Compliance Program
Capital Health Plan's Compliance Program known as the Beacon is comprised of eight essential elements. The following represent a brief description of each element.
Beacon Compliance Overview
- Written policies and procedures: Capital Health Plan's Compliance Code of Conduct is found in the "Beacon Program for Compliance" located on the intranet with related Compliance policies which can be viewed, e-mailed, or printed. A hard copy is issued to all workforce upon hire and upon request. Additional clarifications regarding compliance guidance are issued in various communications i.e. the 'Network News', 'Healthline' and employee newsletter 'The Source', as well as by memo as needed.
- Designation of Compliance Officer and Compliance Committee: Capital Health Plan has had a Compliance Officer since November 1999, and a Compliance Committee chaired by that officer since December 1999. This committee meets regularly throughout the year. Additional information regarding the dates and responsibilities of the Compliance Officer are found in the "Beacon Program for Compliance".
- Effective training and education: Compliance training is a combination of classroom, one on one and computer based training. All new members of CHP's work force are trained usually by the first day of employment, but no later than within their first month. Thereafter compliance training is an annual event with the assignments based upon job associated responsibilities/risks, and the compliance Committee's review of the available training materials. Successful training completion requires a minimum score and all work force are required to meet this standard. Additionally, Compliance training is also required for temporary staff, students and in some circumstances consultants.
- Effective lines of communication: In addition to office 'open door policy', standard e-mail, mail, and phone access there is also a hot line (850) 383-3566 available for anonymous communication to the Compliance office. The responsibility to report any violations of the Compliance policies is explained in the Beacon, as well as, the non-retaliation policy for good faith reporting of suspected violations. Annual Compliance surveys, Compliance evaluation inquires and exit Compliance statements are also communication tools used for Compliance.
- Enforcement of Compliance standards: This is the responsibility of all CHP management as explained in the Beacon. Compliance with the Beacon Code of Conduct is expected of all members of the work force. Failure to comply would result in disciplinary action up to and including termination.
- Effective internal monitoring and auditing: The Compliance Officer collaborates with Internal Audit, Medical Claims auditors, BCBSFl-SIU and other internal departments throughout the year to monitor processes to ensure compliance with State and Federal regulatory standards. Additionally, the Fraud Waste and Abuse Work Group, a multidisciplinary team monitors Part D Medicare claims and works with our Pharmacy Benefit Manager (PBM) to resolve any issues discovered, as well as reports through the P&T Commitee and the Compliance Committee all findings for appropriate disposition. The SIU, Medic and CMS would be notified as appropriate of all required information, as well as, any situation requiring further investigation or analysis.
- Procedures for prompt responses to offenses: CHP's Compliance program through the Beacon requires timely investigation of any reported violations and appropriate disciplinary action as referenced in the Beacon, Personnel handbook and Fraud, Waste and Abuse Awareness and Reporting Policy.
- Fraud, Waste and Abuse detection, correction and prevention element for Compliance is reflected for CHP in the "Fraud, Waste and Abuse Awareness and Reporting Policy'"found on our intranet and internet pages, as well as, in the Beacon Compliance reference. This policy is a part of new workforce orientation during initial on-boarding at CHP. This concept is also a part of initial and annual computer based Compliance training for all staff, as well as discussed with the Fraud Awareness training provided by Blue Cross Blue Shields' Special Investigatiions Unit presentations. This policy is also communicated to our Network and downstream entities via various communications including remits, Network News and internet postings.
This summary is not intended to be all inclusive of the entire scope of Capital Health Plan's Compliance program, but is designed to present a high level overview of the Compliance elements currently in place.
Please call the Compliance Office at 383-3472 if you have questions regarding this material.
Approved by: Compliance Committee 3/20/07, Reformatted 8/15/2007, Revised 10/2009, Revised 11/16/2010.