01.0 – Standards of Conduct

AHP’s Compliance Policy established the framework for maintaining compliance with all Federal and New York State laws, requirements, and standards for Medicare program participation as a Medicare Advantage plan sponsor, Accountable Care Organization (ACO), or otherwise contracted entity with the Center for Medicare and Medicaid Services (CMS) and as required by contract with a Medicare Advantage plan as a First Tier, Downstream, and Related Entity (FDR). 

AHP maintains Standards of Conduct (The Standards) approved by the Board of Managers. This policy describes and encourages behaviors that support our mission, vision, and values, and that prevent and halt unethical or unlawful behavior, prior to or as soon as reasonably possible after discovery. The Standards provide clarity on expectations and responsibilities for maintaining a workplace that operates with a commitment to the highest ethical and legal standards. The following areas will be covered in the Standards:

01.01 Definitions 

01.02 Scope and Applicability

01.03 Education, Training, and Access

01.04 Information on the Compliance Program

01.05 Responsibilities

01.06 Non-Retaliation 

01.07 Association with other policies and programs

01.01 Definitions

Objective: To define terms used in this policy for clarity. 

AHP Team: All caregivers, professional staff, and members of the Board of Managers, volunteers, trainees, interns, apprentices, students; independent contractors, vendors and all other individuals working for or contracted by AHP, whether they are paid by or under the direct control of AHP. 

FDR: First Tier, Downstream, and Related Entities who provide a service on behalf of AHP, to or affecting a Medicare beneficiary.  An FDR can be an individual, such as a contractor, or an entity, such as a vendor.

FWA: Fraud, Waste and Abuse

• • Fraud: Intentional deception or misrepresentation that an individual or entity knows to be false, or does not believe to be true, made with the knowledge that the deception could result in unauthorized benefit or payment 
  • Waste: The overutilization of services or the misuse of resources, often due to inefficient practices, mismanagement, or poor clinical judgment rather than deliberate deceit.
  • Abuse: Any practice that does not provide patients with medically necessary services or meet professionally recognized standards of care.

Medicare: The federal health insurance program for people 65 years of age or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure with dialysis or a transplant, sometimes called ESRD).  

Medicare Beneficiary: A person eligible to receive Medicare benefits through any Medicare channel, including Traditional Fee-For-Service or any of the various Medicare Advantage programs.

01.02 Scope and Applicability

Objective: To ensure all individuals and entities understand and follow the compliance plan.

This policy applies to AHP Team members in any role or action that affects AHP’s Medicare contracts or a Medicare Beneficiary.

01.03 Education, Training, and Access

Objective: To ensure AHP Team members are knowledgeable on The Standards.

Employees and support staff, such as volunteers, interns, apprentices, or staff augmentation contractors or consultants, will receive mandatory compliance training within 90 days of the first day of work and annually thereafter.  All other AHP Team members shall be provided training through the most efficient channel determined annually, which may include access to an online module, live in-person or web-streamed training, or provision of training materials to an FDR with demonstrated training capabilities.   Training records will be maintained, and failure to complete mandatory training will result in action up to and including termination.

A copy of the Standards of Conduct will be available on an AHP intranet site. 

01.04 Information on the Compliance Program

Objective: To establish a basis for the Standards of Conduct

The AHP Compliance plan: AHP operates a compliance program with the following core elements:

Written Compliance Plan

AHP maintains a compliance plan, evaluated and updated annually, and approved by the Board of Managers. AHP also periodically reviews and approves companion policies, procedures, job and role descriptions, committee charters, training materials, and reports as required to provide guidance to, implement, and evaluate the annual Compliance Plan. 

Designated Compliance Officer

The Compliance Officer reports administratively to the AHP Chief Executive Officer but can only be appointed to or removed from the position by the AHP Board of Managers. The Compliance Officer has expressed authority to provide unfiltered, in-person reports to the CEO or the Board of Managers.  

Compliance Training and Education

AHP administers mandatory compliance training within 90 days of the start date and annually thereafter. 

Mechanisms for Identifying and Reporting Potential Compliance Issues

Potential compliance issues and incidents can be identified through internal monitoring and audits, and, as appropriate, external audits, or through an individual’s experience or observation. Team members are required to report potential noncompliance, which can be reported anonymously through the Integrity Helpline or directly to the Compliance Officer.

 Handling of Potential Compliance Issues

AHP promptly responds to potential compliance issues as they are identified or otherwise raised.  Thorough investigations are pursued for each report.  Actions to be taken will be based on the results of the investigation and determined by the specifics of each situation. Possible actions include, but are not limited to, progressive discipline up to and including termination of employment; corrective actions and contract termination; and reporting to authorities.

01.05 Responsibilities

AHP’s expectation is that all staff, FDRs, and board members read and follow The Standards, including: 

• Perform job duties in accordance with all federal and state laws or regulations 
• Participate in compliance program training and departmental or job-specific compliance education as necessary for assigned job duties
• Report all concerns or alleged violations promptly 
• Keep information obtained at AHP confidential and maintain patient confidentiality
• Disclose any exclusion, suspension, or other event that may make them ineligible to participate in government programs or other federal or state programs
• Recognize that compliance is primary to business results
• Identify any necessary modifications to business area processes as a result of a compliance review 
• Seek guidance whenever in doubt about compliance responsibility

01.06 Non-Retaliation

Objective: To prevent negative consequences for Team members who report a compliance concern.

Retaliation or intimidation against anyone who reports a concern is strictly prohibited and will not be tolerated. 

Anyone who experiences or observes intimidation or retaliatory behavior must report it to the Compliance Officer or the Integrity Helpline.

01.07 Association with other policies and programs

Objective: To clarify that the Compliance Plan and The Standards do not conflict with or override other policies and training.

In addition to The Standards and the annual training on them, Team members will receive training on a variety of topics that complement AHP programs and services, including topics such as privacy, safety, and workplace policies.  The Standards are not intended to replace, supersede, or conflict with other training and policies.  Any individual can seek guidance from the Compliance Officer if they perceive a conflict or confusion in their responsibilities.