FWA/ Compliance Resources

FDR/General Compliance Information

ONECare (Medicare) and Care1st (Medicaid) Compliance Program and ONECare's First-Tier, Downstream, and Other Related Entities (FDRs)

Care1st Health Plan and ONECare by Care1st Health Plan Arizona, Inc. (HMO SNP) (Care1st) is committed to ethical and legal business practices to advance its health care mission.  Care1st is also dedicated to the continued establishment and maintenance of an effective Medicare compliance program through a framework designed to conform to the standards in the Federal Sentencing Commission Guidelines and the compliance program guidance issued by the Office of Inspector General (OIG) of the United States Department of Health and Human Services (DHHS) and the Centers for Medicare & Medicaid Services (CMS).

Care1st’s compliance program is structured to encourage collaborative participation and focuses on the prevention, detection, and correction of identified violations of federal and state laws and regulations, fraud control, and unethical conduct, and fosters an environment that encourages Care1st’s employees to report concerns about business practices without fear of retaliation.  The compliance program has been written in strict adherence to the laws, regulations, and program guidelines of the United States Government and its agencies concerning the Medicare program.

Care1st’s compliance vision is to strengthen and support the Care1st’s compliance mission and strategic initiatives by fostering a work environment that promotes honesty and fairness in Care1st’s dealings, integrity in Care1st’s decisions, ethics in Care1st’s actions, and compliance with the law.

Care1st’s compliance goal is to embed compliance, fraud control, and business ethics into the Care1st’s organizational culture through promotion and facilitation of infrastructures and tools designed to help achieve compliance with Federal, State, and local laws and regulations, licensing requirements, and accreditation standards.

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Distribution of Care1st’s Standards of Conduct for FDRs/Vendors, the Anti-Fraud Plan (AFP), HIPAA Training Slides, and Policies and Procedures to Care1st’s FDRs/Vendors

In accordance with CMS’ compliance guidance, in order to communicate Care1st’s compliance expectations for FDRs, Care1st ensures that the Standards of Conduct (for Vendors), the Anti-Fraud Plan (AFP), and policies and procedures are distributed to FDRs’ employees.  Below are the Care1st’s Standards of Conduct (for FDRs/Vendors) and Compliance’s Policies and Procures.

Please distribute to your employees and submit your attestation form (found on last page of “Compliance Expectations for ONECare’s First Tier, Downstream, and Other Related Entities (FDRs)”, or you may submit via our online portal or by email.
If you have questions or if you suspect a compliance, ethics, or integrity violation, or have questions about specific practices, please use the following resources:

  • Call Care1st’s Compliance HOTLINE at 1-866-364-1350. Anonymous. Available 24/7. Toll-Free
  • Compliance Oversite Specialist: (602) 474-1377
  • Fax: (602) 778-1814
  • Email: ComplianceDepartmentAZ@Care1stAZ.com (ensure your email is sent securely if containing PHI/PII)
  • Market Compliance Officer, Patty Dal Soglio, at (602) 778-8302

Care1st Standards of Conduct, Anti-Fraud Plan, HIPAA Training Slides, and Policies:

HIPAA Training Slides:

Attestation for Distribution of Care1st Standards of Conduct, Anti-Fraud Plan, HIPAA Training Slides, and Policies:

Note: you can submit your attestation online! Click Here

Or, submit a copy of your completed attestation via email to:
ComplianceDepartmentAZ@Care1stAZ.com

Or, fax your completed attestations to: (602) 778-1814

Or, mail your completed attestation to:

Care1st Health Plan Arizona
Attn: Compliance Department
2355 E. Camelback Rd., Ste 300
Phoenix, AZ 85016

Doing the Right Thing First

The Care1st Compliance Department is responsible for the organization's compliance and ethical conduct in all matters.

Our Responsibilities

  • Proactive prevention of fraud and abuse and other illegal activities through education and training of healthcare employees, providers and members.
  • Instrumental in the enforcement of policies and procedures, and in generating an environment where the prevailing goal is "to always do the right thing and to do it the right way."

FWA/General Compliance Training Materials

2013 Fraud, Waste, and Abuse & General Compliance Training Materials

The Centers for Medicare & Medicaid Services (CMS) requires plan Sponsors to provide Fraud, Waste, and Abuse (FWA) & General Compliance Training to health plans’ employees, contracted first-tier, downstream, and related entities (FDRs) as well as FDR employees who are involved in the administration or delivery of Medicare Parts C and D benefits.

Care1st provides its General Compliance and FWA training presentation below.

Note: If you/ your office have already completed CMS’ Fraud, Waste and Abuse & General Compliance Training for this year, please submit a signed copy of your attestation via one of the submission methods referenced above.

Attestation Form for Contracted Entities (FDRs/Vendors) - General Compliance and Fraud, Waste & Abuse

Note: you can submit your attestation online! - Click Here

Or, submit a copy of your completed attestation via email to:
ComplianceDepartmentAZ@Care1stAZ.com

Or, fax your completed attestations to: (602) 778-1814

Or, mail your completed attestation to:

Care1st Health Plan Arizona
Attn: Compliance Department
2355 E. Camelback Rd., Ste 300
Phoenix, AZ 85016

Duty to Report Non-Compliance and Fraud, Waste and Abuse

  • Everyone is responsible for reporting suspected Non-Compliance and fraud, waste and abuse
  • Care1st prohibits retaliation for reporting suspected Fraud, Waste and Abuse
  • Refer to Care1st Anti-Fraud Plan, Standards of Conduct and the Fraud, Waste and Abuse and General Compliance Training Presentation for additional information
  • Compliance Hotline: 1-866-364-1350
  • You can remain anonymous
  • Please be sure to leave as much information as possible
  • Available 24/7

Other ways to report

Care1st Compliance Officer (Patty Dal Soglio)
Phone: 602-778-1800 or toll free 1-866-560-4042
TTY: 1-800-367-8939
Fax: (602) 778-1814
Email: ComplianceDepartmentAZ@Care1stAZ.com
(ensure your email is sent securely if containing PHI/PII)
Address:
Care1st Health Plan Arizona
Attn: Compliance Department
2355 E. Camelback Rd., Ste 300
Phoenix, AZ 85016

WellCare Chief Compliance Officer (Michael C. Yount)
Phone: (813) 206-5282
Email: Michael.Yount@wellcare.com
Address:
WellCare Health Plans, Inc
8735 Henderson Road
Ren 1 - 3rd Floor
Tampa FL, 33634

AHCCCS Office of Inspector General (OIG)
Report suspected Medicaid fraud
Phone: (602) 417-4193 (Maricopa County)
Phone: 1-888-ITS NOT OK (888-487-6686 - outside Maricopa County)
Fax: (602) 417-4102
Online: www.azahcccs.gov; click “Fraud and Abuse” link under the Common Resources section
Address:
Office of Inspector General
701 E. Jefferson St., MD 4500
Phoenix, AZ 85034

Department of Health & Human Services Office of Inspector General Hotline
Report suspected Medicare fraud:
Phone: 1-800-447-8477 (1-800-HHS-TIPS)
TTY: 1-800-377-4950 | FAX: 1-800-223-8164
Submit Report Online: OIG.HHS.gov/fraud/hotline

Medicare Call Center
Phone: 1-800-633-4227 (1-800-MEDICARE)
TTY: 1-877-486-2048
Online:
http://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/FraudAbuseforConsumers/Report_Fraud_and_Suspected_Fraud.html


Healthcare Fraud and Abuse

The Providers' Guide to Detect and Report Fraud and Abuse

Refer to the following link for more information on Fraud, Waste and Abuse - Click Here!

The US Department of Health and Human Services and the Department of Justice offers resources to providers, including ways to safeguard a provider's medical identity, and recommendations for protecting both the patient and provider practice by reducing fraud and abuse:

AHCCCS (Medicaid) provides information on fraud awareness for providers. Choose the "Fraud and Awareness for Providers" link at the bottom of the page:


(HIPAA)

Health Insurance Portability and Accountability Act of 1996

Visit our HIPAA link below for additional information.
Refer also to the Standards of Conduct link above.

 

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Fraud, Waste & Abuse

The Centers for Medicare & Medicaid Services (CMS) requires plan Sponsors to provide Fraud, Waste, and Abuse (FWA) & General Compliance Training to health plans’ contracted first-tier, downstream, and related entities (FDRs) as well as FDR employees who are involved in the administration or delivery of Medicare Parts C and D benefits.

Click Here to locate the following resources for our FDRs/vendors, which include:

  • Training materials and instructions (CMS' General Compliance and Fraud, Waste & Abuse Training Presentation)
  • Attestation template
  • Standards of Conduct for Care1st FDRs/vendors
  • Anti-Fraud Plan for FDRs/vendors
  • Care1st Policies related to FDRs/vendors

United States spends more than $1.5 trillion on health care each year; about 15% of the gross national product.

  • The Government Accounting Office estimates that more than 10% of the healthcare budget is lost to fraud and abuse, which amounts to approximately $150 billion in year 2002.
  • Fraud wastes millions of dollars that can be spent in providing needed health care coverage
  • Fraud increases the cost of health care delivery
  • Fraud endangers the health of patients
  • Fraud undermines public confidence and trust

Refer to the CMS Fraud, Waste and Abuse and General Compliance Training presentation;
Also refer to the Anti-Fraud Plan for detailed information including applicable state and federal laws: Click Here!

Definition of Criminal Fraud

Fraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program, or to obtain, by means of false or fraudulent pretenses, misrepresentations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program (see 18 U.S.C. §1347).

Common Fraud Schemes in Managed Care

I. Administrative/Financial

  • Falsifying credentials
  • Billing fee-for-service (FFS) for capitated services (double-billing)
  • Accepting kickbacks for referrals of sicker patients to FFS specialists
  • Conducting improper enrollment and disenrollment practices
  • Attracting healthy patients or refusing sicker patients
  • Persuading or forcing sicker patients to disenroll
  • Falsifying medical exemptions

II. Services/Encounter

  • Falsifying encounter data
  • Misrepresenting services provided to meet quality of care standards
  • Billing for services/supplies not provided
  • Upcoding charges and unbundling services
  • Excluding distinct groups of beneficiaries [i.e. patients with chronic conditions or terminal illness]
  • Engaging in under-utilization
  • Regularly denying treatment requests and specialist referral without regard to legitimate medical evaluation

III. Member Issues

  • Falsifying eligibility application
  • Using another person’s health plan identification card to obtain medical care
  • Falsifying/altering prescriptions
  • Misrepresenting medical condition
  • Failing to report third party liability

Definition of Waste

Waste is overutilization of services, or other practices that, directly or indirectly, result in unnecessary costs to the Medicare Program. Waste is generally not considered to be caused by criminally negligent actions but rather the misuse of resources.

Definition of Abuse

Abuse includes actions that may, directly or indirectly, result in unnecessary costs to the Medicare Program. Abuse involves payment for items or services when there is not legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment.

Abuse can also mean when an individual (provider or member) touches or talks to another person in a prohibited way. Some examples of abuse include:

  • causing physical harm
  • injury
    • due to carelessness
    • by not saying or doing something that would prevent injury
  • keeping you against your will
  • emotional or sexual abuse
  • sexual assault

Duty to Report Suspected Fraud, Waste and Abuse

Everyone is responsible for reporting suspected Non-Compliance and fraud, waste and abuse.

Care1st prohibits retaliation for reporting in good faith.

Refer to Care1st Anti-Fraud Plan, Standards of Conduct and the Fraud, Waste and Abuse and General Compliance Training Presentation for additional information.

Ways to Report Suspected Fraud, Waste and Abuse

Compliance Hotline: 1-866-364-1350

  • You can remain anonymous
  • Please be sure to leave as much information as possible
  • Available 24/7

Other ways to report

Care1st Compliance Officer (Patty Dal Soglio)
Phone: 602-778-1800 or toll free 1-866-560-4042
TTY: 1-800-367-8939
Fax: 602-778-1814
Email: ComplianceDepartmentAZ@Care1stAZ.com
(ensure your email is sent securely if containing PHI/PII)
Address:
Care1st Health Plan Arizona
Attn: Compliance Department
2355 E. Camelback Rd., Ste 300
Phoenix, AZ 85016

WellCare Chief Compliance Officer (Michael C. Yount)
Phone: (813) 206-5282
Email: Michael.Yount@wellcare.com
Address:
WellCare Health Plans, Inc.
8735 Henderson Road
Ren 1 - 3rd Floor
Tampa FL, 33634

Arizona Medicaid: AHCCCS Office of Inspector General (OIG)
Report suspected Medicaid fraud
Phone: (602) 417-4193 (Maricopa County)
Phone: 1-888-ITS NOT OK (888-487-6686 - outside Maricopa County)
Fax: (602) 417-4102
Online: www.azahcccs.gov; click “Fraud and Abuse” link under the Common Resources section
Address:
Office of Inspector General
701 E. Jefferson St., MD 4500
Phoenix, AZ 85034

Department of Health & Human Services Office of Inspector General Hotline
Report suspected Medicare fraud:
Phone: 1-800-447-8477 (1-800-HHS-TIPS)
TTY: 1-800-377-4950 | FAX: 1-800-223-8164
Submit Report Online: OIG.HHS.gov/fraud/hotline
Medicare
Phone: 1-800-633-4227 (1-800-MEDICARE)
TTY: 1-877-486-2048
Online:
http://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/FraudAbuseforConsumers/Report_Fraud_and_Suspected_Fraud.html

What Can You Do?

  • Review the Anti-Fraud Plan
  • Report potential fraud immediately by contacting any of the above-referenced entities
  • Establish policies and procedures for the prevention, detection and reporting of fraud and abuse
  • Share this important information with your office staff

Deficit Reduction Act (DRA)

AHCCCS requires Care1st to train our provider network and their staff on the following aspects of the Federal False Claims Act provisions:

  • AHCCCS - Prohibited Acts and Remedies

For training materials regarding the DRA, please visit the AHCCCS website (training link is located on the left side of the page): http://www.azahcccs.gov/DRA/about.aspx

Federal and state links to additional Provider Fraud and Abuse information

The US Department of Health and Human Services and the Department of Justice offers resources to providers, including ways to safeguard a provider's medical identity, and recommendations for protecting both the patient and provider practice by reducing fraud and abuse:

AHCCCS (Medicaid) provides information on fraud awareness for providers. Choose the “Fraud and Awareness for Providers” link at the bottom of the page:

 

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HIPAA

Health Insurance Portability and Accountability Act of 1996

The Health Insurance Portability and Accountability Act of 1996 called for many changes in health care. Finalized federal regulations (called HIPAA Privacy Regulations) became effective as of April 14, 2003. These regulations require that we take extra precautions to protect personal health information (PHI). Care1st Health Plan and ONECare by Care1st Health Plan Arizona, Inc. (HMO SNP) has taken the necessary precautions to protect PHI. This is reflected through various means, including (but not limited to) developed policies and HIPAA-related training to assist our staff, as well as providers, companies and facilities we work with.

Another reason Congress enacted HIPAA was to improve efficiency and effectiveness of health care delivery (administrative simplification). The HIPAA established national standards for this, including:

  • Electronic health care transactions / Transaction Code Sets.
    • These provisions require that health plans and health care payors follow requirements established by the federal government regarding health care billing and reimbursement. This is crucial in light of increased electronic data exchange involving providers, clearinghouses and health plans and other business associates. Examples:
  • Unique identifiers, such as a National Provider Identifier (NPI)
  • Security

Congress enacted two additional laws to amend the HIPAA by adding more requirements and revising some provisions. These changes include streamlining efficacy through administration simplification.

Health Information Technology for Economic and Clinical Health Act (HITECH) - a provision of the American Recovery and Reinvestment Act of 2009 (ARRA)

  • criminalized some HIPAA violations committed through willful neglect
  • limitations of the sale of PHI
  • stronger individual rights to access electronic medical records
  • more restrictions on disclosure of certain information
  • increased civil fines for HIPAA violations
  • breach notification applicability to covered entities & business associates

and

the Patient Protection and Affordable Care Act of 2010 (ACA) includes additional and revised provisions that require:

  • Operating rules for each of the HIPAA transactions
  • A unique, standard Health Plan Identifier (HPID)
  • Standards for electronic funds transfer and electronic health care claims attachments
  • Health plans to certify compliance with the standards and operating rules
  • Penalties for health plans that are non-compliant and for failing to certify compliance with applicable standards and operating rules.

Additional information

Health & Human Services Office of Civil Rights (OCR)
If you have questions or concerns about HIPAA in your office, visit the Department of Health Services, Office of Civil Rights website - Click Here!

  • Or call OCR’s toll-free number at: 1-866.627.7748

CMS Resources

Care1st / ONECare Standards of Conduct - Click Here!

For more Compliance information, please visit our links for:

 

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Cultural Competency

We Respect the Diverse Languages and Cultures Our Members

Care1st Health Plan and ONECare by Care1st Health Plan Arizona, Inc. (HMO SNP) (“Care1st”) recognize that language misunderstandings and lack of cultural awareness can sometimes disrupt clear communication. So we emphasize our understanding in those areas to make sure we can communicate clearly with our members-no matter what language they're most comfortable speaking.

We Support our Members and the Providers Who Care for Them

In order to protect member privacy and to ensure accurate interpretation, both Limited English Proficiency (LEP) and hearing impaired members are encouraged to utilize contracted interpretation services. Please discourage patients of using friends and family members as interpreters unless the member requests it after being informed about the availability of the free interpreter services. The following are just some ways we demonstrate our commitment in assisting our members and the providers who care for them:

  • FREE face-to-face interpreter services for our hearing impaired members (see more info in the following sections on how to schedule an in-person interpreter at your office).
  • FREE TTY services for our hearing impaired members.
  • FREE interpreter language line
  • Member handbooks and other important information are available in English and Spanish. Other languages are available upon request.
  • Educational information that is designed for our providers and their staff, and our employees to improve understanding of how a member's cultural background affects their approach to healthcare.

Resource Corner

Care1st actively participates in a multi-AHCCCS plan collaboration (called C-3) which focuses on ways to foster and improve Cultural Competency awareness in order to better serve our members. Thanks to the combined effort of the C-3 group, Care1st is pleased to offer the following tools for our providers and their staff:

Please fill out our Surveys!

In an effort to better assist you regarding cultural competency education/training, please fill out the survey regarding the Provider & Patient Communication Guide and AHCCCS Contractor Interpretation Services List.

Please submit your surveys online, by fax or mail.

ONLINE Surveys

Download our survey forms:

Submit completed surveys via:

Email: ComplianceDepartmentAZ@Care1stAZ.com

Fax:
(602) 778-1814
Attn: Compliance Department

Mail:
Care1st Health Plan Arizona
Attn: Compliance Department
2355 E. Camelback Rd., Ste 300
Phoenix, AZ 85016

Provider & Staff Training

The Industry Collaboration Effort (ICE) is a non-profit organization comprised of health care industry volunteers. The ICE organization has produced the following educational training presentation and toolkit for providers regarding cultural competency. Topics include ways to improve communication with the diverse member population you serve: Please review and share with others/staff who are involved in our members’ (your patients’) care.

Free Continuing Medical Education (CME)/CE Credits!

The US Department of Health & Human Services, Office of Minority Health offers Physicians and Physician Assistants up to 9 free CME credits, and Nurse Practitioners can earn up to 9 contact hours. “A Physician's Practical Guide to Culturally Competent Care Web site equips health care professionals with awareness, knowledge, and skills to better treat the increasingly diverse U.S. population they serve” (US Department of Health & Human Services Office of Minority Health website: Click Here!).


Interpretation Services

Language interpretation is available at no cost to members and contracted providers. Care1st also offers free face-to-face sign language interpretation. Call our Member Services Department at the numbers below for more info on TTY service.

  • Protocol on How to request Language Interpreting Services (1-800-481-3293) - Click Here
  • Protocol for TTY Assistance:
    • Please allow at least 5-7 business days for in-person sign language assistance
    • Start by Calling our Member Services Department at the numbers below to schedule an appointment:
      • Care1st Member Services Department:
        • (602) 778-1800 OR
        • toll free at 1-866-560-4042
      • ONECare Member Services Department:
        • (602) 778-8345 OR
        • toll free at 1-877-778-1855

We also offer free TTY service to all our members when they call us (1-800-367-8939)


Additional Federal Resources

The US Department of Health & Human Services Office of Minority Health issues National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care. For more information on CLAS standards, Click Here!

US Department of Health & Human Services Fact sheets

 

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