October 8, 2024
Compliance4U newsletter provides you with insight into the day-to-day functions of Health Plan’s Compliance Program.
Overview of Compliance Element #4: Effective Lines of Communication
Health Plan promotes open lines of communication for anyone to reach the Compliance Officer to reduce the potential for fraud, waste, and abuse. Did you know that you – a Health Plan employee, contractor, or agent - can reach the compliance officer directly via email, telephone, or through a Teams chat? You are encouraged to reach out to her with any compliance question or concern. In fact, we’re listing her information here to make it even easier for you!
Sunny Cooper
scooper@hpsj.com (209) 425-5611
In addition to contacting Sunny directly, other ways you can report concerns –including reporting anonymously - are:
Email: Compliance1@hpsj.com
Phone: Compliance Hotline 855.400.6002
Online: Report an Incident on the Compliance SharePoint Home Page
While we encourage you to share compliance concerns with your manager, you are not required to do so – you can come straight to us! No matter how you get in touch with the Compliance Division to submit a concern, you can do so without fear of retaliation – click here to see the policy on Non-Retaliation for Reporting Violations
Health Plan of San Joaquin (compliance360.com). Check out more from Regulatory Affairs & Communication (RAC) about effective communication.
Regulatory Affairs & Communication (RAC)
The Compliance Program is built on seven essential elements:
Today, let’s dive into the fourth element: Effective Lines of Communication. This is a key part of our compliance program, ensuring everyone in our Health Plan is well-informed and ready to follow compliance standards. By promoting open and transparent communication, we can build trust, encourage the reporting of concerns, and raise awareness about compliance issues.
Effective communication in our organization is more than just sharing information. It’s about creating a culture where dialogue is encouraged, and feedback is valued. This helps us spot potential compliance risks early and address them proactively. It also ensures that everyone, from top management to the newest employee, understands their role in maintaining compliance and feels empowered to speak up if they notice any discrepancies.
To help with this, we use our Compliance Inquiry Log as one of our communication methods to ensure that we have effective lines of communication within HPSJ. This log is designed to document and track compliance-related inquiries, ad-hoc government submissions, and internal Corrective Action Plans (CAPs) requests. The Compliance Inquiry Log serves as a centralized place where all compliance-related issues can be recorded, monitored, and resolved efficiently. This systematic approach not only helps keep a clear record of all inquiries but also ensures that each issue is addressed promptly and effectively.
To create an inquiry, please use the following link: “Submit an Inquiry/Issue”, or find it on the compliance page under the “Requests” tab. When creating a ticket, it’s important to include comprehensive details to ensure we fully understand your request. Please provide the following information:
• What you need: Select the nature of your request based off the options provided.
• Title: Provide a concise title that summarizes the inquiry.
• Who is requesting: Name of the person making the request.
• Your director/manager: Include the name of your director or manager.
• Description: Offer a detailed description of the issue or inquiry. The more information you provide, the better we can assist you.
By following these guidelines and using the Compliance Inquiry Log, we can maintain a high standard of compliance within our organization. Open and transparent communication is the cornerstone of our compliance efforts, and your active participation is crucial in achieving our goals.
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.
What’s going on at the State and Federal levels? 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 CallMCPC) and other regulatory meetings/calls where key regulatory information is shared.
DHCS hosted a webinar on “FQHC and D-SNP Contracting Opportunities”
On September 19th, DHCS hosted a webinar regarding FQHC and D-SNP Contracting Opportunities. This webinar provided foundational information on the role of FQHCs, FQHC payment for dually eligible populations, and strategies and opportunities for contracting between D-SNPs and FQHCs. Integrated Health Partners of Southern California (IHP) shared valuable insights through a brief presentation, including their lessons learned and overall perspectives. For more details, please refer to DHCS Webinar on FQHC and DSNP Contracting Opportunities 9.20.2024
DHCS hosted a webinar on “Dental Data & Encounter Data Quality Initiative (EDQI)”
On September 25th, DHCS hosted the monthly Managed Care Data Quality Monitoring Webinar. This monthly meeting series facilitates ongoing discussions on various Managed Care Data Quality Monitoring topics. This monthly meeting series facilitates ongoing discussions on various Managed Care Data Quality Monitoring topics. This month’s focus was on the “Dental Data & Encounter Data Quality Initiative (EDQI)”, along with a brief review of mandated HIPAA standards, their implementations, and relevant companion guides. For more information, please see the linked meeting minutes.
RAC maintains material from those weekly calls. Check out previous meetings 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
APL 24-009 Skilled Nursing Facilities – Long Term Benefit Standardization and Transition of Members to Managed Care (Supersedes APL 23-004)
APL 24-009 vs APL 23-004 Redlined
Issued Date: September 16, 2024
Summary: This APL outlines requirements for the Skilled Nursing Facility (SNF) Long Term Care (LTC) benefit standardization provisions of the California Advancing and Innovating Medi-Cal (CalAIM) initiative, including the mandatory transition of Medi-Cal members to managed care
APL 24-010 Subacute Care Facilities - Long Term Care Benefit Standardization and Transition of Members to Managed Care (Supersedes APL 23-027)
APL 24-010 vs APL 23-027 Redlined
Issued Date: September 16, 2024
Summary: This APL outlines requirements for the Subacute Care Facility Long Term Care (LTC) benefit standardization provisions of the California
Advancing and Innovating Medi-Cal (CalAIM) initiative, including the mandatory transition of Medi-Cal members to managed care
APL 24-011 Intermediate Care Facilities for Individuals with Developmental Disabilities - Long Term Care Benefit Standardization and Transition of Members to Managed Care (Supersedes APL 23-023)
APL 24-011 vs APL 23-023 Redlined
Issued Date: September 16, 2024
Summary: This APL outlines requirements for the Long-Term Care (LTC) Intermediate Care Facility/Home for Individuals with Developmental Disabilities services provisions of the California Advancing and Innovating Medi-Cal (CalAIM) benefit standardization initiative. This APL contains requirements related to Intermediate Care Facilities for the Developmentally Disabled (ICF/DD) Homes, Intermediate Care Facilities for the Developmentally Disabled-Habilitative (ICF/DD-H) Homes, and Intermediate Care Facilities for the Developmentally Disabled-Nursing (ICF/DD-N) Homes.
APL 24-012 Non-Specialty Mental Health Services: Member Outreach, Education, and Experience Requirements
Issued Date: September 17, 2024
Summary: This APL provides guidance to Medi-Cal managed care plans (MCPs) regarding requirements for Member outreach, education, and assessing Member experience for Non-Specialty Mental Health Services (NSMHS), as required by Senate Bill (SB) 1019 (Gonzalez, Chapter 879, Statutes of 2022).
APL 24-013 Managed Care Plan Child Welfare Liaison
Issued Date: September 18, 2024
Summary: This APL provides clarification on the intent and objectives of the Medi-Cal managed care plan (MCP) Child Welfare Liaison, formerly referred to as the Foster Care Liaison, as outlined and required by the 2024 Contract with the Department of Health Care Services (DHCS). Additionally, this APL provides guidance regarding the requirements and expectations in relation to the role and responsibilities of the MCP Child Welfare Liaison
APL 24-014 Continuity of Care for Medi-Cal Members who are Foster Youth and Former Foster Youth in Single Plan counties
Issued Date: September 27, 2024
Summary: This APL provides guidance to Medi-Cal managed care plans (MCPs) in Single Plan counties on enhanced continuity of care protections for Foster Youth and Former Foster Youth Medi-Cal members who live in a Single Plan county and are mandatorily transitioning from Medi-Cal Fee-For-Service (FFS) to enroll as Members in Medi-Cal managed care. ** This APL is not applicable to Health Plan **
B. DMHC Regulatory Notices
No new APLs or draft APLs have been issued since the last reporting period.
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 2024-10
ECM/CM JSON 2024-10
CBAS Waiver 2024-09
274 File 2024-09
MCPDIP 2024-09
Data Certification 2024-09
Clarence Rao
Clarence Rao
Pamela Lee
Clarence Rao
Clarence Rao
Tamara Hayes
Global Subcap Member Level Q3 2024 Christopher Navarro
Post Payment Recovery 2024-09
SRF 2024-09
PIN 2024-09
Contract Flagging CY 2 Phase 1
DHCS Annual Finance Report
Encounter Data 2024-09
EOC 2025
PHMS(Population Health Management Strategy)
LTC-SNF 2024-Q3
MOT Post Transitional Quarterly
Monitoring
CBAS Quarterly Q3 2-24
NEMT/NMT 2024-07
Quarterly Network Change 2024-Q3
Interoperability API Utlization Metrics
2024-Q3
MOU Status Report Q3 2024
Victoria Worthy
Victoria Worthy
Tracy Hitzeman
Victoria Worthy
Victoria Worthy
Sunny Cooper
Michelle Tetreault
Christopher Navarro Michelle Tetreault
Clarence Rao
Ana Aranda
Clarence Rao
Victoria Worthy
Liz Le
Victoria Worthy
Michelle Tetreault Michelle Tetreault
Clarence Rao
Victoria Worthy
Vena Ford Evert Hendrix
Kathleen Daziel
Lakshmi
Dhanvanthari
Johnathan Yeh Lakshmi Dhanvanthari
Johnathan Yeh
Pamela Lee
Lakshmi
Dhavanthari
Tracy Hitzeman
Dale Standfill Liz Le
Ana Aranda Liz Le
Clarence Rao
Paul Sohn
Victoria Worthy
Evert Hendrix
Provider Complaints
Provider complaints come to our Health Plan in different forms (e.g. Direct call to Health Plan or submission of dispute to DMHC). While our Provider Services and Claims team address those coming into Health Plan, Compliance is the point of contact for those coming through DMHC. From January 2024 through September 2024, we received 56 requests (21 Provider Complaints and 35 additional information requests), disputing 49 claims. In addition, each complaint may contain multiple issues that require a response.
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.
These tables outline the status:
Table 1: Provider Complaints Received from DMHC as of October 2nd, 2024.
PROVIDER COMPLAINT TREND ANALYSIS:
We have received 21 Original Provider Complaints as of September 20th, 2024, and 35 AIRs. In 2023, we received 13 Original Provider Complaints and 7 AIRs. This is an increase of 61.5% from 2023 to 2024.
Table 2: Provider Complaint Closures by Decision as of October 2nd, 2024:
Of the 13 Provider Complaints issued in 2023, 8 decisions were made in our Favor and 5 in the Provider’s Favor.
Of the 21 Provider Complaints issued in 2024, One (1) decision was made in our favor, 11 in the Provider’s Favor and 10 are pending decision and still under review. The 11 Provider Complaints were determined in favor of the provider because we changed our determination or issued payment after further information was received. The payment on all claims were made and issued to the provider.
Compliance will be holding monthly meetings to review all trends and opportunities for improvement to mitigate future issues in relation to Provider Complaints with Configuration, Provider Services and Contracting.
Regulatory Audits
As we work diligently to implement the various changes required by our regulators, we are also working to ensure ongoing audit readiness. Compliance has been working with all of our internal customers, YOU, to prepare for the virtual onsite audit scheduled for 10/28/24 through 11/08/24.
In addition to filing our response to the pre-audit documents and questionnaires, we have mock audits planned for critical areas of focus.
What are Mock Audits?
A mock audit is a practice run of questions and answers that may be asked by our auditors. Compliance has scheduled 16 mock audit sessions with key staff to ensure we are ready for what’s coming.
The questions are pulled from transcripts of previous audit interview sessions, the corrective actions plans, technical assistance guides and sister plans that have been through the 2024 DHCS audit. Compliance, acting as the auditor, mimics the virtual audit sessions and provides recommendations for responding to auditor questions.
The DHCS 2024 audit review period is 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
What’s Next?
The DHCS auditors have selected case files, i.e., specific cases that they will focus on during their desk review and interviews of us, from our universe of files which are a collection of data files from which DHCS randomly selected cases to review further.
Following DHCS guidelines, we have prepared a series of documents of these cases including critical elements that demonstrate our policies and procedures are in compliance with regulatory requirements
These case files will be reviewed by the DHCS auditors and questions will be posed to us during the virtual onsite interviews.
The audit schedule is available here
Regulatory Monitoring and Corrective Action Plan (CAP): RAC monitors regulatory filing and reporting for compliance. When we fall short it is important to address these issues as early as possible. Just like reporting privacy or FWA incidents we should also report when we are at risk of sanction or corrective action by our regulators. Self-reporting is critical to our success in staying compliant.
The Data Services team self-reported a problem with Quality Measures for Encounter Data (QMED). After an assessment and interview regarding the issues, RAC issued a CAP request due to a failure to submit complete, accurate and timely encounter data to DHCS. Since the issuance of the CAP request, quality controls have been put in place to remediate this deficiency. The most recent Encounter Data Quality Report Card from DHCS shows that we are making progress submitting complete and timely encounter data, demonstrating the effectiveness of the remediation plan. The RAC team will continue to work with
the business owner and responsible department to ensure this CAP is resolved and closed out.
Program Integrity Unit (PIU)
The PIU investigates and reports all potential fraud, waste or abuse (FWA) and HIPAA violations, along with conducting exclusion monitoring for Third Parties. Here are some recent items we have been working on:
Privacy & Security Incidents
Privacy Tip – Before sending out a fax, double check that the fax number you have entered is correct. Remember to report all privacy incidents to the PIU Team by submitting a privacy incident report at this link, within 24 hours of discovering the privacy incident.
Below is a summary of the types of HIPAA 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 12 HIPAA incidents that occurred between September 1 –September 30, 2024. Three of these were reportable to DHCS.
Reminder: Member PHI is not for personal use, ever. We are only authorized to access PHI to perform our job.
Reminder: Double check the parameters for automated reports that contain PHI. It’s a good idea to verify the accuracy of autogenerated reports prior to sending to the recipient, to make sure the report contains the information that was intended.
Fraud, Waste, and Abuse (FWA)
Covered Entities that are Medi-Cal Enrolled Should Report Breaches Directly to DHCS
Covered Entities that are Medi-Cal enrolled (through PAVE) should report breaches or unauthorized disclosures of PHI directly to DHCS and cc our PIU at piu@hpsj.com. If a provider is not MediCal enrolled (some ECM/CS providers), we will report the breach or unauthorized disclosure to DHCS on their behalf. For more information refer to Section 16 of the Provider Manual posted on https://www.hpsj.com.
The PIU is on constant alert, managing potential FWA incidents at every stage of investigation.
Recent
Updates: In the last month, we received four (4) leads. One was converted into an active case, while the others were closed. Our team is actively investigating 22 ongoing cases.
Did You Know?
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 well-being.
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.
Provider Exclusion Monitoring
A phantom provider is a licensed clinician or facility that is listed in an insurance plan directory but is not actually available to patients.
A Phantom provider can cause a number of problems, including:
• Delayed treatment
• Discontinuities in care
• Patient frustration
• Inability to obtain necessary care
• Undermined access to care
We are obligated to verify the eligibility of our Third-Parties 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 51 requests during this reporting period. Zero (0) restrictions were found.
Audit & Oversight (A&O)
Carelon Corrective Action Plan (CAP) Update
We are pleased to announce that A&O has successfully closed all twenty-two (22) CAPs issued to Carelon! This process included the remediation of CAPs issued during CY 2023 – 2024 following Health Plan and Regulatory oversight activities.
This marks an important milestone in ensuring quality of care provided to our members, while upholding compliance standards. We appreciate the dedication and hard work from all internal and external parties involved to achieve this outcome.
For detailed information and to review the respective CAPs, please visit our Compliance and Regulatory CAP Tracker.
This is the last installment of our Carelon CAP updates. Please stay tuned for next month’s newsletter where we will be diving into the A&O Improvement Plan!
Compliance Program Projects and other Key information
Our Compliance team supports and leads various projects that impact ALL OF US!
Policies and Procedures
We have a backlog of 147 past due policies that need to be reviewed by the end of the year. Therefore, we are asking that both policies scheduled for annual review this month (19) and all high priority past due (expired) policies (47) are reviewed and submitted to October Policy Review Committee (PRC) for approval. We are asking the both the Policy Owners and Executives complete
revisions and approvals within C360 by Friday, 10/11/2024. The October Policy Review Committee (PRC) is rescheduled on Thursday, 10/24/2024, to allow time for Compliance and CEO reviews to be completed. If you have any questions regarding policies, please contact our Compliance Policy Team at policies@hpsj.com.
September 2024 PRC
The following are published policies reviewed and approved by the PRC (Policy Review Committee) as of September 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.
Published (8/24/2024 - 9/23/2024)
Policy # and Name
Revision/Update
CM12 Private Duty Nursing Revised for clarity. No substantive changes
FAC01 HPSJ Vehicle Policy Annual Review
FAC04 Office and Cubicle Assignment Annual Review
UM06 Medical Review Criteria Updates made due to EPSDT
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). If you have any policy-related questions, please contact the Policy Review Team at Policies@hpsj.com.
Did you know?
The next Policy Review Committee (PRC) meeting will be held on Wednesday, October 24, 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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