Providers | Blue Shield Promise Health Plan
Compliance

Board of Directors Compliance Spotlight

Compliance Bulletins

FDR HIPAA Training Materials, Attestation, and DHCS PIR Form

Attestation Form for First-Tier, Downstream, and Other Related Entities (FDRs)

Distribution of Standards of Conduct For Vendors and FDRs

In accordance with CMS Compliance Guidance, Care1st requires that Anti-Fraud Plan (AFP) and Policies and Procedures be distributed to Vendor and FDR employees. These documents are provided in the section Care1st Standards of Conduct, Anti-Fraud Plan, and Policies & Procedures Documents, below. Please distribute these to your employees, and ask them to complete and return the FDR Attestation document to:

  • ComplianceDepartment@care1st.com or fax to (323) 889-2104, Attention: Janet F. Eisenberg, Compliance Director. Please call (323) 889-6638, ext. 6476, for any questions you may have.

If you suspect compliance, ethics, or integrity violation, or have questions about specific practices, please use the following resources:

  • Call Care1st’s Compliance HOTLINE at 1-877-837-6057 anonymously. Available 24/7. Toll-Free
  • Contact the Compliance Department at ComplianceDepartment@care1st.com
  • Contact the Care1st’s Corporate Compliance Office at extension 6202

Care1st Standards of Conduct, Anti-Fraud Plan, and Policies & Procedures Documents:

Fraud & Abuse

What is Fraud?
Fraud is "... Knowingly and willfully executing (or attempting to execute) a scheme to defraud any health care benefit program, or to obtain money or property from a health care benefit program through false representations..." [18 U.S.C. 1347].

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

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

What Can You Do?

  • Review Blue Shield of California Promise Health Plan Provider Manual section 16.1. Blue Shield of California Promise Health Plan Anti-Fraud Policy and Program
  • Report potential fraud immediately by calling the Blue Shield of California Promise Health Plan Compliance Hotline at 1-877-837-6057. You may also call the State of California Department of Health Services (SDHS) at 1-800-822-6222
  • Educate and train office staff
  • Establish policies and procedures for the prevention, detection and reporting of fraud and abuse
  • Share this important information with your office staff
  • Report potential fraud by calling Blue Shield of California Promise Health Plan’s Compliance Hotline at 1-877-837-6057. You may also call the State of California Department of Health Services (SDHS) Medi-Cal Fraud Hotline at 1-800-822-6222

Compliance Hotline: 1-877-837-6057

If you suspect compliance, ethics or integrity violation, or have questions about specific practices, call Care1st’s Compliance Office, or send an e-mail to ComplianceDepartment@care1st.com.

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