CurrenthometownhealthprovidersPolicy Hometown.HCP.002
Compliance Program Scope and Objectives
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Defines the scope, objectives and required elements of Hometown Health's Compliance Program and identifies who the policy applies to, including staff, board members, first-tier/downstream/related entities, and network providers.
Policy Summary
Payerhometownhealthproviders
PolicyCompliance Program Scope and Objectives
Policy CodePolicy Hometown.HCP.002
Change TypeNo material change
Effective DateMay 1, 2019
Last ReviewApr 18, 2019
Next Review DateMay 1, 2020
Key ActionDo not make Medicare payments for services furnished or prescribed by excluded or precluded providers or entities.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
8fundamental compliance program elements listed
4 groupspopulations covered
05/01/19effective date
8+revision dates listed
2named contributors
Compliance Program Requirements
Compliance Program requirements
Program requirements and operational elements the organization must maintain:
Develop and distribute written policies, procedures and a Code of Conduct that provide guidance on reporting, investigation, resolution, and non‑retaliation.
Designate a Compliance Officer and a Compliance Committee responsible for implementing and overseeing the Program; they shall report to the Renown Chief Compliance Officer, the Hometown Health Board of Directors, and senior management as designated.
Establish, implement and provide an effective compliance education and training program to all persons upon hire and at least annually (consistent with RENOWN.CCD.015).
Maintain accessible lines of confidential and anonymous reporting for employees, managers, board members and FDRs; ensure communication between the Compliance Officer, Compliance Committee, Renown and Hometown governance (consistent with RENOWN.CCD.020 and RENOWN.CCD.065).
Develop and publicize disciplinary standards and procedures to encourage good‑faith participation in the Program and ensure consistent enforcement when non‑compliance or unethical behavior is identified (consistent with RENOWN.CCD.025).
Implement auditing and monitoring including an audit work plan, targeted audits, routine internal monitoring by business unit, periodic internal auditing, external audits of FDR entities, and participation in Renown or applicable external audits (CMS, URAC, Nevada, independent auditors).
Establish systems for prompt response through inquiries, investigations and corrective action for potential non‑compliance, illegal or unethical conduct, and fraud, waste and abuse (reporting to the Compliance Officer; consistent with RENOWN.CCD.025).
Perform comprehensive compliance risk assessments of program effectiveness and operational performance; maintain a Fraud, Waste and Abuse (FWA) program to prevent, detect and resolve FWA and recover improper payments for substantiated claims.
Screen hires, contractors and delegated entities against OIG LEIE, GSA/EPLS and SAM prior to hire/contracting and conduct monthly reviews thereafter to ensure no excluded or precluded individuals or entities are engaged (per RENOWN.CCD.035).
Maintain oversight and management of delegated entities to ensure delegated functions comply with applicable standards, regulations and Program requirements; notify delegated contractors of changes impacting compliance (e.g., MHPAEI parity) that affect benefits, policies, procedures or utilization management protocols.
Provide guidance, receive and report suspected or actual HIPAA/HITECH incidents to Renown Corporate Compliance and Privacy Officer and document/report breaches consistent with RENOWN.CCD.705‑RENOWN.CCD.790 and RENOWN.CCD.050.
Regulatory and Organizational References
Regulatory and organizational referencesmixed
| Federal Register / Vol. 64, No. 219 / Monday, November 15, 1999 / Notices | Department of Health and Human Services, Office of Inspector General, Publication of the OIG's Compliance Program Guidance for Medicare+Choice Organizations Offering Coordinated Care Plan |
| 42 C.F.R. Part 422 | Medicare Advantage Program |
| Medicare Managed Care Manual, Chapter 21 | Compliance Program Guidelines |
| Nevada Revised Statutes Title 57, Chapters 679A through 689C | Nevada statutes governing commercial insurance regulations |
| Prescription Drug Benefit Manual, Chapter 9 | Compliance Program Guidelines |
| Renown Health Compliance Program | Organizational compliance program |
| Renown Health Code of Conduct | Organizational code of conduct |
| RENOWN.CCD.010 | Auditing and Monitoring |
| RENOWN.CCD.015 | Compliance Education and Training |
| RENOWN.CCD.020 | Compliance Violation Reporting |
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Federal and statutory referencesmixed
| Federal Register / Vol. 64, No. 219 / 11/15/1999 | OIG Publication of Compliance Program Guidance for Medicare+Choice Organizations |
| 42 C.F.R. Part 422 | Medicare Advantage Program regulations |
| Medicare Managed Care Manual, Chapter 21 | Compliance Program Guidelines |
| Prescription Drug Benefit Manual, Chapter 9 | Compliance Program Guidelines |
Provider Obligations and Payment Prohibitions
Denial Risk
Do not pay excluded or precluded providers/entities
Hometown Health must not make Medicare payments for items or services furnished or prescribed by an excluded or precluded provider or entity; federal funds must not be used to pay for services, equipment, or drugs prescribed or provided by excluded individuals/entities.
- Screen hires and contractors against OIG LEIE, GSA/EPLS, and SAM at hire and monthly thereafter as part of exclusion screening obligations (see risk assessment and screening requirements).
- Ensure delegated entities are overseen so excluded providers/entities do not receive payment from Medicare or federal funds through the organization.
Documentation Required
Document screening, oversight, and FWA investigations
Maintain and provide documentation necessary to support compliance activities, exclusion screening, oversight of delegated entities, and investigations of suspected FWA; follow referenced Renown policies and regulatory guidance for records and reporting.
- Retain documentation in accordance with Renown and Hometown Health records policies referenced in the program (see RENOWN.CCD.035 and RENOWN.HIM.016735).
- Document screening results, investigations, corrective actions and any recovered improper payments to support audits and regulatory inquiries.
Terms and Definitions
Abuse — definition entry
DefinitionAbuse: Provider or beneficiary 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 fail to meet professionally recognized standards (42 C.F.R. 455.2).
Regulatory citation42 C.F.R. 455.2
Scope exampleIncludes beneficiary practices that result in unnecessary cost to the Medicaid program.
First‑Tier Entity — definition entry
DefinitionFirst‑Tier Entity: Any party that enters into a written arrangement, acceptable to CMS, with the 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).
RelationshipContracts directly with the MA organization or Part D sponsor to deliver administrative or health care services.
Regulatory citation42 C.F.R. 422.2, 423.4
Downstream Entity — definition entry
DefinitionDownstream Entity: Any party that enters into a written arrangement, acceptable to CMS, with persons or entities involved with the MA organization or Part D benefit, below the level of the arrangement between an MA organization or Part D sponsor and a first‑tier entity; these arrangements continue down to the ultimate provider of both health and administrative services (42 C.F.R. 422.2, 423.4).
RelationshipContractual arrangements below the first‑tier level, extending to ultimate providers of services.
Regulatory citation42 C.F.R. 422.2, 423.4
Fraud — definition entry
DefinitionFraud: A 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 (paraphrase from Black's Law Dictionary).
Source guidanceParaphrase from Black's Law Dictionary (thelawdictionary.org).
ImplicationFraud involves intentional deception through false statements or concealment to mislead another party.
HIPAA / HITECH — definition entry
DefinitionHIPAA / HITECH: HIPAA sets the standard for protecting sensitive patient data; HITECH provides HHS authority to promote health IT, including electronic health records and secure electronic health information exchange.
PurposeProtect sensitive patient data and promote secure electronic health information exchange.
Related authorityHITECH expands HHS authority for health IT and electronic records security.
MA / PDP — definition entry
DefinitionMA / PDP: Medicare Advantage (MA or Part C) provides Medicare beneficiaries with additional plan choices; Prescription Drug Plan (PDP or Part D) assists eligible beneficiaries with the cost of prescription drugs.
MA noteMA plans (Medicare Advantage) are available to those with Medicare Parts A and B, with limited ESRD exceptions.
PDP notePrescription Drug Plans provide drug coverage either standalone (PDP) or as part of an MA plan that includes drug coverage.
Revision/Metadata — document metadata and revision history
Policy identifier & authorshipPolicy number: Hometown.HCP.002; Author/Manager of Compliance listed in header and revision history.
Revision history & datesRevision history entries: 02/28/13, 04/17/15, 08/19/16, 04/28/17, 11/28/17, 04/27/18, 04/18/19; Current version effective date: 05/01/19; Next review date: 05/01/20.
Document categoryCategory: Compliance; Creation date: 02/26/07.
References — external and internal policies, statutes, regulations, and guidance
Key external referencesFederal Register Vol. 64, No. 219 (OIG Compliance Program Guidance for Medicare+Choice Organizations); Medicare Advantage Program, 42 C.F.R. Part 422; Medicare Managed Care Manual, Chapter 21; Prescription Drug Benefit Manual, Chapter 9.
State & regulatory referencesNevada Revised Statutes Title 57, Chapters 679A–689C.
Organizational referencesRenown Health Compliance Program and Renown Health Code of Conduct; multiple RENOWN.CCD.* policies (e.g., RENOWN.CCD.010, .015, .020, .025, .035, .065, .085) and RENOWN.HIM.* policies cited.
Policy Summary
Payerhometownhealthproviders
PolicyCompliance Program Scope and Objectives
Policy CodePolicy Hometown.HCP.002
Change TypeNo material change
Effective DateMay 1, 2019
Last ReviewApr 18, 2019
Next Review DateMay 1, 2020
Key ActionDo not make Medicare payments for services furnished or prescribed by excluded or precluded providers or entities.
SourceLink
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