Compliance
ProCare Advantage Plan Compliance
We are committed to acting with integrity and making decisions based on the highest standards of excellence, including complying with applicable federal and state laws and regulations.
To ensure the provision of quality health care services in compliance with these rules, ProCare Advantage’s compliance program provides guidelines and assigns responsibilities for controls and procedures that promote consistent and ethical organizational behavior.
The compliance program establishes a culture that promotes the prevention, detection, and resolution of instances of misconduct or circumstances violating rules governing our industry.
The compliance program supports our commitment to ethical business practices and behavior. It provides the framework to assure that our employees, Board members, vendors, and first-tier, downstream, and related entities (FDRs) work to prevent, detect, and mitigate fraud, waste, and abuse (FWA).
Code of Ethics
ProCare Advantage Plan’s Code of Ethics describes the overarching principles and values of our organization. Its purpose is to provide a clear understanding of our commitment to following ethical and legal principles as well as a reference point for guidance and instruction for all our workforce, including employees and contractors. Compliance with the Code is the responsibility of all ProCare Advantage Plan workforce members, as well as first tier and downstream entities performing services on behalf of ProCare.
The ProCare Advantage Code of Ethics describes our expectations that:
- All employees and first tier, downstream, and related entities (FDRs) conduct themselves in an ethical manner.
- Issues of noncompliance and potential fraud, waste, and abuse (FWA) are promptly reported through appropriate mechanisms.
- Reported issues will be promptly reviewed, addressed, and corrected.
The Code of Ethics communicates to employees and FDRs that compliance is everyone’s responsibility, no matter what position they hold.
Medicare FWA & General Compliance for FDRs
ProCare Advantage contracts with the Centers for Medicare & Medicaid Services (CMS) to provide health care and prescription drug benefits under Medicare Advantage Part C and Part D programs. As a part of these contracts, CMS requires ProCare Advantage to oversee our first tier, downstream, and related entities (FDRs) that provide health care or administrative services.
An FDR is an important partner in the continued success of our compliance program.
Vendors and FDRs have the option to:
- Adopt and follow ProCare Advantage’s Compliance Program, related policies, procedures, and Code of Ethics;
- Develop and follow their own equivalent Compliance Program, related policies, procedures, and Standards of Conduct that describe their organization’s commitment to comply with applicable laws, regulations and conduct themselves in an ethical manner; or
- Adopt and follow equivalent Compliance Program, related policies, procedures, and Standards of Conduct of another entity contracted with CMS to administer Medicare Advantage (Part C) and Prescription Drug (Part D) plans.
ProCare Advantage has the right to review and approve vendor and FDR compliance policies, procedures, and Standards of Conduct.
In accordance with CMS guidance, providers who have enrolled in Medicare Parts A or B, or are accredited as Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers are deemed to have met the requirement for the annual FWA training and education. However, this does not exempt your organization from having to complete the general compliance training available on the CMS website on an annual basis.
In order to ensure consistency and reduce the burden on providers, suppliers, contractors, and organizations, CMS has developed a web-based training module that can be used to satisfy the FWA and the general compliance training and education requirements.
FDRs must satisfy CMS’ general compliance and FWA training requirements. FDRs can complete the general compliance and/or FWA training modules available through the CMS Medicare Learning Network (MLN). Alternatively, FDRs may download, view or print the content of the CMS standardized training modules from the CMS website to incorporate into their organization’s existing compliance training materials/systems. The CMS training content cannot be modified to ensure the integrity and completeness of the training.
Regardless of the training program used, ProCare Advantage requires FDR agents to complete the FWA training within 90 days of contracting with ProCare Advantage and annually thereafter.
Thank you for your cooperation. If you have any questions about whether your organization is required to complete FWA and general compliance training, or whether your organization’s internal training or third-party training is sufficient, please contact ProCare Advantage Compliance Officer compliance@procareadvantageplan.com.
Compliance Hotline
Compliance Hotline: (844) 317 – 9059 (toll free)
ProCare Advantage Plan’s Compliance Hotline is available to individuals 24 hours per day, seven days per week to report matters of concern. Individuals calling the Hotline may choose to remain anonymous when raising matters or questions. Plan Members, workforce members, FDRs, and other contractors and agents using the Hotline should not be concerned about sharing their thoughts, as they are protected by ProCare Advantage’s Non-Retaliation policy.
The Compliance Hotline provides a mechanism for callers to report activity related to known or suspected non-compliance with ProCare Advantage’s mission; policies and procedures; Compliance program; Standards of Conduct; or any applicable Federal, State, or local laws and regulations.
Calls to the Compliance Hotline will be treated as confidential and private to the fullest extent possible.
Compliance Hotline: (844) 317 – 9059 (toll free)
If you are not comfortable or able to make a report via the Compliance Hotline, you may send a written report by mail to:
Nancy Roht
ProCare Advantage Plan
PO Box 5849
Glen Allen, VA 23058-5849
Or Email: compliance@procareadvantageplan.com
Or Fax: 1-833-572-2387
When contacting us by phone or in writing, please provide as much detail as possible, including, but not limited to, names, dates, times, locations, and the specific conduct you feel may violate the law or ProCare Advantage Policy.
No individual making a good faith report of a suspected violation shall be retaliated against. However, any individual who knowingly makes a false allegation shall be subject to disciplinary action in accordance with ProCare Advantage policy.
