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Affinity Health Plan
Billing and Coding Issues Concerns regarding questionable billing, coding and medical record documentation practices.
Complaint General complaint.
Conflict of Interest A conflict of interest is defined as a situation in which a person, such as a public official, an employee, or a professional, has a private or personal interest sufficient to appear to influence the objective exercise of his or her official duties. (Examples include: inappropriate vendor relations, bribery, misuse of confidential information, inappropriate customer relations)
Discrimination or Harassment Uninvited and unwelcome verbal or physical conduct directed at an employee because of his or her sex, religion, ethnicity, or beliefs. (Examples include: bias in hiring, bias in assignments, wrongful termination, bias in promotions, bias in educational decisions, unfair compensation, inappropriate language)
Enrollment Concerns regarding questionable;
a) Premium payments
b) Effective coverage
c) Did not receive my membership card, and
d) Disenrollment from the plan.
Health Insurance Portability and Accountability Act This Category should be selected if there is a concern with the improper use or disclosure of Protected Health Information. Protected Health Information is information that:
(1) is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse; and (2) relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and (i) that identifies the individual; or (ii) for which there is a reasonable basis to believe the information can be used to identify the individual.
Hospital Inappropriate billing or practices by a Hospital.
Identity Theft; Identity Sharing Report of an Affinity Member or non-member inappropriately using an Insurance ID Card.
Improper Lobbying or Political Contribution Inappropriate activities in violation of federal and state lobbying and political action, including the contribution or acceptance of funds meant for another candidate or the improper use of contributed funds for personal gain.
Management and Work Place Practices Any questionable activity conducted by Management staff.
Misconduct or Inappropriate Behavior Intentional wrongdoing; specifically: deliberate violation of a law or standard.
Pharmacy Inappropriate billing or practice by a pharmacy.
Potential Member Misrepresentation Any report of a member suspected of abusive or fraudulent activity.
Questionable EE Activities Activities such as: retaliatory and intimidation tactics, solicitations, suspected fraudulent behavior, etc.
Questionable MK Activities Inappropriate and questionable Marketing Staff behavior. Example, suspected fraud, forgeries.
Questionable Plan or Staff Activities a) Quality of care or Service; i.e., staff rudeness
b) Receiving unnecessary/unrelated calls or mailings
Questionable Provider Activities Inappropriate billing or practice by a doctor/provider.
Sabotage or Vandalism Destruction of an employer's property (as tools or materials) or the hindering of manufacturing by discontented workers (Examples include: Equipment destruction, stealing, work slowdown, computer virus)
Substance Abuse Substance abuse is defined as the misuse of both legal and illegal drugs including alcohol. (Examples include: cocaine, narcotics, marijuana, stimulants)
Theft The act of stealing; specifically: the felonious taking and removing of personal property with intent to deprive the rightful owner of it.
Unauthorized/Fraudulent Use of Company facilities and equipment The misuse/abuse of Company Support Services, equipment, or assets.
Unsafe working conditions Failure of meeting requirements needed to perform all duties in a secure environment. Potential areas of harm. (Examples include: environmental damage, OSHA, EPA, supervisor directive, poor housekeeping)
Violation of Policy Willful or innocent actions that are in direct violation of company policy, procedures, code of conduct, and/or implied contractual responsibilities. (Examples include: non- disclosure agreements, hiring standards, safety, Internet usage, corporate guidelines)
Violence or Threat Violence is an expression of the intention to inflict evil, injury, or damage to a person or their property. (Examples include: direct, veiled, conditional, violent)
Suggestion  
Concern  
Inquiry