Compliance Program

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:

  • Ensure we comply with applicable laws, rules, and regulations
  • Reduce or eliminate Fraud, Waste, and Abuse (FWA)
  • Prevent, detect, and correct non-compliance
  • Reinforce our commitment to culture of compliance for which we strive
  • Establish and implement our shared commitment to honesty, integrity, transparency, and accountability

Code of Business Conduct and Ethics

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.


Compliance, Fraud, Waste, and Abuse (FWA), and Privacy Program Training

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

Eligibility to Participate in Federal and State Health Program

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:

  • Office of Inspector General (OIG) List of Excluded Individuals and Entities (LEIE list)
  • GSA Excluded Parties List System (EPLS)
  • DHCS Medi-Cal Suspended and Ineligible Provider List
  • System for Award Management(

Exclusion Screening

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:

  • Prior to contracts and monthly thereafter, review of the GSA System for Award Management (SAM), the Department of Health Care Services Medi-Cal Suspended and Ineligible list, and the Office of Inspector General’s (OIG) List of Excluded Individuals and Entities (LEIE) that are excluded from participation in government health care programs (42 CFR §10011901).
  • A monthly review of the Department of Health Care Services Medi-Cal Suspended and Ineligible list.
  • Criminal record checks when appropriate or as required by law.
  • Review of the National Practitioner Databank (NPDB).
  • Review of professional license status for sanctions and/or adverse actions.
  • Reporting results to Compliance Committee, Governing Body, and SAMG as necessary.

Fraud, Waste, and Abuse (FWA)

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:

  • Knowingly billing for services or prescriptions not furnished or supplies not provided
  • Knowingly altering claim forms for a higher payment
  • Selling medicine, medical equipment, or other things received through SAMG

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:

  • Conducting excessive office visits
  • Writing excessive prescriptions or ordering excessive tests
  • Prescribing more medications than necessary for the treatment of a specific condition

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:

  • Billing for unnecessary medical services or medical equipment
  • Billing for brand name drugs when generics are dispensed
  • Misusing codes on a claim, such as upcoding and unbundling codes.

Privacy Incident/ Breach

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.

Reporting Information

SAMG has the following resources available for reporting fraud, waste or abuse, Privacy issues, and other compliance issues:

Compliance Hotline: (323) 725-0167
Fax: (323) 725-6933

SAMG Compliance Officer
5504 E. Whittier Boulevard,

Los Angeles, CA 90022

Frequently Asked Questions (FAQs)

What are some common examples of fraud?


  • Billing for services not rendered
  • Paying a “kickback” in exchange for a referral for medical services or goods
  • Unbundling
  • Overcharging for services or goods
  • Using false credentials


  • Allowing unauthorized individuals to use ID card to obtain benefits
  • Altering prescriptions
  • Falsifying residence information to obtain benefits
  • Drug seeking or doctor shopping to obtain narcotics

What do I do if I suspect an SAMG Member is engaging in possible fraud, waste or abuse?

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:

Compliance Hotline: (323) 725-0167
Fax: (323) 725-6933

SAMG Compliance Officer
5504 E. Whittier Boulevard,

Los Angeles, CA 90022

What do I do if my facility has made some billing errors?

If you suspect that errors in billing may have occurred, contact your SAMG Provider Services Representative.

What are some other things I can do as a Provider?

  • Periodically perform internal audits of billing practices and compare billing records with payments received.
  • Do not leave prescription pads, which include a Provider’s identification and license number, out in the open. For example, do not store prescription pads in exam room cabinets or leave on office counters.

Contact the OIG

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)

Additional Hotlines

DHCS MEDI-Cal Fraud Hotline
Phone: (800) 822-6222

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

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).