We are Committed to Doing the Right Thing


As a community health plan that values partnership, service excellence community and personal relationships, we are committed to doing the right thing. We have a Compliance Program and Fraud Waste and Abuse (FWA) Plan that we follow to ensure we comply with State and Federal laws, regulations, and our internal policies and procedures.

Please help us stop health care fraud. In this section, we provide useful tools to help us fight health care fraud. If you are a PacificSource member, provider, contractor, or sales agent, please report suspicious activities to us immediately. Thank you for your continued support. We are committed to serving our members in the best and most ethical manner.

For more information, including how to recognize these activities, how to report them, and ways you can help prevent health care fraud, please click on the link that applies to you on the left hand side of this page. We have pages that include specific information for:


Compliance Program & Standards of Conduct


We maintain a comprehensive Compliance Program that allows us to carry out the activities needed to support our culture of compliance. The Compliance Program includes important topics such as:

  • Training and education
  • Standards of Conduct
  • Compliance policies and procedures
  • Compliance Officer and Compliance Committee
  • Monitoring and auditing
  • How to report compliance issues
  • How we look into and resolve compliance issues
  • How we correct compliance issues

We also have a Standards of Conduct which includes our written commitment to compliance and ethical behavior. The Standards of Conduct has been approved by our Board of Directors and Executive Management. This document provides information on things such as:

  • Responsibility to report compliance issues
  • Non-retaliation policy
  • Federal and State laws that oversee our business
  • Conflict of interest policy
  • Responsibilities and expectations
  • Disciplinary actions due to noncompliance


Workplan


We maintain a comprehensive work plan that focuses on higher risk activities. This plan allows us to monitor the activities of our internal operations, external vendors, providers, and other areas of our business. Thank you for your cooperation in providing information in an accurate and timely manner if you are identified in our work plan.


FDR Newsletter


We maintain a Compliance Newsletter for our business partners and vendors. The Compliance Corner is a quarterly article that will raise compliance awareness, provide training and education, and encourage and promote the reporting of compliance and fraud, waste and abuse (FWA) issues.

For Members


Health care fraud is a growing problem. It drives up the cost of health care, and puts a burden on taxpayers and the health care system. We are committed to stopping health care fraud. To help us protect you against fraudulent claims and practices, we have included examples of activities you should look for:

  • Does your Explanation of Benefits (EOB) show a charge that you did not receive?
  • Did you get a phone call from an unknown caller offering low cost or free medical services? Did the caller ask for your personal information, such as your Social Security number, Medicare number, or date of birth?
  • Did a sales agent call you or show up at your residence without your permission to market a Medicare Advantage product or service?
  • Do you know someone who changed or forged a prescription?
  • Do you know someone who visits multiple doctors to get the same prescription?
  • Do you know someone who fills a prescription and then sells the medication?
  • Does a provider primarily write for narcotics or controlled substances?
  • Is a provider prescribing a higher quantity than medically necessary for a condition?
  • Is a provider giving unnecessary services?
  • Does a provider bill for services not provided?
  • Are medications expired, fake, or diluted?
  • Are generics given when the prescription requires that brand be dispensed?
  • Does a pharmacist provide less than the prescribed quantity and bill for the full amount?
  • Are there claims for prescriptions that you never picked up?

If you see any of these activities, please contact us immediately. We will look into and work with State and Federal government agencies about your concerns.


Useful Information


Below are documents and websites with tips and important information on how to protect yourself against fraudulent activities. This includes how to spot fraud and how to report your concerns.

For Providers


Health care fraud is a growing problem. It drives up the cost of health care, and puts a burden on tax payers and the health care system. We are committed to combating health care fraud. You can help us to prevent, detect, and correct noncompliance and fraud, waste, and abuse (FWA).


Compliance Reporting


If you suspect noncompliance or FWA activities, you must report them to us by calling (800) 624-6052 ext. 2580 or emailing providerservicerep@pacificsource.com. You may also report anonymously by contacting EthicsPoint (a PacificSource vendor) 24 hours a day/seven days a week at (888) 265-4068.

Here are some common examples of noncompliant and FWA activities:

  • Submitting claims when you are on the Office of Inspector General's (OIG) exclusion list
  • Billing multiple payers for the same service, except as required for coordination of benefit
  • Inappropriate up-coding
  • Billing for services not rendered
  • Providing excessive or unnecessary services
  • Prescription forging or altering
  • Receiving illegal payments or other benefits to prescribe certain medications
  • Prescription drug shorting
  • Providing false or misleading information to justify coverage
  • Dispensing expired or adulterated prescription drugs
  • Illegal distribution of free samples
  • Billing for non-covered services as covered
  • Stolen prescriber Drug Enforcement Agency (DEA) number or prescription pad

Annual Compliance Training


You and your employees are required to take Part 1 and Part 2 of the training annually. If you have met the fraud, waste, and abuse certification requirements through enrollment into the Original Medicare program, you do not have to take Part 1 FWA Training. If you and your employees have taken the training for other Medicare Advantage health plans, you do not have to take PacificSource’s training.

For your convenience, we have provided you with the following training material.

You must ensure that all of your employees and any downstream entities (i.e., subcontractors) take both of these CMS-approved training modules annually and read our Compliance Program and Standards of Conduct. All new employees and any downstream entities (i.e., subcontractors) must complete this as part of their orientation within 90 days of hire. Please document and retain proof of completion. You must use the Training Attendance Log to track your completion. If your employees and any downstream entities (i.e., subcontractors) have taken a CMS-approved training for other Medicare Advantage health plans, you do not have to take PacificSource’s CMS-approved training. However, they must still document their completion using the other health plan’s Training Attendance Log, or a modified version thereof. You do not need to send anything to PacificSource. However, your proof of training attendance and completion will be subject to PacificSource audit and verification.


Questions


If you have any questions about the content of this page, you may contact your provider service representative at (800) 624-6052 ext. 2580 or providerservicerep@pacificsource.com.


Useful Information


Below are documents and websites that provide you with tips and information on how to protect you and your patients against fraudulent activities, including how to detect and report them.

For Sales Agents


Health care fraud is a growing problem. It drives up the cost of health care, and puts a burden on tax payers and the health care system. At PacificSource, we are committed to combating health care fraud. You can help us to prevent, detect and correct noncompliance and fraud, waste and abuse (FWA).


Compliance Reporting


If you suspect noncompliance or FWA activities, you must report them by contacting us. You may also report anonymously by contacting EthicsPoint (a PacificSource vendor) 24 hours a day, seven days a week at (888) 265-4068.

Here are some common examples of noncompliant and FWA activities:

  • Performing work when you are on the Office of Inspector General's (OIG) exclusion list
  • Failing to meet your contractual performance standards
  • Using marketing materials not approved by PacificSource or the Centers for Medicare and Medicaid (CMS)
  • Using high pressure sale tactics
  • Using deceptive and misleading sale tactics
  • Selling or marketing when you are not licensed or appointed
  • Making unsolicited contacts with beneficiaries
  • Inappropriate disclosure or violation of the HIPAA Privacy and Security Rule

Annual Compliance Training


You and your employees are required to take Part 1 and Part 2 of the training annually. If you have met the fraud, waste, and abuse certification requirements through enrollment into the Original Medicare program, you do not have to take Part 1 FWA Training. If you and your employees have taken the training for other Medicare Advantage health plans, you do not have to take PacificSource’s training.

For your convenience, we have provided you with the following training material.

You must ensure that all of your employees and any downstream entities (i.e., subcontractors) take both of these CMS-approved training modules annually and read our Compliance Program and Standards of Conduct. All new employees and any downstream entities (i.e., subcontractors) must complete this as part of their orientation within 90 days of hire. Please document and retain proof of completion. You must use the Training Attendance Log to track your completion. If your employees and any downstream entities (i.e., subcontractors) have taken a CMS-approved training for other Medicare Advantage health plans, you do not have to take PacificSource’s CMS-approved training. However, they must still document their completion using the other health plan’s Training Attendance Log, or a modified version thereof. You do not need to send anything to PacificSource. However, your proof of training attendance and completion will be subject to PacificSource audit and verification.


Annual Broker Training


You and your employees are required to take broker compliance training and PacificSource’s product training annually and at the time you are appointed with PacificSource. For the compliance training, you may do so through nationally-recognized organizations such as America’s Health Insurance Plans (AHIP) or Gorman Health Group. The training must conform to CMS minimal training guidelines.

Please document and retain proof of training records. You may need to send your proof of training to PacificSource as part of your appointment process. Your proof of training attendance and completion may be subject to PacificSource audit and verification.


Medicare Marketing Guidelines


The CMS Medicare Marketing Guidelines is a comprehensive document that provides information on both permissible and prohibitive marketing activities. Please take the time to read the guidelines and familiarize yourself with what you can and cannot do with Medicare beneficiaries.


Questions


If you have any questions about the content of this page, please contact us.


Useful Information


Below are documents and websites that provide you with tips and information on how to protect you and your clients against fraudulent activities, including how to detect and report them.

For Contractors


Health care fraud is a growing problem. It drives up the cost of health care, and puts a burden on tax payers and the health care system. We are committed to combating health care fraud. You can help us to prevent, detect and correct noncompliance and fraud, waste and abuse (FWA).


Compliance Reporting


If you suspect noncompliance or FWA activities, you must report them by contacting us. You may also report anonymously by contacting EthicsPoint (a PacificSource vendor) 24 hours a day, seven days a week at (888) 265-4068.

Here are some common examples of noncompliant and FWA activities:

  • Performing work when you are on the Office of Inspector General's (OIG) exclusion list
  • Failing to meet your contractual performance standards
  • Inappropriate disclosure or violation of the HIPAA Privacy and Security Rule
  • Not paying claims accurately or timely
  • Failing to send member notices timely
  • Billing multiple payers for the same service, except as required for coordination of benefit
  • Inappropriate up-coding
  • Billing for services not rendered
  • Providing excessive or unnecessary services
  • Prescription forging or altering
  • Receiving illegal payments or other benefits to prescribe certain medications
  • Prescription drug shorting
  • Providing false or misleading information to justify coverage
  • Dispensing expired or adulterated prescription drugs
  • Illegal distribution of free samples
  • Billing for non-covered services as covered
  • Stolen prescriber Drug Enforcement Administration (DEA) number or prescription pad

Annual Compliance Training


You and your employees are required to take Part 1 and Part 2 of the training annually. If you and your employees have taken the training for other Medicare Advantage health plans, you do not have to take PacificSource's training.

For your convenience, we have provided you with the following training material.

You must ensure that all of your employees and any downstream entities (i.e., subcontractors) take both of these CMS-approved training modules annually and read our Compliance Program and Standards of Conduct. All new employees and any downstream entities (i.e., subcontractors) must complete this as part of their orientation within 90 days of hire. Please document and retain proof of completion. You must use the Training Attendance Log to track your completion. If your employees and any downstream entities (i.e., subcontractors) have taken a CMS-approved training for other Medicare Advantage health plans, you do not have to take PacificSource’s CMS-approved training. However, they must still document their completion using the other health plan’s Training Attendance Log, or a modified version thereof. You do not need to send anything to PacificSource. However, your proof of training attendance and completion will be subject to PacificSource audit and verification.


Questions


If you have any questions about the content of this page, please contact us.


Useful Information


Listed below are documents and websites that provide you with tips and information on how to protect yourself against fraudulent activities, including how to detect and report them.