Nivano Physicians, Inc.
Effective Date: August 7, 2025
Last Updated: March 12, 2026
Board Approval Date: August 7, 2025
Version: 2.0
Program Foundation
Nivano Physicians has established a comprehensive compliance program in accordance with 42 C.F.R. § 422.503 (Medicare Advantage) and § 423.504 (Part D), incorporating the seven core elements mandated by the Centers for Medicare & Medicaid Services (CMS). This program reflects our commitment to ethical healthcare delivery and our legal obligations as a Medicare Advantage organization and ACO REACH participant.
Regulatory Framework
| Authority | Requirement |
|---|---|
| 42 C.F.R. Part 422, Subpart M | Medicare Advantage compliance program requirements |
| 42 C.F.R. Part 423, Subparts M and U | Part D prescription drug plan compliance |
| Medicare Managed Care Manual, Chapter 21 | Compliance program guidelines |
| Prescription Drug Benefit Manual, Chapter 9 | Part D compliance requirements |
| OIG General Compliance Program Guidance | Healthcare organization best practices |
The Seven Core Compliance Program Elements
1. Internal Monitoring and Auditing
Nivano Physicians maintains monitoring and auditing systems to detect compliance issues and measure program effectiveness. Monitoring activities cover claims review and billing pattern analysis, utilization management, marketing and enrollment activity review, provider network credentialing and performance oversight, and quality monitoring of member and provider interactions.
Our audit program includes an annual comprehensive risk assessment, targeted audits of high-risk areas, independent third-party compliance assessments, preparation for and response to CMS audits, and follow-up on identified deficiencies through corrective action monitoring. Findings are tracked through quarterly compliance reports to leadership and the Board, with immediate escalation for significant issues.
2. Written Compliance Standards and Procedures
We maintain written policies and procedures covering all operational areas: clinical operations (medical necessity, prior authorization, utilization management), administrative functions (enrollment, billing, claims, member services), privacy and security (HIPAA compliance, data protection), quality assurance (patient safety, outcomes measurement), and fraud prevention (detection, investigation, reporting).
All policies are reviewed and updated annually, tracked against regulatory changes, and distributed to relevant personnel in current, version-controlled form.
3. Designated Compliance Officer
Nivano Physicians has designated a Chief Compliance Officer with direct authority and resources to oversee all compliance program activities. The Compliance Officer has direct access to the Board of Directors, authority to investigate potential violations and implement corrective actions, and responsibility for regulatory liaison with CMS and other agencies.
The Compliance Committee — a cross-functional team including department compliance liaisons — supports the Compliance Officer across all operational areas. Legal counsel and external compliance consultants are engaged as needed.
4. Compliance Training and Education
We maintain training programs ensuring all personnel understand and meet their regulatory obligations. See the CMS Training / Provider Compliance Training page for full details on required training modules, timelines, FDR obligations, and completion documentation.
Training is delivered through web-based platforms with progress tracking, in-person sessions for complex topics, and ongoing communications about regulatory updates.
5. Response Procedures for Compliance Violations
When a potential violation is identified, we follow a structured process: intake and preliminary assessment, investigation planning, evidence gathering, root cause analysis, and comprehensive findings documentation. Immediate corrective actions stop ongoing violations and prevent harm. Systemic improvements address underlying process failures. Personnel actions, financial remediation, and enhanced monitoring follow as warranted.
External disclosure and self-reporting to government agencies occurs as required by law or CMS contract terms. Nivano Physicians cooperates fully with government investigations and enforcement actions.
6. Open Communication and Reporting
We maintain multiple channels through which personnel, providers, and members can report compliance concerns without fear of retaliation.
Compliance Department
Phone: (916) 407-2000
Email: compliance@nivanophysicians.com
Concerns may also be submitted in writing by mail or in person. Anonymous reporting is available. Retaliation against any individual who makes a good-faith compliance report is strictly prohibited.
7. Disciplinary Guidelines
Compliance violations are subject to progressive discipline — escalating in proportion to violation severity and compliance history. Disciplinary decisions follow due process, are applied consistently, and are documented comprehensively. All personnel are informed of disciplinary expectations through training and policy distribution.
Program Effectiveness and Board Oversight
The Compliance Officer conducts a comprehensive annual program evaluation that includes risk assessment updates, analysis of key performance indicators, stakeholder feedback, external benchmarking, and action planning to address identified gaps.
The Board of Directors receives quarterly compliance reports, an annual program review presentation, and immediate notification of significant compliance matters. The Board holds management accountable for compliance performance and ensures adequate resources are allocated to the program.
Compliance Training and Attestation Forms
The following forms are available for download:
- Standard of Conduct
- Fraud, Waste, and Abuse
- HIPAA and PHI
- Compliance Program
- Notice of Privacy Practices
- Terms of Service
- Compliance Training Attestation
- Nivano SMS Privacy Policy
External Resources
- Centers for Medicare & Medicaid Services (CMS): cms.gov
- Office of Inspector General (OIG): oig.hhs.gov
- U.S. Department of Health and Human Services: hhs.gov
- Health Care Compliance Association (HCCA): hcca-info.org
- American Health Lawyers Association: healthlawyers.org
Contact Information
Compliance Department — Nivano Physicians, Inc.
2554 Millcreek Dr., Suite 100, Sacramento, CA 95833
Phone: (916) 407-2000
Toll Free: (844) 889-2273
Email: compliance@nivanophysicians.com
Policy Review
This overview is reviewed annually and updated to reflect changes in CMS requirements, OIG guidance, and organizational operations. The next scheduled review is August 7, 2026.
This document was last updated on March 12, 2026 and approved by the Board of Directors on August 7, 2025.