Medicaid Compliance PolicyA school board is responsible for the education of the children residing in its district and must provide for the governance and oversight of the district’s affairs, personnel, and properties. To address these responsibilities, the board should establish a strong control environment, issue comprehensive policies, ensure the district operates in accordance with its mission and all legal requirements monitor the district’s financial condition, and ensure the district hires qualified individuals.The control environment sets the tone of an organization, influencing the control consciousness of its people. The governing board and other management personnel set the proper tone for the control environment when they establish and effectively communicate a code of ethics and written policies and procedures, behave in an ethical manner, observe the same rules they expect everyone else to observe, and require the appropriate standard of conduct from everyone in the organization. Employees observe how management conducts itself, and that conduct often speaks more fluently then the written policies that management expects employees to follow.The Kenmore-Tonawanda UFSD, therefore, promulgates:
It is the board’s policy to fairly and firmly enforce the disciplinary policies pertaining to Medicaid non-compliance.Part 521, Title 18 of Codes, Rules and Regulations of the State of New YorkMedicaid Complaint Procedure/HotlineAny officer or employee that believes he/she has seen or suspects non-compliant behavior concerning billing, payments, medical necessity of services, quality of services, governance, mandatory reporting, credentialing or other risk areas shall report such to Medicaid Compliance Officer through informal or formal means. Upon receipt of such compliant, the Medicaid Compliance Officer shall notify the Superintendent who shall determine who shall do the investigation.All complaints of non compliance will be held in confidence to the extent practicable to enable the District to conduct a thorough investigation and as permitted by law. While the District respects the privacy and anonymity of all parties and witnesses to complaints brought under the policy, it cannot guarantee absolute confidentiality. At the conclusion of the investigation and at such time when the written report is issued and become a final agency determination (30 days after the issuance of the report if no appeal is made or after the issuance of the appeal determination), the report may become public.Upon receipt of any complaint of non compliance, the designated investigator shall conduct a thorough, prompt and impartial investigation of the charges within 30 calendar days of receipt of the complaint. All complaints of the non compliance shall be taken seriously and an investigation shall be conducted to the extent possible. The investigator shall prepare a written report of the investigation. The report shall be filed with the Superintendent.If after investigating the complaint, it is found to have merit, the case will be reported to the Office of the Medicaid Inspector General and any overpayments associated with the non compliance will be refunded.When a complaint involves allegations which constitute or may constitute criminal behavior, the police authorities or the District Attorney’s office shall be immediately notified.Such problems will promptly and thoroughly be corrected. Policies, procedures and systems will be implemented as necessary to reduce the potential for reoccurrence.Any complaint or suspicion shall be communicated to the Medicaid Compliance Officer either:
- A code of ethics as applies to Medicaid billing, payments, medical necessity and quality of services, mandatory reporting, credentialing and other risk areas that may be identified by due diligence.
- A staff/governance board training schedule on procedures and compliance issues.
- A communication process where compliance issues can be reported confidentially.
- The appointment of a Medicaid compliance officer with the responsibilities articulated.
- Disciplinary procedures that encourage good faith reporting and sanctions for failure to do so.
- Definition of administrative responsibilities for fair and firm enforcement of discipline for failure to comply.
- A system for routine identification of compliance risk areas.
- A system for responding to, investigating, correcting, reporting and developing policies that discourage non-compliance issues or activities.
Brenda Chmura, Medicaid Compliance OfficerKenmore-Town of Tonawanda UFSD1500 Colvin BoulevardBuffalo, New York firstname.lastname@example.org
- Informally through a conversation
- Formally through a letter
- By phone at (716) 874-8400 ext. 5321
Last Modified on February 18, 2015