New York Codes, Rules and Regulations › Title 18 - DEPARTMENT OF SOCIAL SERVICES › Chapter II - Regulations of the Department of Social Services › Subchapter E - Medical Care › Article 3 - Policies and Standards Governing Provision of Medical and Dental Care › Part 521 - Fraud, Waste and Abuse Prevention › Subpart 521-1 - COMPLIANCE PROGRAMS › Section 521-1.4 - Compliance program requirements

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Written policies and procedures.
(1) General. Required providers shall have
			   written policies, procedures, and standards of conduct. The required provider
			   shall establish a process for drafting, revising, and approving the written
			   policies and procedures required by this subdivision. The written policies and
			   procedures described in this subdivision must be available, accessible, and
			   applicable to all affected individuals.
(2) The written policies and procedures
			   shall:
(i) articulate the required provider's
			   commitment and obligation to comply with all applicable federal and state
			   standards. The required provider shall identify governing laws, and regulations
			   that are applicable to the provider's risk areas, including any MA program
			   policies and procedures, as specified in subdivision (d) of section
			   521-1.3  of this SubPart or
			   category of service.
(ii) describe
			   compliance expectations as embodied in standards of conduct. The standards of
			   conduct shall serve as a foundational document which describes the required
			   provider's fundamental principles and values, and commitment to conduct its
			   business in an ethical manner.
(iii) document the implementation of each of
			   the subdivisions under this section and outline the ongoing operation of the
			   compliance program. Policies and procedures shall describe, at a minimum, the
			   structure of the compliance program, including the responsibilities of all
			   affected individuals in carrying out the functions of the compliance
			   program.
(iv) provide guidance to
			   affected individuals on dealing with potential compliance issues. Such guidance
			   shall, at a minimum:
(a) assist affected
			   individuals in identifying potential compliance issues, questions and concerns,
			   set forth expectations for reporting compliance issues, and explain how to
			   report such issues, questions, and concerns to the compliance officer;
			   and
(b) establish the expectation
			   that all affected individuals will act in accordance with the standards of
			   conduct, that they must refuse to participate in unethical or illegal conduct,
			   and that they must report any unethical or illegal conduct to the compliance
			   officer.
(v) identify
			   the methods and procedures for communicating compliance issues to the
			   appropriate compliance personnel.
(vi) describe how potential compliance issues
			   are investigated and resolved by the required provider and the procedures for
			   documenting the investigation and the resolution or outcome.
(vii) include a policy of non-intimidation
			   and non-retaliation for good faith participation in the compliance program,
			   including, but not limited to:
(a) reporting
			   potential compliance issues to appropriate personnel;
(b) participating in investigation of
			   potential compliance issues;
(c)
			   self-evaluations;
(d)
			   audits
(e) remedial
			   actions
(f) reporting instances of
			   intimidation or retaliation; and
(g) reporting potential fraud, waste or abuse
			   to the appropriate State or Federal entities.
(viii) Disciplinary standards. Include a
			   written statement setting forth the required provider's policy regarding
			   affected individuals who fail to comply with the written policies and
			   procedures, standards of conduct, or State and Federal laws, rules and
			   regulations.
(a) Such statement shall
			   establish standards for escalating disciplinary actions that must be taken in
			   response to non-compliance, with intentional or reckless behavior being subject
			   to more significant sanctions. Sanctions may include oral or written warnings,
			   suspension, and/or termination.
(b)
			   The written policies and procedures shall also outline the procedures for
			   taking disciplinary action and sanctioning individuals. Disciplinary procedures
			   shall conform with collective bargaining agreements when applicable.
(ix) Additionally, notwithstanding
			   the requirement under 42
			   U.S.C. 1396a(a)(68), which
			   applies to entities that receive or make annual payments of at least $5,000,000
			   annually, all required providers shall comply with the provisions of
			   42 U.S.C.
			   1396 a(a)(68) (United States Code, 2006
			   edition, Title 42, Chapter 7, SubChapter XIX, Government Printing Office,
https://www.govinfo.gov/content/pkg/USCODE-2006-title42/pdf/USCODE-2006-title42-chap7-subchapXIX-sec1396a.pdf
.
			   A copy of which is available for copying and inspection at the Office of the
			   Medicaid Inspector General, 800 North Pearl Street,
			   2nd Floor, Albany, NY 12204).
(x) for MMCOs, describe the MMCO's
			   implementation, where applicable, of the requirements of SubPart 521-2 of this
			   Part.
(3) The required
			   provider shall review the written policies and procedures, and standards of
			   conduct required by this subdivision at least annually to determine:
(i) if such written policies, procedures, and
			   standards of conduct have been implemented;
(ii) whether affected individuals are
			   following the policies, procedures, and standards of conduct;
(iii) whether such policies, procedures, and
			   standards of conduct are effective; and
(iv) whether any updates are
			   required.