Scope
This Code of Business Conduct and Standards of Conduct applies to all Affected Individuals, as defined in the Ackerman Institute for the Family Compliance Program Policy and Procedures.
Affected Individuals are required to comply with this Code of Business Conduct and Standards of Conduct, the Compliance Program Policy and Procedures, applicable compliance policies and procedures, training requirements, reporting obligations, disciplinary standards, exclusion screening requirements, and any corrective actions applicable to their role or relationship with the Institute.
Purpose
The purpose of this Code of Business Conduct and Standards of Conduct is to establish the ethical, legal, and compliance expectations that apply to all Affected Individuals. This policy supports the Ackerman Institute for the Family’s Compliance Program by providing standards for lawful conduct, ethical decision-making, fraud, waste, and abuse prevention, accurate documentation and billing, reporting compliance concerns, non-retaliation, conflicts of interest, confidentiality, and compliance with applicable federal and New York State requirements.
Policy/Procedure
Commitment to Integrity, Compliance, and Reporting
The Ackerman Institute for the Family prides itself on adhering to the highest standards of ethical, legal, and honest practices. All individuals representing the Ackerman Institute for the Family must uphold values of truthfulness, precision, fairness, and mutual respect.
Any suspected or known policy breach, misconduct, fraud, waste, abuse, billing concern, documentation concern, privacy/security concern, conflict of interest, exclusion concern, retaliation concern, or other compliance-related issue must be reported promptly in accordance with the Institute’s Reporting Compliance Related Concerns Policy. Reports may be made to the Compliance Officer, through leadership or supervisory channels, or through the Institute’s confidential or anonymous reporting options.
The Ackerman Institute for the Family prohibits retaliation, intimidation, harassment, discrimination, or adverse action against any individual who reports a compliance concern in good faith, asks compliance-related questions, refuses to participate in unlawful or unethical conduct, or participates in a compliance investigation, audit, monitoring activity, corrective action, or other Compliance Program activity.
Affected Individuals who violate this policy, fail to report known or suspected compliance concerns, participate in non-compliant conduct, obstruct an investigation, knowingly make a false report, or retaliate against another person may be subject to corrective or disciplinary action, up to and including termination of employment, termination of contract or affiliation, removal from duties, loss of system access, or other action appropriate to their role and relationship with the Institute.
Questions regarding compliance may be directed to the Compliance Officer at compliance@ackerman.org. Reports may also be submitted through the Institute’s confidential or anonymous reporting options as described in the Reporting Compliance Related Concerns Policy.
Compliance with Laws, Regulations, and Program Requirements
The Ackerman Institute for the Family is committed to complying with all applicable federal, state, and local laws, regulations, payer requirements, and program standards, including requirements related to Medicaid, Medicare, OMH Article 31 programs, HIPAA/HITECH, documentation, billing, supervision, client confidentiality, and professional ethics. Affected Individuals are expected to understand and comply with the laws, regulations, policies, procedures, and standards that apply to their role and responsibilities. Questions about applicable requirements should be directed to a supervisor, leadership, or the Compliance Officer.
Fraud, Waste, and Abuse Prevention
The Ackerman Institute for the Family prohibits fraud, waste, and abuse in connection with any healthcare program, including Medicaid, Medicare, and other government or private payer programs. Fraud, waste, and abuse may include, but are not limited to, billing for services not rendered, billing for services that are not medically necessary, misrepresenting services provided, submitting claims that are not supported by documentation, duplicate billing, falsifying or altering records, knowingly retaining overpayments, or engaging in any practice intended to improperly obtain payment.
All Affected Individuals are expected to support accurate documentation, truthful billing, appropriate use of Institute resources, and compliance with applicable payer and regulatory requirements. Suspected or known fraud, waste, abuse, false claims, overpayments, or improper billing practices must be reported promptly in accordance with the Institute’s Reporting Compliance Related Concerns Policy.
Excluded Individuals
The Ackerman Institute for the Family prohibits the employment, contracting, engagement, or use of any individual or entity that is excluded, suspended, debarred, or otherwise ineligible to participate in federal or state healthcare programs, including Medicaid and Medicare. This includes individuals or entities listed on the U.S. Department of Health and Human Services Office of Inspector General List of Excluded Individuals and Entities, the New York State Office of the Medicaid Inspector General exclusion list, or any other applicable exclusion, debarment, or sanction list required by law, regulation, payer requirement, or Institute policy.
Affected Individuals are required to notify the Compliance Officer immediately if they become excluded, suspended, debarred, sanctioned, or aware of any exclusion-related concern involving themselves or another individual or entity connected to the Institute. Compliance with the Institute’s Exclusions Program Policy and Procedure is a condition of employment, contract, affiliation, placement, service, or participation with the Institute.
Maintaining Ethical Standards in Professional Practice
Affected Individuals are expected to maintain ethical, professional, and compliant practices in all services, documentation, billing, administrative activities, supervision, training, and client interactions. Clinical and non-clinical activities must be performed truthfully, accurately, and within the scope of the individual’s role, licensure, training, authorization, and relationship with the Institute.
Affected Individuals involved in clinical care, documentation, supervision, intake, billing, data collection, or claims-related processes are responsible for ensuring that services are accurately represented, appropriately documented, and compliant with applicable Medicaid, Medicare, OMH, payer, professional, ethical, privacy, and confidentiality requirements. Any concern regarding documentation integrity, clinical quality, billing accuracy, professional conduct, or ethical compliance must be reported in accordance with the Institute’s Reporting Compliance Related Concerns Policy.
Conflicts of Interest
Affected Individuals are expected to conduct Institute business and professional activities in a manner that avoids actual, potential, or perceived conflicts of interest. A conflict of interest may arise when an individual’s personal, financial, professional, academic, supervisory, clinical, or other interests interfere, or appear to interfere, with their responsibilities to the Institute, clients, payers, regulatory bodies, or the Compliance Program.
Affected Individuals must disclose actual, potential, or perceived conflicts of interest promptly and must cooperate with any review, management plan, restriction, recusal, or other action determined necessary by the Institute. Undisclosed conflicts of interest or failure to comply with a conflict management plan may result in corrective or disciplinary action in accordance with applicable Institute policies.
Commitment to Ethical Patient Care and Service Quality
The Ackerman Institute for the Family is committed to providing clinically appropriate, ethical, respectful, culturally responsive, and legally compliant services. Clients are treated with dignity and without discrimination based on race, color, religion, national origin, age, disability, sex, sexual orientation, gender identity or expression, marital status, source of payment, or any other status protected by applicable law.
Affected Individuals are expected to support quality care by practicing within their authorized role and scope, maintaining appropriate professional boundaries, protecting client rights and confidentiality, documenting services accurately, escalating clinical or safety concerns, and complying with applicable OMH, Medicaid, Medicare, HIPAA/HITECH, payer, professional, ethical, and Institute requirements.
Concerns related to client care, service quality, documentation, confidentiality, discrimination, access, safety, professional conduct, or compliance with client rights must be reported promptly through appropriate supervisory, clinical, administrative, or compliance reporting channels.
Recordkeeping and Document Management
Affected Individuals are expected to create, maintain, protect, and retain accurate, complete, timely, and truthful records related to Institute operations, clinical services, supervision, training, billing, compliance, privacy, security, and administrative activities. Records must accurately reflect the services provided, actions taken, decisions made, and information known at the time the record is created.
Affected Individuals may not falsify, backdate, alter, destroy, omit, or improperly modify any record, document, clinical note, billing record, supervision record, training record, compliance record, or other Institute record. Any correction or amendment to a record must be made in accordance with applicable Institute policy, system functionality, legal requirements, and documentation standards.
Institute records must be maintained in approved systems and retained in accordance with applicable federal and New York State requirements, payer requirements, HIPAA/HITECH, OMH requirements, Medicaid and Medicare requirements, and Institute record retention policies. Records must be made available for authorized audit, monitoring, compliance review, investigation, and regulatory purposes as required.
Concerns regarding inaccurate documentation, missing records, improper record alteration, unauthorized access, inappropriate disclosure, record retention issues, or destruction of records must be reported promptly in accordance with the Institute’s Reporting Compliance Related Concerns Policy.
Confidentiality
The Ackerman Institute for the Family is committed to protecting confidential, proprietary, financial, operational, personnel, client, and protected health information. Affected Individuals must maintain the confidentiality of all information entrusted to them through their role or relationship with the Institute, including client records, clinical information, billing information, personnel information, financial information, compliance records, and organizational information.
Affected Individuals may access, use, disclose, or share confidential information only as authorized and only as necessary to perform their assigned role or responsibilities. Confidential information may not be discussed, accessed, downloaded, stored, transmitted, or disclosed through unauthorized systems, personal accounts, personal devices, or other non-approved methods. Any suspected or known unauthorized access, use, disclosure, loss, or breach of confidential information must be reported promptly in accordance with Institute policy.
Policy Violation Prevention and Identification
The Ackerman Institute for the Family maintains a Compliance Program designed to prevent, detect, correct, and respond to compliance risks, including fraud, waste, abuse, billing errors, documentation deficiencies, privacy/security concerns, conflicts of interest, exclusion concerns, and other violations of law, regulation, payer requirements, or Institute policy.
Leadership, management, supervisors, and the Compliance Officer are responsible for supporting appropriate internal controls, monitoring activities, training, communication, and corrective actions. All Affected Individuals are expected to participate in the Compliance Program by following applicable policies, completing required training, asking questions, reporting concerns, cooperating with audits and reviews, and supporting corrective actions when required.
Affected Individuals must cooperate fully and truthfully with internal audits, compliance reviews, investigations, monitoring activities, and external regulatory or payer reviews. Failure to cooperate, obstruction of an investigation, falsification of information, or retaliation against another individual may result in corrective or disciplinary action.
Adherence to HIPAA
The Ackerman Institute for the Family complies with the Health Insurance Portability and Accountability Act of 1996, the Health Information Technology for Economic and Clinical Health Act, applicable New York State confidentiality requirements, and related privacy and security policies. Affected Individuals are required to safeguard protected health information and other confidential client information in accordance with Institute policies and applicable law.
Affected Individuals must use only Institute-approved systems, communication methods, storage locations, and devices when accessing, documenting, transmitting, or storing protected health information. Protected health information may not be accessed, used, or disclosed unless authorized and necessary for the individual’s assigned role.
HIPAA privacy and security training is provided upon hire or engagement and periodically thereafter, as required by Institute policy. Any suspected or known privacy, security, or confidentiality concern must be reported promptly in accordance with Institute reporting procedures.
Training and Acknowledgment
All Affected Individuals are required to receive training on this Code of Business Conduct and Standards of Conduct, the Compliance Program, and applicable compliance policies upon hire or engagement and periodically thereafter, in accordance with Institute policy. Training may include general compliance, fraud, waste, and abuse prevention, reporting obligations, non-retaliation protections, privacy/security, documentation and billing expectations, exclusion screening obligations, and role-specific compliance risks.
Affected Individuals must acknowledge their receipt, understanding, and commitment to comply with this Code as a condition of employment, contract, affiliation, placement, service, or continued association with the Institute. Training completion and acknowledgments are documented and retained in accordance with Institute policy.
Respect for Intellectual Property Rights
Affected Individuals are expected to respect intellectual property rights, copyright laws, licensing restrictions, and Institute ownership of materials. Books, journals, articles, training materials, software, images, videos, templates, clinical materials, and other copyrighted or proprietary resources may be used, copied, shared, distributed, or modified only as authorized by law, license, contract, or Institute policy.
Institute-created materials, templates, training resources, policies, procedures, and other work products may not be used for unauthorized personal, commercial, or external purposes without appropriate approval.
Audit and Review Protocols
The Ackerman Institute for the Family conducts auditing, monitoring, and review activities to assess compliance with applicable laws, regulations, payer requirements, documentation standards, billing requirements, privacy/security obligations, and Institute policies. These activities may include internal audits, record reviews, billing reviews, exclusion screening reviews, training compliance reviews, policy implementation reviews, and other monitoring activities based on identified compliance risks.
Audit and monitoring results may be used to identify trends, provide education, strengthen internal controls, update policies, improve documentation or billing practices, and implement corrective action plans. All Affected Individuals are expected to cooperate fully and truthfully with audit, monitoring, review, and remediation activities.
If an audit, review, investigation, or other internal or external assessment identifies an overpayment, billing error, documentation concern, privacy/security issue, or other compliance concern, the Institute will take appropriate corrective action. Corrective action may include education, policy revision, claim correction, repayment, self-disclosure when required, disciplinary action, monitoring, or other remediation appropriate to the issue identified.
Applicable Federal and State Laws and Whistleblower Protections
In accordance with applicable federal and New York State requirements, including 18 NYCRR SubPart 521-1 and 42 U.S.C. § 1396a(a)(68), the Ackerman Institute for the Family provides Affected Individuals with information regarding federal and state laws that prohibit fraud, waste, abuse, false claims, and improper billing, and that protect individuals who report concerns in good faith.
Federal False Claims Act — 31 U.S.C. §§ 3729–3733
The Federal False Claims Act prohibits any person or entity from knowingly submitting, causing the submission of, or conspiring to submit false or fraudulent claims for payment to the federal government, including claims involving Medicaid and Medicare funds. Examples may include billing for services not rendered, billing for services not medically necessary, misrepresenting services provided, falsifying documentation, or knowingly retaining overpayments. Violations may result in civil penalties, as adjusted for inflation, plus three times the amount of damages sustained by the government. The law also permits private individuals, known as relators, to file actions on behalf of the government and potentially share in any recovery.
Federal Administrative Remedies for False Claims and Statements — 31 U.S.C. §§ 3801–3812
Federal law authorizes federal agencies to impose administrative remedies, including civil monetary penalties and assessments, against individuals or entities that submit false claims or false statements to the federal government.
New York State False Claims Act — State Finance Law §§ 187–194
The New York State False Claims Act prohibits knowingly submitting, causing the submission of, or conspiring to submit false or fraudulent claims to New York State or local governments, including claims involving Medicaid funds. Violations may result in civil penalties, damages, and other remedies. The law also permits private individuals to bring actions on behalf of the State under certain circumstances.
New York Social Services Law § 145 — Penalties
New York Social Services Law § 145 authorizes penalties for certain violations related to public assistance and medical assistance programs, including Medicaid.
New York Social Services Law § 145-b — False Statements
New York Social Services Law § 145-b prohibits knowingly making or causing to be made a false statement or representation, or deliberately concealing material information, in order to obtain Medicaid payment or other benefits. Violations may result in monetary penalties, repayment obligations, and other sanctions.
New York Social Services Law § 145-c — Sanctions
New York Social Services Law § 145-c authorizes sanctions against individuals or entities that engage in improper practices related to Medicaid or other medical assistance programs, including exclusion or other program participation restrictions where applicable.
New York Social Services Law § 366-b — Fraudulent Practices
New York Social Services Law § 366-b establishes criminal penalties for certain fraudulent practices involving Medicaid, including knowingly obtaining or attempting to obtain medical assistance benefits or payments by false statement, concealment, impersonation, or other fraudulent means.
New York Penal Law Article 155 — Larceny
Theft of property, including theft of Medicaid or government healthcare program funds through fraudulent billing or misrepresentation, may constitute larceny under New York law.
New York Penal Law Article 175 — False Written Statements and Falsifying Business Records
New York Penal Law Article 175 includes offenses related to false written statements and falsifying business records. This may include creating, altering, or using false documentation or records in connection with healthcare services or claims.
New York Penal Law Article 176 — Insurance Fraud
New York Penal Law Article 176 prohibits knowingly committing fraudulent acts involving insurance claims. This may include improper claims submitted to insurers or managed care organizations.
New York Penal Law Article 177 — Health Care Fraud
New York Penal Law Article 177 prohibits knowingly and willfully providing false information, or omitting material information, for the purpose of obtaining payment from a public or private health plan. Penalties vary based on the amount involved and may include misdemeanor or felony charges.
Whistleblower and Anti-Retaliation Protections
The Ackerman Institute for the Family prohibits retaliation, intimidation, harassment, discrimination, or adverse action against any Affected Individual who reports a compliance concern in good faith, participates in an investigation, assists with an audit or review, refuses to participate in unlawful conduct, or otherwise participates in the Compliance Program.
Whistleblower protections may include, but are not limited to:
- Federal False Claims Act Anti-Retaliation Protections — 31 U.S.C. § 3730(h): protects employees, contractors, and agents from retaliation for lawful acts taken in furtherance of a False Claims Act action or efforts to stop violations of the False Claims Act.
- New York State False Claims Act Anti-Retaliation Protections — State Finance Law § 191: protects individuals from retaliation for lawful acts related to reporting or pursuing false claims concerns involving New York State or local government funds.
- New York Labor Law § 740: prohibits retaliation against employees who disclose, threaten to disclose, object to, or refuse to participate in certain activities, policies, or practices that they reasonably believe violate law, rule, or regulation or pose a substantial and specific danger to public health or safety.
- New York Labor Law § 741: provides protections for healthcare workers who disclose or object to practices they reasonably believe constitute improper quality of patient care.
Any Affected Individual who believes they have experienced retaliation or intimidation for raising a compliance concern, participating in an investigation, or engaging in other protected activity should report the concern immediately to the Compliance Officer at compliance@ackerman.org or through the confidential hotline at 1-855-662-7233.
Review and Revision
This Code of Business Conduct and Standards of Conduct is reviewed at least annually by the Compliance Officer, Compliance Committee, and executive leadership. The review evaluates whether the Code has been implemented, whether Affected Individuals are following the Code in practice, whether the Code remains effective in supporting lawful and ethical conduct, and whether updates are needed based on regulatory changes, audit findings, corrective actions, organizational changes, or operational experience. Results of the annual review, including any identified updates, gaps, trends, or corrective actions, are reported to the Compliance Committee and the governing body or Board of Directors, as appropriate.
Material revisions are documented in the Document Revision Tracking table. Updated versions are distributed to applicable Affected Individuals, and acknowledgments are collected and retained in accordance with Institute policy.
Document Revision Tracking: Eff 8/1/23; Rev. 12/30/24, 12/30/25, 6/19/26
6/19/26: Revised to align with the Compliance Program Policy and Procedures; renamed policy to Code of Business Conduct and Standards of Conduct; standardized scope language for Affected Individuals; strengthened expectations related to reporting, non-retaliation, non-intimidation, disciplinary consequences, fraud/waste/abuse prevention, excluded individuals, ethical practice, conflicts of interest, client care, recordkeeping, confidentiality, HIPAA, training acknowledgment, intellectual property, and audit/review protocols; added applicable federal and state false claims laws and whistleblower protection information; and strengthened the Review and Revision section to include reporting of annual review results, identified gaps, trends, updates, and corrective actions to the Compliance Committee and governing body or Board of Directors, as appropriate.