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 these laws, ProCare Advantage has 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 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).
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 first tier, downstream, and related entities (FDRs) 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 FDRs that compliance is everyone’s responsibility, no matter what position they hold.
Medicare FWA & General Compliance Training
ProCare Advantage contracts with the Centers for Medicare & 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 our first tier, downstream, and related entities (FDRs) who provide health care or administrative services.
As an FDR for ProCare Advantage, you 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 you with the tools needed to ensure you meet the obligations of this program. Our Standards of Conduct and other resources for reporting concerns or issues are available to you.
CMS requires our FDRs to complete Medicare FWA and general compliance training on an annual basis.
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 FWA training and education. However, this does not exempt your organization from having to complete the general compliance training 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). Or, 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 at firstname.lastname@example.org.
Compliance Hotline:1-844-317-9059 (toll free)
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.
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
PO Box 5849
Glen Allen, VA 23058-2190
Or Email: email@example.com
Or Fax: 800-335-0270
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.