South Atlantic Medical Group IPA (SAMG) is committed to conducting its IPA operations in compliance with ethical standards, contractual obligations under State and Federal programs, laws, and regulations applicable to Medi-Cal and Medicare. This commitment extends to our business associates and delegated entities that support SAMG’s mission to improve the delivery of quality, accessible, and wellness based healthcare services for our community.
Our Compliance Program is designed to:
South Atlantic Medical Group IPA (SAMG) expects Team Members and business entities doing business with SAMG to conduct business activities in an ethical and professional manner that promotes public trust and confidence in the integrity of SAMG. The Code is meant to provide guidance about the compliance culture at SAMG and the role that each Team Member, including management, Chief Officers and the Governing Board, plays in building and preserving that culture.
The SAMG Compliance, FWA, and Privacy Training Program focuses on the elements of an effective Compliance Program, conduct & ethics, and the Fraud, Waste and Abuse and Privacy Programs.
SAMG requires delegated entities to provide Compliance Training to their employees, Providers, downstream entities, Board of Directors, and Contractors within 90 days of hire/start.
SAMG is committed to a culture of compliance, ethics, and integrity, the goal of Compliance Training is to provide all associated parties the ability to demonstrate awareness of SAMG’s requirements, including regulations and policies & procedures associated with Compliance as it relates to daily work.
If you have questions or additional suggestions, please e-mail The SAMG Compliance Department at compliance@samg.org.
South Atlantic Medical Group IPA (SAMG) is prohibited from issuing payment for services provided, ordered, or prescribed by an individual or entity that is excluded, ineligible, or terminated from participation in State and Federal health care programs in accordance with regulatory and contractual requirements.
SAMG conducts regular reviews of the following Federal and State exclusionary lists:
SAMG has a screening process to identify individuals and entities that appear on the DHHS OIG LEIE, the GSA EPLS, SAM, the Medicare Opt-Out List and the DHCS Medi-Cal Suspended and Ineligible Provider List prior to appointment, contracting, and/or employment and monthly thereafter to ensure that none of these individuals or entities are excluded, ineligible or terminated from participation in State and Federal programs.
Delegated entities must implement a screening program for employees, Board Members, contractors, and business partners to avoid relationships with individuals and/or entities that tend toward inappropriate conduct.
This program includes:
SAMG has established a Fraud, Waste, and Abuse Program to detect, correct, and prevent fraud, waste, and abuse on part of Team Members, SAMG Members, Providers, Vendors, delegated entities and any other entity doing business with SAMG.
Fraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program, or to 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.
Examples include:
Waste includes overuse of services, or other practices that, directly or indirectly, result in unnecessary costs. Waste is generally not considered to be caused by criminally negligent actions but rather by the misuse of resources.
Examples include:
Abuse includes actions that may, directly or indirectly, result in unnecessary costs and improper payment or services. Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment.
Examples include:
SAMG has established a HIPAA Privacy Program to ensure that Member’s health information is properly protected while allowing the flow of health information needed to provide and promote high-quality health care.
A privacy breach is defined as unauthorized acquisition, access, use, or disclosure of protected health information (PHI) which compromises the security or privacy of such information.
PHI is health information that relates to a Member’s past, present or future physical or mental health or condition, including the provision of his/her health care, or payment for that care and contains personally identifiable information (PII) such as name, SSN, DOB, Member ID, address, or any other unique identifier related to the Member.
This generally means that a breach occurs when PHI is accessed, used, or disclosed to an individual or entity that does not have a business reason to know that information. The law does allow information to be accessed, used, or disclosed when it is related to treatment, payment, or healthcare operations directly associated with the work that we do at SAMG on behalf of our Members.
SAMG has the following resources available for reporting fraud, waste or abuse, Privacy issues, and other compliance issues:
You may report fraud anonymously (24) hours a day, (7) days a week Compliance Hotline: 1-833-718-1025
Fax: (323) 725-6933
E-mail: compliance@samg.org.
Mail:
SAMG Compliance Officer
5504 E. Whittier Boulevard,
Los Angeles, CA 90022
What are some common examples of fraud?
Providers
Members
First, document your suspicions. Then, contact SAMG’s Compliance Department and explain the case to one of our Representatives. At times, SAMG may request additional information that is necessary to investigate the case. Thus, Provider documentation is strongly encouraged.
SAMG also has the following resources available for reporting fraud, waste or abuse, Privacy issues, and other compliance issues:
You may report fraud anonymously (24) hours a day, (7) days a week Compliance Hotline: 1-833-718-1025
Fax: (323) 725-6933
E-mail: compliance@samg.org.
Mail:
SAMG Compliance Officer
5504 E. Whittier Boulevard,
Los Angeles, CA 90022
If you suspect that errors in billing may have occurred, contact your SAMG Provider Services Representative.
The Office of the Inspector General (OIG) is there to assist you and maintains a hotline, which offers a confidential means for reporting vital information. For information on confidentiality, please contact the hotline and ask about their confidential source program. Each caller is encouraged to assist the OIG by providing information on how they can be contacted for additional information but the caller may remain anonymous.
Contacting the Office of the Inspector General
Phone: (800) HHS-TIPS (447-8477)
E-mail: Htips@oc.dhhs.gov
Additional Hotlines
DHCS MEDI-Cal Fraud Hotline
Phone: (800) 822-6222
E-mail: stopmedicalfraud@dhs.ca.gov
The recorded message may be heard in English and four other languages: Spanish, Vietnamese, Cambodian, and Russian. The call is free and the caller may remain anonymous.
Fraud Prevention, it’s a Team Effort
In an effort to prevent fraud and abuse, SAMG encourages Providers and their staff to report any suspicious circumstances when they arise. You may want to ask for another form of identification in addition to the Healthplan’s Member identification card. Identification with both a picture and a signature, such a valid driver’s license or State identification card, are suggested. We are informing Members of this concern and are requesting that they have additional identification available when they come to you.
To obtain more compliance guidelines, the Department of Health and Human Services (HHS) offers assistance (By clicking on this link, you will be leaving the SAMG website).