July 2, 2024
Compliance Division is re-organizing to better serve your and organization’s needs. This change is, in part, our effort to prepare for the Medicare D-SNP Line of Business (LOB).
As we prepare to implement Medicare D-SNP, we will need to fulfill our compliance responsibilities at both the state and federal levels Each Department highlighted in blue blow will be shared services between Medi-Cal and Medicare programs while Medi-Cal Regulatory Affairs & Communication (RAC) and Medicare RAC will fulfill LOBspecific requirements.
In preparation for this change, effective July 1, 2024, Compliance also standardized our job titles across the board to create clarity of our job functions Listed below are our new job titles by Department.
Department
Compliance Job Titles Effective July 1, 2024
Audit & Oversight Director, Compliance (Audit & Oversight)
Audit & Oversight Manager, Compliance (Non-Clinical Audit & Oversight)
Audit & Oversight Manager, Compliance (Clinical Audit & Oversight)
Audit & Oversight Compliance Program Manager (Audit & Oversight)
Audit & Oversight Compliance Program Manager (Clinical Audit & Oversight)
Audit & Oversight Compliance Analyst (Audit & Oversight)
Compliance Operations Director, Compliance (Operations)
Compliance Operations Compliance Systems Analyst
Compliance Operations Compliance Program Manager (Policy)
Medicare Program Director, Compliance (Medicare)
Medicare Program Compliance Program Manager (Medicare)
Program Integrity Unit Manager, Compliance (Program Integrity)
Program Integrity Unit Compliance Analyst (Program Integrity)
Program Integrity Unit Compliance Analyst, Senior (Program Integrity)
Medi-Cal Program Director, Compliance (Medi-Cal)
Medi-Cal Program Manager, Compliance (Medi-Cal)
Medi-Cal Program Compliance Analyst (Medi-Cal)
Medi-Cal Program Compliance Specialist (Medi-Cal)
Reminder! Compliance Week is November 3, 2024 - November 9, 2024. The Compliance team will “hide” information in the newsletter for employees to learn more about the
Seven Elements of Compliance. Make sure you read the Newsletters as the hidden information will be one of the ways to win prizes Now let’s check out what’s been happening in Compliance.
Regulatory Affairs & Communication (RAC)
In compliance with policies, the Regulatory Affairs & Communications (RAC) Department 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.
As our Point of Contact (POC), RAC attends calls held by our regulators including the DHCS Managed Care Plan Call and other regulatory meetings/calls. During the weekly Managed Care Plan Call, DHCS can share key regulatory information with all Managed Care Plans (MCPs). RAC maintains a copy of the agenda and material from those weekly calls. Check it out HERE.
RAC Spotlight!
NEW! Filings and submissions now require Department ET approval. The purpose is to support the cross-functional collaboration and to continuously improve the quality and accuracy of deliverables.
Did you know there is an Inquiry Section on the Compliance Navigation Panel? Use this link to submit inquiry questions check it out here where we track our turnaround time in responding to your inquiries.
Compliance1@hpsj.com is designed to receive communication from our external stakeholders and issue regulatory notices to our internal stakeholders. For faster services or to avoid your inquiries getting lost in the sea of emails, use the inquiry request so your inquiries are tracked online and historical discussion threads are made available to viewers
Reminder Providers have the right to submit complaints related to payment to the DMHC Providers must submit a provider dispute resolution to the Health Plan before filing a complaint with DMHC. When the complaints are received, we have a cross-functional group that reviews each complaint. The group investigates the cases from the original request to claims processing and dispute resolution. Formulating a comprehensive response to DMHC and the provider’s concerns. Between January and June of 2024, the Health Plan received 14
Provider Complaints (original requests) and 26 additional information requests (total of 40 requests). and each complaint may contain multiple issues that require us to respond individually. The following captures the outcomes:
Provider Complaints year-to-date, as of June 26, 2024.
Table 1: Provider Complaints Received as of June 26, 2024.
Table 2: Provider Complaint Closures by Decision.
All Plan Letters (APL)
Both the DHCS and DMHC release APLs to communicate changes in policy or procedure at the Federal or State levels and provide instruction to MCPs like us on implementing these changes. In support of our internal (that's ALL OF US!) and external stakeholders, RAC completes an analysis of the APL to ensure timely filing and compliance with the implementation of changes. The following are APLs recently released:
A. DHCS Regulatory Notices
DHCS APL 24-007: Targeted Provider Rate Increases
Date issued: June 20, 2024
Summary: This APL provides MCPs with guidance on Network Provider payment requirements applicable to Medi-Cal Targeted Rate Increases (TRI) effective for dates of service on or after January 1, 2024
• Health Plan will need to configure rates to align with the Medi-Cal-TRI-FeeSchedule-CY-1062024.xlsx
• Upon DHCS request, Health Plan will need to attest compliance with Provider Reimbursement according to this APL and provide documentation that supports their attestation to DHCS upon request.
o Health Plan may request similar attestations and documentation from Subcontractors.
• Report to DHCS using the appropriate HCPCS and CPT codes in Encounter Data
• Ensure full compliance with this APL by 12/31/2024, full compliance includes ensuring that eligible Network Providers receive payment according to this APL.
• Ensure claims are paid timely according to the DHCS contract and APL 23-020: Requirements for Timely Payments of Claims
• Have a formal procedure for the acceptance, acknowledgment, and resolution of Network Provider grievances related to the processing or non-payment of payments
• Communicate to providers:
o P&Ps
o Health Plan's claims or Encounter submission processes (what constitutes a clean claim or an acceptable Encounter)
o The minimum requirements for a qualifying service
o How payments will be processed
o How to file a grievance
o How to identify the responsible payor
o An itemization of the reimbursement adjustments in an electronic format
• Review the Division of Financial Responsibility (DOFR) of the Network Provider and/or Subcontractor Agreement to align with APL.
• Review and update P&Ps and Network Provider agreements to align with APL requirements.
DHCS APL 24-008: Immunization Requirements
Date issued: June 21, 2024
Summary: This APL provides clarifications on the requirements related to the provision of immunization services.
• Health Plan must ensure timely provision of immunizations to Members in accordance with the most recent schedule and recommendations published by Advisory Committee on Immunization Practices (ACIP), regardless of a member’s age, sex, or medical condition, including pregnancy.
• Must require their Network Providers to document each Member’s need for ACIP-recommended immunizations as part of all regular health visits, including, but not limited to the following types of Encounters:
o Illness, care management, or follow-up appointments
o Initial Health Appointments (IHAs)
o Pharmacy services
o Prenatal and postpartum care
o Pre-travel visits
o Sports, school, or work physicals
o Visits to an LHD
o Well-patient checkups
• Health Plan must ensure that initiating and administering immunizations as a pharmacist service is a reimbursable Medi-Cal benefit when rendered to an MCP Member in the outpatient pharmacy setting by a pharmacist who is enrolled as an ORP Medi-Cal provider
• Health Plan is required to report Member-specific immunization records to a registry and is responsible for ensuring their contracted Providers are complying by submitting patient vaccination records to local health departments operating countywide or regional immunization information and reminder systems and the State Department of Public Health, as soon as possible
• Review and update P&Ps to align with APL requirements and communicate APL requirements to Network Providers and Subcontractors
Draft APL 24-XX Minor Consent Requirements
Summary: This draft APL provides guidance on the provision of outpatient mental health services to minors as a result of Assembly Bill (AB) 665 (Chapter 338, Statutes of 2023), Family Code (Fam. Code) section 6924, and Minor Consent Services available to eligible Members. Compliance will host a meeting with the impacted business owners to collect feedback.
B. DMHC Regulatory Notices
DMHC APL 24-011: Request for Health Plan Information and Addendum Revisions
Date issued: June 17, 2024
Summary: This APL provides MCPs with guidance on the revised Request for Health Plan Information (RHPI) and RHPI Addendum forms as health plans are required to use the revised forms effective June 30. 2024.
DMHC APL 24-012: Single Point of Contact for Hospitals to Request Authorization for Post-stabilization Care
Date issued: June 25, 2024
Summary: This APL reminds plans they may not require a hospital to make more than one telephone call to request authorization to provide post-stabilization care to plan enrollees.
Regulatory Reports due in the next TWO WEEKS
The table below shows the reports which are coming up for submission, who is responsible for the report, and when the report is due. Check out the list to see if any are in your department to ensure you know what’s being reported. Be sure to click on the report title for more details.
Member Death Notification Q2 2024
Provider Directory File and Use July
ECM/CS JSON 2024-07
274 File 2024-06
MCPDIP 2024-06
Data Certification Report 2024-06
Fraud Waste Abuse Status Report Q2 2024
Global Subcapitation Member Level Q4 2023-Q2 2024
Post Payment Recovery 2024-06
SRF 2024-06
C. Our Policies & Procedures
Sheela Srinivasan Michelle Tetreault
Ana Aranda Liz Le
Clarence Rao Victoria Worthy
CBAS Waiver 2024-06 Pam Lee Tracy Hitzeman
Clarence Rao Victoria Worthy
Clarence Rao Victoria Worthy
Tamara Hayes Sunny Cooper
Tamara Hayes Sunny Cooper
Christopher Navarro Michelle Tetreault
Aimee Griffin Michelle Tetreault
Clarence Rao Victoria Worthy
The following are published policies reviewed and approved by the PRC (Policy Review Committee) as of June 2024. We encourage you to read and be familiar with the policies which impact your job functions as compliance is required for employees of HPSJ/MVHP. If for any reason you have questions regarding policy changes, please submit your question to the policy owner and/or submit a Compliance inquiry.
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) Report Title
Published (5/29/2024 – 6/25/2024):
Policy
CLMS01 Third Party Liability and Worker’s Compensation Recovery
CM66 Case Management Programs
CS05 Primary Care Provider Assignment
GRV04 Grievance Committee
GRV05 State Fair Hearings
GRV06 Independent Medical Review
Minor/No changes for annual review and moved to the co-branded template
Minor/No changes for annual review and moved to the co-branded template
Minor/No changes for annual review and moved to the co-branded template
Minor/No changes for annual review and moved to the co-branded template
Minor/No changes for annual review and moved to the co-branded template
Minor/No changes for annual review and moved to the co-branded template
QM07 Reporting of diseases and conditions to Public Health Authorities New Policy
QM22 Initial Health Assessments
QM27 Potential Quality Issue Report
Minor/No changes for annual review and moved to the co-branded template
Minor/No changes for annual review and moved to the co-branded template
Policy # and Name
QM33 Mandatory 805 Reporting
Provider Appeal Rights Regarding Non 805 Actions
UM02 Inpatient Admissions and Concurrent Review
Revision/Update
Minor/No changes for annual review and moved to the co-branded template
Minor/No changes for annual review and moved to the co-branded template
UM05 Over/Under Utilization of Services Monitoring Annual update to ensure regulatory requirements are accurately reflected and internal processes related to monitoring, identifying, reporting, and curing over/under-utilization identified
UM82 Long Term Care
Moved policy to new template and updated to include having a liaison for the long-term Services and Supports (LTSS) Provider community
UM89 UM System Controls Moved policy to new template and aligned policy with NCQA standards
UM90 Intermediate Care Facilities Moved policy to new template and updated to include bed hold and LOA requirements
*Publicly posted
Program Integrity Unit (PIU)
PIU oversees the Fraud Prevention Program, investigation and reporting of Privacy & Security Incidents, Exclusion Monitoring, Disclosures and much more.
A. PIU is Hiring!
We are looking to fill a Senior Compliance Analyst role. The specific skill set we are looking for is related to Fraud, Waste, and Abuse (FWA) investigations. Do you know someone who has knowledge in claims billing and coding, identifying FWA fraud trends in claim data, and investigation skills? If so, please have them apply for the “Analyst, Compliance Senior” position which is posted online here.
B. PIU Spotlight
A new attestation and policy “HPA44 Allowed, Restricted, and Prohibited Disclosures for Sensitive Services” have been developed to comply with assembly bills AB352 and AB254. The IT Security Department will also be updating their process to ensure that the information for services that fall
into the categories outlined in these assembly bills such as abortion and other sensitive services won’t be exchanged with our HIE vendor starting July 1, 2024. Version one of policy HPA44 was recently approved, and its published version will be available soon.
C. Privacy & Security Incidents
It is so important to avoid unintentional disclosures of member’s Protected Health Information/ Personal Information (PHI/PI). Per policy HPA34 Use of Member PHI/PI, it is our responsibility to protect the PHI/PI of our members. Remember your training!
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 4 privacy/security incidents that occurred between June 10 – June 21, 2024, none of these were reportable to DHCS.
1. The discovery of a file containing malware or viruses on the Health Plan’s Sharepoint.
Reminder: If a file is suspected of containing malware or viruses on our network, report it to our IT Security Team using the icon in your Outlook or send an email.
2. Assisting a caller with a member’s account, without the caller having an active authorized representative form on file for the account or assisting the caller without obtaining a members’ verbal consent.
Reminder: Before assisting another person with a member’s account, ensure that there is either an active authorized representative form on file for that person in the member’s account, and that the member has given you verbal consent to assist that person on their behalf.
3. Assisting a member without correctly verifying a minimum of three HIPAA validation questions to confirm their identity, prior to assisting them.
Reminder: Confirming the identity of a member is mandatory to prevent unintentional disclosure of PHI/PI to the wrong party.
4. A contracted provider sent non-member PHI to another provider.
Reminder: It is the responsibility of the provider (a Covered Entity or CE) who receives the non-member PHI to destroy it and inform the provider who sent the non-member PHI about the incident.
D. Fraud, Waste, and Abuse (FWA) Incidents
Our PIU actively manages potential FWA incidents across different stages of investigation. In the past two weeks, we have received two new leads and closed three cases Currently, the PIU is investigating 23 cases.
Our investigations recently uncovered overpayments: one case involved an overpayment of $12,807.00 due to exceeding approved medication units and administering treatment beyond authorized duration. In another case, we identified an overpayment of $819.84 due to a billing error.
Protecting the integrity of the Medi-Cal Program is important to ensure that funds are used appropriately to provide necessary, high-quality care These funds come from taxpayers, so it is crucial that they are not wasted or abused. If you notice or suspect fraudulent activity, please REPORT IT to help safeguard our resources.
E. 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 Third-Party 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 23 requests during this reporting period No restrictions were found.
Audit & Oversight (A&O)
Let’s continue our dive into the essential elements of an effective compliance program as outlined by the Office of Inspector General (OIG). The “Seven
Elements of an Effective Compliance Program” aim to promote the discovery, remediation, and prompt response to potential violations in accordance with state and federal standards. In the last newsletter we introduced the fifth element: “Conduct internal auditing and monitoring” and focused on auditing.
While auditing typically involves examining past records, program processes, and practices to identify deviations or non-compliance issues, compliance monitoring entails ongoing surveillance and oversight aimed at detecting and preventing compliance breaches in real-time or near real-time. Monitoring involves continuous data collection, analysis, and feedback to ensure that operations remain in line with established standards and protocols. Unlike audits, which are typically retrospective, monitoring offers a proactive approach, allowing organizations to identify potential issues as they arise and take prompt corrective action.
Effective monitoring mechanisms serve as a vital component of a comprehensive compliance program, fostering a culture of accountability and transparency within the organization. The A&O Department is in the process of enhancing our monitoring efforts to ensure and verify that processes are working as intended. This includes data integrity checks and the monitoring of procedures to detect and prevent inaccuracies or compliance issues. Monitoring helps maintain operational effectiveness and ensures that the Health Plan adheres to regulatory requirements and internal policies.
Stay tuned for more information on specific audit activities at the Health Plan in the upcoming newsletters!
Carelon Corrective Action Plan (CAP) Update
We are pleased to share the progress the A&O team has 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. Since the initiation of these meetings Carelon has resolved nine (9) of the twenty-two (22) CAPs that were issued for 2023 and 2024 Audit and Monitoring Oversight Activities. We are excited to share that the Carelon 2024 TP Monitoring (iCAP) was closed on 06/24/2024. Four (4) new CAPs were issued for 2024 Carelon Annual Audit on June 18, 2024, increasing the total CAPs issued.
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 on 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!
DHCS Operational Readiness (OR)
We are very excited to announce that as of June 30th, 2024, 100% of all milestones have been identified by Business Owners and Project Managers as complete! (See current status: Operational Readiness Milestone Tracker.)
As mentioned previously, the Compliance Project Team is busy validating evidence submitted to ensure that regulatory requirements are met, and operational gaps are remediated for this fiscal year (7/1/23 - 6/30/24). As of 6/28/2024, all the contract sections, but two have been reviewed and feedback has been provided to the assigned business owners.
Debbie Rieger, the assigned Project Manager, will be transitioning off the project at the beginning of July and Toni White will be your primary contact going forward. If for any reason the Project Team outreaches because of missing evidence or the evidence provided does not sufficiently evidence compliance, please be sure to submit the requested evidence within 5 business days. If you
have any questions about DHCS Operational Readiness, please reach out to Toni White or Angelika Torrella.
Stay Connected with Compliance!
Stay informed and up-to-date with Compliance 4 U, a biweekly newsletter focused on connecting and informing ALL OF US as Champions who Play as One!!
