August 14, 2024
Compliance4U newsletter provides you with insight into the day-to-day functions of Health Plan’s Compliance Program.
Overview of Compliance Element #1: Written Policies and Procedures
The key to building anything that lasts is a strong foundation. The foundation of an effective compliance program is having policies and procedures that are written, shared, and updated periodically as the organization grows and the health care landscape evolves. Policies and procedures demonstrate how the Health Plan complies with applicable laws, regulations, and requirements.
The Compliance Division chairs the Policy Review Committee which meets monthly to review and periodically update policies. This committee provides consistent standards, development, review and oversight of organization-wide policies and procedures. Key participants ensure that policies approved by the committee are cascaded within their departments.
Health Plan has several mechanisms to share these policies and procedures with you:
• New hire and annual compliance training
• Company and compliance policies SAI360 (compliance360.com)
Having these policies and procedures is one of the many ways the Health Plan ensures a strong Compliance Program foundation.
Regulatory Affairs & Communication (RAC)
RAC is our Health Plan’s primary point of contact with the Department of Health Care Services (DHCS) and the Department of Managed Care’s (DMHC) Office of Plan Licensing.
RAC attends regulatory calls (DHCS Managed Care Plan Call - MCPC) and other regulatory meetings/calls where key regulatory information is shared. RAC maintains material from those weekly calls. Check it out HERE.
Do you have a question for Compliance? To submit an inquiry, on SharePoint go to TeamSites > Compliance > Requests > Submit an Inquiry or simply use this link: check it out here.
All Plan Letters (APL)
DHCS and DMHC release APLs to communicate changes in Federal or State policy or procedure and provide instruction to MCPs on implementing these changes. RAC analyzes the APLs to ensure compliance with the requirements and to meet timely filing. Draft APLs (denoted by “XXX” indicating that a policy number has not been assigned by both regulators) are issued by both DHCS and DMHC on a regular basis to solicit feedback from MCPs before they are officially published and become effective. During this period, MCPs have the opportunity to provide feedback or concerns to DHCS and DMHC on upcoming APLs. Here are the APLs that were recently released:
A. DHCS Regulatory Notices
No new APL or draft APL has been issued since the last reporting period.
B. DMHC Regulatory Notices
DMHC APL 24-016: Request for Health Plan Contact Information
Date Issued: July 25th , 2024
Summary: The Department of Managed Health Care (Department) issued this All-Plan Letter (APL) to request that all health care service plans (health plans) provide the Department with updated health plan contact information. All health plans shall provide updated information to the Department in one filing by no later than August 30, 2024.
DMHC APL 24-017: RY 2025/MY 2024 Provider Appointment Availability Survey
NPMH Provider Follow-Up Appointment Rate of Compliance
Date Issued: July 31st, 2024
Summary: Senate Bill (SB) 221 (Wiener, Chapter 724, Statutes of 2021) amended the Knox-Keene Act to include a follow-up appointment standard for non-physician mental health and substance use disorder providers
(collectively “NPMH providers”). Beginning July 1, 2022, a health plan network must have adequate capacity and availability of licensed health care providers to offer enrollees undergoing a course of treatment for an ongoing mental health or substance use disorder condition follow-up non-urgent appointments with a NPMH provider within 10 business days of the prior appointment.
Regulatory Reports
Below is a list of reports due for submission in the next few weeks. The table also includes the Director and Executive accountable for the report. Check out the list to find out which ones are in your department Click on the report title for more information.
MOT CY 2022 Risk Corridor SDR
Christopher Navarro Michelle Tetreault
Provider information Network (PIN) Ana Aranda Liz Le
Provider Incentives/VBR
Christopher Navarro Michelle Tetreault
DHCS Quarterly Financial Report Sheela Srinivasan Michelle Tetreault
Encounter Data Clarence Rao Victoria Worthy
DMHC Claims Settlement Report
DHCS Annual Forecast
Aimee Griffin Michelle Tetreault
Christopher Navarro Michelle Tetreault
NEMT/NMT Report 2024-05 Dale Standfill Liz Le
Provider Complaints
When providers exercise their right to submit complaints related to payment to the DMHC, they must submit a provider dispute resolution request to us before filing with the DMHC. Compliance coordinates a cross-functional group to review each complaint received by Health Plan. This group investigates the cases (from the original request to claims processing and dispute resolution) and prepares a comprehensive response to the DMHC about the provider’s concerns and the actions taken by Health Plan.
From January 2024 through August 2024, Health Plan received 52 requests (19 Provider Complaints and 33 additional information requests). In addition, each
complaint may contain multiple issues that require a response. These tables outline the status:
Table 1: Provider Complaints Received as of August 7th, 2024:
Table 2: Provider Complaint Closures by Decision:
Regulatory Audits and Corrective Action Plans (CAP)
We received notification from the Department of Health Care Services (DHCS) of the annual routine medical survey. The survey is a comprehensive evaluation of Health Plan’s compliance with managed care laws and regulations. The audit covers the following areas:
• Utilization Management
• Case Management and Coordination of Care
• Access and Availability
• Member Rights
• Quality Improvement
• Administrative and Organizational Capacity
• State Supported Services
The virtual onsite will be conducted 10/28/24-11/08/24. The review period for this audit will cover 08/01/23 – 07/31/24. In preparation for this audit, Compliance will conduct a series of mock audits focused on those areas of higher concern or with previous findings. In addition to mock audits, Compliance will work with key personnel to ensure validation of files prior to submission.
Let's work together to reach our goal to achieve a successful audit outcome.
Program Integrity Unit (PIU)
PIU oversees Health Plan’s Fraud Prevention Program, which includes but is not limited to investigation and reporting of privacy & security incidents and disclosures, potential fraud, waste or abuse (FWA), and Medical/Medicare exclusion monitoring. Check out what’s been happening in our program:
Privacy & Security Incidents
Privacy Tip – when sending emails, send documents containing PHI as a link, when possible, instead of attaching them. If our email system is infiltrated by unauthorized individuals, they would not have access to the link, but would have access to an attachment. Protect our members’ PHI!
Below is a summary of the types of incidents investigated. As you read these, think through what NOT to do – and when you see it, REPORT IT! We had 5 privacy/security incidents that occurred between July 22 – August 2, 2024. None of these were reportable to DHCS.
• A Health Plan staff member sent an unencrypted email to a provider. Reminder: Ensure all emails containing PHI are encrypted before sending them.
• Two incidents occurred in which a Health Plan staff member assisted a member without correctly verifying a minimum of three HIPAA validation questions to confirm their identity.
Reminder: Confirming the identity of a member is mandatory to reduce the risk of unintentional disclosure of PHI/PI to the wrong party.
• A Health Plan staff member assisted a member’s family member who was not an authorized representative for that member.
Reminder: It is important to do our due diligence to ensure an authorized representative form is on file for a member’s family member, prior to disclosing any PHI/PI to them.
• A contracted provider sent non-member PHI to the Health Plan. Reminder: Let’s remind providers of their responsibility as a Covered Entity (CE) to protect member PHI. Verifying the sender prior to sending is a little step that goes a long way.
Fraud, Waste, and Abuse (FWA)
The PIU is on constant alert, managing potential FWA incidents at every stage of investigation.
Recent Updates
In the last two weeks, one new lead was reported, but it was closed at the development stage, as the Health Plan has not had exposure to the suspect provider. Our team is actively investigating 23 ongoing cases. These include:
• Duplicate Billing: Billing for the same service twice in one claim
• Upcoding: Using a higher paying code to reflect that more costly equipment, supplies, or services were involved in a patient’s treatment or care
• Services Not Rendered: Submitting claims for services that were never performed, medical supplies and equipment that were never delivered, lab or medical tests that never occurred, or prescriptions that were never filled
• Stark Law Violation: Referrals for certain designated health services to an entity with which the doctor or a member of the doctor’s immediate family has a financial relationship, unless an exception applies
• Forgery: Forging or altering clinical documentation to misrepresent facts/information
Why It Matters
The funds we manage come from taxpayers, and it’s our duty to use them responsibly. Preventing fraud, waste, and abuse isn’t just about compliance–it’s about safeguarding resources that support our community’s health and wellbeing.
Your Role
If you observe suspicious activity or have concerns about possible FWA, don’t hesitate to report it. Together, we can ensure our resources are used efficiently and ethically. Stay vigilant. Stay committed.
Provider Exclusion Monitoring
We are obligated to verify the eligibility of our Providers for their participation in the Medi-Cal Program. In accordance with state and federal regulations, our PIU team assesses eligibility no less than monthly. This is performed with a ThirdParty vendor that checks an inventory of our providers against several sources
(e.g. List of Suspended and Ineligible Providers, U.S. Department of Health and Human Services, Office of Inspector General, System of Award Management, SSA Death Master file, and more). In addition to the monthly monitoring, exclusion checks are completed throughout the month ahead of a new Letter of Agreement1 (LOA) being established with an out of network provider. PIU received 35 requests during this reporting period. 0 restrictions were found.
Audit & Oversight (A&O)
Welcome back to the A&O series about auditing and monitoring! In this edition we’ll cover the benefits of Auditing and Monitoring in healthcare compliance.
Legal and Financial Benefits
Auditing and monitoring are critical to ensure that healthcare organizations adhere to regulatory requirements and laws. This adherence helps safeguard the organization against non-compliance issues and avoid significant fines and legal repercussions from state and federal entities.
Member Care Benefits
Auditing and monitoring are key functions in any business, but in healthcare the impact goes beyond the typical benefits and plays a crucial role in the delivery of member care. By pinpointing areas for improvement, confirming member safety, and optimizing billing practices to thwart fraud and financial irregularities, effective audit and oversight leads to overall better resource management, streamlined operations, and ultimately enhances the quality of member care.
Health Plan Reputation Benefits
Auditing and monitoring help foster a culture of compliance at Health Plan. Regular audits uncover risks and vulnerabilities, enabling a quick and proactive response. Auditing and monitoring are critical to safeguarding the integrity and confidentiality of member information which is crucial for maintaining member trust and satisfaction. By cultivating a reputation for compliance and high ethical standards, the overall credibility of Health Plan is bolstered. 1Compliance - Provider Exclusions Check - All Entries (sharepoint.com)
Curious about how auditing and monitoring synergize for an even more effective outcome? Stay tuned for our final segment of the Auditing and Monitoring series in the next newsletter to learn more!
Carelon Corrective Action Plan (CAP) Update
We are pleased to share the progress made to mitigate the outstanding CAPs issued to Carelon to enhance compliance and operational excellence.
A&O continues to host weekly meetings with Carelon to discuss remediation of outstanding CAPs. In this reporting period, Carelon closed one more CAP. As a result, since the initiation of these meetings, Carelon has now resolved fourteen (14) of the twenty-two (22) CAPs that were issued for 2023 and 2024 Audit and Monitoring Oversight Activities.
For the remaining CAPs, A&O is working closely with Carelon to obtain the required validation elements, such as evidence of reporting and implementation, to ensure complete remediation of the issues identified. We are also working closely with our internal business partners impacted by the respective CAPs to ensure we receive insight into performance data and enhanced workflows needed to remediate the CAPs.
For detailed information and to review the respective CAPs, please visit our Compliance and Regulatory CAP Tracker.
Compliance Program Projects and other Key information
Our Compliance team supports and leads various projects that impact ALL OF US!
Policies and Procedures
The Compliance Operations Team is a new department within the Compliance division. One of our key responsibilities is to help and support business areas develop and update policies and procedures (P&Ps) that comply with all applicable laws, regulations, and guidelines. As mentioned earlier in this newsletter, we also ensure these P&Ps are reviewed and approved by our Policy Review Committee (PRC), executive leadership, and regulators, if required. Lastly, our most important role is to ensure these P&Ps are disseminated to YOU so that you are familiar with the P&Ps pertinent to your role. Click HERE to access Health Plan Policies and Procedures.
Did you know?
The next Policy Review Committee (PRC) meeting will be held on Wednesday, August 21st, 2024.
Reminder! Compliance Week is November 4, 2024 - November 8, 2024.
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