August 27, 2024
Compliance4U newsletter provides you with insight into the day-to-day functions of Health Plan’s Compliance Program.
Overview of Compliance Element #2: Compliance Leadership and Oversight
An effective compliance program reduces and mitigates risk, provides safe and high-quality care to patients and saves costs. The second fundamental element of an effective compliance program is to have a board and senior leadership that understand the value of compliance and are committed to its success, including having a Compliance Officer. Health Plan is fully committed to this, and our Compliance Officer is Sunny Cooper.
As our Compliance Officer, Sunny’s responsibilities include:
• overseeing and monitoring the implementation and operation of the compliance program.
• advising the CEO, Commission, and other senior leaders on compliance risks that we may be facing and how the risks may impact our strategic and operational decisions.
• chairing our Compliance Committee
• independently investigating and acting on matters related to noncompliance matters.
• developing policies and programs that encourage ALL OF US to report suspected fraud and other improprieties without fear of retaliation.
You can report an incident or potential compliance risk by calling the Compliance Hotline at 855.400.6002 or online at Compliance - Home (sharepoint.com) where you can report a suspected Private Health information (PHI) violation incident, a Fraud Waste or Abuse (FWA) incident or any other non-compliance incident.
Email: Compliance1@hpsj.com
Phone: Compliance Hotline 855.400.6002
Online: Compliance - Home (sharepoint.com)
Regulatory Affairs & Communication (RAC)
An effective communication is critical to an effective compliance program. The RAC department is our primary point of contact with the Department of Health Care Services (DHCS) and the Department of Managed Care’s (DMHC) Office of Plan Licensing.
The RAC Team introduced a collaborative process to enhance the quality of filings. Additionally, we’ve established an escalation procedure that involves jointly reviewing regulatory notices, AIR/Comment tables, and other intricate filings. The team continues to identify opportunities for improvement of the filing and submission process to support the Corporate Goal of Operational Excellence & Growth. The following are some improvements recently implemented:
1. Templates and Forms: The team is working with our Regulators to ensure we have an updated inventory of approved templates and forms for filings and submissions. Enrollee Notices were recently updated with revised continuity of care language. Updated notices will be distributed after receiving approval.
2. Contract Amendments: The team has enhanced the process for distribution of contract amendments. All contract amendments are available on the Compliance Teams SharePoint > Regulatory Communications > DHCS Contract.
3. Regulatory Meetings: To support you in your role and ensure timely awareness of changes to regulatory and contractual requirements, 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 out the meeting held 08/14 HERE DHCS does not facilitate a MCPC on the 3rd Wednesday of the month (8/21) due to the Monthly Payment Plan Call
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 APLs or draft APLs have been issued since the last reporting period.
B. DMHC Regulatory Notices
DMHC APL 24-018: Compliance with Senate Bill 923
Date Issued: August 15th, 2024
Summary: This APL formally adopts the Transgender, Gender Diverse or Intersex (TGI) Inclusive Care Act (SB 923) Working Group’s Recommendations regarding the topics for inclusion in the training curriculum for health care service plan staff. The Health Plan is required to submit evidence of compliance (e.g. training material, policies & procedures, etc.) with all requirements by March 14th, 2025.
Regulatory Reports
Under our contract with DHCS and in compliance with our Knox Keene license (DMHC), we must routinely submit reports demonstrating compliance and performance. Below is a list of reports due for submission in the next few weeks. The table includes a hyperlink to the report and the accountable Director and Executive for the report. Check out the list to find out which ones are in your department. Click on the report title for more information.
Provider Directory File and Use 2024-09
ECM/CS JSON
CBAS Waiver 2024-08
274 File 2024-07
MCPDIP 2024-08
Ana Aranda Liz Le
Clarence Rao Victoria Worthy
Pamela Lee Tracy Hitzeman
Clarence Rao Victoria Worthy
Clarence Rao Victoria Worthy
Performance Improvement Project Reporting Catrina Rodriguez Tracy Hitzeman
Data Certification Report 2024-07
Post Payment Recovery 2024-07
SRF 2024-07
Provider Complaints
Tamara Hayes Sunny Cooper
Aimee Griffin Michelle Tetreault
Clarence Rao Victoria Worthy
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 us.
From January 2024 through August 2024, we received 55 requests (21 Provider Complaints and 34 additional information requests), disputing 49 claims. 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 21st , 2024:
Table 2: Provider Complaint Closures by Decision:
Regulatory Audits and Corrective Action Plans (CAP)
As previously reported, DHCS has notified us about our annual medical audit. As a reminder the virtual onsite will be conducted between 10/28/24 and 11/08/24. The audit review period for this audit will cover from 08/01/23 to 07/31/24 And it will cover 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
Compliance has set internal due dates to allow for Quality Assurance reviews of the universe files (files containing all data by audit topic) required for case reviews. Additionally, internal due dates were set to review program documents and reports requested on the Pre-audit information request form. Priority documents are due to Compliance by Wednesday 08/28 and the remaining documents are due Friday 08/30/24 Mock audits will start after document QA is completed and will continue through the week prior to our virtual onsite interviews.
Let's work together to reach our goal of having a successful audit outcome.
Program Integrity Unit (PIU)
The Program Integrity Unit investigates and reports all potential fraud, waste or abuse (FWA) and HIPAA violations, along with conducting exclusion monitoring for Providers. Here are some recent items we have been working on:
Privacy & Security Incidents
Privacy Tip – send emails containing PHI, by typing #PHI or #Secure in the subject or body of the email you are sending. Before sending or forwarding emails –
Pause and Ask yourself “Does this email contain PHI?”
If it does send it securely, #PHI or #Secure.
Below is a summary of the types of privacy incidents that have recently been investigated. As you look through these, think about how you can prevent these incidents from recurring, and make sure to report them when they occur We had 8 privacy/security incidents that occurred between August 5 – August 16, 2024. None of these were reportable to DHCS.
• A staff member assisted a member’s family member who had an expired authorized representative form on file.
Reminder: It is important for us to do our due diligence to ensure an active authorized representative form is on file for a member’s family member, prior to disclosing any PHI/PI to them.
• A member suspected that a delegate of ours may have disclosed her PHI without her permission.
Reminder: Our delegates are allowed to share PHI with us for the purposes of treatment, payment, and operations.
• A staff member suspected a HIPAA violation may have occurred; however, upon further investigation it was determined that a HIPAA violation didn’t occur.
Reminder: Always submit a privacy incident, if you suspect a HIPAA violation may have occurred. PIU will investigate and determine if there is a violation.
• A caller misrepresented himself/herself as the member.
Reminder: Confirming the identity of a member is mandatory to eliminate the risk of unintentional disclosure of PHI/PI to the wrong party.
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, we received one (1) new lead, which is currently pending triage. 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 notice a 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.
You can help fight FWA by identifying it in your daily work!
Things to look for; questionable billing patterns, patterns of unreasonable requests from members or providers, provider offices that seem pushy, insistent and call frequently, patterns of frequent requests for “exceptions for the rule”. Make a referral to the PIU using the SharePoint link on the Compliance home page.
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 Agreement 1 (LOA) being established with an out of network provider. PIU received 37 requests during this reporting period Zero (0) restrictions were found; however, one (1) request is pending due to incorrect information provided.
Audit & Oversight (A&O)
Integrating Auditing and Monitoring: Two Great Things that Go Great Together
Integrating auditing and monitoring is crucial for achieving comprehensive oversight and risk management. While audits provide in-depth assessments of compliance performance at specific points in time, monitoring offers continuous review, enabling us to identify and address compliance issues promptly. By combining the strengths of both approaches, we can reap the multiple benefits of both retrospective analysis and near/real-time monitoring.
Continuous Improvement through Auditing and Monitoring – The synergy between auditing and monitoring leads to ongoing, continuous improvement in practices and outcomes. On one hand, audits uncover underlying trends, patterns, and root causes of non-compliance, leading to targeted interventions and process enhancements. On the other hand, monitoring enables organizations to track the effectiveness of these interventions, measure compliance, and adjust strategies as needed. Ongoing cycles of auditing plus monitoring will allow A&O to drive sustainable improvements in complianceleading to enhanced patient care, regulatory compliance, and resilience in the face of never-ending challenges.
Thanks for joining us over these past several editions while we’ve taken a deep dive into Auditing and Monitoring – what it is and the benefits of using both approaches. In our next newsletter we’ll cover the A&O improvement plan and
outline a number of initiatives A&O is undertaking this fiscal year – from communication improvements to automation to enhancing monitoring processes. We look forward to sharing ongoing Audit and Oversight (A&O) news in future newsletters!
We are 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 following are published policies reviewed and approved by the PRC (Policy Review Committee) as of August 2024. We encourage you to read and be familiar with the policies which impact your job functions as we are all required to be in compliance with our policies and procedures. If for any reason you have questions regarding policy changes, please submit your question to the policy owner and/or submit a Compliance inquiry
Policy # and Name
QM08 Quality Improvement and Health Equity Transformation Program (QIHETP)
QM17 External Quality Review Requirements
Revision/Update
Policy updated per DHCS APL 24-004
Updated to include additional DHCS and DMHC requirements for measure reporting, measure stratification and CAHPS.
SS01 Social Services Supports New Policy
UM55 Emergency Transportation, Non-Emergency Medical Transportation and Related Expenses
UM91 Subacute Facilities
Revised to align with APL 24-002
Update to include Medi-Cal enrollment requirement of Subacute facilities per APL 23-027
Policies (except for HR policies) are published to the Compliance Management System (C360) and selected policies are made available publicly on the Health Plan website. You can access all published policies directly via the Policies link on our Intranet (see screenshot below).
San Joaquin Health Plan Team Site - Home (sharepoint.com)
New Automated Compliance Dashboard Development
As part of our commitment to operational excellence, we are excited to share that a significant upgrade is underway for our Compliance Regulatory
Dashboard. Since its launch in 2022, this dashboard has been crucial in tracking regulatory metrics and ensuring our alignment with various regulatory bodies. This initiative is a key component of our broader efforts to enhance operational efficiency, bringing us to the 21st century.
This advanced Automated Compliance Dashboard, crafted in collaboration with our dedicated Compliance and BI teams, will offer improved visibility and automation, elevating our ability to manage and monitor compliance metrics more effectively.
Stay tuned for further updates as we finalize this innovative solution. We look forward to unveiling the new dashboard and demonstrating how it will streamline our compliance processes.
Did you know?
The next Policy Review Committee (PRC) meeting will be held on Wednesday, September 18, 2024.
Reminder! Compliance Week is November 4, 2024 - November 8, 2024. The Compliance workgroup has engaged CMME to develop some material. We are also planning games to challenge your knowledge. Prizes will be offered.
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