Delegated entities (Delegates) otherwise known as Vendors, Subcontractors, and First Tier, Downstream and Related Entities (FDRs)
This page provides education, important links and resources to guide our Delegated Entities through Compliance Program requirements.
FirstCare Health Plans (FirstCare) and its wholly owned subsidiaries maintain a process to monitor delegated functions and responsibilities so that we are able to validate compliance with Federal and State laws, as well as contractual regulations. Guidelines indicate that vendors, subcontractors and delegated entities (delegates), including First Tier, Downstream and Related Entities (FDRs) who partner with us should follow the same compliance guidelines as FirstCare while working on FirstCare business.
The Why
Our organization is responsible for fulfilling the terms and conditions of our contract with Federal and State agencies. The Centers for Medicare and Medicaid Services (CMS) and Federal and State regulators ultimately hold us responsible for delegate activities and performance. Our Delegates are also responsible for complying with these requirements and must ensure their Downstream Entities comply with such applicable laws and regulations.
The How
Code of Conduct
Distribute your own or adopt our organization Code of Conduct to your employees within 90 days of hire and annually thereafter or when the Code of Conduct is updated. Code of Conduct is designed to promote honest, ethical and lawful conduct by employees, officers, directors, Delegates, including agents and brokers. These standards of conduct should clearly define expectations of professional behavior.
- Include the expectation that employees and Delegates act in an ethical and compliant manner.
- Ramifications of failure to comply with applicable statutory and regulatory requirements.
- Encourage employees and Delegates to report violations of the law and policies, including providing guidance on how reporting can occur.
Training and Education
Delegates are expected to make sure that applicable employees of the entity receive General Compliance and Fraud, Waste and Abuse (FWA) education, either through the entity’s processes or through training materials provided by a regulatory agency. Training should occur within 90 days of hire or contracting and annually thereafter.
Training programs are expected to meet the following requirements.
- Education will include general compliance information, FWA and HIPAA training materials.
- FWA training includes the risks associated with the function being performed by the Delegate.
- Training is provided to Delegates’ employees who have involvement in the administration or delivery of benefits on behalf of our organization.
- Training materials should be reviewed and revised, as appropriate, no less than annually and whenever there are material changes in regulations, policy or guidance.
- Training is documented and maintained appropriately, including training materials, sign-in sheets, certificates of completion, test results, etc.
- Delegates will attest to meeting these training requirements as part of the Annual Attestation.
Exclusion and Identity Screening
Delegates must, at a minimum, utilize the following government sources to screen their employees and Downstream Entities prior to hire or contract and monthly thereafter. Regulators prohibit our organization from hiring, employing or making payments to any person or entity excluded or debarred from Federal or State health care programs:
- Office of Inspector General’s (OIG) List of Excluded Inpiduals and Entities (LEIE)
- System for Awards Management (SAM), formerly the Excluded Parties List System (EPLS)
- Texas State Level Excluded Parties Lists
- Office of Personnel Management (OPM) debarment
- Office of Foreign Assets Control (OFAC) Specially Designated Nationals (SDN) and Bureau of Industry and Security (BIS) consolidated lists (USA Patriot Act)
- Social Security Administration Death Master File (SSA-DMF) (MEDICAID Delegates ONLY)
- National Plan and Provider Enumeration System (NPPES)
- Centers for Medicare and Medicaid Services (CMS) Preclusion List (MEDICARE ADVANTAGE Delegates ONLY)
Helpful Links
Compliance Concerns and FWA Reporting Mechanisms
Our organization has designated a Compliance & Ethics HelpLine as a confidential and secure reporting mechanism. Delegates are encouraged to report potential Compliance or FWA concerns to our organization without fear of retaliation. Delegates are encouraged to have such reporting mechanisms for their employees and delegates.
Audit and Monitoring
Delegates must perform routine monitoring of delegated functions. Monitoring activities include using performance-based metrics or scorecards, that are repeatedly measured in the normal course of operations. Results over time may identify systemic issues that require corrective action. Delegates are responsible for providing monitoring results that impact our organization on an ongoing basis.
Areas of focus can include but not limited to:
- Risks identified through Delegate’s risk assessment process
- Operational performance standards
- Delegate and Downstream service levels
- Complaint rates and trends
- Quality measures
- Industry best practices
- Risks identified through FWA, Compliance and Ethics Helpline
Such monitoring efforts enable our organization to detect failures in the Compliance Program, recommend or require corrective action plans and confirm corrective actions result in ongoing compliance.
Communication and Regulatory Change Management
Delegates are expected to adhere to regulatory and program changes received from Federal and State agencies, including but not limited to CMS HPMS and Qualified Health Plan (QHP) memos, fraud alerts and policy updates, as applicable. Any changes or concerns related to such updates must be reported to our organization immediately.
Annual Attestation
Our organization requires an Annual Attestation of compliance from its Delegates. At a minimum, the Delegate attests to meeting all requirements outlined above. Signed attestations (digital signatures acceptable) following the completion of a contract year should be emailed to HPCOMPLIANCE@BSWHealth.org.