Policy/Procedure Number: CMP-06 / Lead Department: Administration
Policy/Procedure Title: Compliance Issues and Complaints / ☒External Policy
☒Internal Policy
Original Date: 06/05/2007 / Next Review Date: 11/15/2018
Last Review Date: 11/15/2017
Applies to: / ☒ Medi-Cal / ☐ Healthy Kids / ☒ Employees
Policy/Procedure Number: CMP-06 / Lead Department: Administration
Policy/Procedure Title: Compliance Issues and Complaints / External Policy
Internal Policy
Original Date: 06/05/2007 / Next Review Date:11/15/2018
Last Review Date:11/15/2017
Applies to: / Medi-Cal / Healthy Kids / Employees
Reviewing Entities: / IQI / P & T / QUAC
OPerations / Executive / Compliance / Department
Approving Entities: / BOARD / COMPLIANCE / FINANCE / PAC
CEO / COO / Credentialing / DEPT. DIRECTOR/OFFICER
Approval Signature: Elizabeth Gibboney, CEO / Approval Date: 11/15/2017
  1. RELATED POLICIES:

CMP-09 Investigating & Reporting Fraud, Waste, and Abuse

CMP-21 Conflict of Interest Code

CMP-27 Non-Intimidation & Non-Retaliation

  1. IMPACTED DEPTS.:

All.

  1. DEFINITIONS:
  2. Abuse: describes acts inconsistent with generally accepted medical and commercial practices.
  3. Fraud: involves a knowing misrepresentation or omission of fact.
  4. Good Faith: honest and sincere intention.
  5. Non-Compliance: not acting in accordance with internally and/or externally established standards, policies, or procedures. Non-compliance can be unintentional or intentional, where individuals or other, can act with deliberate intent to violate the law or internal/external policy or, may be unaware or unclear on established standards may not be aware they are in violation.
  6. Open Door: all levels of management shall maintain an open line of communication with any employee or staff or other individual regarding discussion of potential misconduct or compliance/ethics concerns or issues.
  7. PHC4ME: intra-net SharePoint site at PHC that lists and posts department Policies & Procedures.
  8. PHC Compliance Hotline: a national toll-free telephone line accessible by all employees, physicians, vendors, and contractors twenty-four (24) hours a day, seven (7) days a week, to report problems and concerns, anonymously or otherwise.
  9. Waste: includes careless and needless expenditure of healthcare benefits and/or services of healthcare benefits and/or services.
  1. ATTACHMENTS:

N/A.

  1. PURPOSE:

All employees and healthcare providers have a duty and a responsibility to report actual or potential compliance/ethics concerns and misconduct using the designated processes and systems. This internal/external policy is to establish a process by which non-compliance issues or complaints, suspected violations, and ethics concerns are managed, expeditiously as possible while ensuring that the investigation is thorough and documented, as possible, to uphold the integrity, reputation and legal standing of Partnership HealthPlan of California (PHC).

  1. POLICY / PROCEDURE:
  2. Policy.
  3. PHC shall establish a process by which compliance inquiries, issues or complaints and reports of non-complianceviolations or ethics-related issue(s) by PHC staff or its contractors are documented, investigated and addressed.
  4. PHC shall establish and publicize mechanisms for the reporting of suspected wrongdoing, including non-compliance violation(s) and/or improper or unethical conduct.,
  5. PHC shall establish and publicize guidance regarding disciplinary actions for non-compliance violations.
  6. PHC shall establish procedures for acknowledging and conducting timely investigations, as is reasonably possible, for reported concerns of non-compliance violations, misconduct, or ethics-related issues.
  7. PHC shall require corrective action plans in all cases of detected misconduct and violations.
  8. PHC shall coordinate and cooperate with State and/or Federal agencies and law enforcement entities regarding violations of existing state and/or federal law.
  9. Procedure.
  10. Inquiries.
  11. All PHCstaff are encouraged to check with their immediate supervisor, manager, department director, or the Regulatory Affairs & Compliance unit with compliance inquiries. It is recommended that staff check with department supervisors, managers, or directors, regarding department specific policies and procedures, or visit Policies & Procedures on PHC4ME
  12. All Board Members are encouraged to check with the Compliance Officer with non-compliance or ethics concerns, or violations.
  13. All PHC contractors and providers are encouraged to check with the Provider Relations Department with compliance inquiries, concerns, or violations.
  14. Inquiries include, but are not limited to:
  15. Issues.
  16. All PHC Staff are trained to inform their immediate supervisor, manager, or department director or the Regulatory Affairs & Compliance unit, Compliance Officer (or his/her designee) about compliance issues immediately.
  17. All PHC Board Members are trained to inform the Compliance Officer about compliance issues immediately.
  18. All PHC contractors and providers are notified to report to PHC’s Provider Relations Department, use PHC’s Hotline, and contact the proper State/Federal agency through newsletters and other communications.
  19. Discipline.
  20. PHC Staff cases resulting in a recommendation of discipline are forwarded to the Human Resources Department. Contractor and provider issues resulting in a recommendation of discipline are forwarded to the Provider Relations Department.
  21. PHC Staff, Board Member, contractor and provider non-compliance may result in disciplinary action up to and including termination, depending on the circumstances of the violation.
  22. Minor infractions due to misunderstanding/miscommunication may result in corrective action plan, including but not limited to retraining and education.
  23. Minor and major infractions, including the willful withholding of information, selling of protected health information (PHI), or other actions that are otherwise unlawful or violate PHC policy and procedure, the PHC Code of Conduct, etc. may result in suspension and/or termination of employment and/or contract when behavior is serious, repeated, or when knowledge of a possible or actual violation is not reported.
  24. Investigations of non-compliance issues or concerns and complaints filed with a member of the Compliance Committee shall be documented and forwarded to the department director with expertise in the type of compliance issue under review.
  25. The department director shall coordinate their review with the Compliance Officer and Human Resources Director or Provider Relations Director, as necessary.
  26. The Compliance Committee, at the direction of the CEO, COO or CFO, shall coordinate with legal counsel, and, if required by contractual or statutory obligation, with law enforcement and/or any State/Federal regulatory agency.
  1. REFERENCES:

N/A

  1. DISTRIBUTION:
  2. SharePoint
  3. Directors
  1. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE:

N/A

  1. REVISION DATES:

Medi-Cal

12/06/2011, 12/04/2012, 03/26/2013, 09/01/2015, 12/01/2015, 12/06/2016, 08/16/2017

PREVIOUSLY APPLIED TO:

PartnershipAdvantage:

CMP-06 – 06/05/2007 to 01/01/2015

Healthy Families:

CMP-06 – 10/01/2010 to 03/01/2013

Healthy Kids

CMP-06 – 06/05/2007 to 12/01/2016

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