Compliance Program: Preventing and Detecting Improper Conduct

The Agency's program for preventing, detecting, reporting and resolving conduct that is improper or abusive of MO HealthNet, such as misappropriation of participant funds or property, falsified service delivery documents or agency records, false claims and kickbacks. It names a compliance lead, sets standards, training, monitoring and audits, a reporting route without retaliation, investigation, self-disclosure and repayment, conflict of interest rules, information on false claims laws, and the annual Deficit Reduction Act attestation to MMAC.

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About this policy

Policy number: MO-HC-ETH-03
Version: 1.0
Main rule: 13 CSR 70-3.030(3)
Library: Missouri home care · 50 policies
Category: Ethics
Sections: 20

In short

Report anything that looks like fraud: false visit times, billing for care not given, missing participant money or changed records.
Tell your supervisor, Pat Sample, or the governing body. You can report without giving your name.
You will not be punished for reporting in good faith. Missouri and federal law protect people who report.
Never pay or accept anything for referring a participant.
The Agency looks into every report, fixes the problem and pays back any money it should not have received.

What's inside

20 sections. The full text comes with the One-time Policy Pack.

Full text with a package

Terms of Reference
1. Purpose
2. Scope
3. Definitions
4. Policy Statement (13 CSR 70-3.030(3))
5. Examples of Improper Conduct
6. Elements of the Compliance Program
7. Reporting a Concern
8. Investigation and Resolution
9. Overpayments and Self-Disclosure
10. Deficit Reduction Act Attestation and Annual Review
11. False Claims Laws and Protections for Those Who Report
12. Conflicts of Interest and Kickbacks
13. Responsibilities
14. Records and Compliance Monitoring
15. Staff Training
16. References
17. Related Policies and Forms
18. Approval
19. Revision History

An inspector may ask

How would an aide report a suspected billing or EVV problem, and who looks into it?
Show me your last claims audit and what you did about the errors.

Missouri home care

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Rules it follows

13 CSR 70-3.030(3)13 CSR 70-3.030(2)(D)13 CSR 70-3.030(3)(A)3, 4, 8, 11, 12, 16, 24-27, 29-31, 35, 3913 CSR 70-3.030(4)13 CSR 70-3.030(6)13 CSR 70-3.320(2)(I)19 CSR 15-7.021(4)(A)1RSMo 192.2475.9RSMo 192.2480.1, .3, .9MMAC In-Home Services Program Requirements 4.4, 5.7, 5.8MMAC In-Home Services Proposal for Contract, Section VI item 442 U.S.C. §1396a(a)(68)31 U.S.C. §§3729-373331 U.S.C. §3730(h)31 U.S.C. §3801 et seq.42 U.S.C. §1320a-7b(b)42 U.S.C. §1320a-7k(d)

Forms included

MO-HC-ETH-03-A Compliance Concern Report
MO-HC-ETH-03-B Annual Compliance Review and DRA Attestation Record

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