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CORPORATE COMPLIANCE PROGRAM

 

EIHAB Human Services is dedicated and committed to:

 

  • Providing housing and comprehensive supportive services designed to meet the physical, social and emotional needs of each individual.

  • Helping individuals whose needs have been neglected or whose circumstances have prevented use of existing services.

  • Promoting greater public understanding the unmet needs of individuals with special needs.

 

EIHAB Human Services is further dedicated and committed to meeting high ethical standards and compliance with all applicable laws in all activities regarding the delivery of health care through its licensed and certified facilities. It is our goal that our established and effective Compliance Program will assist the Agency in fulfilling its fundamental vision, mission, and values.

 

As such our Compliance Plan is an integral part of EIHAB Human Services’ ongoing efforts to achieve compliance with federal and state laws relating to Medicaid billing. The Plan creates a comprehensive system of oversight for Medicaid billing, reporting and practices and describes our procedures for detecting and preventing fraud, waste and abuse. The goal of the Agency’s Compliance Program is to ensure that Medicaid eligible services are properly documented and accurately billed and that services rendered, but not properly documented are not billed. In addition, the Compliance Program establishes systematic checks and balances to detect and prevent inaccurate billings and inappropriate practices in compliance with Medicaid standards.

 

EIHAB Human Services will communicate its compliance standards and policies through required training and communication initiatives and distribution of this Compliance Plan and the Standards of Conduct to all Affected Individuals.

 

EIHAB Human Services has appointed a Compliance Officer who is responsible for the overall operation of the Compliance Program.  A Compliance Committee works with the Compliance Officer to implement and maintain an effective Compliance Program.

 

The Compliance Plan shall be overseen by EIHAB Human Services’ Compliance Officer who shall report directly to the Chief Executive Officer. It remains, however, the responsibility of all Affected Individuals involved in the provision of services and the billing process to comply with the provisions of the law. The Compliance Plan also advises that all Affected Individuals of the procedures to be used in reporting non-compliance with such Federal and State laws. The Compliance Plan will be consistently enforced through appropriate disciplinary mechanisms including, if appropriate, discipline of Affected Individuals responsible for failure to detect and/or report noncompliance. 

 

As is detailed within this Compliance Plan, it is the duty of all Affected Individuals to comply with the policies as applicable to their individual areas of employment or contracts.

 

Detected noncompliance, discovered through any mechanism, such as compliance auditing procedures and/or confidential reporting of noncompliance, will be responded to in an expedient manner.  EIHAB Human Services is dedicated to the resolution of such matters and will take all reasonable steps to prevent further similar violations, including any necessary modifications to the Compliance Plan and policies and procedures.

 

EIHAB Human Services will not take any retaliatory action against an Affected Individual who, in good faith, reports actual or suspected noncompliance or illegal activities or for good faith participation in the Compliance Program.

EIHAB Human Services will not take any retaliatory action against an employee if the employee discloses certain information about the Agency’s policies, practices, or activities to a regulatory, law enforcement, or other similar agency or public official.  Protected disclosures are those that assert that the Agency is in violation of a law that creates a substantial and specific danger to the public health and safety; or that constitute healthcare fraud under the law; or that assert that the employee, in good faith, believes constitutes improper quality of care.

 

 

A. Benefits to our Compliance Program

Benefits to our Compliance Plan include, but are not limited to the following:

 

  • Demonstrates to all Affected Individuals and community at large our strong commitment to honesty, responsibility and appropriate conduct.

  • Develops a system to encourage all Affected Individuals to report potential problems that may be detrimental to the client and the Agency.

  • Develops procedures that allow for a thorough investigation of alleged misconduct.

  • Develops procedures for promptly and effectively conducting internal monitoring and auditing which may prevent non-compliance.

  • Through early detection and reporting, minimizes the risk to the Agency and, thereby, reduces our exposure to any civil damages or penalties, criminal sanctions or administrative remedies.

 

 

 

Policies and Procedures and Standards of Conduct

To support the operation of EIHAB Human Services’ Compliance Program, policies and procedures are established to provide direction to Affected Individuals and address the following components of the Compliance Plan:

  • Conflict of Interest

  • Reporting and investigation of noncompliance

  • Non-retaliation and non-intimidation

  • False Claims Act and Whistleblower protections

  • Compliance Program education and training

  • Auditing and monitoring

  • Billing errors and overpayments

  • Kickbacks and business courtesies

  • Discipline for noncompliance or failure to report

  • Responding to governmental investigations

 

All Affected Individuals are expected to be familiar with and knowledgeable about the Compliance Program Policies and Procedures.  The Policies can be accessed at www.eihab.org or on-site.

The Standards of Conduct serves as a foundational document that describes the Agency’s fundamental principles and values, and commitment to conduct its business in an ethical manner.  The Standards of Conduct provides Affected Individuals with guidance on requirements for conduct related to their employment, contract, assignment or association with EIHAB Human Services.

When any person knows or reasonably suspects that the expectations in the Standards of Conduct and the Compliance Program have not been met, this must be reported to the immediate supervisor, a member of Management, the Compliance Officer, member of the Compliance Committee, or the Chief Executive so that each situation may be appropriately dealt with.  The Compliance Officer may be reached at (718) 276-6101 Extension.311.  The Chief Executive can be reached at (718) 276-6101 Extension. 113. Reports may be made in person; by phone, fax, mail, or email; or anonymously by other means

Compliance Program Oversight

 

Compliance Officer

EIHAB Human Services has designated a Compliance Officer who oversees the development, implementation and effectiveness of EIHAB Human Services Compliance Program and ensures appropriate handling of instances of suspected or known illegal or unethical conduct.

 

We have identified the Corporate Compliance Officer as Lelia Quiroz. However, in the event that the Corporate Compliance Officer is not available, we have designated and alternate contact. The following responsible individuals will receive and coordinate complaints or concerns involving our compliance operations.

 

Lelia Quiroz

Corporate Compliance Officer

lelia.quiroz@eihab.org

718-276-6101 Ext.311

Mona Saleh

Director of Quality Assurance

mona.saleh@eihab.org

718-276-6101 Ext:214

 

Duties of the Compliance Officer include but not limited to:

 

  • Overseeing and monitoring the implementation of the Compliance Program.

  • Developing and implementing Compliance Program policies and procedures and Standards of Conduct.

  • Reviewing and revising, periodically, the Standards of Conduct, the Compliance Program, and policies and procedures as changes occur within EIHAB Human Services, and/or in the law, regulations, or governmental and third-party payers.

  • Developing, implementing, and monitoring the annual Compliance Work Plan.

  • Reporting, no less frequently than quarterly, to the Board of Directors, Chief Executive, and Compliance Committee on the progress of implementation of the Compliance Program.

  • Assisting the Chief Executive, Senior Leadership, Management, and the Compliance Committee in establishing methods to improve EIHAB Human Services’ quality of service and to reduce vulnerability to fraud, abuse, and waste.

  • Developing, coordinating, and participating in a multifaceted educational and training program that focuses on the elements of the Compliance Program and seeks to ensure that all Affected Individuals, consistent with roles and any associated risk areas, are knowledgeable of, and comply with, pertinent Federal and State standards and EIHAB Human Services’, Standards of Conduct.

  • Ensuring that excluded individuals and entities are not employed or retained by the Agency.

  • Directing EIHAB Human Services internal audits established to monitor effectiveness of compliance standards and the Compliance Program.

  • Independently investigating and acting on matters related to compliance, including the flexibility to design and coordinate internal investigations (e.g., responding to reports of problems or suspected violations) and any resulting corrective action with all departments, providers, and sub-providers, agents, and, if appropriate, independent contractors.

  • Coordinating internal investigations and ensuring the implementing corrective action.

  • Developing policies and programs that encourage managers and employees to report suspected fraud and other improprieties without fear of retaliation. Providing guidance to Management medical/clinical program personnel, and individual departments regarding Policy and Procedures and governmental laws, rules and regulations.

  • Maintaining a reporting system, including an anonymous means to report, and responding to concerns, complaints, and questions related to the Compliance Program.

  • Maintaining a reporting system (hotline) and responding to concerns, complaints and questions related to the Compliance Program.

  • Overseeing efforts to communicate awareness of the existence and contents of the Compliance Program.

  • Ensuring that independent contractors (recipient service provision, vendors, billing services, etc.) are aware of the requirements of EIHAB Human Services Compliance Program.

  • Acting as a resourceful leader regarding regulatory compliance issues. Actively seeking up to date material and releases regarding regulatory compliance.

  • Continuing the momentum of the Compliance Program and the accomplishment of its objectives.

 

The Structure and Duties and Role of the Compliance Committee

Reporting Structure and Purpose

Compliance Committee members are appointed by the Chief Executive Officer (CEO) and approved by the Board of Directors. Compliance issues are reported by the Compliance Committee to the CEO and Board, where appropriate. The Compliance Committee’s purpose is to advise and assist the Compliance Officer with implementation of the Compliance Plan.

 

The Compliance Committee will meet on a regular basis, but not less than quarterly.  Meeting minutes will be maintained by the Compliance Officer.

Function

The roles of the Compliance Committee include:

 

  • Analyzing the environment where EIHAB Human Services does business, including legal requirements with which it must comply.

  • Reviewing and assessing existing Policy and Procedures that address these risk areas for possible incorporation into the Compliance Program.

  • Reviewing and monitoring Compliance Program training and education to ensure that they are effective and completed in a timely manner.

  • Ensuring that the Agency has effective systems and processes in place to identify Compliance Program risks, overpayments, and other issues and has effective policies and procedures for correcting and reporting such issues.

  • Working with departments to develop standards and policy and procedures that address specific risk areas and encourage compliance according to legal and ethical requirements

  • Coordinating with the Compliance Officer to ensure that the written policies and procedures and Standards of Conduct are current, accurate, and complete.

  • Developing internal systems and controls to carry out compliance standards, Standards of Conduct, and policies and procedures.

  • Coordinating with the Compliance Officer to ensure communication and cooperation by Affected Individuals on compliance-related issues, internal or external audits, or any other function or activity. 

  • Developing a process to solicit, evaluate and respond to complaints and problems.

  • Monitoring internal and external audits to identify issues related to non-compliance.

  • Implementing corrective and preventative action plans and follow-up to determine effectiveness.

  • Ensuring the development and implementation of an annual Compliance Work Plan.

  • Advocating for sufficient funding, staff, and resources to be allocated to the Compliance Officer to carry out duties related to the Compliance Program.

  • Ensuring that the Agency has appropriate systems and policies in place that effectively identify risks, overpayments, and other areas of concerns including fraud, waste, and abuse.

  • Monitoring and evaluating the Agency’s Compliance Program for effectiveness at least annually and making recommendations for necessary modifications to the Compliance Program as applicable.

  • Developing and implementing a Compliance Committee Charter.  The Charter will outline the Compliance Committee’s duties and responsibilities, membership, designation of a chairperson and frequency of meetings.  The Charter will be reviewed and updated annually.

 

Delegation of Substantial Discretionary Authority

Any employee or prospective employee who holds, or intends to hold, a position with substantial discretionary authority for the Agency is required to disclose any name changes and any involvement in non-compliant activities including healthcare-related crimes.  In addition, the Agency performs reasonable inquiries into the background of such applicants, all prospective employees, the Chief Executive and other senior administrators, Board members, interns, contractors, and vendors.

 

The following resources may be queried when conducting screening:

 

a)  The System for Award Management (SAM) available on the SAM website.  The URL address is: https://www.sam.gov

b) HHS/OIG List of Excluded Individuals and Entities.  The URL address is: http://exclusions.oig.hhs.gov/.

c) Medicaid Exclusions | Office of the Medicaid Inspector General.  The URL address is: https://omig.ny.gov/medicaid-fraud/medicaid-exclusions

d)  Licensure and disciplinary record with NYS Office of Professional Medical Conduct (Physicians, Physician Assistants) (the URL address is http://www.health.state.ny.us/nysdoh/opmc/main.htm) and/or New York State Department of Education (other licensed professionals) (the URL address is http://www.op.nysed.gov/opsearches.htm). 

 

Education and Training

Expectations

 

Education and training are critical elements of the Compliance Program. All Affected Individuals are expected to be familiar and knowledgeable about EIHAB Human Services’ Compliance Plan and have a solid working knowledge of his or her responsibilities under the plan. Compliance policies and standards will be communicated to all Affected Individuals through required participation in training programs.

 

The proper education and training of all Affected Individuals is a significant element of an effective compliance program. As such, all Affected Individuals will be expected to participate in appropriate training.

 

It is the Compliance Officer’s responsibility to ensure that all Affected Individuals involved with the Medicaid service and billing process is educated about the applicable laws and regulations governing provider billing and documentation. In addition, EIHAB Human Services Compliance Plan shall be shared with all Affected Individuals, be available for inspection and shall be published on the EIHAB Human Services website.

 

The Compliance Officer shall also develop, oversee and/or provide in- service training on Medicaid billing and documentation requirements for all Affected Individuals involved in providing and/or billing for Medicaid services periodically and at other times, including initial employment or assignment or appointment.

 

Such training shall be mandatory and EIHAB Human Services shall maintain records of all trainings.

 

Training Topics - General

All Affected Individuals shall participate in training on the topics identified below:

 

  • EIHAB Human Service’s Compliance Plan;

  • Standards of Conduct and other related written guidance;

  • Federal False Claims Act;

  • New York False Claims Act;

  • Whistleblower Protections;

  • Risk areas and organizational experience;

  • The role and responsibilities of the Compliance Officer and the Compliance Committee;

  • Communication channels (name of Compliance Officer, reporting mechanisms, anonymous reporting mechanism);

  • EIHAB Human Services’ expectations for reporting known or suspected fraud, waste, and abuse; illegal or unethical acts; actual or suspected violations of Federal or State laws and regulations; actual or suspected violations of the Standards of Conduct, the Compliance Program, and  EIHAB Human Services’ policies and procedures; improper acts in the delivery or billing of services; and other wrongdoing (collectively referred to as “compliance concerns”) and how the Agency responds to such reports including the investigation process and corrective actions;

  • EIHAB Human Services’ disciplinary policy and standards;

  • Prevention of fraud, waste, and abuse; and

  • Non-retaliation and non-intimidation policy.

 

All Affected Individuals will complete the Compliance Program training no less frequently than annually.
 

EIHAB Human Services will maintain an annual training plan.  The training plan will, at a minimum, outline the subjects or topics for compliance training and education, the timing and frequency of the training, which Affected Individuals are required to attend, how attendance will be tracked, and how the effectiveness of the training will be periodically evaluated.  The training plan will be reviewed by the Compliance Officer and Compliance Committee and updated as needed, but at minimum on an annual basis.  

 

Training Topics - Targeted

In addition to the above, targeted training will be provided to all Affected Individuals whose job responsibilities include activities related to compliance topics. Managers shall assist the Compliance Officers in identifying areas that require specific training and are responsible for communication of the terms of this Compliance Plan to all independent contractors doing business with EIHAB Human Services.

 

Orientation

As part of orientation, all Affected Individuals shall receive a written copy of the Compliance Plan and Standards of Conduct and be provided access to Compliance Program policies and procedures.

 

Attendance

All education and training relating to the Compliance Plan will be verified by attendance and a signed acknowledgement of receipt of the Compliance Plan and Standards of Conduct.

 

Attendance at compliance training sessions is mandatory and is a condition of continued employment/ contract/appointment/assignment with the Agency.

 

Lines of Confidential Communication

 

Expectations

Open lines of communication between the Compliance Officer and all Affected Individuals subject to this Compliance Plan are essential to the success of our Compliance Program and commitment to comply with all applicable laws and regulations and the prevention of Medicaid fraud, waste, and abuse.

 

All Affected Individuals have an obligation to refuse to participate in any wrongful course of action and to report the actions according to the procedure listed below. Failure to report is deemed misconduct and a violation of this requirement.

 

Reporting Procedure

If any of the Affected Individuals learns of, or is asked to participate in potential noncompliant activities, in violation of this Compliance Plan, he or she should contact the Compliance Officer, his or her immediate supervisor, a member of the Management Team, or a member of the Compliance Committee. Reports may be made in person or by calling a telephone line dedicated for the purpose of receiving such notification (631) 771-7718, mailing information to 168-18 South Conduit Boulevard, Springfield Gardens, NY 11434 - Attention: Compliance Officer.

 

Upon receipt of a question or concern, any supervisor, officer or director shall document the issue at hand and report issue to the Compliance Officer. Any questions or concerns relating to potential non-compliance by the Compliance Officer should be reported immediately to the Chief Executive Officer.

 

The Compliance Officer or designee shall record the information necessary to conduct an appropriate investigation of all complaints. If the employee was seeking information concerning the Standards of Conduct or its application, the Compliance Officer or designee shall record the facts of the call, the nature of the information sought and respond as appropriate.

 

Protections

EIHAB Human Services shall, as much as is possible, protect the anonymity of all Affected Individuals who reports any complaint or question about EIHAB Human Services’ Compliance Program and Standards of Conduct. Strict confidentiality regarding the reporting of compliance concerns will be maintained unless the matter is subject to a disciplinary proceeding, referred to, or under investigation by Federal, State, or local law enforcement, or disclosure is required during a legal proceeding.

 

Policy of Non-Retaliation and Non-Intimidation

EIHAB Human Services will not take any retaliatory action against an Affected Individual who, in good faith, reports a compliance concern, as defined by this Plan or for good faith participation in the Compliance Program, including but not limited to:

  • Reporting potential issues;

  • Investigating issues;

  • Self-evaluations;

  • Audits;

  • Remedial actions; and

  • Reporting to appropriate officials as provided in sections 740 and 741 of the New York State Labor Law.

 

Any threat of retribution, retaliation, or intimidation against a person who acts in good faith pursuant to their responsibilities under the Compliance Plan is acting against EIHAB Human Services’ Compliance Policy.  Discipline, up to and including termination of employment, contract, appointment, or assignment, will result if such retribution, retaliation, or intimidation is proven.

Affected Individuals who believe they have been subject to retribution, retaliation and/or intimidation for reporting a compliance concern or for good faith participation in the Compliance Program shall report the actions to the Compliance Officer who shall conduct an investigation into the allegation in accordance with this Compliance Plan (Response to Compliance Issues).

Guidance

Any Affected Individual may seek guidance about the Compliance Plan or Standards of Conduct at any time by following the reporting mechanisms outlined above.

Disciplinary Action - General

Affected Individuals who fail to comply with EIHAB Human Services’ Compliance Program and Standards of Conduct, or who, upon investigation, are found to have committed illegal or unethical acts or violations of applicable Federal and State laws and regulations, the Compliance Program, the Standards of Conduct, or the Agency’s policies and procedures, will be subject to appropriate disciplinary action, up to and including termination of employment, contract, assignment, or appointment with the Agency.

 

When the determination is made that a compliance violation occurred involving a contractor or vendor, the Compliance Officer will notify the Chief Executive and work collaboratively to determine and execute the appropriate corrective action.

The Agency will apply progressive discipline consistent with the violation.  Examples of the disciplinary action that may be taken in accordance with the nature and scope of the infraction include but are not limited to: (a) verbal counseling or warning; (b) counseling with written warning; (c) retraining; (d) reassignment or demotion; (e) suspension without pay; and (f) termination of employment, contract, assignment, or appointment.  The Agency will consider intentional or reckless behavior as being subject to more significant discipline.

 

The following actions will result in more significant disciplinary action:

 

  • Authorization of or participation in actions that violate Federal or State laws, regulations, the Compliance Program, Standards of Conduct, or any related policies and procedures;

  • Failure to comply with the Agency’s policies governing the prevention, detection, or reporting of fraud and abuse;

  • Falsification of records;

  • Submitting or causing to submit a false claim;

  • Failure to report a violation by a peer or subordinate;

  • Failure to cooperate in an investigation; and

  • Retaliation/intimidation against an individual for reporting a possible violation or participating in an investigation.

 

Any discipline will be appropriately documented in the Affected Individual’s file, along with a written statement of reason(s) for imposing such discipline. Such documentation will be considered during an employee’s regular and promotional evaluations.

 

The Compliance Officer will maintain a written record of all disciplinary actions taken against Affected Individuals related to non-compliance and violations, including verbal warnings, and will reference these records when necessary to ensure consistency in application of disciplinary measures. The Compliance Officer will provide a report on disciplinary actions taken to the Compliance Committee and the Board of Directors.

Disciplinary Action -Supervisory

Managers and supervisors will be disciplined for failure to adequately instruct their subordinates, or for failing to detect noncompliance with applicable policies and legal requirements, where reasonable diligence on the part of the manager or supervisor would have led to the earlier discovery of any problems or violations and would have provided EIHAB Human Services with the opportunity to correct them.

Auditing and Monitoring

Internal Audits

Ongoing evaluation is critical in detecting non-compliance and will help ensure the success of EIHAB Human Services’ Compliance Program. An ongoing auditing and monitoring system, implemented by the Compliance Officer, in consultation with the Compliance Committee, is an integral component of our auditing and monitoring systems.

 

On an annual basis, the Compliance Officer, in conjunction with the Chief Executive, Senior Management, and Compliance Committee, will develop an audit plan based on an organizational risk assessment. 

 

This ongoing auditing and monitoring will evaluate at minimum, the following risk areas:

 

  • Billings;

  • Payments;

  • Ordered services;

  • Medical necessity;

  • Quality of care

  • Governance;

  • Mandatory reporting;

  • Credentialing;

  • Contractor, subcontractor, agent or independent contract oversight;

  • Review of contracts and relationships with contractors, specifically those with substantive exposure to government enforcement actions;

  • Review of documentation and billing relating to claims made to Federal, State and third-party payers for reimbursement;

  • Compliance training and education;

  • Effectiveness of the Compliance Program; and

  • Other risk areas that are or should be reasonably identified by EIHAB Human Services through its organizational experience.

 

 

The audits and reviews will examine EIHAB Human Services’ compliance with specific rules and policies through on-site visits, personnel interviews, general questionnaires (submitted to employees and contractors), and record documentation reviews.

 

Results of all auditing and monitoring activities will be reported to the Compliance Committee and Board of Directors.

Compliance Plan Integrity

Additional steps to ensure the integrity of the Compliance Plan will include:

 

  • The Compliance Officer will be notified immediately in the event of any visits, audits, investigations or surveys by any Federal or State agency or authority and shall immediately receive a photocopy of any correspondence from any regulatory agency charged with licensing EIHAB Human Services and/or administering a Federally or State-funded program or county-funded program with which EIHAB Human Services participates.

  • Establishment of a process detailing ongoing notification by the Compliance Officer to all appropriate personnel of any changes in laws, regulations, or policies; as well as appropriate training to assure continuous compliance.

 

 

Response to Compliance Issues

Violation Detection

EIHAB Human Services maintains a formal confidential and anonymous compliance reporting process to encourage the reporting of any compliance concerns.  Affected Individuals must promptly report any compliance concerns to Compliance Officer, the immediate supervisor, a member of Management, or a member of the Compliance Committee.  Service recipients, vendors, and any party conducting business with EIHAB Human Services may report compliance concerns to the Compliance Officer through the confidential or anonymous reporting process.

As part of its Compliance Program, EIHAB Human Services will ensure that all reports of compliance concerns are immediately and objectively investigated and resolved promptly.  Such investigations may be conducted by the Compliance Officer, members of the Compliance Committee, other employees or external parties as indicated or recommended by the Compliance Officer, the Chief Executive or legal counsel.

The Compliance Officer will take immediate measures to secure relevant evidence or documentation and will ensure the confidentiality of any information obtained from a report, interview or through an investigation, unless otherwise required by law.

Unless a potential conflict of interest exists, the Compliance Officer will inform the Chief Executive of any pending investigations.  The Compliance Officer or Chief Executive will arrange to retain legal counsel, as deemed appropriate.

 

Reporting

The results of the investigation and remedial actions will be communicated confidentially to the Chief Executive, members of the Board of Directors, and other employees based on a need-to-know basis.  The Compliance Officer shall report to the Compliance Committee regarding each investigation conducted unless conducted under attorney privilege.

At the conclusion of an investigation involving legal counsel, he/she shall issue a report to the Compliance Officer, Chief Executive Officer, and Compliance Committee summarizing his or her findings, conclusions and recommendations and will render an opinion as to whether a violation of the law has occurred. The report will be reviewed with legal counsel in attendance. Any additional action will be on the advice of counsel.

 

Rectification

If the Compliance Officer, in consultation with legal counsel, identifies credible evidence or credibly believes that a State or Federal law, rule, or regulation has been violated, the Compliance Officer will promptly report such violation to the appropriate governmental entity, where such reporting is otherwise required by law, rule, or regulation.

 

If EIHAB Human Services identifies that an overpayment was received from any third-party payer, the appropriate regulatory (funder) or prosecutorial (attorney general/police) authority will be appropriately notified with the advice and assistance of counsel.

 

It is our policy to not retain any funds, which are received as a result of overpayments. Overpayments will be reported and refunded to Medicaid in accordance with the appropriate self-disclosure protocols and any required time frames.

In instances where it appears an affirmative fraud may have occurred; appropriate amounts shall be returned after consultation and approval by involved regulatory and/or prosecutorial authorities. Systems shall also be put in place to prevent such overpayments in the future.

 

Recordkeeping

Regardless of whether a report is made to a governmental agency, the Compliance Officer shall maintain a record of the investigation, including copies of all pertinent documentation. The Compliance Officer will organize the information so that the Agency can determine if an infraction occurred.  The Compliance Officer will securely maintain all notes of the interviews, all evidence and review of documents as part of the investigation file.  This record will be considered confidential and privileged and will not be released without the approval of the Chief Executive Officer or legal counsel.

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