Medicare compliance

We value our partners who help us serve our members and share our commitment to excellence in service, performance and compliance.

Compliance Plan and policies

Moda Health’s Medicare Compliance Department oversees and monitors our First Tier, Downstream and Related Entities (FDRs) as required by CMS and described in CMS Compliance Program Guidelines in the Medicare Managed Care Manual Chapters 9 and 21 and as required by Moda Health’s Medicare Compliance Plan and policies regarding FDRs. All our FDR partners are expected to adhere to CMS program requirements and compliance guidance we provide.

Code of Conduct

Please distribute or make available Moda Health’s Code of Conduct to your employees if your Code of Conduct is not comparable to ours.

Report compliance concerns

You must report and use the contact information below to report suspected Medicare program violations and fraud, waste, and abuse (FWA) concerns that affect Moda Health payments and members. Moda Health has a strict no retaliation policy for good faith reporting.

Fraud, Waste and Abuse Hotline
Toll-free: 855-801-2991
Email: stopfraud@modahealth.com

In addition, FDR partners are expected to provide notice to their employees throughout their facilities of their duty to report any observed or suspected noncompliance or potential fraud, waste, or abuse. This notice should be provided through the use of posters, table tents, mouse pads, or other forms of notice.

The notice must provide the alternative to contact EthicsPoint (toll free number 866-294-5591 or online at www.ethicspoint.com) provided by Moda or the Moda Medicare compliance officer at medicarecompliance@modahealth.com or some other third-party reporting service provided by the FDR so that a reporting party can remain anonymous. The notice must make it clear that there are strict rules forbidding any retaliation against anyone for making such a report.

Disciplinary standards

Failure to report suspected Medicare program violations and/or fraud, waste and abuse concerns may result in disciplinary action up to and including termination of your contract with Moda Health. We expect that you have disciplinary standards in place and publicized for your employees and downstream and related entities and the Moda Health Medicare Compliance Department may ask to see them. Examples of downstream subcontracted work may be services performed by clinics or physicians, or services provided by your subcontractor for Moda Health. A related entity is a subsidiary or affiliated corporation. CMS requires that you monitor the compliance of your downstream entities and Moda Health may request proof of the monitoring activities.

General Compliance and FWA Training

All employees of the FDR who have any involvement in the administration or delivery of Medicare services must receive the CMS MLN Fraud, Waste, and Abuse and General Compliance trainings within 90 days of their hiring date and annually thereafter. The trainings can be administered either through the CMS MLN website or by incorporating the content of the trainings into the FDR's internal training materials/systems.

The CMS web based training modules that satisfy the Medicare Compliance and FWA Training requirement can be accessed via the Medicare Learning Network (MLN) Learning Management System (LMS).

NOTE: An MLN account must be created, if not done so already in order to access the CMS training modules. Step by step instructions on how to create an MLN account can be found on the CMS Medicare Learning Network Learning Management System FAQs document.

A PDF copy of the CMS Medicare Compliance Training is located at the following link: Medicare Parts C and D General Compliance Training and a PDF copy of the CMS Fraud Waste & Abuse Training is located at the following link: Medicare Parts C and D Fraud, Waste, and Abuse Training.

Exclusions from participation in federal healthcare programs

For any employee or downstream and/or related entity relationships administrating or delivering Medicare Parts C and D benefits, you must ensure they are not excluded from participation in federal health care programs prior to hire or contract and monthly thereafter. Medicare payments many not be made for items or sources furnished or prescribed by a producer or entity excluded by the office of the Inspector General at the U.S. Department of Health and Human Services (HHS) or the General Services Administration (GSA).

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