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2022 KCA Employee Compliance Attestation
Compliance and FWA attestation
*
1.
By checking the boxes below, I hereby certify that:
(Required.)
Consistent with CMS requirements, (42 CFR §§ 422.503(b)(4)(vi)(C), 423.504(b)(4)(vi)(C), I attest that I have received and reviewed the following documents: (These documents are always readily available for review on the
Compliance webpage
of the KelseyCare Advantage website.)
* KCA Code of Conduct,
* KCA Conflict of Interest Policy,
* KCA Compliance Training and
* Fraud, Waste and Abuse education and training to identify, correct, and prevent potential FWA within the first 90 days of employment and annually, thereafter.
I have read, understand and agree to abide by the KS Plan Administrators Code of Conduct and Business Ethics.
I have not been convicted of, or charged with, a criminal offense related to health care, nor have I been listed by a federal agency as debarred, excluded or otherwise ineligible for participation in federally funded health programs.
I agree to report suspected violations of any Federal and/or State laws, regulations, the Code of Conduct or the Anti-Fraud Plan to my supervisor or the Compliance Department. Online reporting is available on the
Compliance webpage
, you can also call our hotline at 713-442-9595. KSPA has a no-tolerance policy for retaliation or retribution against any employee who in good
faith reports suspected misconduct or violations.
I understand that any violation of any Federal and/or State laws, regulations, the Code of Conduct, the Anti-Fraud Plan or any other KCA compliance policy or procedure is grounds for disciplinary action, up to and including discharge from employment.
I agree to report any instance in which I become convicted, charged with criminal offense or listed by a federal agency as debarred, excluded or otherwise ineligible for participation.
Unless otherwise noted in item 2 (Conflict of Interest) below, I am not aware of any possible personal violations of any Federal and/or State laws, regulations, the Code of Conduct or participation in fraud, waste or abuse activities.
*
2.
Conflict of Interest
I am reporting a conflict of interest so that there may be full disclosure of any current conflict of interest.
Please indicate
Yes
or
No
below, if
Yes
you are required to furnish details to the KelseyCare Advantage Compliance department immediately and complete the comment box after clicking "Next".
(Required.)
Yes
No
