Boston Medical Center

CODE OF CONDUCT

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BMC’s CORE PURPOSE, VISION AND VALUES................... 2 MAINTAINING INTEGRITY IN VENDOR RELATIONSHIPS
CARING FOR OUR PATIENTS WITH INTEGRITY Vendor Relationships................................................................. 16
Quality Care................................................................................ 3 Vendors on Campus.................................................................. 16
Patient Safety.............................................................................. 3 Relationships with Referral Sources............................................ 17
Patient Rights.............................................................................. 4 WORKING WITH INTEGRITY WITH GOVERNMENT
Non-Discrimination...................................................................... 4 Compliance with Federal and State Laws................................... 18
Advocating for our Patients and their Documentation, Coding and Billing .......................................... 18
Families and Caregivers .............................................................. 5 False Claims Acts and the Deficit Reduction Act......................... 19
Protecting Patient Privacy............................................................ 6 Cost Reports.............................................................................. 19
Financial Assistance for Patients ................................................. 7 Record Retention....................................................................... 20
EMTALA (The Emergency Medical Treatment Responding to Government Inquiries......................................... 20
and Active Labor Act)................................................................... 8
Accreditation Efforts and Surveys............................................... 20
INTEGRITY IN OUR WORKPLACE
Research................................................................................... 21
Equal Employment Opportunity for All Employees........................ 9
Protecting the Marketplace........................................................ 21
Professional Conduct................................................................... 9
THE BMC COMPLIANCE AND PRIVACY/SECURITY
Safe and Secure Workplace........................................................ 10 PROGRAMS PROMOTE INTEGRITY
BMC is a Green Workplace........................................................ 10 The BMC Compliance Program.................................................. 22
Credentialing and Licensing ...................................................... 10 The BMC Privacy and Security Programs..................................... 22
No Retaliation........................................................................... 11 Duty to Comply, Report and Cooperate...................................... 23
Conflicts of Interest................................................................... 11 The BMC Compliance Hotline.................................................... 23
Substance Abuse or Impairment at Work ................................... 12 Special Role of Managers and Supervisors................................. 23
Excluded Providers.................................................................... 12 Discipline Imposed Fairly and Firmly........................................... 24
Political Contributions and BMC’s Not-for-Profit Status.............. 12
RESOURCES..................................................................... 25
Use of BMC Assets.................................................................... 13
Confidential Business Information.............................................. 13
Cybersecurity............................................................................. 14
Intellectual Property................................................................... 14
Advertising and Marketing......................................................... 14
Media Relations and Communications....................................... 15

Si quiere leer el Código de Conducta en español, por favor vaya a la página web del Departamento de Cumplimiento bajo la pestaña “Departments”
(Departamentos) en el sitio de Intranet de BMC y haga clic en Código de Conducta, o envíe un correo electrónico a compliancehelp@bmc.org para
solicitar una copia impresa.

Si ou vle li Kòd Konduit la nan lang Kreyòl Ayisyen, tanpri ale nan paj sitwèb Depatman Konfòmite a anba onglè “Departments” sou sit Entranèt BMC
epi klike sou Kòd Konduit la oswa voye yon imèl ba compliancehelp@bmc.org pou mande yon kopi enprime.

Para ler o Código de Conduta em português, acesse a página da web do Departamento de Conformidade (Compliance Department), na guia
“Departments” (Departamentos) do site da Intranet do BMC e clique em Code of Conduct (Código de Conduta) ou envie um e-mail para
compliancehelp@bmc.org para solicitar uma cópia impressa.
 BOSTON MEDICAL CENTER CODE OF CONDUCT

Dear Colleagues,
Compliance is here – wherever and whenever you need it – to help you do the right
thing for our patients, for one another, and for BMC.
Many of you know that our Compliance and Privacy program investigates allegations
of fraud, waste, abuse, and HIPAA violations. But did you know that one of the most
important things that Compliance does is provide advice, guidance and support to help
us answer the tough questions that arise in the course of our work?
Are you wondering if you can accept a gift from a vendor? Attend a conference paid for by a
pharmaceutical company? Serve on the board of a competing health care institution? Give patient
information to a friend of the patient? Share research data with a non-BMC researcher? Bill as a teaching
physician? How you can report a concern about the misuse of BMC assets? Answer a ten minute online quiz
from a vendor and receive a gift card for it?
Our Compliance and Privacy program is here to answer these questions and others like them for you.
BMC’s newly-revised Code of Conduct centers on integrity, which is defined as the adherence to moral
and ethical principles, soundness of moral character, and honesty. Without integrity we could not provide
exceptional care without exception every day.
It is vitally important that you read and understand this Code of Conduct and complete the annual
Compliance training program. The Compliance program cannot succeed without your participation –
integrity at BMC starts with me and you.
Please remember that you can seek out advice and guidance from Compliance at any time. Thank you for
everything you do every day to provide patient care with integrity at BMC.

Kate Walsh
CEO & President
Boston Medical Center

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BOSTON MEDICAL CENTER CODE OF CONDUCT

BMC’S CORE PURPOSE, VISION AND VALUES

Our Core Purpose
Exceptional Care. Without Exception.

Our Vision 2030

Make Boston the Healthiest Urban Population in the World.

Our Three Core Values

• Above all, care.

• What matters
to you?

• Make it happen.
• We ask why.
• We ask why not.

• Inclusion always.
• Diversity is our
heart and soul.

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 BOSTON MEDICAL CENTER CODE OF CONDUCT

CARING FOR OUR PATIENTS WITH INTEGRITY

Quality Care
Caring for our patients with integrity means providing high
quality, effective, compassionate and appropriate care to
every patient. We are committed to the delivery of honest and
necessary care, regardless of the patient’s ability to pay. We
always put the patient first in everything we do.
We ensure the quality of the patient care we provide by
continuously monitoring and improving it. We meet the quality
of care standards set by The Centers for Medicare and Medicaid
Services (CMS), The Joint Commission (TJC) and other accrediting
institutions. Every BMC colleague is responsible for ensuring that
we provide high quality care to every patient.
In any circumstance where you question whether BMC is providing the highest quality care possible, you have
an obligation to raise your concern with your manager, with Quality and Patient Safety (page 31-SAFE [7233])
or Compliance and ensure that it is satisfactorily addressed and resolved.

Patient Safety
Caring for our patients with integrity also means keeping our patients safe at all time and avoiding preventable
harm. At BMC, we work to create an effective patient safety culture. A “culture of safety” is one where all employees
are always mindful of the risks inherent in our work and continuously striving to eliminate them.
We do this by:
• Asking for help or offering help in uncertain circumstances;
• Reporting adverse events, including errors, near misses and unsafe situations, by paging 31-SAFE (7233)
and filing a STARS Incident Report;
• Seeking to understand the root causes of adverse I almost gave a patient an
events; and Q incorrect dose of medication.
• Participating in problem-solving and process
improvement to prevent errors and increase patient
Do I need to report this “near miss”
safety. even though no harm occurred?
It is imperative that all BMC colleagues report any incident or Yes. Reporting this incident to
unsafe situation they see or are involved in that could or did
cause harm to patients or visitors, our colleagues or BMC.
A the STARS system allows BMC
For more information, please consult BMC policy to understand the root cause and
“STARS Incident Reporting.” make any changes in process
needed to prevent this from
happening again.

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BOSTON MEDICAL CENTER CODE OF CONDUCT

Patient Rights
Our patients have rights that are guaranteed by federal and Massachusetts laws. Patients
have a right to review and receive copies of medical records (for a nominal copying fee in
some cases), the right to privacy during medical treatment or care and the right to informed
consent. BMC ensures that the rights described in the Patients’ Bill of Rights are respected
at all times.
We also believe that all of our patients have the right to consistently excellent and
accessible health care services regardless of status or ability to pay. We serve all patients
and their families with dignity and respect. We are sensitive to the ethnic, religious,
language and cultural differences of our patients.
To protect our patients’ rights, we:
• Involve patients in all material aspects of their care, including obtaining informed
consent for treatment;
•  ommunicate effectively with patients, families and caregivers and use BMC
C
Interpreter Services as needed;
• T reat patients in a culturally-appropriate manner that preserves their
I need to obtain a copy of
Q the Patients’ Bill of Rights.
dignity, autonomy and civil rights;
• Inform each patient (or representative) of his or her rights in
Where can I find it? advance of providing or discontinuing care; and,
• Respect patients’ decisions even when we do not agree with them.
The Patients’ Bill of Rights
A can be found on BMC’s For more information, please consult BMC policies “Patient Rights
and Responsibilities,” “Patient Consent,” and “Interpreter Services
external website, www.BMC.org. Department.”

Non-Discrimination
BMC treats all patients with integrity regardless of race, color, national origin, sex, age or disability consistent with
the requirements of Section 1557 of the federal Affordable Care Act, which prohibits BMC from discriminating
against patients based on any of these factors. The law requires that women be treated equally with men in the
health care they receive and also prohibits the denial of health care or health coverage based on an individual’s
sex, including discrimination based on pregnancy, gender identity and sex stereotyping.
For individuals with disabilities, the law requires BMC to make all programs and activities provided through
electronic and information technology accessible, to ensure the physical accessibility of newly constructed or
altered facilities and to provide appropriate auxiliary aids and services for individuals with disabilities. BMC also
must take reasonable steps to provide meaningful access to each individual with limited English proficiency
eligible to be served or likely to be encountered in their health programs and activities. Patients who are denied
any of these rights can make a complaint to the Office of Civil Rights of the U.S. Department of Health and Human
Services.

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 BOSTON MEDICAL CENTER CODE OF CONDUCT

If a patient’s gender expression

In addition, BMC respects the personal dignity and rights
of each patient and is committed to providing transgender Q does not clearly indicate the
and gender non-conforming patients with professional,
considerate and respectful care. When transgender and patient’s gender identity, how should I
gender non-conforming patients present for health care
address this person?
services, they will be addressed and referenced on the
basis of their self-identified gender identity, using their You should use the patient’s
preferred pronouns and names, regardless of appearance, A name and discreetly and politely
surgical history, legal name or sex recorded at birth.
All BMC patients may use the restrooms and facilities ask what pronoun the patient uses.
that match their gender identity. BMC patients also may
request that the Health Information Management
Department change their name or gender marker in their electronic medical record.
For more information, please consult BMC Policies “Gender Identity and the Transgender/Gender Non-conforming
Patient” and “Medical Record Amendment or Correction.”

Advocating for our Patients and their Families and Caregivers

Our goal is to create a care environment in which patients and their families receive exceptional care without
exception. One way we do this is by advocating for our patients, at the bedside and in the community. Despite
our best efforts, we may not always meet our patients’ expectations. When this occurs, we want to learn from our
patients so that we can remedy their concerns.
BMC’s Patient Advocacy Program serves as the liaison between patients, families and the BMC community. The
program advocates work collaboratively with staff to address and resolve patients’ expressions of commendation
and concern. This program ensures a prompt and sensitive response to each patient.
Patient advocates assist patients and their families in the following areas: patients’ rights and responsibilities;
patients’ rights to make a complaint; the Health Care Proxy; and, problems, concerns or unmet needs of patients
and their families.
Patient advocates:
• Seek solutions to the concerns and unmet needs of our patients and their families;
• Empower patients to become active participants in their own health care;
• Educate the community about patients’ rights and responsibilities;
• Facilitate effective communication among patients, families and staff;
My patient has
Q questions about a
• E ncourage our patients and their families to share their concerns with BMC
colleagues or the BMC Patient Advocacy Program; and,

health care proxy. Who do • Provide guidance to patients regarding Advance Directives, including the
Massachusetts Health Care Proxy.
I call?
For more information, please consult BMC policy “Patient Advocacy Program.”
Call the Patient
A Advocacy Office at
617.414.4970

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BOSTON MEDICAL CENTER CODE OF CONDUCT

Protecting Patient Privacy

We maintain the privacy and security of our patients’ protected health information and other personal and
financial information at all times. The Health Insurance Portability and Accountability Act of 1996, known as HIPAA,
and other federal and state laws, prohibit the use or disclosure of patient information without patient consent
unless it is for treatment, payment or hospital operations. These rules also apply to BMC colleagues when they
receive medical care at BMC.
Accessing or sharing patient information in violation of HIPAA, other laws or BMC policy is a serious matter that
can result in significant individual criminal or civil liability, including but not limited to, fines and imprisonment.
Any BMC colleague who violates these laws may be subject to disciplinary action up to and including immediate
termination of their employment or BMC affiliation.
We protect the confidentiality and security of patient information by:
• Never disclosing a patient’s confidential information to anyone, including family and friends, except to
complete BMC work (i.e., for treatment, payment or hospital operations) or as permitted by law and BMC policy;
• Not accessing or obtaining any patient information other than that which is necessary to do our jobs;
• Using only devices that are approved for use in the BMC IT Security policies and only when they are
password protected and encrypted;
• Never discussing confidential patient information in public areas or other locations where we may be
overheard by others;
• Releasing patient information only to persons who have the patient’s written authorization or who are
authorized by law to receive it;
• Never discussing BMC patients or posting patient information or photos on social media sites, even if the
patient authorizes it;
• Remembering only the BMC Communications Department may answer health care questions asked by others
on BMC’s social media sites;
• Never creating a new BMC social media site without the express consent of the BMC Communications
Department;
• Acknowledging our obligation to protect BMC’s
How can I protect patient
confidential information, including patient and
business information;
Q privacy when I am caring for
• Contacting the BMC Privacy Officer if we have patients in shared rooms?
a question about releasing patient information
You can close the curtains
•
before we release it; and,
Reporting to your supervisor or manager or the
A around the bed, speak as quietly
BMC Privacy Officer any actual or suspected as possible to the patient and make
unauthorized use, access or disclosure of
patient information.
sure the patient is willing to discuss
treatment and care if visitors are
present.

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 BOSTON MEDICAL CENTER CODE OF CONDUCT

HIPAA also provides patients with certain rights regarding their

Q Atocolleague has been admitted
BMC and our department is
protected health information. Patients can request an amendment
or correction to the information contained in their medical records
worried about him. Can I look at his and an accounting of all disclosures of their protected health
information. Patients also can choose to opt out of the hospital
medical record to see how he is directory in order to maintain their privacy. When first registering at
doing? BMC, all patients must be given a Notice of Privacy Practices, which
informs them of these and other rights.
Absolutely not. HIPAA
A protections apply to BMC
Identity theft is a growing problem for health care providers
throughout the United States. It occurs when a patient’s personal
employees who also are patients. You and financial information is illegally obtained from a provider and
then used to open credit accounts or obtain goods and services.
can only look at the medical record if We follow the requirements of the BMC Identity Theft Prevention
your job duties and responsibilities Program and take all possible actions to prevent the improper or
illegal use of patient information.
require you to do so.
If you have any questions about the release of patient information
or identity theft, you should contact the BMC Privacy Officer at
617.414.1800. For more information, please consult BMC policies “Release of Medical Records and Protected
Information,” “Confidentiality and Use of Information,” “HIPAA Minimum Necessary Standard,” “Red Flags and
Identity Theft Prevention Program,” “Social Media,” and “Notice of Privacy Practices.”

Financial Assistance for Patients

We work with patients who are uninsured or underinsured to assist with applying for available financial assistance
programs that may cover some or all of their unpaid hospital bills. In order to help uninsured and underinsured
patients find available and appropriate financial assistance programs, BMC provides all patients with a general
notice of the availability of programs in both the bills that are sent to patients as well as in general notices that
are posted throughout BMC. The goal of these notices is to assist patients in applying to a financial assistance
program, such as MassHealth Qualified Health Plans Health Safety Net, for coverage or to assist with a Medical
Hardship application to help pay for bills already received. We provide, upon request, specific information about the
eligibility process to be a Low Income Patient under the Massachusetts Health Safety Net Program or additional
assistance for patients who are low income through BMC’s own internal financial assistance program.
For more information, please consult BMC policies “Credit and Collection Policy,” and “Self-Pay.”

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BOSTON MEDICAL CENTER CODE OF CONDUCT

EMTALA (The Emergency Medical Treatment and Active Labor Act)

The Emergency Medical Treatment and Active Labor Act, known as EMTALA, requires us to perform a medical
screening examination and stabilize every patient who arrives in our Emergency Department or elsewhere on the
BMC campus with an emergency medical condition, regardless of the patient’s ability to pay. “Emergency medical
condition” includes pregnant women who are in active labor.
Patients can be transferred to another medical facility at their request or when an authorized BMC clinician
determines that the patient’s medical needs cannot be met at BMC because we do not have the capability or
capacity to treat the patient. Patients must consent to the transfer and all other EMTALA transfer requirements
must be fulfilled.
At BMC, we carefully follow all of the requirements of EMTALA. We do not delay the medical screening examination
or stabilizing treatment in order to seek financial or insurance coverage information. We do not admit, discharge
or transfer patients with emergency medical conditions based on their ability or inability to pay or any other
discriminatory factor.
For more information, please consult BMC policy “Treatment and Transfer of Emergency Patients.”

INTEGRITY IN OUR WORKPLACE

Equal Employment Opportunity for All Employees
BMC is proud to be an integral part of the diverse community of Boston. BMC draws upon this community, which is
comprised of people from a wide variety of cultures and backgrounds, as a resource for our employees and patients.
BMC is committed to creating and sustaining a workplace where we respect and value our employees, not in spite of,
but because of the differences in their backgrounds and cultures.
We believe there is strength in diversity, not only of race, gender, age, religion and disability, but also of education,
family status, national origin, sexual orientation, gender identity and expression and all of the other factors that
make each of us individuals. Honoring the diversity of our community promotes and ensures the mutual respect,
collaboration and productivity that is necessary to provide the highest quality health care.
For more information, please consult BMC policies “Affirmative Action/EEO Statement” and “Diversity Statement.”

Professional Conduct
Everyone affiliated with BMC is expected to conduct themselves in a professional and collegial manner at all times.
BMC complies with all laws and regulations governing all aspects of employment, including hiring, promotion and
termination. We do not tolerate harassing or discriminatory conduct and we do not permit retaliation against or
intimidation of anyone who makes a good-faith complaint of discrimination, harassment or retaliation. We investigate
and take appropriate action on all reports of such actions that are made to supervisors, Human Resources at
617.638.8582 or the Compliance Hotline, 800.586.2627.
In order to provide the highest quality patient care, we must be able to collaborate, communicate and cooperate at
all times. We can achieve this only if we treat each other with respect, courtesy, dignity and understanding. For this
reason, BMC does not permit disruptive or abusive behavior by anyone in the workplace. Examples of such conduct

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 BOSTON MEDICAL CENTER CODE OF CONDUCT

include threatening or intimidating behavior or words, taunting, jeering, mocking or humiliating another person,
physical demonstrations of anger (such as throwing equipment), screaming or yelling or any other behavior that
interferes with the optimum delivery of health care services.
If you observe or have been subjected to abusive or disrespectful conduct, you should report it immediately to
your supervisor, Department Chair, the Chief Medical Officer, the Office of General Counsel, Human Resources at
617.638.8582 or the Compliance Hotline, 800.586.2627. All reports will be investigated promptly and resolved
appropriately.
For more information, please consult BMC policies “Discrimination and Harassment Policy,” “Employee Conduct”
and “Medical/Dental Staff Policy Regarding Unprofessional Relationships and Disrespectful and Abusive Conduct.”

Safe and Secure Workplace

BMC prioritizes the well-being and personal safety of its employees and anyone who does business with us. Acts
of violence and threats of violence in the workplace are prohibited. Violent acts include physical violence, stalking,
threats and similar acts. Workplace violence also includes any conduct that is offensive or intimidating enough to
make an individual reasonably fear for his/her personal safety or the safety of family, friends or property. BMC does
not permit firearms, weapons, explosive devices or other dangerous materials in our facilities.
Any BMC colleague, regardless of position, who commits or threatens to commit an act of workplace violence
will be subject to disciplinary action up to and including the termination of employment. You must immediately
report all threats of or actual violence to your supervisor or another member of management and Public Safety
at 617.414.4444. We will promptly and thoroughly investigate all reports and will not tolerate retaliation against
anyone who makes a good faith report.
For more information, please consult BMC policies “Workplace Violence” and “Employee Conduct.”

BMC is a Green Workplace

BMC is committed to being nationally recognized as one of the greenest hospitals in New England. BMC has
established a Green Advisory Committee to provide direction and information about environmentally sustainable
products and practices in order to promote the health of patients, visitors, employees, our local community and the
global community. Among the current initiatives are:
• Engaging in hospital-wide diversion efforts that have resulted in a 25% recycling rate;
• Cutting emissions by 50% and entering into a solar power purchase agreement;
• Creating a roof top farm which is providing fresh produce to our patients and employees; and,
• Diverting four tons of food waste per month to BMC’s bio-digester which keeps this waste out of landfills.
As a result of these and other efforts, Becker’s Hospital Review named BMC one of the 50 greenest hospitals in
America. Practice Greenhealth gave three awards to BMC in 2017, including the highest honor the organization
bestows on hospitals.

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BOSTON MEDICAL CENTER CODE OF CONDUCT

Credentialing and Licensing

BMC employs only those individuals who are properly licensed and credentialed for the position for which they are
hired. Proper credentialing and licensing are important ingredients of high quality patient care and are required
by federal and state laws. We conduct credentialing reviews before providers commence their work for BMC and
we re-credential them at regular intervals in accordance with regulatory requirements. We also conduct criminal
background checks on all colleagues before they are employed by or affiliated with BMC.
For more information, please consult BMC policies “Competency” and “Criminal Offender Record Information (CORI).”

No Retaliation
BMC does not permit retaliation against, or
intimidation of, any BMC colleague who makes a Q I was told by my supervisor that I am
going to be interviewed by Compliance
good-faith report of a violation of law, this Code or
BMC policies and procedures. This applies equally about a report made by one of my co-
to reports made internally and to reports made
workers. I am worried that I will be retaliated
externally to government entities. Retaliation is
prohibited by both federal and state laws and will not against if I tell the truth. What can I do?
be tolerated at BMC.
We seek to have an open and supportive A You are required to participate in the
Compliance investigations and to tell
environment where colleagues feel comfortable
raising issues and everyone works to resolve the truth, but you cannot be retaliated
them as quickly as possible. BMC colleagues are
against for doing so. If you believe you have
protected against retaliation and intimidation even
if the situation giving rise to the report is ultimately been subject to retaliation, please contact the
determined not to have a factual basis. However, Chief Compliance Officer.
false reports made for malicious reasons may subject
the reporter to discipline.
If you believe that you are being retaliated against for making a report or for participating in an investigation,
please contact the Chief Compliance Officer at 617.638.7919.
For more information, please consult BMC policy “BMC Compliance Policy Against Retaliation.”

Conflicts of Interest
BMC makes clinical and business decisions based solely on the best interests of our patients and best business
practices. Your outside financial or other person interests must not influence – or appear to influence – your
professional decision-making on behalf of BMC. You also may not personally benefit from any actions that you take
on behalf of BMC. You must put BMC’s interests ahead of your own at all times.
In order to identify and manage potential conflicts of interest, you are required to disclose any potential or actual
conflict of interest to the BMC Chief Compliance Officer at 617.638.7919. Certain BMC colleagues are required to
file annual disclosure forms that describe any potential or actual conflicts of interest the individual may have. The
Chief Compliance Officer reviews the disclosures and determines how to manage or resolve any conflicts. Most can
be resolved easily; however, in some instances you may be required to refrain from participating in certain decision-
making activities.

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 BOSTON MEDICAL CENTER CODE OF CONDUCT

If you have not been asked to file an annual

disclosure form but believe you may have a Q My wife just took a job with a
vendor who sells medical supplies
potential conflict of interest, please contact the
Chief Compliance Officer. to BMC. What should I do?
For more information, please consult BMC policy
“Conflict of Interest.” A Contact the Chief Compliance
Officer at 617.638.7919 to
Substance Abuse or Impairment at Work disclose this potential conflict. The Chief
We prohibit the use of alcohol, drugs or unsafe Compliance Officer will determine any
medications in the workplace. Abusing substances
actions that should be taken to manage
or working while impaired can lessen your ability to
perform your responsibilities and compromise the the potential conflict.
safety of our patients, colleagues and the public.
On-the-job use, possession, theft or sale of drugs or alcohol is strictly prohibited. BMC reserves the right to test an
employee for drugs or alcohol when there is a reasonable suspicion that the employee is under their influence in
the workplace.
For more information, please consult BMC policy “Drug and Alcohol Policy.”

Excluded Providers
Federal law prohibits BMC from hiring, credentialing or contracting with any “ineligible person.” An “ineligible
person” is any individual or entity that is currently excluded from participation in state and federally-funded health
care programs such as Medicare and Medicaid or that has been convicted of a criminal offense related to the
provision of health care items or services and has not yet been reinstated after a period of exclusion or ineligibility.
We routinely screen all BMC colleagues against the Excluded Provider lists published by the federal government
and the State of Massachusetts. If you are excluded from participation in the federal or state health care programs,
you must notify the Chief Compliance Officer immediately at
617.638.7919. You also must notify the Chief Compliance Officer
Q I just received notice that I have
been excluded by the Office of
if you become aware that a BMC colleague has been excluded.
For more information, please consult BMC policy “Screening for
Inspector General. What should I do? Ineligible and Excluded Persons.”

A Inform you supervisor and

immediately call the Chief
Compliance Officer at 617.638.7919.

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BOSTON MEDICAL CENTER CODE OF CONDUCT

Political Contributions and BMC’s Not-for-Profit Status

We do not use any BMC resources, including email, to engage in political activity either personally or on behalf
of BMC. BMC is a 501(c) (3) tax-exempt, not-for-profit corporation, so BMC cannot take positions on political
elections, campaigns or candidates. BMC also does not make contributions or expenditures, directly or indirectly (or
through the use of intermediaries, consultants or otherwise) on behalf of any candidate for political office, political
party or political committee. This prohibition includes monetary contributions and non-monetary contributions, such
as colleagues’ work time or BMC telephones, vehicles or premises.
BMC may, however, engage in public policy debates by making independent expenditures related to political
speech. For example, BMC may provide relevant, factual information about the impact of public policy decisions on
health care operations.
We can participate as individuals in political activities during our non-working time. However, we must be sure that
we keep our personal political activities separate from our job duties and responsibilities and we can never suggest
or imply that we are representing BMC when we participate in these activities.
For more information, please consult BMC policy “Political Contributions.”

Use of BMC Assets

We do not use BMC resources, such as materials, supplies and equipment, for personal use. Generally, you should
not conduct personal business during working hours and you should not use BMC’s assets for personal financial
gain. Occasional use of certain assets is permissible if the cost to BMC is negligible. However, you should not
expect that any such activities are private, as BMC reserves the right to monitor and review your communication
usage and content and to impose discipline when your usage violates BMC’s policies.
For more information, please consult BMC policies “Internet Access and Use” and “Email and Voicemail
Acceptable Use.”

Confidential Business Information

We expect colleagues to protect BMC’s confidential business information, such as our services in the market, key
costs, employee compensation and marketing plans. Generally, confidential information cannot be shared and can
only be used to perform our jobs. We exercise caution when we share the information with competitors and at trade
association meetings. Our competitors include other health systems and facilities in markets where we operate.
We also respect our competitors’ confidential information. We gather information about competitors ethically and
do not accept information if we suspect it was obtained inappropriately.
The following are examples of the types of information that are considered confidential:
• Information that is not publicly known; • Salary and wage information;
• Organizational strategies; • Business partnerships;
• Patient information; • Affiliations and mergers; and,
• Cost data; • Other financial data.
• Marketing plans;
For more information, please consult BMC policies “Confidentiality and Use of Information” and
“Internet Use and Access.”

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Cybersecurity
Threats to our electronic systems are increasing. BMC is doing everything possible to protect our systems against
malicious attacks. Every BMC colleague has an important role to play in this effort. We have to be careful in using
our email system so that we do not inadvertently introduce malware or other problems to it.
In order to protect our systems, all BMC colleagues should:
• Never click on an attachment or a link in an email unless you know the source
• Never provide your user name or password in response to an email request, even if the email appears to
be from BMC. BMC will never request your user name and password by email.
• Ensure that all devices used to access BMC systems are password protected and encrypted
• Report any suspicious email you receive to the BMC Service Desk at 617.414.4500
• Shut down or log off your computer when not in use
• Never share your user name or password with anyone
If you have any questions about cybersecurity, please contact the BMC Service Desk at 617.414.4500. For more
information, please consult BMC Policy “ITS Written Information Security Program (WISP).”

Intellectual Property
We comply with all applicable intellectual property laws. We respect these laws as they apply to publications,
media and other forms of expression and communication. We only use software that has been properly licensed
and we use it in conformity with the terms of the license.
BMC’s intellectual property rights are valuable business assets. Any work of authorship, invention or creation by
a BMC colleague during the scope of his or her employment is BMC property. This includes, for example, patents,
trademarks and trade secrets. We have a shared responsibility to protect BMC’s property rights during our
employment with BMC and afterwards. Please notify the Chief Compliance Officer at 617.638.7919 if you become
aware of any new work that could benefit from intellectual property protection. We also respect the intellectual
property rights of others and do not knowingly infringe on any valid third party rights.
For more information, please consult “Patent Policy and Agreement Boston University Medical Center” located at
www.internal.bmc.org, Research tab, Grants Administration Pre-Award, Internal forms.

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Advertising and Marketing

Advertising and marketing are useful ways to inform the community, educate patients and their families, and
attract clients, business partners and employees. We engage in truthful, informative and non-deceptive marketing
and advertising. All marketing activities, including the development of websites by clinics and departments, must
go through BMC’s Marketing Department.
For more information, please contact the Marketing Department at 617.638.8990 and consult BMC policy “Use of
PHI for Marketing.”

Media Relations and Communications

The BMC Office of Communications is responsible for our media and public relations and all other types of
communications within BMC and between BMC and the public. All news and other information that is released
to the media by BMC must be approved by and coordinated through the Office of Communications. If you
believe that non-public information from or about BMC has been or will be released inappropriately without
the consent of the Office of Communications, please

Q
notify your supervisor or the Office of Communications A Boston Globe reported called
immediately.
me for comment on BMC’s new
For more information, please consult BMC policy
“Media Requests for Information, Interviews and Grayken Center for Addiction Medicine.
Photographs.” Can I talk with the reporter?

A No. You need to contact the

Office of Communications first
and describe the inquiry. Communications
will decide how best to handle it.

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MAINTAINING INTEGRITY IN VENDOR RELATIONSHIPS

Vendor Relationships
BMC recognizes that relationships between providers and vendors can further a mutually beneficial exchange of
information about products or services relevant to patient care. At the same time, these relationships may create potential
conflicts of interest or opportunities for abuse or unfair advantage. For this reason, BMC has adopted a strict policy that
prohibits BMC colleagues from accepting any form of personal gift, regardless of value, from health care vendors or their
representatives. This prohibition includes food funded, directly or indirectly, by vendors and provided on the BMC campus.
This policy also sets forth the basic requirements for consulting relationships between providers and vendors,
attendance by providers and others at educational conferences and other activities sponsored by vendors, vendor
access to BMC facilities, educational grants and scholarships funded by vendors and the disclosure of provider/
vendor financial relationships.
For more information, please consult BMC policy “Policy for Interactions with Industry by BMC Clinicians and Staff.”

Vendors on Campus
The BMC policy on interactions with industry also contains requirements for vendor representatives who come on to
our campus. Under these requirements, vendor representatives:
• Cannot visit our campus without an appointment;
• Must check in at a RepTrax® kiosk before traveling around our campus;
• Generally cannot interact with trainees on campus; and,
• Are not permitted in patient care areas, except in limited circumstances.
All of the policy requirements must be followed by BMC colleagues in order to ensure the integrity and transparency
of our industry relationships and to assure our patients that we provide the best and most appropriate care for each
individual, free from the influence of industry or personal self-interest.
For more information, please consult BMC policies “Policy for Interactions with Industry by BMC Clinicians and Staff”
and “Pharmaceutical Vendor Representatives: Rules and Regulations for Conduct.”

Relationships with Referral Sources

The Federal Anti-Kickback Statute

The federal Anti-Kickback Statute and other laws prohibit the receipt of anything of value in return for making
referrals of patients who are beneficiaries of federal or state health care programs. These laws also bar the payment
or receipt of anything of value in return for directly purchasing, leasing or ordering (or for recommendations to
purchase lease or order) any goods, facilities, services or items covered reimbursable under the Medicare or Medicaid
programs. A similar law in Massachusetts applies these prohibitions to all patients, regardless of payer source.
BMC is committed to complying with these federal and state laws. All BMC colleagues are expected to be vigilant in
identifying potential violations and reporting them immediately to the Chief Compliance Officer at 617.638.7919 or
to the Compliance Hotline, 800.586.2627.
For more information, please consult BMC policy “Compliance with Anti-Kickback Laws.”

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The Federal Stark Law

The federal Stark Law generally prohibits a physician from referring a patient for certain health services to an entity
in which the physician (or his/her immediate family) has a financial interest. There are certain specific exceptions to
this rule, such as contracts for professional services and fair market value leases.
Patient referrals are important to the delivery of
appropriate health care services. It is our policy
that patients, or their legal representatives, are
Q What actions might influence referrals
and violate the Anti-Kickback Statute?
free to select their health care providers and
suppliers, subject to the requirements of their health
insurance plans. The choice of hospital, diagnostic A Three examples are: a hospital
providing discounted office space to a
facility or supplier should be made by the patient
with guidance from his/her physician as to which physician to induce the physician to make
providers are qualified and medically-appropriate. referrals; a pharmacy routinely waiving co-
For more information, please consult BMC policy payments to encourage patients to get their
“Patient Referrals: Compliance with Stark.”
prescriptions filled there; and, a gift from a
health care vendor to thank hospital staff for
or to encourage their purchases.

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 BOSTON MEDICAL CENTER CODE OF CONDUCT

WORKING WITH INTEGRITY WITH GOVERNMENT

Compliance with Federal and State Laws
At BMC, we comply with all applicable federal and state laws and regulations and professional standards
governing our operations and the delivery of health care services and products. These laws, regulations and
standards are numerous, complex and technical in nature.
BMC colleagues whose positions may affect BMC’s compliance with those laws, regulations and standards
are expected to attend educational or training programs offered by BMC for the purpose of knowing and
understanding those laws, regulations and standards and to certify their intent to comply with them.
It is important to remember that violation of any of these laws may result in personal criminal and civil sanctions
and penalties. Some laws even subject violators to imprisonment, fines of up to $100,000 per occurrence, loss of
licensure or exclusion from participation in the Medicare and Medicaid programs for a specified number of years or
permanently.
Because the penalties can be so severe, BMC cautions and advises all colleagues to always act wisely and in
strict accordance with all applicable laws, regulations and professional standards. You can contact the Compliance
Office at 617.638.7919 or by emailing compliancehelp@bmc.org to get support and guidance in complying with
the laws.

Documentation, Coding and Billing

BMC is committed to complying with all federal and state regulations governing health care documentation and
the coding and billing of claims submitted for payment. Complete and factual documentation in medical records is
essential for accurate coding and billing. Accurate records also demonstrate our credibility as a health care provider
and allow us to make the best decisions possible regarding the treatment and care of our patients.
All BMC colleagues involved in documentation, coding or billing should:
• Carefully follow departmental procedures for documenting in the medical record;
• Never alter, falsify or destroy any information in a medical record; and,
• Ensure that any contractors or agents who perform billing or coding work for BMC comply with our
policies and all applicable laws.
For more information, please consult BMC policy “Documentation Requirements for Medical Record.”

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False Claims Acts and the Deficit Reduction Act

The federal and state False Claims Acts and the federal Deficit Reduction Act protect government programs such
as Medicaid and Medicare from fraud, waste and abuse. It is a violation of the False Claims Acts to knowingly
submit, or cause another person or entity to submit, false claims for payment by the government. These Acts also
allow individuals with actual knowledge of alleged false claims to sue on behalf of the government and provide
protection against retaliation for filing a false claims action.
It is illegal to submit claims for payment to the
government that we know or should know are false.
No specific intent to defraud the government is Q What are some examples of false
claims?
required for the claim to be deemed false. The False
Claims Acts define “knowing” to include not only
actual knowledge, but also deliberate ignorance or A Examples could include billing for
services not provided; billing for a
reckless disregard of the truth or falsity of a claim.
Filing false claims may result in fines up to three higher level of service than was actually
times the amount of each false claim submitted
for payment, other penalties, imprisonment and provided; billing under one provider’s
exclusion from participation in federal and state name/NPI for a service provided by another
health care programs.
provider; and, billing for services not
Under federal law, all identified overpayments must
documented in the medical record.
be refunded to the government payer within 60
days of identification. Failure to do so can result in
fines and other penalties. Colleagues who make good-faith reports regarding potential or actual violations of the
False Claims Acts may not be subjected to retaliation or intimidation.
For more information, please consult BMC policies “Billing and Claim Submission Policy – Compliance with False
Claims Act and Whistleblower Laws” and “Reporting and Returning Overpayments to Medicaid and Medicare.”

Cost Reports
Federal and state laws require BMC to submit reports of our operating costs and statistics, known as cost reports.
These laws define what costs are allowable and describe the appropriate methodologies to claim reimbursement
for the cost of services provided to government program beneficiaries. BMC is committed to the preparation,
submission and settlement of accurate, timely and complete cost reports.

Q We found boxes of old medical

records when we cleaned out a
storage area recently. What should we do?

A Please report your discovery to the

BMC Privacy Officer at 617.638.7919.

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 BOSTON MEDICAL CENTER CODE OF CONDUCT

Record Retention
Federal and state laws require that we retain medical and other records for specified periods of time. We carefully
follow the rules for each type of record. All BMC colleagues are responsible for ensuring that our records are
accurate, up-to-date and maintained in compliance with the law and BMC policies. BMC may suffer serious
consequences up to and including sanctions, fines and loss of accreditation if we fail to comply with legal
requirements.
For more information, please consult BMC policies “Policy for Retention and Destruction of Medical Records” and
“Policy for Retention and Destructions of Documents Other than Medical Records.”

Responding to Government Inquiries

BMC fully cooperates with all appropriate government requests for information, site visits, audits and investigations.
These interactions with government authorities may have significant legal and financial impacts on BMC and you.
It is vitally important that you notify your supervisor and the BMC Chief Compliance Officer at 617.638.7919
immediately if you are contacted by a government agent for information relating to your work at BMC or if
any government agency initiates a non-routine site visit. In this situation, you should ask for the government
representative’s official identification, the reason for the visit and whether he/she has a subpoena or warrant. You
should then notify your supervisor and the Chief Compliance Officer and ask the government agent to wait while
you do so.
If you are approached by a government agent regarding your relationship with BMC, you have the right to:
• Speak with the agent;
• Schedule an interview at a time and place that is convenient for you;
• Have counsel present;
• End the discussion with the agent at any time for any reason; or,
• Decline to talk with the agent.
For more information, please consult BMC policy “Responding to Government Inquiries.”

Accreditation Efforts and Surveys

BMC holds a number of accreditations and certifications which are vitally important to our continued successful
operation. We maintain these accreditations and certifications by participating in surveys and audits. We must
always be direct, open and honest when we interact with accrediting bodies and surveyors. We cannot mislead
these agency representatives or conceal or alter any documents in preparation for or during a survey or encourage
our colleagues to do so.

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BOSTON MEDICAL CENTER CODE OF CONDUCT

Research
BMC conducts research that will lead to improvements in health care and health status for all people and further
scientific advances in medicine. All research must be conducted according to the highest ethical standards and
in compliance with all applicable policies, federal and state laws and regulations. We protect the rights and well-
being of our patients who choose to participate in research studies. Refusal of a patient to participate in research
will not compromise their access to our services or the care they receive at BMC.
We require our Institutional Review Board (IRB) to review and approve all research that involves human subjects.
We engage human research participants in a meaningful informed consent process. We also maintain an
environment that fosters privacy and security.
BMC will not tolerate acts of plagiarism, falsification or fabrication of data, or other research misconduct. We are
committed to full compliance with our policy for responding to allegations of research misconduct. Our research
investigators are expected to be accountable for the funds received from sponsors of research and to comply with
the terms and conditions of research grants and contracts.
If you have any questions or concerns about research, please contact the Research Compliance Officer at
617.638.7919 and consult BMC policy “Research and Scholarship Misconduct.”

Protecting the Marketplace

BMC strives to win business by providing high quality and cost effective services. We comply with antitrust laws,
which prohibit agreements between competitors that undermine the principles of fair competition. We do not
tolerate behavior that fixes prices, divides markets, manipulates competitive bidding processes, causes boycotts of
competitors or places unreasonable restraints on competition.
For more information, please consult BMC policy “Compliance with Antitrust Laws.”

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 BOSTON MEDICAL CENTER CODE OF CONDUCT

THE BMC COMPLIANCE AND PRIVACY/ SECURITY

PROGRAMS PROMOTE INTEGRITY
The BMC Compliance Program
The mission of the BMC Compliance Program is to protect public confidence in BMC’s clinical and business
practices through:
• Education;
• Establishment and enforcement of standards that comply with applicable laws and regulations; and,
• Identification and prompt resolution of instances of non-compliance.
The Program partners with BMC leadership and operational departments to promote an ethical workplace through
adherence to this Code of Conduct and BMC’s policies and procedures. The Program is designed to detect and
prevent fraud, waste and abuse and to ensure our adherence to the many laws and regulations that govern
the provision of health care. It also is a vehicle for preventing violations of law and enabling BMC to rectify any
situation before it becomes a problem or a legal violation.
BMC expects good-faith cooperation from all colleagues to make the program effective. Compliance is everyone’s
responsibility.
The Program also promotes ethical decision-making. When you are confronted with a difficult decision at BMC, ask
yourself:
• Is it legal?
• Does it comply with our Code of Conduct and policies?
• Is it the fair and honest thing to do?
• Is it in the best interests of our patients and BMC?
• Would I be comfortable if my decision were published on the front page of a newspaper or a website?
If you answer to all of the above questions is “yes,” you are making the right decision.

The BMC Privacy and Security Programs

The BMC Privacy and Security Programs are designed to implement the requirements of HIPAA and other
federal and state laws that govern the use and disclosure of patient medical, financial and personal information.
The Security Program, which is led by our IT Department, ensures the security of our electronic systems,
communications and confidential patient information. The Privacy Program provides education and training on
patient privacy issues and conducts regular audits of BMC patients’ medical records to ensure that records have
been accessed only as needed to perform job duties and responsibilities. It also receives reports of potential and
actual privacy violations and investigates and resolves them appropriately. Finally, the Program can give you
guidance regarding the release of patient and other confidential information.
For more information, please contact the Security Program at 800.586.2627 and the Privacy Officer at
617.414.1800.

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BOSTON MEDICAL CENTER CODE OF CONDUCT

Duty to Comply, Report and Cooperate

Everyone at BMC has a duty to comply with this Code of Conduct, BMC policies and procedures and all applicable
federal and state laws. If you become aware of any actual or potential violation of these requirements, you must
report the situation to the Chief Compliance Officer at 617.638.7919 or to the Compliance Hotline, 800.586.2627,
immediately.
BMC will not take any action against any BMC colleague who reports, in good faith, any violation, actual or
threatened, regardless of whether the situation giving rise to the violation is ultimately determined to not have a
factual basis. If you fail to report a violation, you may be subject to disciplinary action.

The BMC Compliance Hotline

BMC has a Compliance Hotline to encourage all BMC colleagues to ask questions, seek support and report
concerns. The Hotline, 800.586.2627, is operated by an outside vendor and is available seven days a week,
24 hours a day. You can make a report using your name or
anonymously if it is more comfortable for you. The Hotline
provides interpreter services for individuals with limited English Q I want to report a problem but
I’m afraid my supervisor will
proficiency.
You are encouraged to report any concerns to your supervisor or find out I made the report. What can
to the Compliance Department at 617.638.7919 directly. You do I do?
not have to report the matter to your supervisor before calling
You can call the Compliance
Compliance or making a report on the Compliance Hotline.
You also can send an email to the Compliance Department at A Hotline 800.586.2627 at any
compliancehelp@bmc.org.
time to make an anonymous report.
As stated earlier, BMC will not retaliate against anyone who
brings a compliance matter to the attention of our organization.
All reports will be investigated, generally within 30 days of receipt, and appropriately resolved under the direction
of the Chief Compliance Officer.
For more information, please consult BMC policy “Compliance – Availability and Use of Compliance Hotline.”

Special Role of Managers and Supervisors

BMC managers and supervisors have special responsibilities to educate their team members about Compliance,
Privacy and Security. Managerial staff members also serve as role models for their colleagues and BMC expects
them to treat everyone with respect and to act with compassion, honesty and integrity at all times.
It is the duty of BMC managers and supervisors to create an environment where BMC colleagues feel comfortable
expressing concerns or raising issues without fear of reprisal. For this reason, managers and supervisors are
required to know and understand this Code of Conduct and the Compliance, Privacy and Security policies and
procedures and to act to support the programs at every opportunity.
Managers and supervisors requiring additional information or training about Compliance, Privacy and Security
should contact the Compliance Department at 617.638.7919.

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 BOSTON MEDICAL CENTER CODE OF CONDUCT

Discipline Imposed Fairly and Firmly

BMC enforces its standards of conduct through appropriate disciplinary action taken on a fair, equitable and
consistent basis for every employee, regardless of position. Any BMC colleague who violates the provisions of this
Code of Conduct or BMC policies and procedures will be subject to disciplinary action. The appropriate action will
be determined on a case-by-case basis. BMC policy provides for a range of possible disciplinary actions, from a
verbal warning to discharge from BMC employment or termination of affiliation with BMC.
Regardless of the violation, BMC reserves the right to impose any level of discipline, including immediate discharge
from BMC employment, based on our assessment of all of the circumstances of the violation, including, but not
limited to, the seriousness of the violation, the frequency of the violation, the actual or potential consequences of it
and the employee’s prior disciplinary and performance record.
For more information, please consult BMC policy “Employee Conduct.”

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BOSTON MEDICAL CENTER CODE OF CONDUCT

BMC Compliance Office BMC Interpreter Services Department

720 Harrison Avenue, Suite 650 Phone: 617.414.5549
Boston, MA 02118 Fax: 617.414.5017
Phone: 617.638.7919 Office Hours: 8:30 am – 5:00 pm, Monday-Friday
The office hours are 8:00 am – 5:00 pm. Walk-ins are welcome or you Off-hours beeper number: 6042
can call the Compliance Office to make an appointment.
Intranet website: www.internal.bmc.org/interpret
Compliance email: compliancehelp@bmc.org
BMC Office of General Counsel
Compliance Hotline: 800.586.2627
720 Harrison Street, 6th Floor
Intranet website: www.internal.bmc.org/compliance Boston, MA 02118
Phone:617.638.7901 (regular business hours)
BMC Privacy Officer
617.638.7243 (on call attorney – after hours)
Phone: 617.414.1800
Email: Privacyofficer@bmc.org BMC Office of Patient Advocacy
Intranet website: www.internal.bmc.org/compliance Phone: 617.414.4970
To reach a Patient Advocate, please call the number above. A Patient
BMC Director, Pharmacy Compliance
Advocate is available on-site from 8:00 am – 4:30 pm, Monday
Phone: 617.638.5843
through Friday. After hours and on weekends, a Patient Advocate is
available by page through the phone number above.
Other Boston Medical Center Resources BMC Office of Public Safety
85 East Concord Street, 4th Floor
BMC Office of Communications
Boston, MA 02118
85 E. Newton Street, 4th Floor
Phone: 617.414.4444
Boston, MA 02118
Email: communications@bmc.org Website: www.bumc.bu.edu/publicsafety

The Communications Office is available 24 hours a day, 7 days a BMC Patient Safety
week to assist you. For staffing information and phone numbers, Pager number for serious incidents with clear harm:
please visit: 31-SAFE (31-7233)
www.bmc.org/about/news/communications.htm
After hours, call 617.638.8405 and ask to be connected to the Federal Government Resources
on-call staff person
Centers for Medicare and Medicaid Services
BMC Human Resources Division
www.cms.hhs.gov
85 E. Concord Street, 1st Floor
Boston, MA 02118 US Department of Health and Human Services,
Phone: 617.638.8582 Office of Inspector General (OIG)
Intranet website: www.internal.bmc.org/hr/humanresources.htm www.oig.hhs.gov

BU/BMC Institutional Review Board (IRB) US Department of Health and Human Services,
560 Harrison Avenue, 3rd Floor Office of Civil Rights (HIPAA)
Boston, MA 02118 www.hhs.gov/ocr/privacy
Phone: 617.638.7207
Fax: 617.638.7234 Massachusetts Resources
Email: medirb@bu.edu Massachusetts Department of Public Health
Office hours: 8:00 am – 4:30 pm www.mass.gov/eohhs/gov/departments/dph
Board of Registration in Medicine (BORIM)
www.mass.gov/eohhs/gov/departments/borim

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 Compliance Department
Boston Medical Center
720 Harrison Avenue, 6th Floor, Boston, MA 02118