CurrenthometownhealthprovidersPolicy HOMETOWN.HCP.004
Compliance Officer and Compliance Committees
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Defines the duties, authority, structure, and processes of Hometown Health's Compliance Manager, Compliance Committee, and related workgroups; applies to Hometown Health staff, board, first-tier/downstream/related entities, and network providers.
Policy Summary
Payerhometownhealthproviders
PolicyCompliance Officer and Compliance Committees
Policy CodePolicy HOMETOWN.HCP.004
Change TypeAdministrative revision (no material coverage changes)
Effective DateMay 1, 2018
Last ReviewApr 27, 2018
Next Review DateMay 1, 2020
Key ActionThe Compliance Manager has authority to interview staff, review contracts and submissions, seek legal advice, report to senior leadership, and conduct audits/investigations of delegated entities.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
1designated compliance officer for the health plan
1+3oversight bodies (committee + workgroups)
Quarterlymeeting frequency
HCP.007,HCP.015related internal policies referenced
Compliance Program Responsibilities
Compliance Program Criteria
Responsibilities and expectations for Hometown Health personnel, governance bodies, and delegated entities.
Applicability: Applies to all Hometown Health staff (management, staff, contractors, vendors), Board members, officers and managers, first-tier/downstream/related entities (FDRs), and network providers as set forth in Hometown Health policies and procedures.
Compliance Manager Duties: The Compliance Manager shall develop an organizational chart showing reporting relationships; interact with operational units to understand business activities; develop compliance-related policies, procedures, standard work and work aids; create a compliance work plan for auditing and monitoring Medicare and commercial operations; develop and implement educational training programs on the Program, Code of Conduct, compliance policies/procedures, and applicable law; implement programs that encourage reporting of noncompliance and potential fraud, waste and abuse (FWA) without fear of retaliation; report Program status including identification and resolution of suspected, detected or reported instances of noncompliance to the Board, CCO, CEO, and Committee; maintain compliance reporting mechanisms and coordinate with Internal Audit, the Special Investigations Unit (SIU), and delegated entities; collaborate with departments so agents/brokers, delegated entities and network providers follow Medicare and commercial requirements; and respond to reports of potential FWA and coordinate internal investigations with SIU and Internal Audit.
Compliance Manager Authority: The Compliance Manager has authority to interview or delegate the interview of staff, review contracts and submissions, seek legal counsel, report to senior leadership and the Board, report potential FWA to regulatory entities or law enforcement, and conduct audits and investigations of delegated entities.
Committee and Workgroup Structure: Hometown Health maintains one Compliance Committee and three workgroups (Fraud, Waste & Abuse Workgroup; Delegation Oversight Workgroup; Policy & Procedure Workgroup) to assist implementation of the Program. Each committee and workgroup meets quarterly, is chaired by the Compliance Manager or designee, and is composed of stakeholders from applicable departments.
Committee and Workgroup Responsibilities: Committees and workgroups shall provide active oversight and consultation to chairs; resolve interpretation/application issues; assist the Compliance Manager in duties; enforce disciplinary standards when noncompliant or unethical behavior is identified; review and approve Hometown Health policies and adopt Renown Health Network Policies as applicable; oversee compliance training for staff and Board; assist in creation and implementation of the audit and monitoring work plan; track and review compliance results and other risk areas; ensure oversight of contractual obligations of delegated entities (particularly those with direct member impact); promote effective resolution to member complaints through root cause analysis and trend reporting; and maintain reporting systems for staff, members, providers and delegated entities to report potential compliance violations.
Meetings and Reporting: Committees and workgroups should meet quarterly, maintain minutes or notes, and report to senior leadership (CEO) and the Board; quorum is the majority of members. Committees and workgroups should maintain confidentiality and privilege where applicable.
Monitoring and Notification: The Compliance Manager and oversight bodies will conduct risk analysis and ongoing monitoring/auditing of MA and PDP plan activities performed by Hometown Health and delegated entities, and provide notification to delegated contractors of changes impacting compliance (including applicable parity or benefit changes) as part of pre- and post-delegation due diligence and oversight.
Compliance Manager Authority & Actions
Documentation Required
Compliance Manager authority to investigate, review, report, and audit
The Compliance Manager is authorized to investigate compliance concerns by interviewing or delegating investigation of staff and others; review company contracts and other documents related to health plan programs; review or delegate submission of data to regulatory entities to ensure reporting compliance; independently seek legal counsel; report in person to the Chief Compliance Officer, CEO, and the Hometown Health Board; report potential fraud, waste, or abuse to regulatory entities or law enforcement; and conduct and direct audits and investigations of delegated entities and any area or function involved with Medicare and commercial plans. The Compliance Manager may also recommend policy, procedure, and process changes.
- Interview or delegate investigation of staff and others regarding compliance issues
- Review company contracts and documents pertinent to health plan programs
- Review or delegate submission of data to regulatory entities to ensure compliant reporting
- Independently seek advice from legal counsel
- Make in-person reports to the Renown Health CCO, CEO, and Hometown Health Board at sole discretion
- Report potential FWA to regulatory entities, its designee, or law enforcement
- Conduct and direct audits and investigations of delegated entities and any Medicare/commercial functions
- Recommend policy, procedure, and process changes
Definitions
Abuse — definition entry
DefinitionProvider practices inconsistent with sound fiscal, business, or medical practices that result in unnecessary cost to the Medicaid program, or reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards of health care; includes beneficiary practices causing unnecessary cost (42 C.F.R. 455.2).
Regulatory citation42 C.F.R. 455.2
Scope noteIncludes provider and beneficiary practices that lead to unnecessary expenditures or improper reimbursement under Medicaid.
Delegated Entity — definition entry
DefinitionAny party, including an agent or broker, that enters into an agreement with a Qualified Health Plan (QHP) issuer to provide administrative services or health care services to qualified individuals, qualified employers, or qualified employees and their dependents (45 C.F.R. 156.20).
Typical examplesAgents, brokers, third‑party administrators, or contracted service vendors performing administrative or health care services for a QHP issuer.
Regulatory citation45 C.F.R. 156.20
Downstream Entity — definition entry
DefinitionAny party that enters into a written arrangement, acceptable to CMS, with persons or entities involved with a Medicare Advantage (MA) organization or Part D benefit, below the level of the arrangement between an MA organization (or applicant) and a first‑tier entity; these arrangements extend down to the ultimate provider of health and administrative services (42 C.F.R. 422.2, 423.4).
RelationshipDownstream entities have written arrangements below first‑tier entities and may include subcontractors to first‑tier vendors.
Regulatory citation42 C.F.R. 422.2, 423.4
First-Tier Entity — definition entry
DefinitionAny party that enters into a written arrangement, acceptable to CMS, with an MA organization or Part D plan sponsor (or applicant) to provide administrative services or health care services to a Medicare‑eligible individual under the MA or Part D program (42 C.F.R. 422.2, 423.4).
ExamplesFirst‑tier vendors may include medical management firms, networks, or administrative service organizations contracted directly by the MA organization or Part D sponsor.
Regulatory citation42 C.F.R. 422.2, 423.4
Fraud — definition entry
DefinitionA false representation of a material fact, whether by words or conduct, by false or misleading allegations, or by concealment of that which should have been disclosed, which deceives another (paraphrasing Black's Law Dictionary).
Source noteDefinition paraphrases Black's Law Dictionary explanation of fraud.
ImplicationFraudulent acts include intentional deception or concealment that misleads others and may trigger reporting and enforcement actions.
Waste — definition entry
DefinitionOccurs when poor or inefficient practices result in unnecessary healthcare expenditures to a Government program.
Contrast with fraud/abuseWaste reflects inefficiency rather than intentional deception; it leads to unnecessary program spending.
Program impactIdentifying and correcting waste is part of broader FWA prevention efforts overseen by compliance functions.
Medicare Advantage — definition entry
DefinitionMedicare Advantage ('MA' or 'Part C'): A Medicare program that provides additional choices among health plans for individuals enrolled in Medicare Parts A and B (except generally certain ESRD beneficiaries unless exceptions apply).
Also known asMedicare + Choice Plans
Eligibility noteBeneficiaries of Medicare Parts A and B are eligible, with limited exceptions for End‑Stage Renal Disease (ESRD).
Prescription Drug Plan — definition entry
DefinitionPrescription Drug Plan ('PDP' or 'Part D'): A Medicare program to assist with the cost of prescription drugs for eligible Medicare beneficiaries; coverage may be obtained via a standalone PDP or through a Medicare Advantage plan that includes drug coverage.
Access optionsMedicare prescription drug coverage is available either through a PDP or a Medicare Advantage plan that offers drug benefits.
PurposeHelps eligible beneficiaries with prescription drug costs.
Policy Summary
Payerhometownhealthproviders
PolicyCompliance Officer and Compliance Committees
Policy CodePolicy HOMETOWN.HCP.004
Change TypeAdministrative revision (no material coverage changes)
Effective DateMay 1, 2018
Last ReviewApr 27, 2018
Next Review DateMay 1, 2020
Key ActionThe Compliance Manager has authority to interview staff, review contracts and submissions, seek legal advice, report to senior leadership, and conduct audits/investigations of delegated entities.
SourceLink
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