2014 Corporate Compliance
2013 Corporate Compliance
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
- 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
- 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.