Compliance Training for Providers

CMS Provider Training Requirement

The Centers for Medicare and Medicaid Services (CMS) require that all persons who provide health care or administrative services to Medicare enrollees must satisfy the general compliance training requirements. Medicare Parts C and D General Compliance Training is available on the CMS website.

As a provider of health care services for Medicare enrollees, every action you take potentially affects Medicare enrollees, the Medicare program or the Medicare trust fund.

Everyone is required to report violations of standards of conduct and suspected noncompliance. As part of the Medicare program, it is very important that you conduct yourself in an ethical and legal manner.

Provider Responsibilities

  1. You are required to comply with all laws and regulations, including the Affordable Care Act, Health Insurance Portability and Accountability Act (HIPAA) Privacy Rules, HIPAA Security Rules and Medicare and Medicaid program requirements.
  2. You have a duty to the Medicare program to report any violations of laws that you are aware of.

What is noncompliance?

Noncompliance is conduct that does not conform to the law, the Federal health care program requirements or to Horizon BCBSNJ’s ethical and business policies.

Medicare Part C and Part D high-risk areas:

  • Beneficiary Notices
  • Billing practices
  • Conflicts of Interest
  • Documentation Requirements
  • Ethics
  • Formulary Administration
  • HIPAA
  • Quality of Care

Effects of noncompliance

Harm to the patient:

  • Delayed services
  • Denial of benefits
  • Difficulty in using providers of choice
  • Hurdles to care

Harm to everyone:

  • Higher insurance copayments
  • Higher premiums
  • Lower benefits for individuals/employers
  • Lower profits

Compliance Assistance and Reporting Noncompliance

If you have any questions, concerns or need to report noncompliance, please contact:

  • Horizon BCBSNJ Compliance Hot Line: 1-800-658-6781
  • Horizon BCBSNJ Fraud Hotline: 1-800-624-2048
  • Horizon BCBSNJ Medicare Advantage Fraud, Waste and Abuse Hotline: 1-800-624-2048
  • Horizon BCBSNJ Medicare Part D Fraud, Waste and Abuse Hotline: 1-888-889-2231

It is important to know that there can be NO retaliation against you for reporting suspected noncompliance in good faith. Horizon BCBSNJ must offer reporting methods that are anonymous, confidential and non-retaliatory.