees and third party
contractors who are granted access to our
systems must familiarize themselves with the
Sutter Health Privacy and Information Security
policies. Policies are in place to protect both
you and Sutter Health.
Please follow these steps to protect Sutter
Healths information:
Choose strong passwords that differ from
your personal accounts.
Protect your passwords and never share
them with others.
Use a screensaver when stepping
away from your computer
( +L or ctrl+alt+delete).
Type [encrypt] or [confidential] in the
subject line to securely send a message
outside of Sutter Health (be sure to include
the square brackets). Always use this
function when sending PHI.
Store confidential information on a
network drive. Do not save on your local
computers hard drive (c:).
Place portable computing devices in a
secure location when unattended or not
in use.
Question any email you receive with
links or attachments requiring immediate
attention. Validate the message by calling
or initiating a new message by looking up
the address.
Inquire if unfamiliar individuals are in
your area to prevent unauthorized access
to our systems.
Practicing good security often takes extra steps,
but they are well worth the time to protect
our patients information. More detailed
information is available on the Security
Awareness and Training intranet website.
 Q. I have been asked to share my password with
another employee. Is this okay?
A. No, never share your password with anyone.
You are responsible for all actions associated
with your user ID and password. Indicate
that you are uncomfortable with the request
and that sharing your password would
violate the Sutter Health Passwords policy. If
your supervisor or manager approaches you
to share a password, you can contact your
compliance, privacy or security officer for
guidance.
Q. If I receive a suspicious looking email
message that includes a link in the message
or an attachment, should I be skeptical?
A. Yes. Phishing is a fraudulent email attempt
to trick you into revealing confidential
information or providing access to your
computer and our information systems. Health
information is valuable, so its safer to be
skeptical of unsolicited email messages with
links and/or attachments. Be extra cautious
of messages requesting immediate action.
Validate whether the message is legitimate by
calling the sender or by sending a separate
email directly to the individual.
12 | Sutter Health Confidential Message Line 1-800-500-1950
Emergency Medical Treatment and
Labor Act (EMTALA)
EMTALA is, in effect, a national safety net
that requires hospitals to provide a clinical
evaluation by a physician or other qualified
hospital staff member to any individual who
comes to the facility and requests an assessment
or treatment of a possible emergency
medical condition. Hospitals are required to
use whatever resources they have available
to provide such evaluation. If the patients
condition is determined to be an emergency,
the hospital is further required to provide
whatever care may be necessary to stabilize
the condition and prevent worsening of the
patients condition. If, however, the complexity
of the patients needs exceed the hospitals
resources or capacity to provide the required
assessment and treatment, the patient must be
promptly transferred to a facility that has such
resources available. All services mandated by
EMTALA must be provided without regard to
the patients ability to pay, pre-existing medical
condition, age or citizenship. Compliance with
EMTALA is a condition of a hospitals Medicare
provider agreement. Additional information
about EMTALA may be found in Sutter Health
Risk Services EMTALA Snake Bite Kit
publication or in your hospital policies.
Charity Care: Our Commitment to
Low Income Uninsured Patients
It is the policy of Sutter Health to provide
income based Financial Assistance (charity
care) to qualified individuals and to provide
uninsured and insured patients with the
information required by law regarding
financial assistance. Charity care is based
on the individuals ability to pay, as defined
by Federal Poverty Income Guidelines, and
available in the form of free or discounted care
to eligible low-income uninsured patients, and
insured patients with high medical costs.
Charity Care is generally not available for
elective procedures, or applicable to charges
for services rendered by physicians or other
medical providers charges not included on the
hospital bill.
Information about financial assistance is
provided through notices that are posted
in the primary languages of the hospital
or foundation service areas in a variety of
locations, such as admitting, emergency
departments, billing offices and other
outpatient settings. Information about financial
assistance is also provided on the Sutter Health
website and on patient bills.
 Patients with Disabilities:
Our Commitment to Equal Access
Sutter Health partners with patients by assuring
patients with disabilities can come into our
facilities, get services and participate during care.
Specific steps facilitating full access to care may
require scheduling physically accessible spaces
or equipment, communicating in ways that allow
effective participation by patients with hearing
or vision loss or changing ways of positioning on
equipment during care. Sutter Health is proud to
be a leader in disability access in the health care
industry. All patient care entities have a set of
policies that guide you in how to care for patients
with disabilities.
Q. Who can I ask if I have questions about
patients with disabilities?
A. Each care facility has an ADA Coordinator
trained to help you understand your
responsibilities to patients with disabilities.
You may also consult the set of policies
with the captioned Patients/Visitors with
Disabilities. Additional resources may be
found on the Disability Access Compliance
page on the MySutter site.
13 | Sutter Health Confidential Message Line 1-800-500-1950
Caring for Patients with print, audio recordings, or computer disks
Communication Challenges pictographs. Contact information can be found
Communication is an important part of patient in your Affiliates policy entitled Patients/
care. If our patients cannot understand us Visitors with Disabilities: Communication
due to language barriers or hearing or visual Assistance. This website lists contracted
issues, it could negatively impact the patient language assistance vendors.
experience and health outcomes. Resources: http://mysutter/Resources/
Therefore, Sutter Health provides, at no cost CulturalCompetence/Pages/default.aspx
to the patient, language assistance to Limited
English Proficient (LEP) patients and effective
communication tools for persons with hearing
or visual impairments.
Interpreting services are available through
bilingual staff members who have
demonstrated competency as an interpreter,
or through telephone or in-person interpreter
vendors.
Family members should not be used as
interpreters except in an emergency, or when
the patient refuses the offer of an interpreter
and insists the family member provide this
service. In this case, refusal of the interpreter
should be documented in the patient record.
Minors should NEVER be used as interpreters.
Effective communication tools for persons
with visual, hearing, speech or cognitive issues
may include the use of an assistive listening
system, a qualified American Sign Language
interpreter, a qualified oral interpreter,
computer-assisted real time transcription,
or alternative formats such as Braille, large
 Q. I was taking care of a non-English speaking
female patient who was being treated for
issues related to her reproductive system. I
had to ask many personal questions related
to her sexual history. Her 15-year old son
was serving as an interpreter for her, and I
felt very uncomfortable asking such personal
information about his mother in front of
him. Could I have insisted she use a hospital
provided interpreter?
A. Minors should never be utilized as
interpreters due to the sensitive nature
of many health issues and patient
confidentiality. Every Sutter Health Affiliate
has language assistance services for patients
with limited English speaking ability. If a
patient insists on using a family member as
an interpreter, it should be documented in
the patient record and the patient should be
advised that the family member must be 18
years of age or older.
Communicating Patient Care
Concerns to Joint Commission
Any hospital employee who has concerns about
the safety or quality of care provided in the
hospital may report these concerns to the Joint
Commission. Sutter Health hospitals should
take no disciplinary action against an employee
who reports safety or quality of care concerns
to the Joint Commission.
14 | Sutter Health Confidential Message Line 1-800-500-1950
Q. I have concerns about one of the surgeons concerned that a patient is really going to
at my hospital. His patients never do as get hurt. What should I do?
well after surgery as patients who have the
same surgery performed by other doctors. I A. Ensuring patient safety is a cornerstone of
know I am not a doctor, but I am concerned our mission. Be certain that your supervisor
about the quality of care that this surgeon understands your concerns. Complete and
gives his patients. Is there anything I can do submit an Incident Report (also known as
about this? a QAR or Unusual Occurrence Report).
Contact your Risk Manager immediately
A. Yes. Each time there is an unfavorable if you believe that patient safety may be
patient outcome complete an Incident in immediate jeopardy or if a patient is
Report (example: Quality Assessment actually injured as a result of defective
Report (QAR) or Unusual Occurrence equipment or supplies.
Report). Use the report to describe
problems experienced by your surgical
patients. The information will be provided
to Medical Staff leadership, and peer review
will be conducted, if warranted. Without
your reports, it is difficult for the hospital to
recognize and correct problems. You should
also consult with your Risk Manager.
Q. I am a unit clerk in an acute care hospital.
I know that the side rails on one of the
patient beds on the unit where I work
sometimes fail to lock in the up position.
Just today, I heard that a patient fell out
of bed because the rail was down. My
supervisor knows about this incident, and
he said, because of the high census, we do
not have enough beds to go around right
now, and this bed must remain in use. I am
 WORKPLACE CONDUCT AND
EMPLOYMENT PRACTICES

15 | Sutter Health Confidential Message Line 1-800-500-1950

 Workplace Conduct and Employment Practices
All employees deserve to be treated with respect,
dignity and fairness. Sutter Health strives to
create and maintain a work environment in
which employees are treated with respect, where
diversity is valued, and where opportunities are
provided for development.
If an employee of any Sutter Health Affiliate
perceives that inappropriate or unfair conduct
is occurring in the workplace, the employee
is encouraged to discuss this with his or her
supervisor, his or her chain of command,
Human Resources, his or her Compliance
Officer or use the confidential message line at
1-800-500-1950 to resolve the issue.
Q. I have reason to believe a co-worker may be
falsifying his timecard. He always comes in
late but documents that he is on time. I am
certain our supervisor knows about it, but
he has not done anything. I do not think it
is fair that my co-worker is allowed to get
away with this. What can I do?
A. Timecards are legal documents that
should accurately reflect the hours worked.
You should inform your supervisor if
you believe any employee is improperly
recording his/her work hours. If you do
not believe your supervisor is handling the
matter in the best interest of the Affiliate,
you have an obligation to report your
concern by notifying your department
director, Human Resources or the
Compliance Officer. You can also use the
16 | Sutter Health Confidential Message Line 1-800-500-1950
confidential message line at 1-800-500-1950 to
report the concern.
Q. I have worked at Sutter Health for about a
year. Yesterday, my supervisor terminated
my employment on the grounds that I was
not performing at the level he expected
of me. My last review stated that I was
mostly meeting expectations, and I have not
received any disciplinary actions, just a few
coaching sessions. Can he do that?
A. Maybe. Introductory periods, conditions
of employment, disciplinary policies
and grievance procedures vary among
Sutter Affiliates. If you disagree with the
termination, contact Human Resources
to find out what the grievance or appeal
process is for your Affiliate.
Prohibition Against Discrimination,
Harassment and Retaliation
Discrimination, harassment and retaliation
are examples of inappropriate conduct that
undermine our work environment. Sutter
Health does not tolerate discrimination or
harassment on the basis of
Race
Color
Creed
Religion
M
 arital Status
Sexual Orientation
Registered Domestic Partner Status
Sex
Gender
Gender Identity or Expression
Ancestry
National Origin (including possession
of a drivers license issued to individuals
who did not present proof of authorized
presence in the U.S.)
Age
Medical Condition
Physical or Mental Disability
Military or Protected Veteran Status
Political Affiliation
Pregnancy or Preceived Pregnancy
Childbirth
Breast feeding or Related Medical
Condition
Genetic Information
or any other characteristic made unlawful
by local, state or federal law, ordinance or
regulation. Sutter Health also prohibits
retaliation against anyone who, in good faith,
objects to or reports perceived discrimination
or harassment, participates in an investigation
of discrimination, harassment or retaliation,
or engages in other legally protected activity.
Employees who are found to have engaged
in discrimination, harassment, or retaliation,
 regardless of their level in the organization,
are subject to discipline up to and including
termination of employment.
Employees who feel that they are subjected to
or have witnessed discrimination, harassment
or retaliation of any nature must report the
conduct. Employees are encouraged, when
appropriate, to firmly and promptly notify
the offender that his or her behavior is
inappropriate and unwelcome. It may at times
be difficult to initiate such a communication
and employees should use their judgment and
discretion in deciding whether to confront the
offender. Additionally, employees must report
the incident immediately to their supervisor,
somebody in their chain of command, Human
Resources, or the Sutter Health Confidential
Message Line at 1-800-500-1950.
Q. My new boss is overly friendly. He likes to
shake my hand every shift and I feel like he
lingers in that handshake. It makes me very
uncomfortable. Is this sexual harassment?
How can I get him to stop?
A. Sexual harassment is any unwanted sexual
advances, or visual, verbal or physical
conduct of a sexual nature. This definition
includes many forms of offensive behavior
and includes gender-based harassment of a
person of the same sex as the harasser. The
following is a partial list of conduct that
may be considered sexual harassment:
17 | Sutter Health Confidential Message Line 1-800-500-1950
U
 nwanted sexual advances Confidential Employee Information
O
 ffering employment benefits in exchange All employees are required to abide by the
for sexual favors Workforce Confidentiality and Privacy
M
 aking or threatening reprisals after a Policy, Use of Internet, E-Mail and Instant
negative response to sexual advances Messaging Policy, and other Privacy
and Information Security policies and
V
 isual conduct: leering, making sexual Procedures. Employees will be asked to
gestures, displaying of suggestive objects or sign a Workforce Confidentiality
pictures, cartoon or posters Agreement annually and acknowledge the
Verbal conduct: making or using derogatory Privacy and Information Security policies.
comments, epithets, slurs, and jokes
V
 erbal sexual advances or propositions
V
 erbal abuse of a sexual nature, graphic
verbal commentaries about an individuals
body, sexually degrading words used
to describe an individual, suggestive or
obscene letters, notes or invitations
P
 hysical conduct: touching, assault,
impeding or blocking movements
Even if your new bosss conduct is not sexual
harassment, if it makes you uncomfortable, you
should find a way to communicate this, either
directly to your supervisor, somebody in their
chain of command, Human Resources, or the
Sutter Health Confidential Message Line at
1-800-500-1950.
 FINANCIAL INTEGRITY

18 | Sutter Health Confidential Message Line 1-800-500-1950

 Financial Integrity
Employee Use of Charitable Assets
All Sutter Health employees are expected to
be good stewards of Sutter Healths charitable
assets. Specifically, they are expected to maintain
and properly care for Sutter Healths and any
Affiliates charitable assets for the benefit of
those communities that Sutter Health serves.
Sutter Health and its not-for-profit Affiliates
hold charitable assets in trust for the benefit
of the communities they serve. Sutter Health
charitable assets, including monies, must not
be used for improper or illegal activities and
should be used with care solely for authorized
purposes. Personal use of Sutter Health
property is generally prohibited, including,
but not limited to, the use of Sutter Health
resources or facilities to support an employees
own outside business activities or those of
another organization. This applies to physical
assets such as office equipment, computers,
software and supplies, including medical
supplies, as well as other types of property
such as business records, patient information
and customer lists. Employees having access
to e-mail and the Internet should follow all
policies relating to its proper usage. Sutter
Health property should not be removed from
Sutter Health facilities unless it is necessary
to do so to perform your job and you must
return the property to its proper location
as soon as it is no longer needed off-site for
business purposes.
19 | Sutter Health Confidential Message Line 1-800-500-1950
Q. It has come to my attention that a co-worker
in the accounting department regularly
stays after work and comes in on weekends
to do billing and bookkeeping for his wifes
janitorial business. This has been going on
for a long time and it doesnt seem right
to me. Am I being overly reactive to
this practice?
A. No. Personal use of your Sutter Healths
computer, software, copier, paper and
printer by your co-worker on a long-term,
continuous basis is prohibited. You should
report this conduct to your supervisor,
Human Resources or Compliance Officer.
Q. I know for a fact that one of my co-workers
takes home a lot of pens, flashlights,
batteries, copy paper and other office
supplies. Ive told him I think this is wrong
and that he should stop doing it, but he just
laughs at me, saying the hospital is rich and
can afford the losses. Im the only one who
knows about it, so if I report it, he will know
I told on him.
A. In addition to general criminal laws
prohibiting the taking of other peoples
property, we have an additional reason to
guard against the personal use of Sutter
Health property. Sutter Health and many of
its Affiliates are not-for-profit corporations.
As not-for-profits, assets are held in trust
for the benefit of the communities Sutter
Health and its not-for-profit Affiliates
serve. Assets include items like pens,
flashlights, batteries, copy paper and
other office supplies. If we take business
property home for personal use, we are not
only stealing from the hospital or medical
or philanthropic foundation, but we are
stealing from our neighbors who are the
individuals who make up the communities
we serve. In this case, you should report
the misuse of property to your supervisor,
the Human Resources Department, or
your Compliance Officer. You may request
that the investigation be done in such a
way to protect your identity. For example,
the investigation could focus on property
controls throughout the department rather
than focusing specifically on the conduct of
your co-worker.
 Political Contributions
Sutter Health may not use company monies
to contribute to a political party, committee,
organization or candidate in connection with
a federal, state or local campaign. You may, of
course, make personal contributions of your
own funds to the campaigns of candidates of
your own choice. Such contributions are not
reimbursable by Sutter Health.
Q. I heard that Sutter Health gives large
contributions for political activities that are
sponsored through organizations such as the
California Healthcare Association and the
American Hospital Association. Is this true?
A. While Sutter Health does not make
contributions to candidates for political
offices, it often does make contributions
to organizations that advocate issues that
relate to the delivery of health care.
20 | Sutter Health Confidential Message Line 1-800-500-1950
Anti-Trust Laws
Sutter Health values require that we compete
fairly and be in compliance with all antitrust
laws. In order to succeed in todays health
care marketplace, each of us must be
committed to competing vigorously on behalf
of Sutter Health. But Sutter Health draws
a line between competing vigorously and
competing unfairly and we must never cross
that line.
It is unlawful to agree, or attempt to agree,
with competitors to share price information,
fix prices, divide geographic markets by
agreeing to limit services or otherwise
make any agreement that raises, or is
likely to raise, the price of our services or
improperly reduce, or is likely to reduce
competition. Particular care should be taken
in pursuing joint ventures or alliances with
other health care providers. Seek advice
from your supervisor or manager before
taking any action that may compromise fair
competition or compliance with antitrust
laws. A supervisor or manager who is
contacted regarding antitrust matters should
immediately contact hospital administration
who will contact the appropriate individual at
Sutter Health.
 PATIENT BILLING
PRACTICES

21 | Sutter Health Confidential Message Line 1-800-500-1950

 Patient Billing Practices
Accuracy of Records
Sutter Health policies outline the legal
requirements for preparing and maintaining
accurate patient and business records,
including their retention and confidential
destruction.
Medical records may be amended in order
to complete the documentation or to correct
an error.
Correction of an electronic medical record
should be done in a way that records the
initial entry, the change, the date of the change
and the person making the change. Medical
record information may not be deleted or
inappropriately corrected. Changes in the
medical record made more than 30 days from
the date of service should not be used for
reimbursement purposes.
Affiliate financial and billing records shall
not contain false or misleading information.
Financial transactions will be recorded
in accordance with Generally Accepted
Accounting Principles (GAAP) and Sutter
Health policies and standards.
Q. I noticed what looks like duplicate charges
for the same services posted to the patients
account. My manager says not to worry
about it as the problem belongs to someone
else. What should I do?
22 | Sutter Health Confidential Message Line 1-800-500-1950
A. You have an obligation to report potential documents should be retained for periods
billing errors or suspected misconduct. prescribed by law and by Sutter Health and
Generally, you should discuss these Affiliate record retention policies.
concerns with your supervisor first, but if
Sutter Health Affiliates have policies relating
no action is taken, you should discuss this
to the timely completion of medical record
with your Revenue Cycle Liaison or with
documentation by physicians to support
your Compliance Officer.
billing. Affiliates should ensure all physicians
are aware of policies on completing and
Q. My supervisor asked me to alter some nurse authenticating medical records.
staffing records prior to a Joint Commission
Survey. He told me it was important for Q. I am working on a claim and noticed that
our department to get a good grade on the the physician did not include a diagnosis
survey. I want our department to look good, with his order for several tests. Can I use a
but I do not think this is the right thing to diagnosis from an earlier encounter or the
do. What should I do? patients problem list as the reason for
these tests?
A. Altering any type of documentation is not
permitted. You have an obligation to report A. No. Only a physician (or non-physician
suspected misconduct. Generally, you practitioner) can state the reason for the
discuss these concerns with your supervisor test or procedure. However there are
first, but if no action is taken, you should times when it is permissible to review the
discuss this with another supervisor or encounter from where the order generated
with your Compliance Officer. to clarify or obtain a diagnosis. Please
check with your Compliance Officer for
additional guidelines.
Coding and Billing Practices:
Accurately Bill for Services Rendered
to Our Patients
Correct coding and billing is essential to any
compliance program. Each Sutter Health
Affiliate should submit accurate claims that are
supported by documentation in the medical
record. Services must be accurately and
completely coded to ensure proper billing.
Medical record documentation should support
all services billed. Medical record and billing
 Q. As a coder, I sometimes see lab values in the
medical record that indicate the patient has
gram-negative pneumonia, yet the physician
has not documented this specific type of
pneumonia in the chart. If I code gram-
negative pneumonia (instead of unspecified
pneumonia), the insurance company might
reimburse at a higher rate. Should I code
this diagnosis?
A. No, Diagnosis codes must be fully
supported by physician documentation
in the medical record. Lab results by
themselves do not support a diagnosis; the
physician must state the type of pneumonia
in the chart for you to code it. Follow
your departments coding guidelines for
physician query.
Coding and Billing
Coding and billing policies and procedures
must be written, approved by management
and approved by Ethics & Compliance
Services. These documents must also be
routinely reviewed, updated and maintained
in PolicyStat. These policies and procedures
should be made available to all employees
involved with the coding, billing or auditing of
medical records or accounts receivable.
23 | Sutter Health Confidential Message Line 1-800-500-1950
Coding practices should conform to Official
Coding Guidelines, the American Hospital
Association Coding Clinic, and the American
Medical Association CPT Assistant. Accurate
billing is largely based upon correct coding.
Billing procedures must comply with the
requirements of state and federal laws and
regulations. Employees who enter charges
should be trained on how to select charges
that accurately reflect the services provided.
Billing and coding professionals should not
change codes, sequencing of codes, or the
description of codes on the bill itself for
reimbursement purposes unless the medical
record documentation supports the change.
Q: A patient is admitted with pneumonia
and my principal diagnosis selection
is pneumonia based on physician
documentation. The data abstractor
has asked me to resequence the codes so
pneumonia will not be principal. Should I
change the codes?
A. No. Coding professionals should select the
principal diagnosis based on the specific
guidelines for the conditions documented
by the attending physician and/or
physicians involved the care of the
patient. A coder should never feel pressured
to change a code or resequence a code if it
would conflict with coding guidelines. Any
time you feel pressured to change codes,
discuss this with your supervisor or follow
your chain of command.
Q. I am working on an outpatient radiology
claim for a Medicare patient who received a
chest X-ray. When I looked at the diagnosis
on the claim, I discovered that the only
diagnosis was written as routine chest
X-ray. I realized Medicare does not pay for
routine tests. Can I select a diagnosis from
the patients problem list so Medicare will
pay for the x-ray?
A. No. There needs to be medical justification
for this test based upon a physicians order.
You should never pick a diagnosis from
the problem list to get a claim paid. You
may look at the encounter from which the
order originated to see if a diagnosis can
be re-linked or re-assigned prior to the
test performed. You can also query the
physician about the reason for the test. The
next question may be, Can this test be
billed to the beneficiary? The answer is: it
depends. If you accepted the beneficiarys
Medicare card and did not provide the
patient an Advance Beneficiary Notice
(ABN), you are not permitted to charge the
patient for the x-ray.
 Q. I transmitted a claim to Medicare. The
claim was edited out for an incorrect CPT-4
code. How should I proceed?
A. There are many reasons why a code may be
edited out. You should review the patients
medical record and coding guidelines to
ensure that the CPT initially submitted is
correct. If the initial CPT code is incorrect,
resubmit the claim with the corrected
CPT code. If the initial CPT was correct,
you will need to follow the instructions of
the edit. This may include writing off the
charge or appending a modifier if required
and supported by documentation. If you
have any questions, notify your supervisor
who will review the CPT code, and take
appropriate steps to determine the cause of
the edit. It is not appropriate to change the
code until the cause of the edit is identified.
Q. I am working on a claim and know that if
I submit this claim with the procedure that
was performed and the diagnosis that was
provided, the claim will be denied. However,
I do know of a payable diagnosis, somewhat
similar to the one on the claim form. May I
substitute the payable diagnosis for the one
already on the claim form?
24 | Sutter Health Confidential Message Line 1-800-500-1950
A. No. You can only bill based on documentation receive a percentage of the money recovered
in the medical record or transcribed report. as a reward and the False Claims Act protects
The biller should refer the claim to a trained individuals who report concerns in good faith.
coder who can review the documentation
to determine if another diagonosis code is California FCA: Medi-Cal Fraud
appropriate or query the physician. California was the first state to enact a state
False Claims Act similar to the federal law
Reporting Improper Coding/Billing with whistleblower provisions, but with greater
financial incentives to whistleblowers. The state
If you suspect that improper coding and billing
can file California false claims cases against
are occurring, you should discuss the issue
providers who are alleged to have defrauded
with your immediate supervisor and give your
Medi-Cal (Californias Medicaid program).
supervisor a chance to solve the problem. If
California also has specific criminal statutes
you are not comfortable discussing the issue
for knowingly making or causing to be made a
with your supervisor, you should continue
false or fraudulent claim for payment to non-
up the chain of command in reporting your
governmental insurers recovered as a reward
concern. If you are not comfortable doing this,
and the False Claims Act protects individuals
go to another resource where you work, such as
who report concerns in good faith.
the Compliance Officer, Risk Manager,
Human Resources representative, or call the For additional resources see Guidelines on
Sutter Health Confidential Message Line at Non-Retaliation/Non-Retribution Policy and
1-800-500-1950. the Deficit Reduction Act Policy.
False Claims Act (FCA)
The False Claims Act is a federal law that
prohibits submission of false claims to
government and payers (e.g., Medicare). A
false claim is an attempt to obtain payment by
presenting false or misleading information.
Criminal penalties for submitting false claims
include imprisonment and criminal fines.
The government may decide to pursue civil
remedies and collect up to three times the
amount lost, plus penalties ranging from $5,500
to $11,000 for each false claim. Whistleblowers
who alert the government to false claims may
 FINANCIAL RELATIONSHIPS WITH
PHYSICIANS AND OTHER PROVIDERS

25 | Sutter Health Confidential Message Line 1-800-500-1950

 Financial Relationships with Physicians and Other Providers
The Anti-kickback Laws
Physicians and health care providers (and the
individuals who work for them) cannot pay
or accept any remuneration (which you can
generally think of as money, gifts or other
benefits) if it is intended to influence patient
referrals and recommendations.
The laws are intended to protect patients from
the potential harms that could result from a
referral or recommendation that is based on
economic motives, rather than whats best
for the patient. The laws are also intended to
protect government programs (like Medicare)
from getting billed for more services than
necessarycosts that we as taxpayers will bear.
No payment or benefit should ever be
requested or accepted from someone who
sells us services or supplies, or from post-
discharge providers such as SNFs, home health
companies, DME companies and pharmacies,
because it could be potentially linked to
referrals or recommendations. Similarly no
payments or benefits should be made, given
or offered to physicians for their referrals. For
physician financial relationships, see also the
Stark Law section, below.
Potential Consequences of Noncompliance
Possible consequences of a violation under
the Anti-Kickback law include a fine of up to
$25,000 per violation; imprisonment up to
five years; exclusion from federal health care
26 | Sutter Health Confidential Message Line 1-800-500-1950
programs; potential Civil Monetary Penalties
up to $50,000 per violation; as well as potential
False Claims Act liability with monetary
penalties that could include three times
amount of the kickback.
Physician Financial Relationships:
Stark Law Essentials
The Stark law prohibits a physician from
referring patients for certain services payable
by Medicare if that physician has a financial
relationship with the referral recipient (such as
a hospital, medical foundation or home health
company) unless a specific legal exception
applies. The Stark Law also prohibits the entity
that gets the patient referral from submitting
claims to Medicare for services resulting
from an illegitimate referral. A financial
relationship can be either an ownership or
compensation arrangement, and includes
almost any type of remuneration in cash
or in kind, direct or indirect. Thus, any time
anything of value is passed to a physician from
a hospital or medical foundation to which that
physician refers services, the Stark Law may be
implicated.
It is critical to consult the Office of the General
Counsel (OGC) before offering, providing, or
entering into an arrangement to provide, any of
the following to a physician or physician group:
compensation for goods or services
support services, such as services that
support a physicians private medical
practice
gifts (such as wine or flowers)
meals and entertainment (such as tickets to
a culture or sporting event)
information technology items or services
health care services (sometimes known as
professional courtesy)
office space, equipment or supplies
recruitment support
marketing or promotional support
continuing medical education (CME)
services such as laboratory or imaging
services to be purchased by physicians,
group practices or Independent Physician
Association (IPAs)
Note that these are examples only. This is not a
complete list.
 Q: How do we comply with the Stark Law?
A: Review applicable Sutter Health policies.
Work with the OGC Legal Services Contract
Service Team for new and renewing physician
agreements and for amending and/or
extending any existing physician agreements.
For compliance questions about existing
agreements, and questions about providing
gifts or other items to physicians, contact your
Compliance Officer. For physician offices
leases or space use arrangements, contact
Sutter Health Facility and Property Services.
Some arrangements with physicians may be
okay, but only if a number of conditions or
requirements are met. Sutter Health has policies
and procedures that apply to:
Physician Office Leases
Physician Administrative Services Contracts
(such as medical director agreements,
medical staff leadership agreements,
physician champion agreements, speaking
services agreements, etc.)
Physician Recruitment Agreements
Physician Call Coverage Agreements
Gifts and Incidental Benefits (Non-
Monetary Compensation)
There is no requirement of bad intent under
the Stark law: Good or bad intent does not
matter; if there is a financial relationship with
a referring physician, the relationship must
satisfy an exception even if the arrangement
with
27 | Sutter Health Confidential Message Line 1-800-500-1950
the physician has nothing to do with
Medicare patients.
Potential Consequences of Noncompliance:
Possible consequences include denial of or
repayment of claims; and additional monetary
penalties of thousands of dollars per service;
potential exclusion from participation in
federal health care programs; potential
overpayment liability; potential for False
Claims Act liability.
California Anti-Kickback and Anti-
Referral Law
There are also state anti-kickback and anti-
referral laws that are similar to the Federal
Anti-Kickback Statute and the Stark law. Again,
it is important to consult with the OGC Legal
Services or your Compliance Officer before
entering into any financial relationship with a
physician or before providing anything of value
to a physician.
Payments to Physicians to Reduce or
Limit Care
Federal law prohibits hospitals from knowingly
making a payment directly or indirectly to a
physician as an inducement to reduce or limit
medically necessary items or services furnished
to Medicare and Medi-Cal patients who are
under the physicians direct care. In addition,
a physician cannot knowingly accept such a
payment. Any proposed incentive arrangement
with a physician must be reviewed by the OGC
and, if it is appropriate, would need to be set
forth in a written agreement.
For additional resources see:
The OGCs website: http://mysutter/Resources/
SystemDepartments/GeneralCounsel/Pages/
default.aspx
Q. There is an independent physician on our
medical staff who practices in a building
that is connected to the hospital. Recently,
my supervisor asked me to assist this
physician with scheduling his patients
for office visits. My supervisor also told
this physician that he can help himself to
excess supplies that the hospital is not
using. Are these activities okay?
A. No. The Stark Law prohibits giving items
and services to a physician without charge,
and this conduct potentially conflicts with
other laws.
Q. An independent cardiologist on our medical
staff sometimes uses an office in the hospital
to see his private patients. Is this okay?
A. Maybe. The cardiologists use of space
would create a financial relationship that
implicates Stark. If the space use is pursuant
to a written lease and otherwise meets
the requirements of the rental of office
space exception to the Stark Law, it may be
appropriate. However, physicians offices are
usually located in medical office buildings,
so if there is a concern about a space use
arrangement, talk to your supervisor or
Compliance Officer.
 Q. An independent psychiatrist on our medical
staff came to Grand Rounds at the hospital
yesterday and gave a lecture. Wed like to
now pay her for her time. Is this okay?
A. Maybe. The provision of compensation to a
physician who serves as a referral source to the
hospital would create a financial relationship
that implicates Stark. The compensation
relationship would have to meet all of the
requirements of a Stark exception. Sutter
Health policy requires that you contact the
OGC before administrative services are
rendered by a physician if you do want to
compensate the physician for the services.
Q. The medical director of our emergency
department is retiring from this leadership
position after several years of service at our
hospital. As a retirement gift, wed like to
give him and his wife a trip to Hawaii. Is
that okay?
A. No. Even though you are not paying
compensation to the physician, you would
be giving him something of value (the trip to
28 | Sutter Health Confidential Message Line 1-800-500-1950
Hawaii would be considered remuneration). Q: We have an inpatient who is ready for
As such, the arrangement would trigger discharge, but she doesnt have enough
the Stark Law and would need to meet a money to pay for taxi fare to get home from
Stark exception. While the Non-Monetary the hospital and she has no one to drive
Compensation exception would permit you her. She also mentioned that her heat was
to give a gift to a physician, there is a cap on turned off by the utility company when she
the value of the aggregate gift(s) you can give. couldnt pay her bill. Can we help?
A trip to Hawaii would exceed that cap.
A: In most cases we can provide some
Patient Inducement assistance to patients to facilitate a safe
discharge, after there has been a good faith
Federal law strictly limits the circumstances in
determination of financial need. While the
which a gift, waiver of fees or other benefit can
patient cannot be given cash, we can pay
be given to a Medicare or Medicaid (Medi-Cal)
the vendor such as the taxi company or
patient. In addition, cash payments cannot be
utility company. There are limitations on
given to patients. The laws stem from a concern
the amount and types of assistance that can
that a patient could select a provider based on
be provided. Consult your supervisor before
the reward given or promised by the provider,
providing assistance.
and a concern that unnecessary services will be
billed to government programs.
Q: I think certain lab services are a good source
The laws permit some assistance to be provided of revenue. Could we offer a financial
to financial needy patients, but the assistance reward to patients who choose us over our
must be unadvertised, and is usually limited to competitors for laboratory services?
those who are existing patients. Sutter Health
has Charity Care policies that address free
A: No, in general, gifts or benefits cannot be
and discounted health care to patients with a
provided to patients as part of a marketing
financial need, and we also have guidelines that
campaign. Some very low value items (such
describe when other forms of non-healthcare
as a refrigerator magnet) can be provided
assistance may be given to patients. Consult
to patients as part of a health promotion
your Compliance Officer, Discharge Planning
effort or to encourage patients to obtain
Lead or Finance Leadership before giving
preventive care services. There are often
assistance or anything else to a patient.
dollar limits on what can be provided,
so consult your supervisor before giving
anything to patients.
 TAX-EXEMPT STATUS

29 | Sutter Health Confidential Message Line 1-800-500-1950

 Tax-Exempt Status
Sutter Health and most Affiliates operate as
tax-exempt charities under both California and
federal law. A charitable organization must be
operated primarily to conduct its stated exempt
purpose, as it serves a public rather than a
private interest. As charitable organizations,
any money that we make must primarily
be used to advance our charitable mission.
Generally, Sutter Healths monies are used
for patient care, but we also fund a variety of
purposes, including charity care, maintaining
and upgrading facilities, and developing
new programs to make a difference in the
communities we serve.
Prohibition of Private Benefit
Our organization needs to be aware of any
transaction, arrangement, practice, or policy
that may potentially or actually provide a
private benefit that unjustly enriches any
individual, entity, or business. We need to
enter into contracts and arrangements that
are based on commercially reasonable terms
that bear a proper relationship to our exempt
purpose. Some examples of arrangements that
would violate the prohibition against private
benefit include:
1. P
 ayments to physicians for services if the
payments exceed the fair market value of
the services.
30 | Sutter Health Confidential Message Line 1-800-500-1950
2. P
 urchasing supplies, equipment or influence include, but are not limited to,
services from a vendor where the vendors current and former:
relationship with management resulted in
Officers
a price that was known to exceed the fair
market value. Key Employees (defined as managing 10%
of the organizations assets or expenses)
3. C
 harging rental space that is below fair
market value to physicians or businesses. Board, Directors or Trustees
Physicians, in certain instances (e.g., when
Sanctions of Private Benefit acting as Director, as medical staff leader,
Providing a significant inappropriate or a physician who exerts substantial
private benefit may result in a tax-exempt influence in performing administrative
organization losing its exempt status. services)
Less significant violations of the private
Substantial contributors
benefit rules may result in an intermediate
sanction, such as fines and penalties, on the In addition, family members of, or businesses
owned by, the above referenced persons are
organization and individuals receiving and
approving the transaction. The private benefit also considered to have substantial influence.
will need to be paid back to the organization,
applicable contracts/policies/agreements
modified to prevent any further excess
benefit, and organization managers may be
personally liable for penalties and held jointly
and severally liable.
If the private benefit is received by an
individual that can exert substantial influence
over the exempt organization, the individual is
personally subject to an increased penalty on
the excess benefit plus an additional penalty
if the excess benefit is not repaid in a timely
manner. Typically persons with substantial
 GOVERNMENT
INVESTIGATIONS/AUDITS

31 | Sutter Health Confidential Message Line 1-800-500-1950

 Government Investigations/Audits
Responding to Government
Investigations/Audits
If a law enforcement agency arrives at your
facility what a search warrant or to do an
investigation you should first, notify the most
senior-level individual at your location. They
will contact your affiliates Compliance Officer.
The Compliance Officer may contact the Office
of the General Counsel or other individuals,
as necessary. Next, ask to see the lead law
enforcement officers credentials and request a
business card or contact information. If theres
a search warrant, request a copy of it to provide
to your Compliance Officer. Request that, as a
courtesy, the officers delay initiating their search
in order for counsel to be contacted.
Law enforcement officers presenting a valid
warrant have a legal right to search the premises
and to seize what is designated in the warrant as
evidence. Always be courteous. Do not obstruct
the search and do not volunteer information
that is not necessary. The search warrant entitles
officers to search for physical evidence, but you
are under no legal obligation to be interrogated
or interviewed. If you choose to be interviewed,
you must first contact Sutter Health legal
counsel.
Many government audits begin with a letter
or fax, rather than an in-person visit by an
auditor. If your department receives a letter
from state or federal agency requesting
information for an audit, follow these steps:
1. D
 ate stamp the letter with the date
received.
32 | Sutter Health Confidential Message Line 1-800-500-1950
2. N
 otify your supervisor and Compliance
Officer.
3. Y
 our Compliance Officer will notify
Administration if appropriate.
Posters which identify the many government
agencies are in every mailroom of every Affiliate.
These posters contain the name and phone
number of each Affiliates Compliance Officer.
In some cases, government investigators, or
persons presenting themselves as government
investigators, may contact employees outside
of the workplace, during non-work hours, or
at home. While you have the right to speak to
such a person, do not feel pressured to do so.
You may first want to contact Administration,
OGCs Legal Services, or your Compliance
Officer. Employees have the right to not talk to
the person and the right to have an attorney or
a representative of the Affiliate present if they
do choose to speak.
Sutter Health employees must never:
D
 estroy, alter or amend any Affiliate
document or record in anticipation of a
request for the document or record by a
government agency or court
L
 ie or make false or misleading statements
to any government investigator
A
 ttempt to persuade any other Affiliate
employee, or any other person, to
provide false or misleading information
to a government investigator or to fail to
cooperate with a government investigation
or audit
If a Sutter Health employee receives a subpoena
or other written request for information (such
as a Civil Investigative Demand) regarding
Sutter Health, the employee should immediately
contact an Administrator. The Administrator
will contact OGCs Legal Services and the
Compliance Officer before responding.
Q. I understand that Noridian (our Medicare
Administrative Contractor MAC) is
requesting patient records for review. If I
receive a letter/request, what should I do?
A. Noridian has been given authority by the
Centers for Medicare and Medicaid Services
(CMS) to audit Medicare patient records for
services provided, documented, and billed
to Medicare. When a request for records is
received, as a result of a Noridian review,
follow your Affiliate policy, or notify your
Affiliate Compliance Officer. These requests
are time sensitive, and documents must be
submitted to Noridian within the specified
time period.
Q. Can the government auditors look at my
computer files for information relevant to
an audit?
A. In some circumstances, government
auditors are entitled to review your hard
drive. However, before you give anyone
access to your computer, alert your Affiliate
Administration, OGCs Legal Services and
the Compliance Officer.
 Obstruction of a Federal Audit
Federal law prohibits anyone from intentionally
deceiving or defrauding the United States.
The law prohibits anyone from attempting
to influence, obstruct or impede a federal
auditor in the performance of his official duties.
Routine government audits, as well as any other
government investigation, are subject to this law.
Anyone in violation of this law is subject to
fines and imprisonment of up to five years.
Exclusion Checks
Individual Culpability
The health care industry is regulated by many
laws. It is important that we follow these
laws to protect our patients and to maintain
good business practices. Following these laws
also protects us individually. Government
enforcement agencies investigate and
prosecute companies and individuals for
legal misconduct. In 2015 the Department of
Justice emphasized its focus on investigating
individuals in corporate wrongdoing and
holding these individuals accountable for their
actions.

Federal and State Government agencies

maintain lists of individuals who are generally
ineligible to work for organizations which
receive government payments, such as Sutter
Health. If you become aware of someone at
Sutter Health who is on one of these lists,
contact your Compliance Officer immediately.
This includes employees, temporary agency
workers, travelers, independent contractors,
students, volunteers, physicians or job
candidates for any of these roles regardless of
the reason why the individual is on a list.

33 | Sutter Health Confidential Message Line 1-800-500-1950

 HEALTH, SAFETY AND
ENVIRONMENTAL CONCERNS

34 | Sutter Health Confidential Message Line 1-800-500-1950

 Health, Safety and Environmental Concerns

Sutter Health and its Affiliates require
compliance with all applicable workplace health,
safety and environmental laws, regulations and
standards. We constantly strive to find sound
and innovative methods to reduce the impact of
our activities on the environment.
Sutter Health employees are responsible
for maintaining a safe environment by
participating in training and drills, prompt
reporting of identified hazards, utilizing safe
work practices and adhering to all safety
policies and procedures. If you have a question
regarding unsafe work practices in your work
area promptly contact your supervisor, Safety
Officer or Risk Manager.
Q. I am a new employee in the Environmental
Services Department. A co-worker is
training me on how to properly clean patient
rooms and public areas. Yesterday, we found
a syringe in one of the public bathrooms. My
co-worker picked it up and threw it in the
regular garbage, saying that this happens all
the time. I think it is unsafe to be picking up
these used syringes, but I am afraid that if I
say anything about this, I will be considered
a troublemaker. What should I do?
Q. I work in the Shipping and Receiving
Department. Many of the boxes we receive
are heavy, and we are constantly moving
them. The other day, I felt a sharp pain
in my back. It went away, so I did not say
anything about it. I am now wondering if I
should have reported it.
A. Yes. Every employee has a responsibility to
report any workplace injury to his or her
supervisor. Every Sutter Health Affiliate has
a policy regarding employee work-related
injuries that explains what is required when
accidents or injuries occur. Even though an
employee may not feel pain immediately,
pain and other complications may develop
later. Reporting the incident will facilitate
prompt medical care and a review of work
practices to avoid future injuries.

A. Every employee is responsible for safety

in the workplace. If you do not feel
comfortable discussing this concern with
the employee, you should go to your
supervisor, Safety Officer, Risk Manager or
Compliance Officer. Reporting this incident
will ensure corrective action is taken.

35 | Sutter Health Confidential Message Line 1-800-500-1950

 RESEARCH AND
RESEARCH OVERSIGHT

36 | Sutter Health Confidential Message Line 1-800-500-1950 Clinical Research

 Research and Research Oversight
Research related to health care has been
performed at Sutter Health for many decades.
From prestigious National Institutes of
Health projects to data coordination of
research conducted internationally to classic
drug treatment trials and innovative clinical
care analysis, researchers and research
administrators must meet numerous federal
and state laws and regulations as well as
systemwide institutional policies. These rules
are intended to protect the rights and well
being of patients who enroll in clinical trials
as research subjects, to assure fair treatment of
government and private payers; and to uphold
the privacy and integrity of data.
Human Subjects Protection
Research involving human participants is
subject to Institutional Review Board (IRB)
regulations. The IRB acts as proxy to the Food
and Drug Administration (FDA) in matters
pertaining to drug, device, and biologics
research, but also oversees any other research
that poses more than minimal risk to its human
subjects. The Sutter Health IRB approves
new studies, reviews continuing studies,
and provides IRB exemptions as applicable.
Multiple committees whose members include
physicians, scientists, and community advocates
meet monthly to ensure that clinical trials are
ethical and that the rights and safety of study
participants are protected. The IRB office
collaborates with researchers, operational
leaders, and privacy, legal, and compliance
officers to support the research enterprise.
37 | Sutter Health Confidential Message Line 1-800-500-1950
Informed consent is the hallmark of human
subjects protection. Both a document and
a process, informed consent is intended to
assure that potential participants understand
study procedures, potential risks and benefits,
any treatments that provide an alternative to
participation, any costs or compensation of
participation, and other information crucial
to an informed determination of whether or
not to participate. Before consent is given, the
investigator or a research staff member reviews
the content of the consent form, answers
questions, and monitors the consent interview
for sufficient evidence that a potential
participant is equipped to provide informed
consent and understands that withdrawal
from participation is always an option. If the
participants native language is not English,
translation assistance is available.
A copy of the signed informed consent
document is provided to the participant and
the original is retained by the investigator for
the requisite number of years required by the
FDA or the study sponsor. If a studys design
or other regulated information changes, an
updated consent form and a new informed
consent process are required.
Privacy
The Food and Drug Administrations human
subject protection regulations, which apply
to federally funded and privately funded
research, include protections to help ensure
the privacy of subjects and the confidentiality
of information. The HIPAA privacy rule also
covers the protected health information (PHI)
of all patients who are enrolled in clinical trials.
In some situations, the IRB/Privacy Board
must approve researchers use of PHI.
Research Oversight
Sutter Health Policy requires that all
researchers who make use of Sutter Health
resources e.g. labs, images, clinics, hospitals,
providers, staff, and data must collaborate
with the designated research institute to ensure
that all rules and other requirements are met.
No research may be initiated without the
approval of the research institute; some studies
will also require the approval of the centralized
administration office. Any employee who
believes that research is being conducted or is
planning to be conducted without institutional
oversight is required by policy to inform the
researcher of the requirement and to report the
research to the designated research institute.
Research oversight is intended to facilitate
and assure the meeting of all applicable
requirements while minimizing unnecessary
delay of study initiation. It also serves to
standardize research practices and to support
researchers in satisfying their many compliance
requirements.
Examples of federal, state, or institutional rules
that govern research include:
Human subjects protection (see above)
FDA regulations and other requirements,
stipulating protocol standards and the
 reporting of findings, deviations, and
serious adverse events, and other
study details
Financial conflict of interest, limiting
actual or perceived conflicts that might
unduly influence research outcomes
Federal grants management requirements,
specifying appropriate use of funding and
reporting of that use
Research integrity and scientific
misconduct, prohibiting falsification or
fabrication of data and plagiarism
Research billing compliance, requiring
insurance coverage analysis, adherence to
Medicare rules, determination of clinical
services that must be billed to the study
sponsor, and research-related modification
of claims to federal payers
The Animal Welfare Act, protecting
animals that are involved in research
projects
Q. I am a physician who has been approached
by an academic institute to collaborate in
a research study. If I agree, I would ask my
patients certain questions and record the
answers in the electronic medical record.
Every month or so, a research staff member
would come to the clinic and would review
the data. He or she records certain data
on a spreadsheet but would not record
any information that would identify the
patients. What should I do?
38 | Sutter Health Confidential Message Line 1-800-500-1950
A. The study that you mention is subject
to federal, state, and institutional
requirements. You should call a research
institute that is assigned to your area
(Bay or Valley) and provide any materials
that the academic institute gave to you,
as required by Sutter Health policy. The
research institute will review the materials,
determine compliance requirements, and
contact the applicable officers, which would
include the Research Privacy Officer and
the Research Attorney and may include
the Research Compliance Officer and the
Institutional Review Board manager. The
patients whose PHI is being collected
are not providing consent and no waiver
of Health Information Portability and
Accountability Act authorization appears
to be involved. These privacy issues
must be addressed. In addition, written
agreements are generally required whenever
sharing Sutter Health data to an external
party to ensure that recipients of data are
accountable for proper data governance,
including but not limited to safeguarding
the information, limiting uses, and agreeing
not to attempt to re-identify the data. The
institute will also make sure that the Sutter
Health research site(s) to be involved have
provided permission for study activities to
occur at their location.
Q. I am a nurse who assists medical staff in
conducting device research. We plan to bill
all routine care related to the study to the
patients who consent to be in the study. Is
this allowed?
A. Yes, under certain circumstances, billing
research-related services to patients and
their insurers is allowed. However, extreme
caution must be used to ensure that
patients are not billed for services that are
not medically necessary, are prohibited
by Medicare, or have been promised by
the study sponsor or the consent form. To
prevent misbilling, Sutter Health policy
requires healthcare coverage analysis and
the use of special research billing functions.
In addition, studies of devices assigned an
Investigational Device Exemption by the
FDA are subject to additional requirements.
Please contact a research institute that is
assigned to your area (Bay or Valley). All
research projects must be overseen by the
centralized research administration office
and the designated research institute.
 Notes
1. A
 dditional information about the Sutter Health Ethics and
Compliance Program and Health Insurance Portability and
Accountability Act (HIPAA) Security and Privacy resources
can be found at http://mysutter/Resources/ SystemDepartments/
GeneralCounsel/EthicsCompliance/Pages/default.aspx.
2. Th
 e Compliance Program does not affect the employment at will
status of employees or replace the provisions of any collective
bargaining agreement. The Program does not create any contractual
obligation between Sutter Health or any Affiliate and any employee.
3. S utter Healths Ethics and Compliance Program does not replace
policies governing employee grievance procedures, employee
benefits or other Sutter Health or Affiliate employment and Human
Resource policies.
4. Th
 e term supervisor is used throughout the Standards to include
any person who directly supervises an employee, whether that
persons actual title is supervisor, manager, director, vice president,
senior vice president, executive vice president or other officer of
Sutter Health or Affiliates.
5. A
 ll references to Sutter Health or Sutter in the Standards for Business
Conduct refer to Sutter Health and its Affiliates.
6. W
 herever the terms Sutter Health employees, employees, we, or
us are used in the Standards, such terms refer to all members of the
workforce at Sutter Health and at each Sutter Health Affiliate.

39 | Sutter Health Confidential Message Line 1-800-500-1950

 Acknowledgement of
Standards for Business Conduct Handbook
9th Edition

My signature on this form or my acknowledgement online acknowledges NAME (PLEASE PRINT)
that I have received and agree to read the Sutter Health Standards for
Business Conduct handbook.

I agree to comply fully with the standards contained in this book. I
SIGNATURE
understand that compliance with these standards, policies and procedures
is a condition of my continued employment or association with Sutter

Health. I also understand that Sutter Health reserves the right to
DATE
occasionally amend, modify and update the Standards for Business

Conduct handbook and principles contained in the handbook.
I acknowledge that I have a duty and ethical obligation to report
any concerns about possible improper conduct to a supervisor or a DEPARTMENT
compliance officer or to the Confidential Message Line so that my
concerns can be investigated and resolved.
I also acknowledge that the handbook is only a statement of principles for
individual and business conduct and does not, in any way, constitute an
employment contract or an assurance of continued employment.

Ethics Compliance Services

2200 River Plaza Drive
Sacramento, CA 95833

40 | Sutter Health Confidential Message Line 1-800-500-1950

Ethics & Compliance Services
2200 River Plaza Drive
Sacramento, CA 95833

www.sutterhealth.org

15-SHSO-0003529