June 3, 2024
In this issue of Compliance 4 U, we share our Departments’ search for more support to reach our continued goal to provide timely and high-quality customer service to YOU, and all of our customers. Also, we are nearing the end of the FY23-24, closing our projects and collecting evidence of a successful implementation of new or enhancement of existing business processes. We are so close to our goals!
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.
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.
The Compliance1@hpsj.com email is designed to receive communication from our external stakeholders and issue regulatory notices to our internal stakeholders. For faster service or to avoid your inquiries getting lost in the sea of emails, use the inquiry request.
NEW! Did you know that our 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, Health Plan has a cross functional group that reviews each complaint. The group investigates the cases from the original request, to claims processing and the dispute resolution. Formulating a comprehensive response to DMHC and the provider’s concerns. Between January and April of 2024, the Health Plan received 13 complaints and each complaint may contain multiple issues which require us to respond individually. The following captures the outcomes:
Provider Complaints year-to-date, as of May 29, 2024.
All Plan Letters
Both the DHCS and DMHC release All Plan Letters (APL) 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
No new APL or draft APL has been issued since the last reporting period.
B. DMHC Regulatory Notices
No new APL or draft APL has been issued since the last reporting period.
Regulatory Reports due in the next TWO WEEKS
This list outlines what we are required to submit, who is responsible for it, and by when. Check out the list to see if any are in your department to make sure you know what’s being reported. Be sure to click on the report title for more detail.
ECM/CS JSON
Report Title
MCPDIP-MCPD_PCPA
PDSRF-274 File 2024-05
Data Certification 2024-05
Clarence Rao Victoria Worthy 6/10/2024
Clarence Rao Victoria Worthy 6/10/2024
Clarence Rao Victoria Worthy 6/10/2024
Tamara Hayes Sunny Coooper 6/14/2024 https://hpsjonline.sharepoint.com/sites/C omplianceTeam/Lists/RegulatoryReportsTracker/Dis pForm.aspx?ID=1496
Post Payment Recovery 2024-05
EDSRF- Encounter Data 2024-05
SRF 2024-05
C. Our Policies & Procedures
Eric Cubillo Michelle Tetreault 6/14/2024
Aimee Griffin Michelle Tetreault 6/15/2024
Clarence Rao Victoria Worthy 6/15/2024
Clarence Rao Victoria Worthy 6/15/2024
The following are the published policies reviewed and approved by the PRC (Policy Review Committee) as of 5/15/2024. We encourage you to read and be familiar with the policies which impact your job functions and compliance is required, as an employee 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. You can also access all of our active policies, with the exception of HR policies, using this link on our Intranet home page at any given time.
Published (4/23/2024 – 5/28/2024):
Policy # and Name
CFG01 Maintenance of Provider Data Revisions
CM69 Continuity of Care
CONT05 Provider Network Deficiencies
GRV07 Response Time to DMHC Regarding Urgent Grievances
HEQ01 Health Equity: Diversity, Equity, and Inclusion Training
Revision/Update
Minor/No changes for annual 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
Policy to align with DHCS APL 23-025 Diversity, Equity, and Inclusion Training Program Requirements
*PH32 Non-Opioid Pain Management New Policy
PRO20 Provider Training and Education
QM42 Ongoing Monitoring
*Publicly posted
Minor/No changes for annual review and moved to the co-branded template
Policy updated for MCQA accreditation and mov ed to the cobranded template
Why are policies and procedures important within an effective Compliance Program? Remember when you completed the Code of Conduct and Business Ethics (COC) training earlier this year?
WHAT do we know? The COC is a fundamental document defining the Health Plan’s expectations of YOU. This represents the culture of the Health Plan. WHY do you need to know? The COC summarizes guidelines and expectations, so YOU know the standards we all are held to everyday.
WHEN is it important? Compliance with the COC is always important. It is critical that we all follow the rules, even when no one is looking. WHO needs to follow? All of us are responsible for reviewing, understanding, and adhering to policies, procedures, and the Code of Conduct. HOW do I know what to do? Review the COC and Health Plan policies to ensure you understand what is expected of you. And ask questions if you are unsure. Let’s all do our part to uphold and support Health Plan standards!
Program Integrity Unit (PIU)
The Program Integrity Unit (PIU) oversees the Fraud Prevention Program, investigation and reporting of Privacy & Security Incidents, Exclusion Monitoring, Disclosures and much more.
A. The 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. Privacy & Security Incidents
It is so important to avoid unintentional disclosures of member’s Protected Health Information/ Personal Information (PHI/PI). In compliance with our policy (HPA34 Use of Member PHI/PI and Confidential Information), EVERYONE (each of us!) is accountable for protecting this information. 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 10 privacy incidents that occurred between May 13 – May 24, 2024, only one (1) of these was reportable to DHCS.
1. Sending an email to other Health Plan staff that contains member PHI/PI.
Reminder: All emails containing PHI that are sent externally need to be encrypted. Before encrypting internal emails consider how the phi is contained within the email.
2. Receiving non-member’s PHI/PI from external Third-Party entities.
Reminder: Let’s take these opportunities to remind our external partners the importance of protecting PHI/PI even if it is not our members PHI/PI.
3. Use a personal device for member outreach instead of IT-issued equipment.
Reminder: It is important to follow our policies and procedures and only use IT approved devices to communicate with members.
4. Caller misrepresenting themselves as the member.
Reminder: Confirming the identity of the caller is mandatory to prevent unintentional disclosure of PHI/PI to the wrong party, and when you discover that a caller is misrepresenting themselves as the member, you should let them know that you can no longer further assist them.
5. Faxing, emailing, or mailing member PHI/PI to the wrong recipient. Reminder: Ensure that the member PHI/PI you are sending is going to the correct intended recipient.
C. Fraud, Waste, and Abuse (FWA) Incidents
Our PIU actively manages potential FWA incidents across different stages of investigation. Over the past two weeks, we closed two cases and wrapped up another, identifying an overpayment of over $1M through detailed claims analysis and medical record review. We shared the findings and outcomes of our investigation with the Department of Health Care Services (DHCS), California Department of Justice (CA DOJ), and U.S. Department of Health and Human Services – Office of Inspector General (HHS-OIG).
Currently, the PIU is investigating 27 cases.
D. 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 a number of 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 being established with an out of network provider. PIU received 29 requests. No restrictions were found.
Audit & Oversight (A&O)
A&O is hiring!
We are thrilled to announce two exciting job openings within the team. These roles are critical to the success and enhancement of our oversight efforts, especially in anticipation of the Medicare D-SNP product line!
- Manager, Compliance (Clinical Audit & Oversight)
• Responsibilities: Developing and implementing clinical audit and monitoring workplan and overseeing internal and third-party clinical operations in accordance with state, federal and NCQA requirements, as well as HPSJ goals and objectives. This individual would also be responsible for guiding staff and third parties to ensure compliance with contractual and regulatory standards, while building and maintaining relationships with internal and external customers.
• Qualifications: Licensed Nurse (RN or LVN) or equivalent clinical licensure; In-depth knowledge of clinical audit and oversight processes including, but not limited to, Utilization Management, Quality Improvement, Case Management, Grievance and Appeals, and Behavioral Health.
• Click here to learn more!
- Manager, Compliance (Non-Clinical Audit & Oversight)
• Responsibilities: Developing and implementing non-clinical audit and monitoring workplan and overseeing internal and third-party nonclinical operations in accordance with state, federal and NCQA requirements, as well as HPSJ goals and objectives. This individual would also be responsible for guiding staff and third parties to ensure compliance with contractual and regulatory standards, while building and maintaining relationships with internal and external customers.
1Compliance - Provider Exclusions Check - All Entries (sharepoint.com)
• Qualifications: In-depth knowledge of non-clinical audit and oversight processes including, but not limited to, Claims Operations and Processing, Network Adequacy and Provider Data Management, Cultural Linguistics, and Customer Service.
• Click here to learn more!
If you know someone who would be a great fit, encourage them to apply!
Carelon 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 steps and action items coming out of the discussions. We have successfully resolved six (6) of the thirteen (13) CAPs that have been issued ensuring that we meet compliance standards.
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.
In the upcoming issues of the Compliance 4U newsletter, the A&O team will be kicking off a mini-series that will highlight the complexities of ‘Auditing versus Monitoring’ to share more about why we do what we do! Stay tuned!
