Policy Statement
Nivano Physicians is committed to preventing, detecting, and reporting fraud, waste, and abuse in all federal and state healthcare programs. We maintain a zero-tolerance policy for fraudulent activities and are dedicated to protecting the integrity of healthcare programs including Medicare, Medicaid, and commercial insurance plans.
Legal Framework
This policy is established in compliance with:
- Federal False Claims Act (31 USC 3729-3733)
- Anti-Kickback Statute (42 USC 1320a-7b(b))
- Physician Self-Referral Law (Stark Law) (42 USC 1395nn)
- Criminal Health Care Fraud Statute (18 USC 1347)
- California False Claims Act (Government Code Sections 12650-12656)
- 42 CFR Parts 422 and 423 (Medicare Advantage and Part D requirements)
- 42 CFR Section 438.608 (Medicaid managed care requirements)
Definitions
Fraud
Fraud is the intentional or knowing misrepresentation made by a person with knowledge that the deception could result in unauthorized benefit to themselves or another person. Fraud includes any act that constitutes fraud under applicable federal or state law.
Examples of fraud include:
- Billing for services not provided
- Misrepresenting dates, frequency, duration, or description of services
- Submitting duplicate claims for the same service
- Billing for non-covered services as covered services
- Falsifying patient diagnoses or medical records
- Kickback schemes and illegal referral arrangements
- Identity theft and billing under another provider’s name
Waste
Waste refers to the overutilization or misuse of resources, services, or benefits, including the extravagant, careless, or needless expenditure of healthcare resources.
Examples of waste include:
- Excessive or inappropriate utilization of services
- Prescribing more expensive medications when less expensive alternatives are available
- Ordering unnecessary tests or procedures
- Poor administrative practices leading to inefficient operations
- Duplicate processing of claims or benefits
Abuse
Abuse describes practices that are inconsistent with sound fiscal, business, medical, or recipient practices and result in unnecessary costs to healthcare programs, or reimbursement for services that are not medically necessary or fail to meet professionally recognized standards.
Examples of abuse include:
- Billing for services that are not medically necessary
- Charging excessively for services or supplies
- Providing poor quality of care
- Violating assignment agreements
- Billing practices that result in unnecessary costs to programs
Prevention Strategies
Provider Education and Training
All healthcare providers, staff, and contractors must complete comprehensive fraud, waste, and abuse training:
Initial Training Requirements
- Within 10 days of hire or contract initiation
- Comprehensive overview of FWA laws and regulations
- Specific examples relevant to their role and responsibilities
- Reporting mechanisms and whistleblower protections
- Completion certification with minimum 90% passing score
Annual Training Requirements
- Updated annually with current regulations and guidance
- Case studies of recent enforcement actions
- Role-specific scenarios and compliance challenges
- Regulatory updates from CMS, OIG, and other agencies
- Documentation of completion and competency
Compliance Program Elements
Written Policies and Procedures
- Comprehensive FWA policies covering all aspects of operations
- Billing and coding guidelines based on current standards
- Clinical documentation requirements and medical necessity criteria
- Prior authorization and utilization management procedures
- Claims review and audit protocols
Designated Compliance Officer
- Chief Compliance Officer with direct reporting to senior leadership
- Authority and resources to implement and oversee FWA prevention
- Regular communication with board of directors on compliance matters
- Coordination with legal counsel and external consultants
Monitoring and Auditing
- Regular claims audits using statistical sampling and data analytics
- Provider performance monitoring through utilization reports
- Pre-payment reviews for high-risk claims and services
- Post-payment audits to identify potential FWA
- Trending analysis to detect unusual billing patterns
Detection and Investigation
Detection Methods
Automated Systems
- Claims editing software to identify unusual billing patterns
- Data mining techniques to detect anomalies and outliers
- Predictive analytics to flag high-risk providers and claims
- Real-time monitoring of billing and utilization data
Manual Reviews
- Medical record reviews for medical necessity and documentation
- On-site provider audits and facility inspections
- Beneficiary interviews and complaint investigations
- Referral pattern analysis for potential Stark Law violations
External Sources
- OIG exclusion list monitoring and verification
- Whistleblower reports from employees, providers, and beneficiaries
- Government agency referrals and enforcement actions
- Media reports and public information
Investigation Process
Initial Assessment
- Intake and triage of all FWA allegations and suspicious activities
- Preliminary review to determine credibility and scope
- Resource allocation and investigation team assignment
- Timeline establishment for investigation completion
Formal Investigation
- Evidence collection including documents, data, and interviews
- Expert consultation with clinical and legal professionals
- Root cause analysis to identify systemic vulnerabilities
- Impact assessment to quantify financial and program damage
Investigation Standards
- Prompt initiation within 2 weeks of identification
- Thorough documentation of all investigation activities
- Reasonable timeline for completion based on complexity
- Consistent methodology following established protocols
- Confidentiality protection for all parties involved
Reporting Requirements
Internal Reporting
Immediate Notification (Within 24 Hours)
- Chief Compliance Officer must be notified immediately
- Senior leadership briefing for significant cases
- Legal counsel consultation for potential criminal matters
- Risk management assessment for organizational impact
Formal Reporting
- Written investigation reports with findings and recommendations
- Quarterly compliance reports to board of directors
- Annual FWA program assessment and effectiveness review
- Trend analysis and pattern identification
External Reporting
Federal Agencies
- Centers for Medicare & Medicaid Services (CMS)
- Through Medicare Drug Integrity Contractor (MEDIC)
- For Medicare Advantage and Part D matters
- Within required timeframes per contract terms
- Office of Inspector General (OIG)
- HHS OIG Hotline: 1-800-HHS-TIPS
- Online reporting: https://oig.hhs.gov/report-fraud/
- For potential criminal fraud cases
- Department of Justice
- For cases involving potential False Claims Act violations
- Coordination through legal counsel
State Agencies
- California Department of Health Care Services (DHCS)
- For Medi-Cal fraud, waste, and abuse
- Within 48 hours of potential/suspected violations
- Using required reporting forms and procedures
- California Attorney General’s Office
- For state False Claims Act violations
- Through Medi-Cal fraud reporting mechanisms
Health Plans
- Contracted health plans notified immediately
- No later than 48 hours after identification
- Follow plan-specific reporting procedures and requirements
Corrective Actions and Sanctions
Administrative Actions
- Additional training and education requirements
- Enhanced monitoring and oversight measures
- Corrective action plans with specific timelines
- Process improvements and system modifications
Financial Remedies
- Recovery of overpayments within regulatory timelines
- Interest and penalties as required by law
- Financial sanctions proportionate to violations
- Restitution to affected programs and beneficiaries
Personnel Actions
- Disciplinary measures ranging from counseling to termination
- Retraining requirements for compliance deficiencies
- Performance improvement plans with measurable objectives
- Referral to licensing boards for professional sanctions
Contract Actions
- Contract modification to address compliance deficiencies
- Enhanced monitoring and reporting requirements
- Financial penalties and withholds
- Contract termination for serious or repeated violations
Reporting Mechanisms
Multiple Reporting Channels
Compliance Hotline
- Phone: (916) 407-2000
- Anonymous reporting option available
- Confidential voicemail system
- Professional investigation of all reports
Online Reporting
- Secure reporting form with encryption
- Anonymous submission capability
- Confirmation of receipt provided
Written Reports
- Mail: Nivano Physicians Compliance Officer
2554 Millcreek Drive, Suite 100
Sacramento, CA 95833 - Email: compliance@nivanophysicians.com
- Fax: (916) 471-0332
In-Person Reporting
- Open door policy with compliance officer
- Management reporting through supervisors
- Employee assistance program for support
- Union representative involvement when applicable
Whistleblower Protections
Non-Retaliation Policy
- Strict prohibition against retaliation for good faith reporting
- Protection for employees reporting suspected violations
- Anonymous reporting options to prevent identification
- Investigation of any alleged retaliation
Legal Protections
- Federal False Claims Act whistleblower provisions
- California Whistleblower Protection Act coverage
- Financial incentives for successful qui tam actions
- Job protection and reinstatement rights
Key Federal Laws
False Claims Act (31 USC 3729-3733)
- Prohibits knowingly submitting false or fraudulent claims
- Penalties: Up to 3 times damages plus $11,803-$23,607 per claim
- Qui tam provisions allow private enforcement actions
- Whistleblower protections and rewards
Anti-Kickback Statute (42 USC 1320a-7b(b))
- Prohibits offering, paying, soliciting, or receiving kickbacks
- Includes any remuneration to induce healthcare business
- Safe harbors at 42 CFR 1001.952 provide protection
- Criminal penalties: Up to 5 years imprisonment and $25,000 fine
Stark Law (42 USC 1395nn)
- Prohibits physician self-referrals for designated health services
- Strict liability standard with no intent requirement
- Specific exceptions for permissible arrangements
- Penalties: Denial of payment and civil monetary penalties
Contact Information
Primary Contacts
Chief Compliance Officer
- Email: compliance@nivanophysicians.com
- Phone: (916) 407-2000
- Direct line: Available 24/7 for urgent matters
Compliance Department
- Email: compliance@nivanophysicians.com
- Phone: (916) 407-2000
- Hours: Monday-Friday, 8:00 AM – 5:00 PM PST
Emergency Reporting
24/7 Compliance Hotline: (916) 407-2000
Emergency compliance email: compliance@nivanophysicians.com
This Fraud, Waste, and Abuse Policy reflects our unwavering commitment to program integrity and legal compliance. We regularly review and update this policy to ensure continued effectiveness in preventing, detecting, and responding to fraudulent activities.
Document Version: 1.0
Effective Date: August 7, 2025
Board Approval Date: August 7, 2025
Next Review Date: August 7, 2026