Compliance

LifeWorks Advantage Compliance

 

LifeWorks Advantage I-SNP (HMO I-SNP) is committed to acting with integrity and making decisions based on the highest standards of ethical behavior, including complying with applicable laws and regulations.

To support this commitment and provide our members with quality benefits and services, LifeWorks has established an Ethics and Compliance program, hereinto known as the Compliance program that sets forth the principles, policies, and procedures on how LifeWorks Advantage associates are required to conduct business and themselves.

The Compliance Program has been developed to assist in establishing a culture within LifeWorks that promotes the prevention, detection, and resolution of instances of conduct that do not conform to federal and state law and federal and state health care program requirements.  It provides associates the knowledge and tools to perform their jobs in a compliant manner, identify potential compliance issues, and report suspected or known non-compliance, as well as fraud, waste and abuse.

All business areas are required to follow LifeWorks Ethics, Compliance, and Privacy policies and procedures, regardless of whether there is a direct reporting relationship to the Corporate Compliance. Consistent with the preceding and spirit of LifeWorks Compliance Plan and culture, all major business areas are required to identify key compliance risks and to work with Compliance to develop appropriate mitigation plans and reporting.

LifeWorks Advantage Mission / Standards of Conduct

LifeWorks Advantage mission is to provide an effective, system-wide, measurable approach to continuously monitoring, evaluating, and improving access and quality of care and services for enrolled members and to work with providers to ensure a quality health care experience for enrolled members using a cost-effective and efficient method.

LifeWorks Advantage Mission / Standards of Conduct LifeWorks Ethic and Compliance Program implements and maintains written standard and procedures, including the Standards of Ethical Business Conduct (the Code), a Compliance Plan, and applicable policies and procedures to clearly document expectations regarding various ethics and compliance requirements designed to facilitate compliance with applicable laws, regulations, and guidance.  The Code is the foundation of Lifeworks Ethics and Compliance Program. The Code articulates LifeWorks commitment to comply with all applicable laws and regulations while providing guidance regarding actions, decisions, and operations that help LifeWorks and associate safeguard LifeWorks integrity and reputation as an ethical and compliant organization.  

All associates are expected to read the Code and understand their responsibilities under the Code. In addition, the Code is provided to all new associates upon hire, included in required annual compliance refresher training, and made available to all associates, as well as posted on LifeWorks Internet site for public viewing.

Compliance Hotline

LifeWorks Advantage has implemented a Compliance Hotline for our Members; employees; first-tier, downstream, and related entities; and other contractors and agents.

The Compliance Hotline provides a mechanism for callers to report activity related to known or suspected non-compliance with LifeWorks mission; policies and procedures; Compliance program; Standards of Conduct; or any Federal, State, or local laws and regulations.

All calls to the Compliance Hotline will be treated as confidential and private to the fullest extent possible.

Compliance Hotline: 1-844-317-9059 (toll free)

If you are not comfortable or able to make a report via the Compliance Hotline, you may send a written report by mail to:

Corporate Compliance Officer
LifeWorks Advantage
PO Box 29600
2917 Penn Forest Blvd, Roanoke VA 24018-0796

Or Email: [email protected]
Or Fax: 1-833-572-2367

Whether reporting by telephone or in writing, please provide as much detail as possible, including, but not limited to, names, dates, times, locations, and the specific conduct you feel may violate the law or LifeWorks Policy.

No individual making a good faith report of a suspected violation shall be retaliated against. However, any individual who knowingly makes a false allegation shall be subject to disciplinary action in accordance with LifeWorks Policy.

FDR Medicare Compliance Guidance

As a LifeWorks Advantage First Tier, Downstream and Related Entity (FDR), you must provide LifeWorks code and Medicare compliance policies (or a document of your own that’s comparable to both of those documents) to your employees and downstream entities. If you provide your own comparable version, it must explain your commitment to compliance with federal and state laws, ethical behavior and compliance program operations. You must provide this material:

  • Within 90 days of hire or the effective date of contracting
  • When there are updates to the standards of conduct
  • Annually thereafter You must also show proof that you provided the standards of conduct.

CMS no longer requires FDRs to complete the following Compliance trainings:

  • Medicare Parts C and D General Compliance
  • Combating Medicare Parts C and D Fraud, Waste, and Abuse

Instead, you may use and complete your own version of general compliance and FWA training. It can be specific to your organizational needs.

Prevent and Detect FWA

As a LifeWorks Advantage FDR, you play an important role in protecting the integrity of the Medicare program. To combat FWA, you need to know what it is. And you need to know how to protect your organization from engaging in abusive practices and/or civil or criminal law violations.

What are the definitions for fraud, waste and abuse?

Fraud is intentionally misusing information to persuade another person or entity to part with something of value or to surrender a legal right. It could also be an act of planned deception or misrepresentation.

Waste is using, consuming, spending or expending resources thoughtlessly or carelessly. Abuse is providing information or documentation for a health care claim in a manner that improperly

uses program resources for personal gain or benefit. However, there isn’t enough evidence to prove

criminal intent.

Below are some of the fraud, waste and abuse laws Federal laws that govern Medicare FWA. They include:

  • Anti-kickback statute (31 U.S.C. §§ 3729-3733)
  • Criminal code (18 U.S.C. Section 1347)
  • False Claims Act (31 U.S.C. §§ 3729-3733)
  • Social Security Act (42 U.S.C. chapter 7)
  • Stark law (42 USC § 1395nn)

These laws state the criminal, civil and administrative remedies the federal government may impose when FWA is committed. Violating these laws may result in:

  • Nonpayment of claims
  • Civil money penalties
  • Exclusion from all federal health care programs
  • Criminal and civil liability

The CMS website is a good source of additional information. It includes FWA training options.

Offshore Entities

Offshore entities means and Offshore individual or entity physically located outside the United States or one of its territories. Protected health information (PHI) refers to the types of personal information listed in the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. PHI includes information such as name and address, medical history, and current health status.

Offshore services mean the offshore entity will or may receive, process, transfer, handle, store, or access the PHI — in oral, written, or electronic form — of LifeWorks members. If you have Offshore activities that involve PHI, LifeWorks will submit an attestation of that fact to the U.S. Centers for Medicare & Medicaid (CMS). Please contact [email protected] if you are using Offshore entities that handle LifeWorks PHI.