First Tier, Downstream, or Related Entity Compliance

Yes, if you or your company has a written arrangement with Health First Health Plans (HFHP), which is a Medicare Advantage organization, or you have an arrangement with a company contracted with Health First Health Plans to provide:

• Administrative services (vendors, suppliers, etc.) relating to HFHP's Medicare Advantage contract with the Centers for Medicare and Medicaid Services (CMS); or
• Healthcare services as part of the Health First Health Plans network

Examples of First Tier entities, Downstream entities, and Related entities (FDRs):

• First Tier entities: Network providers (such as a doctor), broker, pharmacy benefit manager, claims processor, etc.
• Downstream entities: Pharmacies, pharmacists, etc.
• Related entities: Health First Family Pharmacy, etc.

Thank you for partnering with us to provide services for our members. We appreciate the relationship between your organization and Health First as partners in compliance.

• Report within a reasonable time frame to Health First Health Plans all suspected or known instances of non-compliance and/or fraud, waste, or abuse
• Sign the Medicare FDR Statement of Attestation every year
  • Broker Attestation is included in the Medicare Advantage Agent Agreement
  • Vendors: To get an email with a link to your organization's Attestation form, contact the Vendor Management Office at VendorManagement@hf.org or HFHP Corporate Integrity at HFHPCorporateIntegrity@hf.org
• Provides/presents required training on general compliance, and fraud, waste, and abuse to all new and established employees (including temporary workers and volunteers) and downstream entities after hire or contracting and annually thereafter.
  • Health First’s Compliance Education: Medicare Parts C and D General Compliance Training
  • Fraud, waste and abuse training can be found under “What can FDRs do about fraud, waste, and abuse?”
• Provide the Health First's Code of Ethics & Business Conduct or your organization's Code of Conduct and applicable policies and procedures to employees, contractors, board members, and volunteers who have an involvement with administering services related to HFHP's Medicare Advantage contract with CMS
  • Health First's Code of Ethics & Business Conduct
    
    Compliance Policies and Procedures
    • CC 01.01 POL Compliance Program Policy
    • CC 01.01.01 PRO Procedure for Reporting Compliance Concerns

    • CC 01.01.05 PRO Effective Training and Education

       

    • CC 01.02 POL Non-Retaliation and Non-Intimidation Policy

    • CC 01.04 POL Exclusion and Sanction Screening Policy

       

    • HP 03.01.01 PRO Health Plans Corporate Integrity Program Policies Procedures and Standards of Conduct

    • HP 03.01.02 PRO Health Plans Designation of a Compliance Officer, Committee and High Level Oversight

       

    • HP 03.01.04 PRO Health Plans Effective Lines of Communication
    • HP 03.01.05 PRO Health Plans Well Publicized Disciplinary Guidelines
    • HP 03.01.06 PRO Health Plans Effective System for Routine Monitoring, Auditing and Identification of Compliance Risks
    • HP 03.01.07 PRO Health Plans Procedures and System for Prompt Responses to Compliance Issues
    • HP 03.02 POL Health Plans First Tier Downstream  Related Entity (FDR) and Delegated Entity (DE) Oversight
    • HP 03.02.03 PRO Health Plans First Tier, Downstream & Related Entity (FDR) and Delegated Entity (DE) Oversight Monitoring & Auditing

• Perform exclusion screening of employees, contractors, board members, and volunteers prior to hire/contracting and monthly thereafter

   

  • OIG List of Excluded Individuals/Entities (LEIE)
  • GSA's System for Award Management (SAM)
• Retain records for 10 years (training records and records relating to services)
• Maintain privacy and security of Health First Health Plans member information

Protecting Privacy

• Maintain oversight of your Downstream entities providing services relating to Health  First Health Plan's Medicare Advantage contract with CMS.
• Inform Health First Health Plans Vendor Management Office before offshoring services or PHI out of the country.
• Correct any deficiencies related to misconduct or Medicare program non-compliance.

Yes, monitoring and auditing by our Compliance Program is a CMS requirement.

Examples of routine monitoring and auditing:

• Verifying exclusion screening has been performed prior to hire/contracting and monthly thereafter.
• Verifying training has occurred after hire/contracting and yearly thereafter.
• Documentation (policies, procedures, standards of conduct) is in compliance with Chapter 21 of the Medicare Managed Care Manual.

Should my organization be monitoring and auditing our Downstream entities that perform services related to Health First Health Plans' Medicare Advantage contract with CMS?

• Yes

Education:

• CMS Fraud, Waste, and Abuse Part C and Part D Education.

• Contact your business contact person at HFHP
• Contact the HFHP Compliance Department:
• Email: HFHPCorporateIntegrity@hf.org
• Phone: 321.434.7496
• Mail: 6450 US Highway 1, Rockledge, FL 32955 Submit anonymous concerns via mail.
• Contact the Special Investigations Unit to report suspicions of fraud, waste or abuse at SIUCompliance@hf.org

• As long as you honestly have a concern and act in good faith, Health First's policy protects you or your company from intimidation and retaliation.