Fraud, Waste, and Abuse Notice

Fraud And Abuse Notice

Capital Health Plan has maintained a program to detect and prevent fraud, waste, and abuse. CHP's program includes promoting awareness among its employees, providers, vendors, first tier, down stream entities and members. Written policies, procedures, and internal controls are in place. If you suspect fraud, waste, and/or abuse or have any questions or concerns, please call Capital Health Plan at one of the telephone numbers listed on this page.

Fraud, Waste, and Abuse Initiatives

Capital Health Plan is committed to fairness in everything that we do, so that our activities reflect positively on those whom we serve and on CHP. CHP has developed comprehensive Compliance Policies and Standards of Conduct, which collectively are known as CHP's Beacon Program. The Beacon Program provides basic guidance on the principal ethical and legal rules that affect CHP's activities. Directors, officers, and employees learn about conduct that might raise legal or ethical questions and the principles to be followed in business relationships.

Capital Health Plan requires all staff to exercise due diligence in the prevention, detection and correction of fraud, waste and abuse. CHP promotes an ethical culture of compliance with all state and federal regulatory requirements, and mandates the reporting of any suspected fraud, waste and abuse to the Compliance Office by any means including the use of the hotline at 383-3566.

In addition to staff reporting and prevention requirements Capital Health Plan encourages members, affiliates, facilities, vendors, consultants, first tier, down stream entities and contractors to report any suspected fraud, waste or abuse to the Compliance Officer directly by calling 383-3472 or anonymously through the hot line at 383-3566.

Fraud Waste and Abuse Awareness reporting and prevention includes but is not limited to the following areas:

• Laws and regulations related to Medicare Advantage and Medicare Part D fraud, waste and abuse (i.e., False Claims Act, Anti-Kickback statute, HIPAA, etc)
• Obligations of the first tier downstream, and related entities to have appropriate policies and procedures to address fraud, waste, and abuse
• Process to report to Capital Health Plan suspected fraud, waste and abuse in first tier, downstream, and related entities
• Protection for employees of first tier, downstream, and related entities who report suspected fraud, waste and abuse
• Types of fraud, waste and abuse that can occur in first tier, downstream, and related entities

Through annual training, CHP staff has developed a heightened awareness of good business ethics and how to identify and prevent fraud, waste, and abuse. CHP also contracts with the Special Investigative Unit of Blue Cross® Blue Shield® of Florida to provide for all new staff training on fraud, waste, and abuse awareness and to investigate any allegations of fraud, waste, or abuse. These activities regularly are reported to CHP's Board of Directors. CHP's Fraud, Waste and Abuse Awareness and Reporting Policy is available below.

Reviewed October 2008, Revised 11/17/09 Approved by Compliance Committee