Code of Conduct: Additional Required CMS Training • The following slides are required by the Centers for Medicare and Medicaid Services. • We were not permitted to edit or annotate the slides in any way. • Please read each slide & sign the attestation.
Additional C MS C ompliance Training C ontent * After HCA added the CMS-required slides to its training, CMS added content to it. The first addition is in the section titled "Why Do I Need Training?" and the content is: Every year billions of dollars are improperly spent because of Fraud, Waste, and Abuse (FWA). It affects everyone - including you. This training helps you detect, correct, and prevent FWA. You are part of the solution. Relative to this, we would point out that HCA has numerous policies designed to prevent fraud, waste and abuse. We would call your attention to the following resources: False Claims Act policies and billing policies. The other addition is an additional Knowledge Check at the end of the course, which reads: You are performing a regular inventory of the controlled substances in the pharmacy. You discover a minor inventory discrepancy. What should you do? S elect the correct ans wer: A. Call local law enforcement B. Perform another review C. Contact your compliance department (via compliance hotline or other mechanism) D. Discuss your concerns with your supervisor E. Follow your pharmacy's procedures While CMS states that E is the correct answer, at HCA the process starts with notifying one's supervisor, and then following the chain of command. Over the past several years, we have developed various tools and processes to detect lost and stolen medications. Through the use of barcoding, RxAuditor and other reconciliation mechanisms, we are able to find discrepancies and take appropriate follow-up action.
Part 2: Medicare Parts C & D Compliance Training Developed by the Centers for Medicare & Medicaid Services
IMPORTANT NOTICE This training module will assist Medicare Parts C and D plan Sponsors in satisfying the Compliance training requirements of the Compliance Program regulations at 42 C.F.R. §§ 422.503(b)(4)(vi) and 423.504(b)(4)(vi) and in Section 50.3 of the Compliance Program Guidelines found in Chapter 9 of the Medicare Prescription Drug Benefit Manual and Chapter 21 of the Medicare Managed Care Manual . While Sponsors may choose to use this module to satisfy compliance training requirements, completion of this training in and of itself does not ensure that a Sponsor has an “effective Compliance Program.” Sponsors are responsible for ensuring the establishment and implementation of an effective Compliance Program in accordance with CMS regulations and program guidelines. 1
Why Do I Need Training? Compliance is EVERYONE’S responsibility! As an individual who provides health or administrative services for Medicare enrollees, every action you take potentially affects Medicare enrollees, the Medicare program, or the Medicare trust fund. 2
Training Objectives To understand the organization’s • commitment to ethical business behavior To understand how a compliance program • operates To gain awareness of how compliance • violations should be reported 3
Where Do I Fit in the Medicare Program? Medicare Advantage Organization, Prescription Drug Plan, and Medicare Advantage-Prescription Drug Plan zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Independent Health Field Fulfillment Call Centers Services/Hospital Practice Marketing Credentialing PBM Vendors Groups Associations Organizations (First Tier) (First Tier) (First Tier ) (First Tier) (First Tier ) (First Tier ) (First Tier) Claims Quality Providers Hospitals Mental Health Agents Pharmacy Processing Radiology Assurance Firm (Downstrea m) (Downstream ) (Downstream) (Downstream ) (Downstream) Firm (Downstream) (Downstream) (Downstream ) Providers Providers (Downstream ) (Downstream ) 4
Background • CMS requires Medicare zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Advantage, Medicare Provide Advantage-Prescription guidance on how to identify and Drug, and Prescription Drug report compliance Plan Sponsors (“Sponsors”) violatio ns to implement an effective compliance program. Provide guidance on how to handle compliance • An effective compliance questions and concerns program should: Articulate and demonstrate an organization’s commitment to legal and ethical conduct 5
Compliance Prevents noncompliance A culture of compliance within an organization: Detects noncompliance Corrects noncompliance 6
Compliance Program Requirements At a minimum, a compliance program must include the 7 core requirements: 1. Written Policies, Procedures and Standards of Conduct; 2. Compliance Officer, Compliance Committee and High Level Oversight; 3. Effective Training and Education; 4. Effective Lines of Communication; 5. Well Publicized Disciplinary Standards; 6. Effective System for Routine Monitoring and Identification of Compliance Risks; and 7. Procedures and System for Prompt Response to Compliance Issues 42 C.F.R. §§ 422.503(b)(4)(vi) and 423.504(b)(4)(vi); Internet-Only Manual (“IOM”), Pub. 100-16, Medicare Managed Care Manual Chapter 21; IOM, Pub. 100-18, Medicare Prescription Drug Benefit Manual Chapter 9 7
Compliance Training • CMS expects that all Sponsors will apply their training requirements and “effective lines of communication” to the entities with which they partner. • Having “effective lines of communication” means that employees of the organization and the partnering entities have several avenues through which to report compliance concerns. 8
Ethics – Do the Right Thing! Act Fairly and Honestly Comply with the letter and spirit of the law As a part of the Medicare program, it is important that you conduct yourself in an ethical and legal manner. It’s about doing the right thing! Adhere to high ethical standards in all that you do Report suspected violations 9
How Do I Know What is Expected of Me? Standards of Conduct (or Code of Conduct) state compliance expectations and the principles and values by which an organization operates. Contents will vary as Standards of Conduct should be tailored to each individual organization’s culture and business operations. 10
How Do I Know What is Expected of Me (cont.)? Everyone is required to report violations of Standards of Conduct and suspected noncompliance. An organization’s Standards of Conduct and Policies and Procedures should identify this obligation and tell you how to report . 11
What Is Noncompliance? Noncompliance is conduct that Appeals and Claims Grievance does not conform to the law, and Processing Review Federal health care program Credentialing requirements, or to an Ethics organization’s ethical and business policies. Marketing and HIPAA Enrollment Medicare Conflicts of Parts C & Interest Beneficiary D Notices Agent / Broker High Risk Areas * Documentation Requirements Formulary * For more information, see the Quality of Care Administration Medicare Managed Care Manual and the Medicare Prescription Drug Benefit 12 Manual on http://www.cms.gov
Noncompliance Harms Enrollees Delayed services Without programs to Difficulty in prevent, detect, Denial of using Benefits and correct providers of choice noncompliance there are: Hurdles to care 13
zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Noncompliance Costs Money Non Compliance affects EVERYBODY! Without programs to prevent, detect, and correct noncompliance you risk : Higher Higher Insurance Premiums Copayments Lower benefits Lower Star for individuals ratings Lower profits and employers 14
I’m Afraid to Report Noncompliance There can be NO retaliation against you for reporting suspected noncompliance in good faith. Each Sponsor must offer reporting methods that are: Confidential Anonymous Non-Retaliatory 15
How Can I Report Potential Noncompliance? • Call the Medicare Compliance Officer Employees of an MA, • Make a report through the Website MA-PD, or PDP Sponsor • Call the Compliance Hotline • Talk to a Manager or Supervisor FDR Employees • Call Your Ethics/Compliance Help Line • Report through the Sponsor • Call the Sponsor’s compliance hotline Beneficiaries • Make a report through Sponsor’s website • Call 1-800-Medicare 16
What Happens Next? After It must be And then promptly noncompliance has investigated correct any been detected… immediately … noncompliance Correcting Noncompliance • Avoids the recurrence of the same noncompliance • Promotes efficiency and effective internal controls • Protects enrollees • Ensures ongoing compliance with CMS requirements 17
How Do I Know the Noncompliance Won’t Happen Again? Once noncompliance is detected • and corrected, an ongoing evaluation process is critical to Prevent ensure the noncompliance does not recur. • Monitoring activities are regular reviews which confirm ongoing Monitor/ Detect compliance and ensure that Audit corrective actions are undertaken and effective. • Auditing is a formal review of compliance with a particular set of standards (e.g., policies and procedures, laws and regulations) Correct Report used as base measures 18
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