Any 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 over payments 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:
- Informally through conversation
- Formally through a letter
- Through the District anonymous hotline: (585)396-5799