PACE of the Triad Fraud, Waste and Abuse Program

PACE of the Triad has adopted a Fraud, Waste, and Abuse (FWA) Compliance Program to reaffirm our commitment to complying with all applicable laws and to meet the requirements for Medicare Part D Prescription Drug Plan. Continue to learn more about PACE of the Triad’s Fraud, Waste and Abuse Program!

Our FWA Program:

  • articulates our commitment to detecting, correcting, and preventing fraud, waste, and abuse in the administration of our Prescription Drug Plan;
  • describes standards of conduct and compliance expectations that employees, and first tier, downstream, and related entities (“FDRs”) of PACE are expected to adhere to;
  • outlines procedures that PACE follows in monitoring and auditing for fraud, waste and abuse, with respect to the prescription and in investigating and resolving any potential improper conduct when identified;
  • provides guidance for our employees and FDRs in reporting compliance issues and addressing questions relating to fraud, waste and abuse in the organization’s PDP; and
  • Identifies specific risk areas for us that merit attention and monitoring.

Components of PACE of the Triad’s Fraud, Waste and Abuse Program

  1. Compliance Coordinator-David Long
  2. Compliance Committee – David Long, Dr. Robert Koehler, Ursula Robinson, Ellen Smith, Jacque Williams, Rena Wright, Lucilla Davis, Porscha Harvey, Marilyn Webb, Adria Smith, Hope Johnson and Melissa Brackin
  3. Risk Assessment – annually our compliance coordinator conducts a FWA Risk Assessment to identify: possible FWA risk areas; the safeguards in place to manage those risks; and any areas where additional safeguards might be appropriate.
  4. Risk Area Monitoring and Audits – we conduct periodic monitoring and auditing activities to detect and prevent potential FWA and to ensure compliance with all applicable federal and state laws, the FWA Program, and Organization’s policies and procedures. The Compliance Officer has an audit work plan outline which includes a schedule of planned auditing and monitoring activities for each year.  Monitoring and/or auditing extends to all areas of PACE including:
    • Operations of third-party contractors;
    • Claims processing;
    • Pricing, rebates and other price concessions;
    • Marketing and enrollment violations;
    • Agent/broker misrepresentation;
    • Enrollment/disenrollment noncompliance;
    • Credentialing;
    • Quality assessment;
    • Appeals and grievance procedures;
    • Utilization management;
  5. Audit Reports and Corrective Actions – PACE of the Triad’s Board of Directors receives the outcome of compliance audits and corrective action plans.
  6. Exclusion – PACE of the Triad screens all employees, contractors (including FDRs) and members of the Board of Directors against the Office of Inspect General List of Excluded Individuals/Entities and the General Services Administration (“GSA”) Exclusion List Check, and/or any state exclusion lists maintained by state Medicaid programs, at the time of initial hire/contract/appointment/election, and at least monthly thereafter. Employees and contractors found to be excluded will be removed immediately from employment with PACE of the Triad.
  7. Disciplinary Guidelines-PACE employees and FDRs are expected to comply with all organization policies related to compliance, including but not limited to this FWA Program, as a condition of employment or contract. We expects our employees and FDRs to meet the highest ethical standards, and comply with all applicable laws. Failure to do so may result in appropriate disciplinary action, up to and including termination of the contract.
  8. Monitoring and Safeguards – to ensure the truth and accuracy of data submitted to CMS, and to identify areas where data collection and submission practices could be improved, PACE of the Triad periodically monitors the following:
    • Prescription Data Event (“PDE”) information;
    • Cost data;
    • Diagnoses information reported through Risk Adjustment Processing Data System (“RAPS”);
    • Information reported to CMS;
    • Data on direct and indirect remuneration;
    • Enrollment and disenrollment data;
    • Submission of claims under the appropriate reimbursement program (e.g., Medicare Part B claims vs. Medicare Part D claims); and
    • All other information required to be reported, including information about vaccines; generic drug utilization; overpayments; pharmaceutical manufacturer rebates, discounts and other price concessions; and long-term care (“LTC”) rebates.

Your Roles in Compliance and Monitoring of Fraud, Waste and Abuse – Please use any of our reporting mechanism to report compliance and fraud, waste and abuse concerns.

  • Compliance Confidential Hotline – (336) 550-4140 this hotline is checked daily. You can leave Compliance and FWA concerns on this hotline 24 hours a day, 7 days a week, and 365 days a year.
  • Compliance Coordinator direct phone number – (256) 508-0478 to be used Monday-Friday 8:00 am until 5:00 pm.
  • Call the main line (336) 550-4040 Monday-Friday 8:00-5:00 and ask to speak with a member of the Compliance Team.