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 or contractor, 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 tab above that applies to you.

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

PacificSource Code of Conduct
PacificSource Compliance Program

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.

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?
  • 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.

  • CMS Compliance Website
    This government website provides information on compliance and actions the government has taken with health plans.
  • Fraud Scheme Tips
    This government document provides tips on how to spot fraudulent activities.
  • Fraud & Identity Theft Tips
    This government document provides comprehensive information on how to detect and protect against fraud and identity theft.
  • Medical Device Fraud Tips
    This government document provides tips on how to spot medical device fraud, such as wheelchairs and scooters.
  • Office of Inspector General Website
    This government website provides news and updates on national health care fraud, including law enforcement actions taken against fraudulent parties.
  • Government Anti-Fraud Website
    This government website provides news and updates on national health care fraud, including tips on how you can protect yourself against fraud.
  • Fraud Tips
    This government document provides tips on how to protect yourself against fraud by checking your personal records.

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 general compliance and FWA 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 the FWA Training. If you and your employees have taken the training for other Medicaid Managed Care, or Medicare Advantage health plans, you do not have to take PacificSource’s training.

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

PacificSource Code of Conduct
PacificSource Compliance Program
OIG Compliance and FWA Training

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 Medicaid Managed Care 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

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.

  • CMS Provider Billing Educational Tips
    This government Medicare Quarterly Provider Compliance newsletter provides education on how to address common billing errors and other claim review findings.
  • Office of Inspector General Website
    This government website provides news and updates on national health care fraud, including law enforcement actions taken against fraudulent parties.
  • Government Anti-Fraud Website
    This government website provides news and updates on national health care fraud, including tips on how you can protect yourself against fraud.

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 general compliance and FWA training. If you and your employees have taken the training for other Medicaid Managed Care, or Medicare Advantage health plans, you do not have to take PacificSource’s training.

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

PacificSource Code of Conduct
PacificSource Compliance Program
OIG Compliance and FWA Training

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 Medicaid Managed Care 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.

  • Office of Inspector General Website
    This government website provides news and updates on national health care fraud, including law enforcement actions taken against fraudulent parties.
  • Government Anti-Fraud Website
    This government website provides news and updates on national health care fraud, including tips on how you can protect yourself against fraud.