General Compliance

Medicare & Medicaid: All delegates working with our Medicare Advantage Parts C and D or Medicaid programs must provide Fraud, Waste & Abuse (FWA) and General Compliance training to their employees who support the delivery administration of program benefits or services.  Delegates can either provide their own training program which includes the FWA and compliance requirements or they can use the UHC Delegate FWA and General Compliance Training deck.
 

Frequency: Delegates must distribute written policies, procedures or standards of conduct within 90 days of hire and annually thereafter, or when the Code of Conduct is updated.

U.S. Department of Health & Human Services – Office of the Inspector General, and the U.S. General Services Administration, and State Exclusion Checks

Regulators prohibit our organization from hiring, employing or making payments to any person or business excluded or debarred from federal or state health care programs. Exclusion Checks Quick Reference Guide

Medicare & Medicaid: All delegates working with our Medicare Advantage Parts C and D or Medicaid programs must review the federal exclusion lists maintained by the U.S. Department of Health & Human Services – Office of the Inspector General (HHS-OIG) and the U.S. General Services Administration (GSA). These exclusion lists name individuals or organizations that are suspended or otherwise excluded from participation in Medicare and Medicaid programs.

Frequency: Delegates must review all employees and subcontractors that support Medicare Advantage Parts C and D and/or Medicaid plans and membership against OIG and GSA federal exclusion lists prior to hiring or contracting with them, and on a monthly basis thereafter.

Federal Exclusion Checks: Find the HHS-OIG List of Excluded Individuals and Entities.

Learn More

• OIG Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs
  
  
• OIG Exclusions Background Information
  
  
• GSA System for Award Management

State Exclusion Checks
Many states maintain state-based sanction/exclusion databases that are in addition to, but do not replace, the OIG and GSA federal exclusion databases. A provider may not participate in the network of a specific state if the provider is listed on that state’s exclusion list, even if the provider is not listed on a federal exclusion list.
 

State Exclusion List Resource: Visit Verify Comply®, a vendor that offers several exclusion list search options.

UnitedHealth Group and its businesses are not affiliated with the above independent websites.

Delegates must maintain records for 10 years to demonstrate compliance with regulatory requirements, including standards of conduct education, FWA and general compliance training, OIG/GSA exclusion checks, and supporting policies and procedures. A delegate may be called upon by our organization or a regulatory agency to provide documentation upon request. Failure to comply may result in any of a series of regulatory enforcement actions and our remediation activities.

Examples

• Communication of Standards/Code of Conduct in an email, website portal or contract.
• FWA and general compliance training methods, materials used for training, attestations or electronic certifications that include the date of the training.
• Method of OIG/GSA and state (if applicable) exclusion checks and a copy of a sanction check report for each employee/contractor.
• Policies and procedures that describe the processes used to meet the regulatory requirements.

Downstream Oversight Requirements
Delegates who subcontract the administrative or health benefit services performed for our organization to a subcontractor or downstream entity have an obligation to ensure the downstream entity complies with all of the same applicable federal and state laws, regulations and requirements through contract language, compliance oversight, monitoring and auditing activities. Records of such activities must be maintained for a minimum of 10 years and be available for review by CMS, state regulators or our organization upon request. (See Document Retention section above.)

Monitoring and/or Auditing of Subcontracted Delegates
Monitoring activities are reviews performed as part of normal operations to confirm ongoing compliance and to help ensure corrective actions happen and are effective. An audit is a formal review of compliance with a particular set of standards (e.g., policies and procedures, laws and regulations) used as base measures. CMS and state regulators require our organization to monitor and/or audit to confirm delegates’ compliance with the following:

• Medicare and Medicaid regulations.
• Sub-regulatory guidance.
• Contractual agreements.
• All applicable federal and state laws.
• Internal policies and procedures to protect against noncompliance and potential FWA.

Reporting suspected fraud is simple – and it’s important.

When you report a situation that you believe is FWA you are doing your part to protect patients, save money for the health care system and prevent personal loss for others. Taking action and making a report is an important first step. After your report is made, UnitedHealthcare works to detect, correct and prevent FWA in the health care system.

You can report FWA concerns to UnitedHealthcare online at uhc.com/fraud, or to Optum by emailing ReportFWA@optum.com or by calling 844-359-7736.
 

To report other Compliance & Ethics concerns: you may email EthicsOffice@uhg.com, report online at UHGhelpcenter.ethicspoint.com or call 800-455-4521.