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First Tier, Downstream or Related Entity Compliance

Am I or is my company a First Tier, Downstream or Related entity (FDR) of Health First Health Plans?

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 HFHP 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 HFHP 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.

What are the responsibilities of an FDR including the annual Medicare Attestation?

  • Report within a reasonable time frame to HFHP all suspected or known instances of non-compliance and/or fraud, waste or abuse

  • Sign the Medicare FDR Statement of Attestation every year

  • 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 PRO Procedure for Reporting Compliance Concerns
      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 Compliance 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 03.01.03 PRO Health Plans Effective Training and Education
      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 and Related Entity (FDR) Oversight
      HP 03.02.02 PRO Health Plans First Tier, Downstream and Related Entity (FDR) Oversight - Initial and Ongoing Training Requirements
      HP 03.02.03 PRO Health Plans First Tier, Downstream and Related Entity (FDR) Oversight - Monitoring
  • Train employees, contractors, board members and volunteers within 90 days after being hired/contracted and yearly thereafter

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

  • Retain records for 10 years (training records and records relating to services)

  • Maintain privacy and security of HFHP member information

  • Maintain oversight of your Downstream entities providing services relating to HFHP's Medicare Advantage contract with CMS

  • Inform HFHP Vendor Management Office before offshoring services or PHI out of the country

  • Correct any deficiencies related to misconduct or Medicare program non-compliance

Will HFHP be monitoring and auditing my organization?

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 HFHP's Medicare Advantage contract with CMS?

  • Yes

What can FDRs do about fraud, waste and abuse?

Education:

Reporting:

How can I contact HFHP to report an instance of suspected or known non-compliance and/or fraud, waste or abuse?

Should my organization be concerned about repercussions of reporting non-compliance and/or fraud, waste or abuse?

  • 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.