Nivano Physicians, Inc.
Effective Date: August 7, 2025
Last Updated: March 12, 2026
Board Approval Date: August 7, 2025
Version: 2.0
Policy Statement
Nivano Physicians maintains a zero-tolerance policy for fraud, waste, and abuse in all federal and state healthcare programs. We are committed to preventing, detecting, and reporting FWA and to protecting the integrity of Medicare, Medi-Cal, and all other programs in which we participate.
Regulatory Framework
| Authority | Requirement |
|---|---|
| Federal False Claims Act (31 U.S.C. §§ 3729–3733) | Prohibition on false or fraudulent claims |
| Anti-Kickback Statute (42 U.S.C. § 1320a-7b(b)) | Prohibition on improper inducements |
| Physician Self-Referral Law / Stark Law (42 U.S.C. § 1395nn) | Physician referral restrictions |
| Criminal Health Care Fraud Statute (18 U.S.C. § 1347) | Criminal penalties for healthcare fraud |
| California False Claims Act (Gov. Code §§ 12650–12656) | State-level false claims prohibition |
| 42 C.F.R. Parts 422 and 423 | Medicare Advantage and Part D requirements |
| 42 C.F.R. § 438.608 | Medicaid managed care FWA requirements |
Definitions
Fraud is the intentional or knowing misrepresentation of a material fact made with knowledge that it could result in an unauthorized benefit. Examples include billing for services not provided, submitting duplicate claims, misrepresenting dates or descriptions of services, falsifying diagnoses or medical records, kickback schemes, and identity theft to bill under another provider’s name.
Waste refers to overutilization or misuse of resources — the extravagant, careless, or needless expenditure of healthcare resources without direct intent to deceive. Examples include ordering unnecessary tests, prescribing more expensive medications when equivalent lower-cost alternatives are available, and poor administrative practices leading to duplicate claim processing.
Abuse describes practices inconsistent with sound fiscal, business, medical, or recipient practices that result in unnecessary costs or reimbursement for services that are not medically necessary or do not meet professionally recognized standards. Examples include billing for services lacking medical necessity, excessive charges, and billing practices that violate assignment agreements.
Prevention
Training Requirements
All providers, staff, and contractors must complete FWA training. New employees and FDRs must complete initial training within 10 days of hire or contract initiation. Annual refresher training is required for all personnel, updated to reflect current regulations, enforcement actions, and role-specific scenarios. See the CMS Training / Provider Compliance Training page for FDR-specific MLN training requirements and exemptions.
Compliance Program Infrastructure
Prevention is supported by written FWA policies and billing guidelines, a designated Compliance Officer with direct board access, regular claims audits using statistical sampling and data analytics, pre-payment reviews for high-risk claims, post-payment audits, and trending analysis to detect unusual billing patterns. The OIG Exclusion List is checked for all new and existing providers and staff.
Detection
Automated detection systems analyze claims for unusual billing patterns, flag anomalies and outliers through data mining, and use predictive analytics to identify high-risk providers and services. Manual review processes include medical record reviews for medical necessity and documentation, on-site provider audits, beneficiary interviews, and referral pattern analysis for potential Stark Law issues.
External detection sources include OIG exclusion list monitoring, whistleblower reports from employees, providers, and beneficiaries, government agency referrals, and media and public information.
Investigation
All FWA allegations are subject to formal investigation beginning with intake, triage, and preliminary assessment — initiated within 2 weeks of identification. Investigations include evidence collection, expert clinical and legal consultation, root cause analysis, and quantification of financial and program impact. All investigation activities are thoroughly documented. Confidentiality of all parties is protected to the extent legally permissible.
Reporting Requirements
Internal Reporting
The Chief Compliance Officer must be notified within 24 hours of identifying a significant potential FWA issue. Senior leadership and legal counsel are briefed for cases with potential criminal implications. Formal written investigation reports are submitted to the Board quarterly, with trend analysis and annual program assessments.
External Reporting — Federal
| Agency | When to Report | How |
|---|---|---|
| CMS / MEDIC | Medicare Advantage and Part D matters | Per contract terms |
| HHS Office of Inspector General | Potential criminal fraud | oig.hhs.gov/report-fraud/ or 1-800-HHS-TIPS |
| Department of Justice | Potential False Claims Act violations | Through legal counsel |
External Reporting — State
| Agency | When to Report | Timeframe |
|---|---|---|
| California DHCS | Medi-Cal fraud, waste, or abuse | Within 48 hours of identification |
| California Attorney General | State False Claims Act violations | Per applicable procedures |
Contracted health plans are notified no later than 48 hours after identification, following plan-specific reporting procedures.
Corrective Actions and Sanctions
Corrective responses are calibrated to the nature and severity of the violation. Administrative actions include additional training, enhanced monitoring, corrective action plans with specific timelines, and process improvements. Financial remedies include overpayment recovery within regulatory timelines, interest and penalties as required by law, and restitution to affected programs and beneficiaries. Personnel actions range from counseling and retraining to termination and referral to licensing boards. Contract actions range from enhanced monitoring and financial penalties to contract termination for serious or repeated violations.
Whistleblower Protections
Nivano Physicians strictly prohibits retaliation against any individual who reports suspected FWA in good faith, participates in an FWA investigation, or refuses to engage in potentially fraudulent activity. This prohibition is enforced and monitored. Personnel who experience or witness retaliation should report it immediately to the Compliance Department.
Legal protections available to reporters include the Federal False Claims Act whistleblower provisions (including qui tam financial incentives for successful actions) and the California Whistleblower Protection Act, which provides job protection and reinstatement rights.
Key Federal Penalties Reference
| Statute | Penalty |
|---|---|
| False Claims Act | Up to 3× damages plus $13,946–$27,894 per false claim (2024 amounts, adjusted annually) |
| Anti-Kickback Statute | Up to $100,000 fine and 10 years imprisonment per violation |
| Stark Law | Denial of payment plus civil monetary penalties up to $15,000 per service |
Reporting Channels
Compliance Department — Nivano Physicians, Inc.
Phone: (916) 407-2000
Email: compliance@nivanophysicians.com
Fax: (916) 471-0332
Mail: 2554 Millcreek Dr., Suite 100, Sacramento, CA 95833
OIG Hotline: 1-800-HHS-TIPS (1-800-447-8477)
OIG Online Reporting: https://oig.hhs.gov/report-fraud/
Policy Review
This policy is reviewed annually and updated to reflect changes in FWA regulations, CMS guidance, OIG enforcement priorities, and California state law. The next scheduled review is August 7, 2026.
This policy was last updated on March 12, 2026 and approved by the Board of Directors on August 7, 2025.