Compliance

Compliance Program

Inland Empire Health Plan (IEHP) is committed to conducting its health plan operations in compliance with ethical standards, contractual obligations under State and Federal programs, laws, and regulations applicable to Medi-Cal and IEHP DualChoice. This commitment extends to our business associates and delegated entities that support IEHP’s mission to organize and improve the delivery of quality, accessible, and wellness based healthcare services for our community. 

 

Our Compliance Program is designed to:
  • Ensure we comply with applicable laws, rules, and regulations
  • Reduce or eliminate Fraud, Waste, and Abuse (FWA)
  • Prevent, detect, and correct non-compliance
  • Reinforce our commitment to culture of compliance for which we strive
  • Establish and implement our shared commitment to honesty, integrity, transparency, and accountability

Code of Business Conduct and Ethics

Inland Empire Health Plan (IEHP) expects Team Members and business entities doing business with IEHP to conduct business activities in an ethical and professional manner that promotes public trust and confidence in the integrity of IEHP. The Code is meant to provide guidance about the compliance culture at IEHP and the role that each Team Member, including management, Chief Officers and the Governing Board, plays in building and preserving that culture.
 

IEHP Code of Business Conduct and Ethics (PDF)

Compliance, Fraud, Waste, and Abuse (FWA), and Privacy Program Training

The IEHP Compliance, FWA, and Privacy Training Program focuses on the elements of an effective Compliance Program, conduct & ethics, and the Fraud, Waste and Abuse and Privacy Programs.
 

IEHP requires delegated entities to provide Compliance Training to their employees, Providers, downstream entities, Board of Directors, and Contractors within 90 days of hire/start, and annually thereafter.
 

IEHP is committed to a culture of compliance, ethics, and integrity. The goal of Compliance Training is to provide all associated parties the ability to demonstrate awareness of IEHP’s requirements, including regulations and policies & procedures associated with Compliance as it relates to daily work.
 

If you have questions or additional suggestions, please e-mail the IEHP Compliance Department at compliance@iehp.org.
 

Compliance Training FWA HIPAA Privacy and Security (PDF)

Eligibility to Participate in Federal and State Health Care Programs

Inland Empire Health Plan (IEHP) is prohibited from issuing payment for services provided, ordered, or prescribed by an individual or entity that is excluded, ineligible, or terminated from participation in State and Federal health care programs in accordance with regulatory and contractual requirements.
 

IEHP conducts regular reviews of Federal and State exclusionary databases and lists, including but not limited to:

  • Office of Inspector General (OIG) List of Excluded Individuals and Entities (LEIE list)
  • GSA Excluded Parties List System (EPLS)
  • DHCS Medi-Cal Suspended and Ineligible Provider List
  • CMS Preclusion List
  • Restricted Provider Database (RPD)

Exclusion Screening

IEHP has implemented a screening process to identify individuals and entities that appear on the DHHS OIG LEIE, the GSA EPLS, the CMS Preclusion List and the DHCS Medi-Cal Suspended and Ineligible Provider List prior to appointment, contracting, and/or employment and monthly thereafter to ensure that none of these individuals or entities are excluded, ineligible or terminated from participation in State and Federal health care programs.
 

Delegated entities must implement a screening program for employees, Board Members, contractors, and business partners to avoid relationships with individuals and/or entities that tend toward inappropriate conduct.

 

This program includes but is not limited to:

  • Prior to contract and monthly thereafter, review of the GSA System for Award Management (SAM), the Department of Health Care Services Medi-Cal Suspended and Ineligible list, and the Office of Inspector General’s (OIG) List of Excluded Individuals and Entities (LEIE) that are excluded from participation in government health care programs (42 CFR §10011901).
  • A monthly review of the Department of Health Care Services Medi-Cal Suspended and Ineligible list.
  • Criminal record checks when appropriate or as required by law.
  • Review of the National Practitioner Databank (NPDB).
  • Review of professional license status for sanctions and/or adverse actions.
  • Reporting results to Compliance Committee, Governing Body, and IEHP as necessary.

Fraud, Waste, and Abuse (FWA)

IEHP has established a Fraud, Waste, and Abuse Program to detect, correct, and prevent fraud, waste, and abuse on part of Team Members, IEHP Members, Providers, Vendors, delegated entities and any other entity doing business with IEHP.

Fraud Prevention

Fraud Prevention, it’s a Team Effort

In an effort to prevent fraud and abuse, IEHP encourages Providers and their staff to report any suspicious circumstances when they arise. You may want to ask for another form of identification in addition to the IEHP Member identification card. Identification with both a picture and a signature, such as a valid driver’s license or State identification card, are suggested. We are informing Members of this concern and are requesting that they have additional identification available when they come to you. To obtain more compliance guidelines, the Department of Health and Human Services (HHS) offers assistance (by clicking on this link you will be leaving the IEHP website).
 

Fraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program, or to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program.
 

Examples include:

  • Knowingly billing for services or prescriptions not furnished or supplies not provided
  • Knowingly altering claim forms for a higher payment
  • Selling medicine, medical equipment, or other things received through IEHP

Waste includes overuse of services, or other practices that, directly or indirectly, result in unnecessary costs. Waste is generally not considered to be caused by criminally negligent actions but rather by the misuse of resources.
 

Examples include:

  • Conducting excessive office visits
  • Writing excessive prescriptions or ordering excessive tests
  • Prescribing more medications than necessary for the treatment of a specific condition

Abuse includes actions that may, directly or indirectly, result in unnecessary costs and improper payment or services. Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment.
 

Examples include:

  • Billing for unnecessary medical services or medical equipment
  • Billing for brand name drugs when generics are dispensed
  • Misusing codes on a claim, such as upcoding and unbundling codes.

Report potential FWA Click Here (By clicking on this link, you will be leaving the IEHP website).

Privacy Incident/Breach

IEHP has established a HIPAA Privacy Program to ensure that Member’s health information is properly protected while allowing the flow of health information needed to provide and promote high-quality health care.

 

A privacy breach is defined as unauthorized acquisition, access, use, or disclosure of protected health information (PHI) which compromises the security or privacy of such information.
 

PHI is health information that relates to a Member’s past, present or future physical or mental health or condition, including the provision of his/her health care, or payment for that care and contains personally identifiable information (PII) such as name, SSN, DOB, Member ID, address, or any other unique identifier related to the Member.
 

This generally means that a breach occurs when PHI is accessed, used, or disclosed to an individual or entity that does not have a business reason to know that information. The law does allow information to be accessed, used, or disclosed when it is related to treatment, payment, or healthcare operations directly associated with the work that we do at IEHP on behalf of our Members.
 

Report a Privacy Incident/Breach Click Here (By clicking on this link, you will be leaving the IEHP website).

Reporting Information

IEHP has the following resources available for reporting fraud, waste or abuse, privacy issues, and other compliance issues:
 

Compliance Hotline: (866) 355-9038
Fax: (909) 477-8536
E-mail: compliance@iehp.org.
 

Mail:
IEHP Compliance Officer
P.O. Box 1800
Rancho Cucamonga, CA 91729-1800
 

Online: (By clicking on this link, you will be leaving the IEHP website)
Report a Compliance Issue: Click Here

Report a Privacy Incident/Breach: Click Here

Report potential FWA: Click Here

Frequently Asked Questions (FAQs)

What are some common examples of fraud?
 

Providers

  • Billing for services not rendered
  • Paying a "kickback" in exchange for a referral for medical services or goods
  • Unbundling
  • Overcharging for services or goods 
  • Using false credentials

Members

  • Allowing unauthorized individuals to use ID card to obtain benefits
  • Altering prescriptions
  • Falsifying residence information to obtain benefits
  • Drug seeking or doctor shopping to obtain narcotics

What do I do if I suspect an IEHP Member is engaging in possible fraud, waste, or abuse?

First, document your suspicions. Then, contact IEHP’s Compliance Department at (866) 355-9038 and make a report with one of our Representatives. At times, IEHP may request additional information that is necessary to investigate.
 

IEHP also has the following resources available for reporting fraud, waste or abuse, privacy issues, and other compliance issues:
 

Compliance Hotline: (866) 355-9038
Fax: (909) 477-8536
E-mail: compliance@iehp.org
 

Mail:
IEHP Compliance Officer
P.O. Box 1800
Rancho Cucamonga, CA 91729-1800
 

Online: (By clicking on the following links, you will be leaving the IEHP website)

Report a Compliance Issue: Click Here

Report a Privacy Incident/Breach: Click Here

Report potential FWA: Click Here

What do I do if my facility has made some billing errors?

If you suspect that errors in billing may have occurred, contact your IEHP Provider Services Representative at (909) 890-2054.

What are some other things I can do as a Provider?

  • Periodically perform internal audits of billing practices and compare billing records with payments received.
  • Do not leave prescription pads, which include a Provider's identification and license number, out in the open. For example, do not store prescription pads in exam room cabinets or leave on office counters.

IEHP DualChoice (HMO D-SNP) Model of Care Training

The Centers for Medicare & Medicaid Services (CMS), the Department of Health Care Services (DHCS) and the National Committee for Quality Assurance (NCQA) require that IEHP staff and contracted consultants/vendors, our Medicare IPAs, Hospitals/SNFs, and Providers, receive training on the Plan’s Model of Care for our D-SNP Members:

Contact the OIG

The Office of the Inspector General (OIG) is there to assist you and maintains a hotline, which offers a confidential means for reporting vital information. For information on confidentiality, please contact the hotline and ask about their confidential source program. Each caller is encouraged to assist the OIG by providing information on how they can be contacted for additional information but the caller may remain anonymous.
 

Contacting the Office of the Inspector General
Phone: (800) HHS-TIPS (447-8477)
E-mail: Htips@oc.dhhs.gov
 

Additional Hotlines
 

DHCS Medi-Cal Fraud Hotline
Phone: (800) 822-6222
E-mail: fraud@dhcs.ca.gov
 

Web: https://apps.dhcs.ca.gov/stopfraud/Default.aspx
 

The recorded message may be heard in English and 10 other languages: Spanish, Vietnamese, Cantonese, Armenian, Hmong, Cambodian, Laotian, Farsi, Korean and Russian. The call is free and the caller may remain anonymous.

  

You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.