AlohaCare Compliance and Fraud, Waste, and Abuse Resources and Information for Business Partners
AlohaCare has a contract with CMS to provide Medicare Advantage Plans and a contract with the State of Hawaii to provide a Medicaid plan (QUEST). As part of these contracts, AlohaCare is required to maintain an effective compliance program, which must include measures to prevent, detect and correct Medicare and QUEST program noncompliance as well as Fraud, Waste and Abuse (FWA). A requirement of the compliance program is the oversight of our Business Partners (technically referred to as first tier, downstream, and related entities (FDR) for Medicare and providers and subcontractors for QUEST).
Example of AlohaCare Business Partners include, but are not limited to:
- Healthcare Providers
- Hospitals
- Certain Vendors
- Agents/Brokers
- Certain Contractors and Consultants
Requirements for Business Partners
- Perform monthly exclusion checks
- Provide FWA and Compliance training
- Maintain compliance and FWA training records
- Maintain Standards of Conduct or use AlohaCare’s Business Conduct Guidelines
- Refrain from providing gifts to AlohaCare employees
- Disclose any Conflict of Interest
- Report all potential misconducts to AlohaCare
We at AlohaCare are committed to our compliance program and we need the assistance of our Business Partners to reach our compliance program goals. We encourage our Business Partners to utilize AlohaCare’s policies and procedures, training resources, and FWA information. On this page our Business Partners can find FWA resources, training information, AlohaCare Business Conduct Guidelines, Exclusion Check requirements, Conflict of Interest declaration, as well as information on how to report compliance issues. If you require further assistance please contact AlohaCare’s Compliance department at 808-973-7486.
AlohaCare Business Partners are to complete FWA training within the first thirty days of contract and annually thereafter. Business Partners are required to maintain all training records to include, date of training, methods of training, training curriculum, training sign in sheet or other employee identifying methods. AlohaCare may request training records to ensure training has occurred.
Business Partners should have policies and procedures to address, fraud, waste and abuse, including training, reporting mechanisms, and methods to respond to detected issues.
FWA Training Resources
QUEST Fraud and Abuse information:
AlohaCare performs monthly exclusion checks and will not enter into contract and does not pay any individuals that are excluded from state and federal healthcare programs. AlohaCare encourages Business Partners to perform their own exclusion checks and to immediately remove any employees that are excluded.
Excluded parties list can be found here:
QUEST Hawaii
If a Business Partner is made aware of potential misconduct it is the expectation that the Business Partner reports the suspected issue to AlohaCare right away. The Business Partner can call AlohaCare’s Compliance Department at 808-973-7486, or call AlohaCare’s Compliance Hotline at 855-973-1852 to report any compliance violation. The Compliance Reporting form can also be utilized to report compliance issues.
Please read our Business Conduct Guidelines. This guideline has multiple facets – ranging from internal monitoring to establishing ethics training and education. One of the program’s integral components is defining our expectations of each Business Partner. To communicate these expectations, we have developed this Business Conduct Guidelines booklet.
It is in the best interest of AlohaCare to be aware of and properly manage all conflict of interest and appearance of a conflict of interest. Each Business Partner is expected to meet high standards of ethical behavior whenever a Business Partner acts on behalf of AlohaCare.
One of the principles of the AlohaCare Code of Conduct relates to Business Relationships.
This principle states:Business dealings with vendors, contractors and other third parties must be transacted free from offers or solicitation of gifts and favors or other improper inducements that would affect AlohaCare’s business in any way. It is AlohaCare’s desire at all times to preserve and protect its reputation and to avoid the appearance of impropriety.
This is particularly important to us, since all of our revenue is derived from the government. Consequently, no gifts of value can be accepted by any AlohaCare employee from anyone AlohaCare does business with (including at holiday time).
Please keep this in mind as you do business with us, and avoid offering gifts and other items or services of value to AlohaCare employees. This includes gifts of food or meals.
AbuseIncludes actions that may, directly or indirectly, result in unnecessary costs to the Medicare and Quest programs, improper payment, payment for services that fail to meet professionally recognized standards of care, or services that are medically unnecessary.
FraudIs knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or obtain by means of false or fraudulent pretenses, representations, or promises any of the money or property owned by, or under the custody or control of, any health care benefit program.
WasteIs the overutilization of services, or other practices that, directly or indirectly, result in unnecessary costs to the Medicare and Quest programs. Waste is generally not considered to be caused by criminally negligent actions but rather the misuse of resources.
First TierAny party that enters into a written agreement with AlohaCare to provide administrative or health care services for our members.
Examples include, but are not limited to: Pharmacy Benefit Manager (PBM), contracted hospitals or providers.
Any party that enters into written agreement with AlohaCare to provide administrative or health care services for our members.
DownstreamAny party that enters into a written agreement below the level of the arrangement between AlohaCare and a first tier entity for the provision of administrative or health care services.