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Key Regulatory Requirements

Vendors are required to follow the spirit and the letter of the laws and regulations to which Horizon BCBSNJ is subject. While the listing below is not inclusive of all of such laws and regulations, it does provide an overview of some important requirements that apply to Horizon BCBSNJ business.

Fraud, Waste and Abuse

Medicare Regulations and Guidelines from the Centers for Medicare and Medicaid Services govern Medicare Advantage Organizations and Medicare Prescription Drug plans and, in part, require the implementation of an effective compliance program to prevent, detect, and correct fraud, waste and abuse and Medicare Program noncompliance.

The Federal False Claims Act (“FCA”) prohibits knowingly submitting a false or fraudulent claim (to Medicare, Medicaid or other federal health care program) for payment. The FCA also allows whistle blower lawsuits, and provides protection of whistle blowers against any retaliation by their employers for reporting potential fraud or abuse.

The Anti-Kickback Statute prohibits knowingly and willfully offering or making, requesting or receiving anything of value (including bribes, kickbacks and rebates) from a vendor, supplier, provider, member or beneficiary in return for payment or reimbursement under a government program.

The Stark Law (Physician Self-Referral Law) prohibits a physician from making certain referrals to a particular entity if he/she has an ownership/ investment interest or a compensation arrangement with that entity.

The New Jersey Insurance Fraud Prevention Act requires the development of fraud prevention programs and the repayment of fraudulently obtained insurance benefits, thereby reducing the amount of premium dollars used to pay fraudulent claims.

Medicaid Contract Provisions require referral of proven cases of fraud to the New Jersey Office of State Comptroller's Medicaid Fraud Division for screening, for advice and/or for the assistance on follow-up actions to be taken.

Privacy and Security

The Health Insurance Portability and Accountability Act (“HIPAA”) requires health plans, providers, clearing houses and their business associates to protect the confidentiality, integrity and availability of health care information, in all forms, and provides safeguards to prevent unauthorized access to protected health care information.

The Patient Protection and Affordable Care Act requires transparency along with the expansion of Medicaid eligibility requirements.