Dear Colleagues,

Members of the University of California community share a commitment to the highest ethical, legal, and professional standards in furtherance of our mission of patient care, teaching, research and public service. We recognize that we hold the University in trust for the people of the State of California. This Code of Business Conduct and our policies, procedures and standards provide guidance for application of the University’s Statement of Ethical Values and Standards of Ethical Conduct in our daily lives and work as members of this community.

Statement of Ethical Values

  • Integrity. We will conduct ourselves with integrity in our dealings with and on behalf of the University.
  • Excellence. We will conscientiously strive for excellence in our work.
  • Accountability. We will be accountable as individuals and as members of this community for our ethical conduct and for compliance with applicable laws and University policies and directives.
  • Respect. We will respect the rights and dignity of others.

The Code of Business Conduct (“Code”) has been adopted by the University of California and is in effect for all UC health science campuses. The Code applies to everyone who is associated with a UC Health Sciences campus — all faculty members, full- and part-time employees, students, volunteers, and vendors or independent contractors performing work on behalf of the University.

Just as we take pride in our reputation for high quality patient care, education, and research, we are equally proud of our commitment to ethical, legal and professional conduct. Please review the Code carefully and familiarize yourself with its content. It is your responsibility to uphold these ethical, legal and professional principles without exception. If you have any questions about this Code, you should contact your supervisor or the UC San Diego (UCSD) Health Science Compliance Program, 858.656.7487 and http://healthsciences.ucsd.edu/compliance.

David A. Brenner, M.D.
Vice Chancellor for Health Sciences and
Dean, School of Medicine

SECTION I. CODE OF BUSINESS CONDUCT (“CODE”)

1. Adherence to the Highest Standards.
We shall, at all times, conduct ourselves with honesty and integrity in accordance with the highest ethical, legal and professional standards.

2. Individual Responsibility & Accountability.
Each of us is expected to become familiar with the laws and regulations that apply to our positions and duties, as well as University of California Campus and Health System policies. We will comply with both their letter and spirit.

  • All questions and concerns about the legality or appropriateness of any action or failure to take action by or on behalf of the UC San Diego Health Sciences should be referred to your supervisor, the Compliance Office, Internal Audit, UC Legal Counsel or the UCSD Hot Line. (Refer to Section 2, Reporting Violations).

3. Respect for the Rights and Dignity of Others.
We treat everyone with respect and dignity.

  • We make no distinction in the availability of services; the admission, transfer or discharge of patients; or in the care we provide based on age, gender, disability, race, color, religion, or national origin.
  • The University prohibits discrimination in any work-related decision on the basis of race, color, national origin, religion, sex, physical or mental disability, medical condition (cancer-related or genetic characteristics), ancestry, marital status, age, sexual orientation, citizenship, or status as a covered veteran. The University is committed to providing equal employment opportunity and an academic and work environment where each individual is treated with fairness, dignity, and respect.
  • Personnel should be committed to the ethical and compassionate treatment of patients and compliance with established policies and statements of patient rights.
  • We act as positive role models for our trainees, staff and visitors; and show due respect to subordinates and each other.

4. Respect for Confidentiality and Privacy (Personal and Confidential Information).
Health information, including billing records, is confidential. We use confidential information only to perform our job responsibilities and do not share such information with others unless the individuals or entities have a legitimate need to know the information. We follow applicable laws and University policies regarding privacy and information security when accessing, using, disclosing, or creating, storing, receiving and transmitting confidential records. Passwords are not to be shared.

5. Strive to Attain the Highest Standards of Patient Care.
We provide quality health care in a manner that is appropriate, medically necessary, and efficient.

  • University physicians (and other health care professionals authorized by law to order items or services) shall only order or provide those services and items that are determined by the professional to be medically appropriate.
  • We place the interests of our patients above our own self-interests.

6. Medical Necessity.
The UCSD Health System shall submit claims for payment to governmental, private, or individual payers only for services or items that are medically necessary and appropriate.

  • Patients may request a service that is not a covered benefit. The service may be provided as long as the patient has been given advance notice that a service is not a covered benefit and has agreed to pay for the services.

7. Compliance with all Coding, Billing, Cost Reports and Other Contractual / Grant Terms and Conditions
Every member of the UCSD Health System who is involved, directly or indirectly, in the preparation or submission of a bill to any governmental or private payer is expected to ensure the bill reflects only those services rendered and products delivered and in the correct amount, supported by appropriate
documentation.

  • UC personnel and agents who are responsible for providing services, for documentation, coding, billing, and accounting for patient care services must comply with all applicable state, federal and payer regulations and policies, as well as UC policies and procedures.
  • Cost reports will be properly prepared, allocated to the correct cost centers, and supported by verifiable and auditable cost data according to all applicable rules and regulations.
  • Certain individuals with responsibility for preparation of financial statements and disclosures will be required to make attestations in support of Standards of Ethical Conduct.

8. Avoidance of Conflicts of Interest or Commitment
We avoid both actual conflicts of interest and commitment and the appearances of such conflicts and devote professional allegiance to patients, the University, and its mission of teaching, research, and patient care by:

  • Complying with University policy and guidelines for reporting and reviewing actual and potential conflicts of interest and conflicts of commitment.
  • Not giving or accepting gifts, gratuities, loans or other special treatment of value from third parties doing business with or wishing to do business with UC in a manner that is not in accordance with the University’s Gifts Policy and the California Political Reform Act.
  • As a general rule, UCSD personnel should avoid contracting for goods or services with family members of other UCSD personnel.
  • Do not use UCSD funds to contribute to a political party, committee, organization or candidate in connection with a federal campaign.
  • Refer to UCSD Health Science policies and guidance regarding vendor relationships with industry.

9. Ethical Conduct of Clinical Trials & Research.
We protect the rights of study participants, their well being and rights of privacy through compliance with ethical standards and all applicable UC policies and federal and state regulations.

  • Everyone involved in teaching and research activities is expected to conform to the highest standards of honesty and integrity.
  • Activities such as plagiarism, misrepresentation, and falsification of data are expressly prohibited.
  • Research must be conducted in strict conformity with the applicable UC policies, human research procedures and approvals, and the requirements of all governmental and private research sponsors.
  • Billing for research subjects shall conform with University policy and law.
  • UCSD policies provide local guidance for compliance with federal, state and UC standards, including protection of the rights and safety of research subjects, possible conflicts of interest and/or commitment, regulatory non-compliance and scientific misconduct. (http://irb.ucsd.edu)

10. Maintenance and Preservation of Accurate Records.
UCSD Health System creates and maintains patient records and documentation that conforms to all applicable legal requirements, professional standards, and UC policies.

  • University personnel will not knowingly create records that contain any false, fraudulent, fictitious, deceptive or misleading information.
  • University personnel must not delete any entry from a medical record. Medical records may be amended and material added to ensure the accuracy of a record in accordance with medical center and medical staff policies and procedures. If records are amended, personnel must indicate that the notation is an addition or correction and include the date / time it was amended.
  • University personnel must not sign someone else’s signature or initials on a record unless they have been authorized and clearly marked that they are signing on behalf of another (e.g., by initialing the signature).
  • Unless authorized by University policy, University personnel shall not destroy or remove any University records from the University’s premises.

11. Compliance with Applicable Policies, Laws & Regulations; Preventing Improper Referrals, Kickbacks, and Influences on Clinical Decisions.
All interactions with patients, payers, vendors, and community health care providers and businesses shall be conducted with honesty and integrity. This duty includes, but is not limited to:

  • Adhering to the University’s policy as defined in the Compendium of University of California Specialized Policies, Guidelines and Regulations related to Conflict of Interest, University Gift Policy and California Political Reform Act.
  • Adhering to anti-trust laws prohibiting actions such as price fixing or improper sharing of competitive information, and
  • Procurement integrity ensuring that goods and services are procured in a competitive, fair and timely manner; and
  • Not accepting or offering for individual benefit, or for the University, anything of value in exchange for referrals of business, equipment or the referral of patients.

12. Government Investigations & Government Requests for Information.
Every member of the UCSD Health System is expected to cooperate with appropriately authorized governmental investigations and audits. Personnel have the legal right to consult a supervisor, Compliance Officer, Risk Management or UC General Counsel before answering questions.

  1. University policy provides advice on the procedures to follow when representatives of the government arrive unannounced at the UCSD Health System, or the offices or homes of present or former University personnel. http://www.ucop.edu/uc-whistleblower/
  2. Guidance: You should immediately notify the appropriate Health System director or Risk Management. If the director is not immediately available, you should contact the Risk Management Department, the Compliance Office, Audit & Management Advisory Services (Internal Audit), or
    campus legal counsel.
  3. Ask to see the government representative’s identification and business card if the government representative is there in person. Otherwise ask for the person’s name and office, address and telephone number, identification number so that the UCSD representative can call the government representative’s office to confirm his or her authority.
  4. Consult with a supervisor before providing the investigator with confidential patient, personnel, student or other UCSD documents.
  5. Do not destroy documents. Do not lie or make misleading statements.
  6. Refer to Appendix A for additional guidance.

Section 2. Reporting Violations & Non-Retaliation Policy

Any suspected violations of the Code or Standards of Ethical Conduct should be reported to a direct supervisor, the Chief Compliance Officer, Risk Management, Audit & Management Advisory Services (Internal Audit), UC Legal Counsel, the Human Resources Department, the Locally Designated Official for Whistleblower Complaints, or the University of California Hotline: 1-800-403-4744 or http://www.ucop.edu/uc-whistleblower/.

How to Report: You may make a report anonymously (by phone, mail, or hotline). The University will, if requested, make every reasonable effort to keep confidential the identity of anyone reporting a suspected violation, except if doing so would effectively prevent the University from conducting a full and fair investigation of the allegations.

Non-Retaliation: University employees are prohibited from retaliating against an employee or applicant for employment who has made a good faith report or refused to obey an illegal order, even if the allegation ultimately proves to be without merit. UC will, however, pursue disciplinary action against any member who is shown to have knowingly filed a false report. UC Whistleblower Protection Policy, http://policy.ucop.edu/doc/1100563/WhistleblowerProtection

Code of Business Conduct will be Enforced: All members of the University community are expected to report all known or suspected code of conduct violations. Managers and persons in supervisory roles are required to report allegations presented to them and to report suspected violations that come to their
attention in the ordinary course of performing their supervisory duties. Reports of suspected violations will be investigated by authorized University personnel. Everyone is expected to cooperate fully with any investigation undertaken.

If it is determined that a violation has occurred, the University reserves the right to take corrective or disciplinary action against any person who was involved in the violation or who allowed it to occur or persist due to their failure to exercise reasonable diligence. The University may make an appropriate disclosure to governmental agencies, including law enforcement authorities. Disciplinary actions will be determined on a case-by-case basis and in accordance with the applicable University policies and procedures.

The University reserves the right, at any time, to amend this Code of Business Conduct.

APPENDIX – A
GUIDELINES FOR RESPONDING TO GOVERNMENT INVESTIGATIONS
Refer to UC-Campus Policies for Specific Procedures

In the unusual event of an investigation by the government, representatives of the government could arrive unannounced at a UC San Diego Health Science (UCSD) facility, including the School of Medicine, Skaggs School of Pharmacy and Pharmaceutical Sciences, Clinical Practice Organization, UC San Diego Health’s medical center(s) and clinics, or at the home of present or former personnel, staff members or contractors (collectively referred to as “personnel”). Generally, these government representatives wish to either conduct interviews or obtain certain documents. The following procedures constitute an orderly response to such government requests and enable UCSD to protect its and its patients’ interests while cooperating with the investigation.

It is the policy of UCSD to comply with all applicable health care laws and regulations and to cooperate with appropriately authorized governmental investigations and audits. Every member of UCSD Health Sciences is expected to cooperate with appropriately authorized governmental investigations and audits. Personnel have the legal right to consult a supervisor, Compliance Officer, Risk Management, Internal Audit or UC General Counsel before answering questions and have the right to refuse to answer questions. The following guidance is intended as a brief supplement to UC Campus policies.

Guidance:

  1. Your rights if you are contacted by a Government Investigator:
    a. You have the right to consult with University Counsel or the Compliance Officer.
    b. You should immediately notify the appropriate hospital director or Risk Management. If the Health System director is not immediately available, you should contact the Risk Management Department, the Compliance Office, Internal Audit, or campus legal counsel.
    c. Ask to see the government representative’s identification and business card if the government representative is there in person. Otherwise ask for the person’s name and office, address and telephone number, identification number so that UCSD can call the government representative’s office to confirm his or her authority.
  2. Refer Requests for Documents to UC Counsel for Legal Review
    a. Refer requests for documents to University general counsel for legal review and response.
    b. Consult with a supervisor before providing the investigator with confidential patient, personnel, student or other UCSD documents.
    c. You may not give or show the investigators any University documents without permission.
    d. Do not destroy or alter documents in anticipation of a government request.
  3. Be Truthful
    a. Do not lie or make misleading statements to government investigators.
    b. Refrain from speculation, hearsay, or opinion, and from decisions beyond your level of responsibility.
    c. Do not pressure or advise anyone to hide information or provide false or misleading information.
  4. If You Agree to be Interviewed
    a. You have the right to specify that the interview take place on University premises during normal business hours and that either University Counsel or your personal counsel be present.
    b. If you elect to be interviewed, you must be truthful in responding to any questions.
    c. Anything you say may be used against you by the government in a future civil or criminal proceeding.
    d. You may refuse to answer any questions asked of you and may stop the interview at any time.
    e. There is no such thing as an “off the record” conversation.

APPENDIX – B
ACKNOWLEDGMENT STATEMENT
UCSD HEALTH SCIENCES “CODE OF BUSINESS CONDUCT”

My signature on this form acknowledges that I have received and agree to read the UCSD Health Sciences “Code of Business Conduct”.

I confirm that I have not been excluded by the federal government from participation in any governmental program nor, to the best of my knowledge, have I been proposed for exclusion by any federal or state agency.

I agree to notify the Compliance Officer or the University’s Office of the General Counsel immediately upon my receiving written or verbal notification that I am proposed for exclusion from any governmental health care program.

Electronic Signature

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