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Compliance & Fraud, Waste and Abuse Program

Commonwealth Care Alliance’s
Compliance Program


Commonwealth Care Alliance, Inc. (CCA) is committed to conducting its business operations in compliance with ethical standards, internal policies and procedures, contractual obligations and all applicable federal and state statutes, regulations and rules, including but not limited to, those pertaining to the Centers for Medicare and Medicaid Services (CMS) Part C and D programs; the Massachusetts Executive Office of Health and Human Services (EOHHS), (MassHealth) and the Office of Inspector General (OIG). This Compliance Program applies to all CCA’s lines of business. CCA’s compliance commitment includes its internal business operations, as well as its oversight and monitoring responsibilities related to its First Tier, Downstream and Related Entities (FDR).

CCA has formalized its compliance activities through a comprehensive Compliance Program. The Compliance Program incorporates the fundamental elements of an effective compliance program identified by CFR 422.503(b) (4) (vi) and CFR 423.504(b) (4) (vi) and the OIG Federal Sentencing Guidelines.

  • CCA’s Compliance Program contains the following core elements including fraud, waste and abuse (FWA):
    • Code of Conduct and Written Policies and Procedures
    • Compliance Officer, Compliance Committee and appropriate Oversight
    • Compliance Training and Education Program
    • Effective Lines of Communication and Reporting
    • Well-Publicized Disciplinary Standards and Enforcement
    • Effective System for Routine Monitoring, Auditing and Identification of Compliance Risks
    • Procedures for Prompt Response to Compliance Issues and Remediation
    • First Tier, Downstream and Related Entity Compliance Oversight
  • CCA’s Compliance Program is developed to:
    • Promote compliance with all applicable federal and state laws and contractual obligations;
    • Prevent, detect, investigate, mitigate and appropriately report suspected incidents of program non-compliance;
    • Prevent, detect, investigate, mitigate and appropriately report suspected incidents of fraud, waste and abuse; and
    • Promote and enforce CCA’s Code of Conduct.

Commonwealth Care Alliance’s Fraud, Waste & Abuse Program

CCA is committed to preventing, identifying, investigating, correcting, and appropriately reporting suspected cases of fraud, waste, and abuse. CCA looks to its providers to assist in this effort.

The mission of CCA’s FWA Program is to assist in protecting the integrity of CCA, federal and state programs by working to prevent, identify, investigate, correct and report suspected incidents of fraud, waste and abuse. This FWA Program is an integral part of CCA’s Compliance Program. CCA must work collaboratively to combat fraud, waste and abuse. Anyone conducting business with CCA is expected to report any suspected cases of fraud, waste or abuse to CCA through one of the following reporting mechanisms without fear of retaliation or retribution for reports made in good faith:

Contact CCA’s Interim Chief Compliance Officer Lisa Fleming

Contact CCA’s Interim Chief Compliance Officer Lisa Fleming

lfleming@commonwealthcare.org
617-426-0600 x1309

Report to the CCA Compliance Hotline

Report to the CCA Compliance Hotline

800-826-6762

Definitions and Examples of Fraud Waste and Abuse:

  • Fraud

    Is defined as knowingly, intentionally 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, representations, or promises, any money or property owned by or under the custody or control of any health care benefit program. Examples of fraud include, but are not limited to: a provider billing for services or supplies that were not provided; or a member knowingly sharing their CCA ID card with a non-CCA member in order to obtain services.

  • Waste

    Is defined as the overutilization of services, or other practices that directly or indirectly result in unnecessary costs. Waste is generally not considered to be caused by criminally negligent actions but rather the misuse of resources. Examples of waste include, but are not limited to: a mail order pharmacy sending medications to members without first confirming the member still needs them; or a physician ordering excessive diagnostic tests.

  • Abuse

    Involves payment for items or services when there is no legal entitlement to that payment even when the provider has not knowingly and/or intentionally misrepresented facts to obtain payment. An example of abuse includes a medical professional providing treatment to a patient that is inconsistent with the diagnosis; or misusing codes and modifiers on a claim such as upcoding or unbundling codes.

CCA’s FWA Program as well as specific policies and procedures are designed to prevent, detect, investigate, mitigate and appropriately report suspected cases of fraud, waste and/or abuse. CCA is subject to several laws and regulations pertaining to FWA, including, but not limited to, the federal Anti-Kickback Statute, the federal False Claims Act, the Massachusetts False Claims Law and federal and state whistleblower protections.

The Anti-Kickback Statute prohibits the exchange, or offer to exchange, anything of value in an effort to induce (or reward) the referral of federal health care program business. It is an intent-based statute requiring that the party “knowingly and willingly” engaged in the prohibited conduct.

The Federal False Claims Act imposes civil liability on any person who knowingly submits, or causes the submission of a false or fraudulent claim to the Federal Government.

Using the Massachusetts False Claims law, the False Claims Division conducts civil investigations and prosecutions against companies and individuals who mislead or defraud state or municipal entities through the use of false or fraudulent claims, records or statements. A whistleblower is a person who exposes any kind of information or activity that is deemed illegal, unethical, or not correct within an organization that is either private or public. Whistleblower protections protect reporters against retaliation and are granted Federal and State Protection.

Whistleblower / Fraud, Wast and Abuse Information, Commonwealth of Massachusetts*

The Whistleblower Protection Program*



Compliance & Fraud Waste and Abuse Program Resources

The Code of Conduct is the fundamental statement of the CCA’s governing principles. The Code of Conduct communicates to CCA’s Workforce, providers, contractors and First Tier, Downstream and Related Entities (FDR) that compliance and ethics are an integral part of CCA. All FDR’s must also distribute a Code of Conduct (Standards of Conduct) to their employees and downstream entities at time of hire/contract and annually thereafter. If an FDR does not have their own Code of Conduct, they may adopt CCA’s Code of Conduct Fraud, Waste & Abuse Program Resources.


 


HPMS Memo: Additional Guidance Compliance Program Training Requirements

Medicare Parts C and D Fraud, Waste and Abuse Training Instructions (pdf)Medicare Parts C and D General Compliance Training (pdf)Combating Medicare Parts C and D Fraud, Waste, and Abuse (pdf)Medicare Fraud and Abuse Preventing Detection and Reporting Fact Sheet* (pdf)Commonwealth Care Alliance Fraud, Waste and Abuse Program Description (pdf)



Visit the Medicare Learning Network* for all CMS sponsored training for Providers and FDRs.



 


To view the PDF files above, you may need to download a free copy of Adobe® Acrobat Reader software on your computer. *When you click this link, you will leave Commonwealth Care Alliance’s website.


 
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Code of Conduct