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Please answer the following 4 questions and post your responses in this Canvas Assignment for grading. Thank you!

1. 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


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


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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