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CHINESE-AMERICAN PLANNING COUNCIL, INC.
MEDICAID COMPLIANCE PLAN

1. INTRODUCTION

Chinese-American Planning Council, Inc. (“CPC”) has adopted this Medicaid Compliance Plan (“Compliance Plan”) to comply with the provisions of New York State Social Services Law § 363-d and 18 NYCRR Part 521, the Federal Deficit Reduction Act (42 USC § 1396a(a)(68)), and the New York State Office of Medicaid Inspector General Work Plan.  This Compliance Plan further describes CPC’s procedures for detecting and preventing fraud and abuse in connection with the provision of services eligible for Medicaid and Medicaid claiming.
As is detailed within this Compliance Plan, it is the duty of all employees, contractors, vendors and agents to comply with the policies as applicable to their individual areas of employment or contracts. 
This Compliance Plan also advises all employees, contractors, vendors and agents of the procedures to be used in reporting non-compliance with such Federal and State laws.
The benefits to this Compliance Plan include, but are not limited to the following:
• Supports our strong commitment to honesty, responsibility and appropriate conduct. 
• Develops a system to encourage employees to report potential problems that may be detrimental to CPC and the community at large.
• 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 CPC and, thereby, reduces CPC’s exposure to any civil damages or penalties, criminal sanctions or administrative remedies. 

1. MEDICAID COMPLIANCE CODE OF CONDUCT

The following policies and directives are not intended to prescribe a specific response to every conceivable situation, but are intended to assist staff and contract providers in recognizing issues and determining an appropriate response as specific situations arise.  Should a staff member have questions about an appropriate response in a given situation, (s)he should consult his/her supervisor and/or administrator or contract manager.

1. CPC will submit claims for Medicaid only for services actually rendered and shall seek the amount to which it is entitled.
2. CPC does not tolerate claiming practices that misrepresent the services actually rendered.
3. Supporting documentation must be prepared for all services rendered.
4. CPC will submit claims for Medicaid only where appropriate and required documentation has been prepared.
5. An accurate and timely billing and documentation structure is critical to ensure that CPC staff can effectively implement and comply with required policies and procedures.
6. Demonstrated lapses in the documentation and claiming systems infrastructure should be remedied in a timely manner at the program level.  The Medicaid Compliance Officer must approve all proposed remedies.
7. CPC staff and vendors are not to falsify documentation for any purposes, including Medicaid claiming.
8. MEDICAID COMPLIANCE OFFICER

CPC has designated a Medicaid Compliance Officer who is directly responsible to the Executive Director and the Board of Directors for overseeing the development and implementation of CPC’s Compliance Program and ensuring appropriate handling of instances of suspected or known illegal or unethical conduct related to Medicaid claiming.  Complaints to the Medicaid Compliance Officer can be made by telephone at (212) 941-9020 ext. 129 or by email to syip@cpc-nyc.org.  Complaints may be made anonymously by calling the Compliance Hotline at (888) 608-9757 or via e-mail at compliance@cpc-nyc.org.
Duties of the Medicaid Compliance Officer
• Oversee and monitor the implementation of the Medicaid Compliance Program;
• Maintain the effectiveness of the Medicaid Compliance Program;
• Establish methods such as conducting periodic audits/reviews of CPC’s compliance with the current State and Federal regulations, developing effective lines of communication on compliance issues and preparing written standards and procedures that reduce CPC’s exposure to fraud and abuse;
• Annually revise the Medicaid Compliance Program to reflect changes in the needs of CPC, the law or policies, and procedures of the government;
• Develop, coordinate and implement a training program that focuses on the components of the Medicaid Compliance Program and seeks to ensure that all appropriate employees and management are knowledgeable of, and comply with, pertinent federal and state standards and that contractors, independent service providers, consultants and others who furnish health services to CPC’s beneficiaries are aware of the requirements of the Medicaid Compliance Program;
• Develop procedures for checking the List of Excluded Individuals and Entities with respect to all staff and vendors who are providing services that may be eligible for Medicaid reimbursement;
• Report on a regular basis to the Executive Director and the Board of Directors on the implementation of the Medicaid Compliance Program, any investigations and necessary corrective actions;
• Consult, as necessary, with the New York State Office of Medicaid Inspector General, investigative and auditing offices and outside law enforcement agencies;
• Assess the impact of current and future Medicaid Regulations on CPC’s day to day operations; 
• Ensure that Medicaid compliance is occurring throughout CPC;
• Recommend solutions to barriers that may exist in the successful implementation of compliance activities;
• Address issues regarding Medicaid claiming that impact CPC’s ability to maximize revenue and make recommendations on how to improve them; and
• Assess the success of this Compliance Plan by reviewing compliance related activities and recommend any needed updates to the Plan.

1. COMMUNICATION AND CHANGES IN COMPLIANCE PLAN

CPC will post this Compliance Plan on its external website.  All employees will be notified of the existence of this Compliance Plan.  CPC will also communicate with contractors and vendors who provide services that may be eligible for Medicaid reimbursement of the existence of this Medicaid Compliance Plan as required by law.  Additionally,  the Medicaid Compliance Officer will conduct training in conjunction with the provided written materials.
Updated information about the compliance program, changes in law and ethical standards that may affect  an employee's or vendor’s responsibilities will be communicated.

1. EDUCATION AND TRAINING

The proper education and training of employees and service providers is a significant element of an effective compliance program.  The Medicaid Compliance Officer will provide periodic training and education to all current employees, service providers, appointees or associates, including executive and governing body members, and such affected persons will be advised of the obligation to review the Compliance Plan and act accordingly.  As new employees enter the system, they will be trained and advised of the obligation to review a copy of this Compliance Plan.  Additional training, tailored to the roles and responsibilities of each group of individuals is provided on a program/division basis.  CPC will routinely identify training topics, including those arising out of internal and external audits and regulatory developments.
Related service contractors who provide any service that may be eligible for Medicaid reimbursement will be advised that this Compliance Plan and any updates will be on CPC’s external website.  If they cannot access internet or email, they will be provided with a hard copy.  Contracts with vendors will require the vendor to certify that they have shared this Compliance Plan with employees providing services to CPC and that they will make their staff available as necessary for training by CPC.
Independent related service providers will be required to certify that they have read this Compliance Plan as part of the process to be included as a potential provider to CPC beneficiaries.

1. REPORTING REQUIREMENTS

CPC’s employees are in a position to know where policies and regulations are not being followed. Therefore, the effectiveness of the Compliance Program depends on the willingness of employees at all levels of the organization to step forward, in good faith, with questions and concerns.
Policy

1. Employees are responsible for conducting their jobs in a manner that is ethical and complies with governing laws and regulations.
2. Employees are encouraged to seek supervisory assistance if they are unclear about their compliance obligations.  If an employee has further concerns, the employee can obtain assistance from the Medicaid Compliance Officer.
3. Employees have a duty to report actions or behaviors they believe violate this Compliance Plan or applicable laws or regulations.  Any employee that fails to report misconduct or illegal behavior may be subject to disciplinary procedures, up to and including termination. (See CPC's Code of Conduct and Ethics, Section 2).
4. CPC will encourage employee questions and/or reports by: 

• taking each report seriously;
• investigating each report; and where there is enough information, determining the extent of the problem and taking any necessary corrective action; and
• ensuring that employees who do report:  (i) do not suffer retaliation by their peers or supervisors for their good faith reports or questions; and (ii) have the choice of keeping their name confidential in regard to a specific report for as long as CPC can reasonably do so.
Examples of fraud or abuse:

1. Claiming or verifying attendance for services that were not provided.
2. Duplicate billing, which occurs when a contractor or an independent provider bills Medicaid while also submitting an invoice for payment to CPC.
3. Claiming for services at a higher rate, when a lower rate service was actually provided (e.g., billing for a one-to-one service session when in fact a group session was provided).
4. Submitting claims where applicable provider requirements have not been satisfied.
5. Certifying attendance for a complete session where a complete session was not provided.

How to Report
All matters relating to possible fraud and abuse or other compliance issues related to Medicaid must be reported.  Employees must report in any of the following ways:  

1. CPC Medicaid Compliance Officer   

• Phone: (212) 941-0920 ext. 129 
• Email: syip@cpc-nyc.org

1. Anonymous Compliance Hotline

• Phone: (888) 608-9757
• compliance@cpc-nyc.org

1. ENFORCEMENT AND DISCIPLINE

If, through investigation, monitoring and/or auditing, it is determined that fraud or abuse has occurred, or that a staff person or program is violating policies and procedures set forth in this Compliance Plan, there may need to be disciplinary action.

1. Discipline Policy and Actions

In any instance where a compliance issue is confirmed, appropriate actions will be taken by CPC.  Upon a finding that an employee, contractor or independent provider has engaged in misconduct, CPC will take appropriate disciplinary action.  CPC may also make a referral to the Office of the Medicaid Inspector General or other external enforcement agency.

1. Non-Retaliation and Non-Intimidation

To the extent possible, all employee reports will be handled in a manner that protects the confidentiality of the reporter if requested.  However, there may be circumstances in which confidentiality cannot be maintained. Some examples of this include situations where the problem is known to only a very few people or where the funding source must be involved.  In all cases, however, CPC is determined that the reporting employee will not suffer from adverse employment action, retaliation or intimidation for his/her good faith actions.  It is the responsibility of the Medicaid Compliance Officer to ensure that those reporting in good faith do not suffer from adverse employment action, retaliation or intimidation.  Employees who believe that they have been subjected to such actions because they have reported a possible instance of misconduct or fraud should immediately contact the Medicaid Compliance Officer.

1. List of Excluded Individuals or Entities

Providers must check the OIG List of Excluded Individuals and Entities on the OIG website http://www.oig.hhs.gov/fraud/exclusions.html prior to hiring or contracting with individuals or entities. Persons and entities who are listed on the federal OIG Exclusion Database must receive reinstatement through the OIG to be eligible for reimbursement through Medicaid.  In addition, the NYS Office of the Medicaid Inspector General has a list of excluded individuals and entities which can be visited at http://www.omig.ny.gov/data/content/view/72/52/.  Providers should also check the Excluded Parties List System at https://www.epls.gov/.  In order to comply with this paragraph, the following will occur:
• Where an employee is identified as a provider of services that may be eligible for Medicaid claiming, CPC will check the OMIG website;
• CPC will review the OMIG database at least monthly to see if any names on the list match the names of employees identified as providers of Medicaid covered services.  If there is a name match, CPC will further investigate to confirm whether the name on the list is a CPC employee.
• In order to determine if contractors or vendors might be on the list of excluded entities, the Medicaid Compliance Officer will check the list at least monthly.

1. MONITORING AND AUDITING

An objective of CPC’s monitoring and auditing procedures is to uncover activities that could potentially constitute violations of this Compliance Plan or failure to comply with federal and state law or other types of misconduct.  CPC recognizes its obligation to investigate any incidents uncovered to determine whether:
• a violation has, in fact, occurred;
• disciplinary action must be taken; and 
• corrective actions have been put into place as required.
All issues reported to the Medicaid Compliance Officer will be handled in a consistent fashion so that the integrity of this Compliance Plan is maintained, and so employees will have confidence in the workings of compliance inquiries.
As part of our effort to implement an effective Compliance Program, CPC will periodically conduct routine self-audits and/or reviews of its operations including its claiming practices and its written standards, policies and procedures to ascertain problems and weaknesses in its operations and to measure the effectiveness of its Compliance Program.  The periodic audits/reviews will be designed to assess whether CPC’s claims are supported by accurate documentation conforming to the requirements of the Corrective Action Plans and Medicaid claiming guidelines and whether information in the data systems upon which CPC relies is valid and controls are working as intended. Additional audits/reviews may be conducted depending on reports of fraud, waste, or abuse or identification of risk areas as determined through regular monitoring activities. 
Audit/Review Findings
The following will be the process for reporting audit findings: 

1. The Medicaid Compliance Officer will provide a report of its audit/review findings to the  Executive Director and the Board of Directors.
2. If applicable, CPC will calculate and repay any duplicate or improper payments made as a result of the noncompliance.
3. The Medicaid Compliance Officer will detail the steps that should be taken to preventing similar non-compliant activity from occurring in the future.

Follow-up monitoring will be conducted as appropriate to ensure effective resolution of noncompliance findings.
Record retention
The Medicaid Compliance Officer will receive and generate both hard copy and electronic records and information.

1. All records related to a specific incident should be retained in accordance with State Record Retention requirements, or as otherwise required by state or federal law or pursuant to contract.
2. Records relating to the Compliance Program including memoranda, meeting minutes and reports will be retained as required by State Record Retention requirements or as otherwise required by law or regulation.
3. RESPONSE AND PREVENTION

The goal of our Compliance Program is to prevent and reduce the likelihood of improper conduct. CPC’s response to information concerning possible violations of law or the requirements of the Compliance Program is an essential component of its commitment to compliance.
Upon receiving a report or other reasonable indication of suspected non-compliance, the Medicaid Compliance Officer will inform the Executive Director and the General Counsel of such allegation.  The Medicaid Compliance Officer in consultation with the Executive Director will arrange for an investigation to be conducted by the Compliance Officer.  CPC’s Legal Department will assist as necessary.  All CPC staff will be directed to cooperate fully with the Medicaid Compliance Officer. 
Upon receipt of information concerning alleged misconduct, the Medicaid Compliance Officer will, at a minimum, take the following actions:
• Complete a Compliance Report Intake Form.
• Notify the Executive Director.
• Ensure that the investigation is initiated as soon as reasonably possible.  The investigation shall  include, as applicable, but need not be limited to: (i) interviews of all persons who may have knowledge of the alleged conduct;  (ii) identification and review of relevant documentation including, where applicable, Medicaid claims submitted, to determine the specific nature and scope of the violation and its frequency, duration and potential financial magnitude; (iii) interviews of persons who appear to play a role in the suspected activity or conduct; and (iv) preparation of a summary report that (a) defines the nature of the alleged misconduct, (b) summarizes the investigation process, and (c) identifies any person who is believed to have acted deliberately or with reckless disregard or intentional indifference of applicable laws
• Ensure that the investigation is completed in a reasonable and timely fashion and that appropriate disciplinary or corrective action is taken;
• The results of the investigation will be reported to the Executive Director and quarterly to the Board of Directors;
• Referrals for further action, including disciplinary action and/or review by a law enforcement agency may be made upon consultation with legal counsel.
In the event the investigation identifies inappropriate Medicaid billing practices, CPC will: 
• Immediately cease the offending practice and all billing potentially affected by the offending practice.
• If applicable, calculate and repay any duplicate or improper payments.
• When appropriate, handle any overpayments through the administrative billing process by informing the billing staff and making appropriate adjustments via software used for billing.
• Undertake appropriate training and education to prevent a recurrence of the misconduct.
• Conduct a review of applicable CPC procedures to determine whether new or revised policies and procedures are needed to minimize future risk of noncompliance.
• Conduct, as appropriate, follow up monitoring to ensure effective resolution of the offending practice.
On a quarterly basis, the Medicaid Compliance Officer will provide a report to the Executive Director and the Board of Directors which includes all investigations and their status.  The Medicaid Compliance Officer will also provide the audit findings from any reviews that have taken place throughout the year, as well as corrective actions that have been implemented.