St. Luke's Health Plan
Compliance Program

What is St. Luke’s Health Plan’s Compliance Program?

St. Luke’s Health Plan is committed to a culture of compliance. St. Luke’s Health Plan’s Compliance Program is modeled after the Office of Inspector General’s Compliance Guidance. Seven specific elements comprise the Program, and each element is designed to prevent, detect and respond to business conduct that does not conform to applicable laws or regulations.

The structural components of St. Luke’s Health Plan’s Compliance Program:
1. Governing board oversight

St. Luke’s Health Plan’s governing body (Board) is responsible for oversight of the Compliance Program. The Board receives reports directly from Compliance leaders, approves compliance work plans, and takes timely and appropriate actions on compliance issues. The Board feels strongly that it has a responsibility to its members, providers, subscribers, suppliers, stakeholders, co-workers and beneficiaries to conduct business with respect, honesty and integrity, and the Compliance Program is an important tool in fulfilling that responsibility.

2. Designation of a Compliance Officer

St. Luke’s Health Plan has designated a Compliance Officer to implement and supervise the Compliance Program. The Compliance Officer serves as an agent of the Board and receives direction from executive leadership in carrying out day-to-day responsibilities. The Compliance Officer has primary responsibility for developing and implementing the Compliance Program.

3. Standards of conduct

St. Luke’s Health Plan has implemented standards of conduct to ensure that the organization and its members conduct themselves in an ethical and honest manner. All employees are required to sign and acknowledge receipt of the standards of conduct at the time of hire and annually thereafter. The standards are reviewed periodically, and any necessary enhancements are recommended to the Board for adoption.

4. Development of written policies and procedures

The development of written policies and procedures is a core component of the Compliance Program. St. Luke’s Health Plan policies and procedures are created to align with current federal, state and local regulations, laws and guidelines, and help drive the organization’s commitment to compliance. The core policies and procedures of the Compliance Program guide on:

  • Reporting compliance concerns

  • Non-retaliation

  • Procedure for investigating reports

  • Compliance education and training

  • Code of conduct

  • Audit and monitoring

  • Member inducements (i.e., gifts and gratuities)

  • HIPAA privacy and security rules

  • Retention of records

  • Employee screening

  • Conflicts of interest

5. Development of education and training

The existence of an educational and training program is an essential component of the Compliance Program. To ensure that employees and participants are aware of their responsibility to comply with relevant laws and procedures and report suspected non-compliance, all employees and participants receive general and specific compliance training within 90 days of the first date of employment and annually thereafter.

6. Compliance communications

St. Luke’s Health Plan encourages an open line of communication between Compliance and professional staff, independent contractors, and suppliers. St. Luke’s Health Plan uses a Compliance Line where individuals can report compliance concerns either by name or anonymously.

Employees and participants are encouraged to report improper activities. When reporting, they can be assured that their concerns will be thoroughly reviewed and that a non-retaliation policy protects them. The policy defines protections from retaliation for employees and participants. It is essential that employees and participants know that bringing concerns forward to the attention of St. Luke’s Health Plan is supported and encouraged.

7. Enforcement of disciplinary guidelines

St. Luke’s Health Plan’s Compliance Program is rendered ineffective if appropriate disciplinary actions related to acts of non-compliance or failure to detect and report non-compliance are not enforced consistently. Disciplinary action for non-compliant behavior is based on St. Luke’s Health Plan’s progressive discipline policies and procedures. The Compliance Officer is responsible for ensuring that all reports of non-compliant behavior are thoroughly investigated, documented, and timely resolved.

St. Luke’s Health Plan is committed to investigating and correcting Fraud, Waste, and Abuse. Preventing Fraud, Waste and Abuse helps to keep healthcare affordable. We encourage our members, employees, and other parties to report suspected unethical or illegal conduct or suspected Fraud, Waste & Abuse.

What is Fraud, Waste and Abuse?

Fraud means knowingly and willfully obtaining or attempting to obtain (by means of false pretenses, representations, or promises) any money or property owned by or under the custody or control of a healthcare benefit program. Fraud can have both 
civil and criminal implications.

Waste means the overutilization of services or other practices that, directly or indirectly, results in unnecessary costs to the healthcare system.

Abuse results from practices that are inconsistent with, or outside the bounds of, generally accepted practices in the industry, resulting in unnecessary services 
and payment. 

Reporting Potential Fraud, Waste & Abuse, or Suspicious Activity.

We need your assistance to ensure the integrity of St. Luke’s Health Plan is never compromised by unlawful activities. If you have knowledge of fraud, waste, abuse, discrimination, or other violations of laws or regulations, call St. Luke’s Health Plan’s Compliance Line anytime at 1-866-291-4234 or submit a compliance report online. Calls to the Compliance Line are answered by a third party not affiliated with St. Luke’s Health Plan. Reports can be made anonymously. All reports are treated as confidential and will be investigated 
fully. We will not release your personal information unless we are required to do so, for example, under court rule or subpoena. We may refer the activity to law enforcement 
or to the appropriate regulatory body.