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audits. Therefore, government investigations of health care entities have become and will continue to be commonplace. FHCP’s policy has been and will continue to be to provide full cooperation to these government authorities, while at the same time protecting the rights of FHCP and all of its employees. Compliance Plan 6 - 7 Revised December 12, 2018 Such government agencies include but are not limited to: Agency Name Description Centers for Medicare & Medicaid Services (CMS) Federal agency overseeing administration of the Medicare and Medicaid programs and FFM This includes the MEDICs engaged by CMS to assist in audit, oversight and anti-fraud efforts. Federal Bureau of Investigation (FBI) Investigative arm of federal government programs Medicare Administrative Contractors Claims processors of the Medicare Part A hospitals, skilled nursing facilities, and home health agencies. Claims processors of the Medicare Part B program (e.g., physicians, clinical laboratories, durable medical equipment, and nursing home supplies). Office of the Inspector General (OIG) Investigative arm of federal government programs Florida Agency for Health Care Administration (AHCA) HMO licensure State of Florida Department of Financial Services (DFS) HMO benefits, rates, forms, and agent licensure. State Attorney General's Office Arm of the state responsible for investigating/prosecuting violations of state laws. State Attorney's Office Local authority responsible for investigating/prosecuting violations of state laws All employees should refer any governmental agency inquiries to the Compliance Officer or a member of the Compliance Committee. Additionally, FHCP recognizes that self-reporting of fraud, waste and abuse is a critical element to an effective program to control fraud, waste and abuse. If, after conducting a reasonable inquiry, FHCP determines that potential fraud or misconduct has occurred, the conduct will be referred to the MEDIC promptly, but no later than 60 days after the determination that a violation may have occurred. To the extent that potential fraud is discovered with respect to a Downstream or Related Entity, FHCP will refer the conduct to the MEDIC on an expedited basis so that the MEDIC can help identify and address any scams or schemes. If this timeframe cannot be met, FHCP shall contact the MEDIC for further guidance. FHCP also maintains, as part of this Compliance Plan, a protocol for voluntary self-disclosure to the OIG and such other law enforcement and/or government agencies. See the description regarding Voluntary Disclosure Submission, below. Compliance Plan 6 - 8 Revised December 12, 2018 VI. Medicare Advantage and Part D Fraud, Waste and Abuse Monitoring and Auditing FHCP recognizes the significant vulnerabilities that accompany FHCP’s participation as a first tier entity under the Medicare Advantage and Part D Programs, and has taken additional measures to ensure that Medicare beneficiaries receive timely access to covered drugs while also conducting its Part D operations in a manner that will minimize the risk of program funds being spent inappropriately. FHCP fills over 95% of all Part D prescriptions at its owned and operated retail pharmacies and FHCP-owned and operated mail-order pharmacy. This gives FHCP tremendous control over the delivery of prescription drugs to its members, and thus the ability to oversee, monitor and audit virtually all of the organization’s Part D operations. Examples of FHCP’s efforts to combat fraud, waste and abuse in its Medicare Advantage and Part D operations include the following: • On-going monitoring and review of member Part D coverage determination requests and appeals, including for exceptions to the formulary or cost-sharing obligation, to identify trends indicating inappropriate prescribing habits and potential need to modify a formulary provision or drug utilization mechanism • On-going monitoring and review of Acumen reports for PDE, Patient Safety, etc. • On-going monitoring and review of prescription drug utilization for various issues, including (i) use of pharmaceuticals identified on the National Specified List of Susceptible Products produced by the National Association of Boards of Pharmacy to ensure appropriate utilization; (ii) adverse drug events (ADR); (iii) allegations of drug seeking/doctor shopping; theft of prescriber’s DEA number or prescription pad; and prescription stockpiling • On-going monitoring and review of use and dispensing of excluded drugs/off-label uses and utilization of contracted vs. FHCP-owned pharmacies. • On-going monitoring and review of member TrOOP calculations to ensure accuracy of real-time tracking, proper application and collection of cost-sharing amounts, and potential for catastrophic coverage manipulation • Audits of bid submissions, and internal Part D payment reconciliation and final payment determinations to minimize errors • All identified risks will be investigated in accordance with FHCP Policy LD012 – Anti-Fraud Plan. Compliance Plan 7 - 1 Revised December 12, 2018 VOLUNTARY DISCLOSURES In the event that FHCP identifies an event or act that violates a state or federal law, FHCP shall promptly report such activity to the appropriate regulatory entity. Additionally, any suspected act of insurance fraud related to FHCP commercial lines of business shall be reported by the Compliance Officer, or his designee, to the Florida Department of Financial Services, Division of Insurance Fraud via their website at Division of Insurance Fraud. FHCP will also follow the protocol published by the U.S. Department of Health and Human Services Office of the Inspector General related to federal health program lines of business as follows: A. Effective DISCLOSURE: The disclosure will be made in writing and will be submitted to the Assistant Inspector General for Investigative Operations, Office of Inspector General, Department of Health and Human Services, 330 Independence Avenue, SW, Cohen Building, Room 5409, Washington, DC 20201. Submissions by telecopier, facsimile or other electronic media will not be acceptable. (Disclosures relating to the Medicare prescription drug benefit program may be made to the Medicare Drug Integrity Contractor (MEDIC) in addition to or in lieu of a disclosure to the OIG, as the Compliance Committee so determines based on Chapter 9 and such other guidance issued by CMS.) B. BASIC INFORMATION: The Submission will: 1. Include FHCP’s name, address, provider identification number(s) and tax identification number(s). Additionally, it will provide the name and address of FHCP’s designated representative for purposes of the voluntary disclosure. 2. Indicate whether FHCP has knowledge that the matter is under current inquiry by a Government agency or contractor. If FHCP has knowledge of a pending inquiry, identify any such Government entity or individual representatives involved. FHCP will also disclose whether it is under investigation or other inquiry for any other matters relating to a Federal Health Care Program and provide similar information relating to those other matters. 3. A full description of the nature of the matter being disclosed, including the type of claim, transaction or other conduct giving rise to the matter, the names of entities and individuals believed to be implicated and an explanation of their roles in the matter, and the relevant periods involved. 4. The type of health care provider implicated and any provider billing numbers or NPI/NCPDP