Compliance

ProCare Advantage Plan Compliance

ProCare Advantage (HMO I-SNP) is committed to acting with integrity and making decisions based on the highest standards of ethical behavior, including complying with applicable laws and regulations.

To ensure the provision of quality health care services in compliance with applicable laws and regulations, ProCare Advantage developed a compliance program that provides guidelines and assigns responsibilities for controls and procedures that promote consistent and proper organizational behavior.

The Compliance Program has been developed to assist in establishing a culture within ProCare Advantage that promotes the prevention, detection, and resolution of instances of conduct that do not conform to federal and state law and federal and state health care program requirements.

The Compliance Program describes our commitment to ethical business practices and behavior. Additionally, the Compliance Program provides the framework for members and providers to notify ProCare Advantage of potential concerns.

Standards of Conduct

ProCare Advantage has implemented a Standards of Conduct that states the overarching principles and values by which ProCare Advantage operates and defines the underlying framework for our Compliance Program.

The ProCare Advantage Standards of Conduct describes our expectations that:

  • All employees and providers conduct themselves in an ethical manner.
  • Issues of noncompliance and potential fraud, waste, and abuse (FWA) are reported through appropriate mechanisms.
  • Reported issues will be addressed and corrected. The Standards of Conduct communicates to employees and providers that compliance is everyone’s responsibility, no matter what position they hold.

Review the full Standards of Conduct: Standards of Conduct

Medicare FWA & General Compliance Training

The Compliance Program describes our commitment to ethical business practices and behavior. Additionally, the Compliance Program provides the framework to assure that our employees, including officers, managers, volunteers, interns, Board of Directors, vendors (contractors, subcontractors), and first-tier, downstream, and related entities (FDRs) comply with the applicable legal and ethical standards of conduct, including our standards of conduct and requirements to prevent, detect, and mitigate fraud, waste, and abuse (FWA).

ProCare Advantage contracts with the Centers for Medicare and Medicaid Services (CMS) to provide health care and prescription drug benefits under Medicare Advantage and Medicare Part D programs to our Medicare beneficiaries. As a part of these contracts, CMS requires ProCare Advantage to oversee FDRs who provide health care or administrative services.

FDRs are an important partner in the continued success of our Compliance program.

Medicare requires FDRs to participate in the ProCare Advantage Compliance Program, and we are committed to providing FDRs with the tools needed to ensure FDRs meet the obligations of this program. ProCare Advantage Standards of Conduct and other resources for reporting concerns or issues are available by clicking the link below.

While Medicare FWA and General Compliance training for FDRs is not required by the Centers for Medicare and Medicaid Services (CMS), FDR agents (e.g., office staff and other personnel associated with or employed by an FDR) are expected to be in compliance with all applicable laws, rules, and regulations, and Medicare requirements.

Contact the ProCare Advantage Compliance Officer at compliance@procareadvantageplan.com with any questions about the ProCare Advantage Compliance Program.

Compliance Hotline

ProCare Advantage has implemented a Compliance Hotline for our Members; employees; first-tier, downstream, and related entities; and other contractors and agents.

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 Federal, State, or local laws and regulations.

All calls to the Compliance Hotline will be treated as confidential and private to the fullest extent possible.

Compliance Hotline: 1-844-317-9059 (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:

Corporate Compliance Officer
ProCare Advantage
PO Box 5849
Glen Allen, VA 23058-5849

Or Email: compliance@procareadvantageplan.com
Or Fax: 1-833-572-2367

Whether reporting by telephone 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.