What is the difference between Medicare Advantage and traditional Medicare? 2. What is a special investigation unit (SIU)? 3. Und
. What is the difference between Medicare Advantage and traditional Medicare?
2. What is a special investigation unit (SIU)?
3. Under certain circumstances, the CMS may wish to perform its own audits of a Sponsor’s or FDR’s activities pertaining to any aspect of the services provided or amounts payable under its Medicare contract. It has the right to do this, and the Sponsor must allow access to any auditor acting on behalf of the CMS or other federal government agency to conduct an on-site audit. What items will be the subject of a typical CMS audit?
4. It is not always easy for a plan sponsor to identify which of its contracted partners qualify as FDRs. The CMS recommends that the Sponsor take certain factors into account. Name four of them and explain.
Chapter 22
Medicare Advantage
Learning Objectives
Operations of Medicare Advantage Organizations (MAO’s)
Responsibility for “FDR entities”
Guidelines for mandatory MAO compliance program
Compliance Officer and Compliance Committee
Agenda of a good compliance training effort
Value of open lines of communication
Effective disciplinary standards
Audits and monitoring to evaluate compliance
Program exclusions and self-reporting
Introduction
MAO’s are managed care organizations for Medicare beneficiaries. There are 3,500 MA plans serving 12 million beneficiaries – 25% of the total.
Compliance programs are mandatory for MA plans. Although the OIG has issued a Compliance Program Guidance for MAO’s, the primary authority on MA compliance is the Medicare Managed Care Manual (Chapter 21 of the Compliance Program Guidelines).
7 Basic Elements of a Mandatory Compliance Program for MA Plans
Policies, Procedures, and Standards of Conduct
Compliance Officer, Compliance Committee, and High Level Oversight
Effective Training and Education
Effective Lines of Communication
Well-Publicized Disciplinary Standards
System for Routine Monitoring and Auditing
Prompt Response to Compliance Issues
FDR Entities
MAO: Plan Sponsor
F: First Tier Entity
D: Downstream Entities
R: Related Entities
FDR entities may be a sources of compliance problems.
MAO’s must work with those entities to prevent and resolve the problems.
Delegating Compliance to FDRs
Plan Sponsors may enter into contracts with FDRs to provide administrative or health care services to their enrollees.
They may not delegate compliance program functions to them.
Activities that Sponsor may delegate to a FDR entity, but remains responsible for them.
Factors in determining which contractors are FDRs.
Policies, Procedures, and Standards of Conduct
Code of Conduct – defines ethical, compliant behavior for employees and FDR’s
Policies and procedures – tell employees and FDR’s how to perform their work tasks in conformity with laws and payor requirements
Emphasis is on areas of high compliance risk as identified by the organization and OIG
Important to impose comparable policies and procedures on FDR’s
7
Compliance Officer, Compliance Committee, & High Level Oversight
Compliance Officer – full-time, report to CEO, final authority on compliance matters, overall management of compliance program
Specific duties, powers, and status within the organization
Compliance Committee – composition, list of responsibilities
Governing board – oversight of compliance efforts and program effectiveness
Effective Training and Education
Two types of mandatory training – General and Fraud, Waste, and Abuse (FWA).
Annually, part of new employee orientation.
Agenda for each type of training.
Training for employees, managers, governing board, FDR’s, temp workers, & volunteers
Various methods of delivery
Proof that training was delivered
Effective Lines of Communication
Between the CO and CC, and employees, managers, governing board, and FDR’s
To seek clarification on compliance issues or report suspected non-compliance or FWA
Insist that employees report suspected problems
Multiple reporting channels, well publicized, available 24 hours a day, readily accessible
Maintain confidentiality, allow anonymity, prevent retaliation
Well-Publicized Disciplinary Standards
To be applied in cases of misconduct, non-compliance, or FWA by employees
Well-publicized to employees and FDR’s
Criteria for disciplinary standards
Maintain records on disciplinary actions
Routine Monitoring, Auditing, and Identification of Compliance Risks (I)
Evaluate compliance with CMS program requirements, and effectiveness of the compliance program itself
Compare monitoring activities and audits
Systematic work plan – reflecting size and resources of the organization, and risks it faces
Content of typical work plan
Routine Monitoring, Auditing, and Identification of Compliance Risks (II)
Baseline assessment of risk areas, then prioritize the risk areas
Monitor and audit first tier entities
Responsible for compliant behavior of all FDR’s
Program Exclusions
Lists of people and organizations that are excluded from participation in Federal health care programs – as a result of fraudulent or other criminal acts they have committed
OIG List of Excluded Individuals and Entities (LEIE)
GSA Excluded Parties Lists System (EPLS)
Review these lists prior to hiring or contracting with any individual or organization
Data Analysis
Data analysis – tool for monitoring operations to detect and prevent FWA
Compare claim information with other data to identify unusual patterns suggesting errors or potential fraud and abuse
How good data analysis works
Special Investigation Units (SIU)
Internal unit that conducts surveillance, interviews, and other forms of investigation relating to potential FWA
Often separate from the Compliance Program
An SIU or comparable functions in the Compliance Program are mandatory
CMS has the right to perform its own audits of Sponsor or FDR activities related to Medicare
Procedures and System for Prompt Response to Compliance Issues
Ingredients of CMS-required response system
When matters must be referred to CMS or NBI-MEDIC
Corrective action – correct the underlying problems and make sure it does occur again
Corrective action plans for FDR’s as well
Self-Reporting of FWA
Self-reporting is voluntary but strongly advised
Report to NBI-MEDIC, OIG, or DOJ
Opportunity to minimize the potential cost and disruption of a full scale audit and investigation, to negotiate a fair monetary settlement, and to potentially avoid an OIG program exclusion
Enforcement Activities Regarding MAO’s
NBI MEDIC identifies & investigates Part C and Part D fraud and abuse, refers cases & gives advice to the OIG, and meets requests for information from law enforcement agencies
OIG 2013 Work Plan shows dissatisfaction with MAO fraud detection
CMS enforcement options: civil money penalties (CMP), intermediate sanctions, and contract terminations
Questions ???
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