Compliance with Laws and Conflicts of Authority
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Defines Hometown Health's compliance program requirements and procedures, and applies to staff, board members, contractors, first-tier/downstream/related entities, and network providers associated with Hometown Health.
No material clinical or coverage changes in this revision.
Compliance Commitments and Controls
Compliance Commitments and Controls
Enumerated legal and regulatory requirements that Hometown Health commits to comply with and the internal control activities used to monitor compliance.
ALL of the following
Laws and Regulations (includes, but not limited to):
- Beneficiary Inducement Law, 42 U.S.C. §§ 1320a-7a(a)(5)
- Certifications and Program Integrity, 42 C.F.R. § 438, Subpart H; Medical Assistance Programs 42 C.F.R §456.3, 456.4 and 456.23; 42 C.F.R. §§ 1000-1008
- Civil monetary penalties of the Social Security Act, 42 U.S.C. § 1395w-27(g)
- False Claims Act, 31 U.S.C. §§ 3729-3733
- Federal Anti-Kickback Statute, 42 U.S.C. §§ 1320a-7b(b)
- Federal Criminal False Claims Statutes, 18 U.S.C. §§ 287, 1001
- Fraud and Abuse, Privacy and Security provisions of HIPAA, as modified by the HITECH Act
- Fraud Enforcement and Recovery Act of 2009
- Nevada Health Care Financing and Policy, N.R.S. §422
- HITECH Act
- Health Insurance Portability and Accountability Act (HIPAA)
- Medicare Advantage program regulations, 42 C.F.R. § 422
- Medicare Prescription Drug Benefit program regulations, 42 C.F.R. § 423
- Nevada False Claims Act, N.R.S. §§ 357.010-357.250
- OIG/CMS/HHS sub-regulatory guidance (manuals, training materials, memoranda, guides)
- Patient Protection and Affordable Care Act
- Physician Self-Referral (Stark) Law, 42 U.S.C. § 1395nn
- Prohibitions on employing/contracting with excluded persons/entities (42 U.S.C. § 1395w-27(g)(1)(G))
- Section 6032 of the Federal Deficit Reduction Act of 2005
- State Anti-Kickback Statute, N.R.S. 439B.420-.430
- The Mental Health Parity and Addiction Equity Act (MHPAEA), 45 U.S.C. §§ 146 and 147
- When a Hometown Health policy is inconsistent with applicable laws, regulations or statutes, employees must follow the applicable laws, regulations or statutes unless the Hometown Health policy imposes more stringent requirements.
- Internal controls to monitor adherence include periodic review and analysis of benefits, policies and utilization management protocols; communication with delegated contractors regarding changes impacting compliance (including parity requirements such as MHPAEA); and ongoing review of state and federal laws and regulations listed in Section I(a), with updates disseminated to employees and delegated contractors.
Conflict of Authority Rule
Conflict of Authority — Follow Law When Policies Conflict
When a Hometown Health policy conflicts with applicable law, employees must follow the law, regulation, or statute unless the Hometown Health policy imposes more stringent requirements. If you have questions or the matter is not addressed by this policy, direct inquiries to the Hometown Health Manager of Compliance. The Compliance department conducts periodic reviews, communicates changes to delegated contractors, and reviews state and federal laws and regulations to monitor adherence.
- Follow applicable laws, regulations and/or statutes when inconsistent with Hometown Health policy unless the Hometown policy is more stringent.
- Direct inquiries about conflicts or unaddressed matters to the Hometown Health Manager of Compliance.
- Be aware that Compliance performs periodic reviews, communicates changes to delegated contractors, and reviews state and federal laws and regulations to ensure ongoing compliance.
Key Definitions and Acronyms
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