FWA
Deliberate omissions, falsification of statements, misrepresentations.
What is Fraud?
Establishes federal standards to protect health information from disclosure without patient consent.
What is HIPPA, or the Heath Insurance Portability and Accountability Act?
Health Plan's Chief Regulatory Affairs & Compliance Officer
What is Betty DeLos Reyes Clark?
Health Plan maintains __ to ensure compliance with laws, regulations, and FWA prevention. These guide Commission Members, employees, and FDRs in identifying, reporting, and resolving compliance issues.
What are Policies and Procedures?
What are dual eligibles (Medi-Medi)?
Providing more services than medically necessary.
What is Abuse?
An independent office established within various government departments to promote efficiency and prevent fraud, waste, and abuse and issues guidance on compliance programs.
What is the Office of Inspector General (OIG)?
DHCS FSR, DHCS Medical, DHCS NAV, DHCS EDV, DMHC Financial, DMHC Medical, and NCQA Survey
What are types of regulatory audits that Health Plan is subject to?
A&O conducts ___ of Health Plan's policies and operations to test and verify compliance with all applicable regulations.
What are Internal Audits?
21 or older at time of enrollment, have Medicare A&B and Full Medi-Cal benefits, and live in San Joaquin, Stanislaus, Alpine, or El Dorado County.
What are Advantage D-SNP eligibility requirements?
Generally not considered to be caused by criminally negligent actions, but rather the misuse of resources.
What is Waste?
Complete a confidential form on the Compliance SharePoint webpage or call the anonymous hotline without fear of intimidation and retaliation.
What are ways to report a compliance issue or incident?
Compliance Hotline number
What are (855) 400-6002 (English) and (800) 216-1288 (Spanish)?
Health Plan must report a breach to the California Department of Health Care Services (DHCS) within ___ of discovery.
What are 10 working days?
The type of D-SNP that Health Plan will be offering, it occurs when a state limits D-SNP enrollment to full-benefit dually eligible individuals who receive their Medi-Cal benefits from an affiliated Medi-Cal managed care plan offered by the same parent organization as the D-SNP.
What is Exclusively Aligned Enrollment (EAE)?
Also known as America's first whistleblower law, this federal law enacted in 1863 imposes liability on individuals and companies who defraud governmental programs.
What is the False Claims Act (FCA)?
These individuals can be personally liable if they breach their "duty of care" to the organization.
Who are Directors and Officers?
Departments that are part of Health Plan's Compliance Team
What are Audit and Oversight (A&O), Medi-Cal Regulatory Affairs (Medi-Cal RA), Medicare Regulatory Affairs (Medicare RA), and Program Integrity Unit (PIU)?
___ oversees activities of Health Plan; establishes policies; hires executive staff and supervises and evaluates their work; assures the fiscal integrity of the organization; appoints members to advisory committees; and responsible for assuring that the goals of the Health Authority are met.
What is the San Joaquin Health Commission?
Provides the basic framework through which the SNP will meet the needs of each of its enrollees and foundation for promoting SNP quality, care management, and care coordination processes.
This criminal law prohibits the knowingly and willfully offering, paying, soliciting, or receiving remuneration to induce referrals for items or services covered by Federal healthcare programs.
What is the Anti-Kickback Statute [42 U.S.C. ยง 1320a-7b(b)]?
Developed by the Department of Health and Human Services (HHS) Office of Inspector General (OIG) to help healthcare institutions develop a culture of compliance in the workplace and address growing healthcare fraud and abuse issues.
What are the Seven Elements of an Effective Compliance Program?
A comprehensive document that outlines an organization's policies, procedures, and processes to ensure adherence to relevant laws, regulations, and ethical standards.
What is a Compliance Program Plan?
___ are penalties and restrictions imposed for non-compliance with detailed plans to address identified compliance deficiencies.
What are Corrective Actions and Sanctions?
Used by CMS, it measures quality of care, member experience, and plan operations for Medicare Advantage and Prescription Drug Plans.
What is the Stars program?