MCOs and other health insurance management companies have begun adding a “Compliance Program” to their service contracts. The program manager establishes its own compliance program, and forces its compliance program upon its independent contractors and health care service providers by contract.
The management company sets up its own reporting system or 1-800 hotline number and demands in the contract for services with your agency that the contractor explain and advertise to its employees the hotline and instructs them to use it if needed to report unethical activities, abuse, fraud, or other illegal acts.
Your employees only have to pick up the telephone and call the program manager to report your agency’s alleged wrongdoings. Then the program manager will investigate, and probably terminate the contract with you or impose some other sanctions on you in order to correct the issue.
If the program involves a Medicare or Medicaid program, you will have a duty to investigate and may be required to report your findings to Medicare or Medicaid formally either through a report and refund process or through the self-disclosure protocol, just as if the compliance program was installed directly at your agency.
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