PARTNERSHIP HEALTHPLAN OF CALIFORNIA
POLICY / PROCEDURE
Policy/Procedure Number: CMP-06
Lead Department: Administration
External Policy
Policy/Procedure Title: Compliance Issues and Complaints
Internal Policy
Next Review Date: 12/01/2016
Original Date: 06/05/2007
Last Review Date: 12/01/2015
Applies to:
Medi-Cal
Healthy Kids
Employees
Reviewing
Entities:
IQI
P&T
QUAC
OPERATIONS
EXECUTIVE
COMPLIANCE
DEPARTMENT
Approving
Entities:
BOARD
COMPLIANCE
FINANCE
PAC
CEO
COO
CREDENTIALING
Approval Signature: Sonja Bjork, COO
DEPT. DIRECTOR/OFFICER
Approval Date: 12/01/2015
I.
RELATED POLICIES:
CMP-21 Conflict of Interest Code
CMP-27 Non-Intimidation & Non-Retaliation
II.
IMPACTED DEPTS.:
All.
III.
DEFINITIONS:
Not applicable.
IV.
ATTACHMENTS:
Not applicable.
V.
PURPOSE:
To establish a process by which compliance issues, complaints and violations are handled completely,
effectively and in a timely fashion to uphold the integrity, reputation and legal standing of PHC.
VI.
POLICY / PROCEDURE:
A. General Policy
1. PHC shall establish a process by which compliance inquiries, issues, complaints and reports of
compliance violations by PHC staff or its contractors are documented, investigated and resolved.
2. PHC shall establish and publicize mechanisms for the reporting of improper conduct.
3. PHC shall establish and publicize guidance regarding disciplinary actions for compliance violations.
4. PHC shall establish procedures for conducting timely and reasonable inquiries into reported
misconduct and detected offenses.
5. PHC shall require corrective action plans in all cases of detected misconduct and violations.
6. PHC shall coordinate and cooperate with State and/or Federal agencies and law enforcement entities
regarding violations of existing state and/or federal law.
B. Inquiries
1. All PHC staff are encouraged to check with their immediate supervisor, department director or the
Regulatory Affairs & Compliance unit with compliance inquiries. It is recommended that staff
check with department administrative assistants, supervisors or directors regarding departmental
specific policies and procedures.
2. All Board Members are encouraged to check with the Compliance Officer with compliance
inquiries.
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Policy/Procedure Number: CMP-06
Lead Department: Administration
☒External Policy
☐Internal Policy
Next Review Date: 12/01/2016
Last Review Date: 12/01/2015
☒ Healthy Kids
☐ Employees
Policy/Procedure Title: Compliance Issues and Complaints
Original Date: 06/05/2007
Applies to:
☒ Medi-Cal
3. All PHC contractors and providers are encouraged to check with the Provider Relations Department
with compliance inquiries.
4. Inquiries include, but are not limited to:
1. Questions pertaining to policy and procedure.
2. Employee conduct.
3. Compliance reporting procedures.
4. Compliance issue work flows.
5. Desktop procedures; etc.
C. Issues.
1. All PHC Staff are trained to inform their immediate supervisor, department director or the
Regulatory Affairs & Compliance unit about compliance issues immediately.
2. All PH Board Members are trained to inform the Compliance Officer about compliance issues
immediately.
3. All PHC contractors and providers are notified to report to PHC’s Provider Relations Department,
use PHC’s Fraud, Waste and Abuse Hotline, and contact the proper State/Federal agency through
newsletters and other communications.
a. PHC Staff are provided a toll-free hotline to report issues anonymously. PHC’s Compliance
Hotline: 1-800-601-2146.
b. Staff may also speak with department directors according to the “open door” policy.
Compliance issues include, but are not limited to: misconduct; violations of policy and
procedure, contractual arrangements, statues, and/or local, state, and federal law; self-reporting
of mistakes that has or may result in damage to a person, property, or PHC.
c. Staff, Board Members, contractors and providers are informed of the importance of selfdisclosure in reporting mistakes or other errors.
d. PHC mandates a policy of non-retaliation for reporting of compliance issues.
D. Discipline.
1. PHC Staff cases resulting in a recommendation of discipline are forwarded to the Human Resources
Department. Contractor and provider issues resulting in a recommendation of discipline are
forwarded to the Provider Relations Department.
2. PHC Staff, Board Member, contractor and provider non-compliance may result in disciplinary action
depending on the circumstances of the violation.
3. Minor infractions due to misunderstanding/miscommunication may result in retraining and
education.
4. Minor and major infractions, including the willful withholding of information, selling of protected
health information (PHI), or other actions that are otherwise unlawful or violate PHC policy and
procedure, the PHC Code of Conduct, etc. may result in suspension and/or termination of
employment and/or contract when behavior is serious, repeated or when knowledge of a possible or
actual violation is not reported.
E. Investigations of compliance issues or complaints filed with a member of the Compliance Committee
shall be documented and forwarded to the department director with expertise in the type of compliance
issue under review.
1. The department director shall coordinate their review with the Compliance Officer and Human
Resources Director or Provider Relations Director.
a. Results of the review shall be presented to the Compliance Committee at the next regular
meeting.
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Policy/Procedure Number: CMP-06
Lead Department: Administration
☒External Policy
☐Internal Policy
Next Review Date: 12/01/2016
Last Review Date: 12/01/2015
☒ Healthy Kids
☐ Employees
Policy/Procedure Title: Compliance Issues and Complaints
Original Date: 06/05/2007
Applies to:
☒ Medi-Cal
b. Emergency meetings may be called at the discretion of the CEO or the Compliance Officer.
2. The Compliance Committee, at the direction of the CEO, COO or CFO, shall coordinate with legal
counsel, and, if required by contractual or statutory obligation, with law enforcement and/or any
State/Federal regulatory agency.
VII.
REFERENCES:
Not applicable.
VIII.
DISTRIBUTION:
A. PHC 4 Me
B. SharePoint
C. www.partnershiphp.org
D. Directors
IX.
POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE:
Chief Operating Officer
X.
REVISION DATES:
Medi-Cal
12/06/2011, 12/04/2012, 03/26/2013, 09/01/2015, 12/01/2015
Healthy Kids
12/06/2011, 12/04/2012, 03/26/2013, 09/01/2015, 12/01/2015
PREVIOUSLY APPLIED TO:
PartnershipAdvantage:
CMP-06 – 06/05/2007 to 01/01/2015
Healthy Families:
CMP-06 – 10/01/2010 to 03/01/2013
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