CurrentprominencehealthfirstoffloridaPolicy COMP.TRAINING.003

Compliance Training and Education

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Governs Prominence HealthFirst of Florida's requirements for establishing and delivering compliance and fraud, waste, and abuse (FWA) training for employees, governing body members, agents/brokers, and first-tier/downstream/related entities.

Policy Summary

Payerprominencehealthfirstofflorida

PolicyCompliance Training and Education

Policy CodePolicy COMP.TRAINING.003

Change TypeNo material change

Effective DateJan 1, 2017

Last ReviewApr 30, 2021

Next Review DateJun 1, 2021

Key ActionAll employees, governing body members, agents/brokers, and relevant downstream entities must complete required compliance and FWA training within 90 days of hire or contracting and annually thereafter.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 daysdeadline for initial training

Annualrecurrence

10 yearsrecord retention

Allapplies to

Yesagents/brokers tested

Training Requirements and Content

Training requirements and content

Specifies who must be trained, timing, topics to be covered, recordkeeping, tracking, and consequences for non‑completion.

ALL of the following

ALL of the following
- All employees (including temporary workers) and governing body members must receive general compliance training (including the Code of Conduct).
ALL of the following
- Initial training within 90 days of hire; annual refresher training thereafter.
ALL of the following
- Description of the compliance program, review of compliance policies and procedures, Code of Conduct, and commitment to business ethics and Medicare program requirements.
- How to ask compliance questions and report suspected or detected non‑compliance; confidentiality, anonymity, and Prominence Health Plan's non‑retaliation policy.
- Requirements to report actual or suspected Medicare program non‑compliance or potential fraud, waste, and abuse, including relevant examples employees might observe.
- Disciplinary guidelines for noncompliant or fraudulent behavior.
- Conflict of interest policies and disclosure procedures.
- Privacy and security.
- Review of relevant laws and policies applicable to the Medicare program (e.g., gifts and entertainment, workplace behavior).

Who This Policy Applies To

Documentation Required

Applicability — All affiliated persons

This policy applies to all persons affiliated with Prominence Health Plan, including management, staff, contractors, and vendors.

Key Definitions

Delegated Entity

TermDelegated Entity

DefinitionAny party, including an agent or broker, that enters into an agreement with a Qualified Health Plan (QHP) issuer to provide administrative services or healthcare services to qualified individuals, qualified employers, or qualified employees and their dependents (45 C.F.R. 156.20).

ContextUsed for entities that perform services under contract with the health plan; distinct from first-tier and downstream entities by reference to agreements with QHP issuers.

Downstream Entity

TermDownstream Entity

DefinitionAny 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 a MA organization or Part D plan sponsor (or applicant) and a first-tier entity. These written arrangements continue down to the level of the ultimate provider of both health and administrative services (42 C.F.R. 422.2, 423.4).

ContextRefers to parties contracted further down the service chain beneath first-tier entities; obligations flow through written arrangements.

First-Tier Entity

TermFirst-Tier Entity

DefinitionAny 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 organization or Part D program (42 C.F.R. 422.2, 423.4).

ContextFirst-tier entities contract directly with the MA organization or Part D sponsor to deliver services; distinguishes them from downstream entities.

NBI MEDIC

TermNBI MEDIC

DefinitionNational Benefit Integrity Medicare Drug Integrity Contract intended to detect and prevent fraud, waste, and abuse in the Part C (Medicare Advantage) and Part D (Prescription Drug Coverage) programs on a national level.

ReferenceSee http://www.healthintegrity.org/contracts/nbi-medic/ for program details.

OIG

TermOIG

DefinitionOffice of Inspector General within the Department of Health & Human Services (HHS) tasked with enforcement of waste, fraud, and abuse efforts in Medicare, Medicaid and other HHS programs; authorized to exclude providers, individuals, contractors, or businesses from Federal health care programs.

AdditionalOIG exclusion reasons include convictions of program-related crimes, patient abuse, healthcare fraud, controlled substances abuse, and license revocation or suspension.

Policy Summary

Payerprominencehealthfirstofflorida

PolicyCompliance Training and Education

Policy CodePolicy COMP.TRAINING.003

Change TypeNo material change

Effective DateJan 1, 2017

Last ReviewApr 30, 2021

Next Review DateJun 1, 2021

SourceLink

On This Page

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Compliance Training and Education

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Training Requirements and Content

Training requirements and content

Specifies who must be trained, timing, topics to be covered, recordkeeping, tracking, and consequences for non‑completion.

ALL of the following

ALL of the following
- All employees (including temporary workers) and governing body members must receive general compliance training (including the Code of Conduct).
ALL of the following
- Initial training within 90 days of hire; annual refresher training thereafter.
ALL of the following
- Description of the compliance program, review of compliance policies and procedures, Code of Conduct, and commitment to business ethics and Medicare program requirements.
- How to ask compliance questions and report suspected or detected non‑compliance; confidentiality, anonymity, and Prominence Health Plan's non‑retaliation policy.
- Requirements to report actual or suspected Medicare program non‑compliance or potential fraud, waste, and abuse, including relevant examples employees might observe.
- Disciplinary guidelines for noncompliant or fraudulent behavior.
- Conflict of interest policies and disclosure procedures.
- Privacy and security.
- Review of relevant laws and policies applicable to the Medicare program (e.g., gifts and entertainment, workplace behavior).

Key Definitions

Delegated Entity

TermDelegated Entity

ContextUsed for entities that perform services under contract with the health plan; distinct from first-tier and downstream entities by reference to agreements with QHP issuers.

Downstream Entity

TermDownstream Entity

ContextRefers to parties contracted further down the service chain beneath first-tier entities; obligations flow through written arrangements.

First-Tier Entity

TermFirst-Tier Entity

ContextFirst-tier entities contract directly with the MA organization or Part D sponsor to deliver services; distinguishes them from downstream entities.

NBI MEDIC

TermNBI MEDIC

ReferenceSee http://www.healthintegrity.org/contracts/nbi-medic/ for program details.

OIG

TermOIG

AdditionalOIG exclusion reasons include convictions of program-related crimes, patient abuse, healthcare fraud, controlled substances abuse, and license revocation or suspension.