Medicare Compliance Training 1 of 2

Contracted Facility Training Compliance with Medicare: Detecting,

Reporting, and Deterring Noncompliance

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General Medicare Compliance Training for ASH Contracted Facility 2013

Medicare Compliance Training

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.

General Medicare Compliance Training for ASH Contracted Facility 2013 2

Training Objectives

1. To understand ASH’s commitment to ethical business behavior

2. To understand how a compliance program operates

3. To gain awareness of how compliance violations should be reported


Report Medicare Noncompliance

• ASH is committed to complying with all federal and state regulations, standards, and sub-regulatory guidance

• When an issue of noncompliance is identified, all ASH contracted facilities are required to report them to ASH

• An issue of noncompliance is defined as a deviation or suspected deviation from Medicare program requirements or other regulations that impact one or more of our members

• This training is designed to ensure that ASH contracted facilities understand the escalation process for reporting issues of noncompliance to ASH


Where Do I Fit in the Medicare Program?

Medicare Advantage Organization (the health plan client)

Independent Practice

Association (First Tier)

Providers (Downstream)

Call Centers (First Tier)

Health Services/ Hospital Groups

(First Tier)

Radiology (Downstream)

Hospitals (Downstream)


Mental Health (Downstream)


Field Marketing Organizations

(First Tier)

Agents (Downstream)

Credentialing (First Tier)

Provider Groups (First Tier)


ASH entities fall into the “first tier entity” category. ASH’s contracted providers and fitness facilities fall into the “downstream entity” category.

ASH


Background and Requirements

• For years, ASH has contracted with Medicare Advantage (MA) plans to provide their Medicare beneficiaries with access to fitness programs

• The Centers for Medicare and Medicaid Services (CMS) require that our MA plan clients operate in compliance with all CMS regulations and report any issues that may be out of compliance

• ASH, as a first-tier entity or delegated entity of several MA plans, must report instances of noncompliance up to our contracted MA plan clients

• As such, ASH contracted facilities should report any issues that may be considered non-compliant to the Practitioner Contract Services department


Effective Compliance Program

ASH must have an effective compliance program to support its MA health plan clients. An effective compliance program should:

• Articulate and demonstrate an organization’s commitment to legal and ethical conduct

• Provide guidance on how to identify and report compliance violations

• Provide guidance on how to handle compliance questions and concerns


Compliance Culture

A culture of compliance:

• Prevents noncompliance

• Detects noncompliance

• Corrects noncompliance


Compliance Program Requirements

At a minimum, ASH’s compliance program includes these 7 core requirements:

1. Written policies, procedures and standards of conduct

2. Designation of a 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

7. Procedures and system for prompt response to compliance issues


Ethics Do the Right Thing!

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!

• Act fairly and honestly

• Comply with the letter and spirit of the law

• Adhere to high ethical standards in all that you do

• Report suspected violations


How Do I Know What is Expected of Me?

• ASH’s Code of Conduct and Ethics state the compliance expectations and the principles and values by which ASH operates

• Everyone is required to report violations of ASH’s Code of Conduct and suspected noncompliance

• Your Fitness Facility Agreement and the program manual also identify this obligation and tell you how to report


What is Noncompliance? Noncompliance is conduct that does not conform to the law and federal health care program requirements or to ASH’s ethical and business policies.

For more information, see the Medicare Managed Care Manual and the Medicare Prescription Drug Benefit Manual on http://www.cms.gov

Medicare Part C

High-Risk Areas

Appeals and Grievance

Review

Claims Processing

Marketing

Beneficiary Notices

Documentation Requirements

Credentialing

Ethics

HIPAA

Conflicts of Interest

Quality of Care


Noncompliance Harms ASH Members Without programs to prevent, detect, and correct noncompliance, there are: • Delayed services • Difficulty in using providers of choice • Hurdles to care • Denial of benefits


General Medicare Compliance Training for ASH Contracted Facility 2013

I’m afraid to report

noncompliance

There can be NO retaliation against you for reporting suspected noncompliance in good faith.

ASH offers reporting methods that are: 1. Confidential 2. Anonymous 3. Non-retaliatory

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Issue Evaluation If you answer YES to any of the following questions, those are reportable issues that should be brought to ASH’s attention:

Does the issue have a negative impact on the member, such as impeding access to the fitness facility?

Does the issue impact, or potentially impact, more than one member?

Does the issue impact your ability to file a grievance?

Will there be a political or media interest in the issue?

Could this be harmful to the member’s health?

Will the issue result in a complaint to Medicare?


Issue Reporting • All ASH contracted facilities must

report issues as soon as the issue is identified. This is not to exceed 12 hours after identification.

• Contracted facilities should include the following information when reporting the issue to the ASH Practitioner Contract Services representative:

− Persons involved

− Date of incident

− Identification of issue

− Summary of issue


Issue Write-up Requirements

Issue write-up may not be required for a one-time mistake or error, unless there is a systemic problem that impacts members. Contact the Practitioner Contract Services department for assistance in reporting issues.

If you are unable to determine whether the issue is reportable, follow the procedures for a reportable issue submission.

Fitness facilities can also report issues to ASH’s Ethics and

Integrity Hotline at

1-866-998-2746

The hotline allows you to report issues anonymously.


What Happens Next?

Correcting Noncompliance: • Avoids the recurrence of the same noncompliance • Promotes efficiency and effective internal controls • Protects members • Ensures ongoing compliance with CMS requirements

After non-compliance has been detected…

The fitness facility must report the

noncompliance…

ASH must investigate & promptly correct any noncompliance


Compliance Effectiveness

• Once noncompliance is detected and corrected, ASH takes steps to ensure the noncompliance does not recur

• ASH monitors activities with regular reviews to confirm ongoing compliance and ensure that corrective actions are implemented and effective

• Client audits and accreditations further support compliance through formal reviews using a particular set of standards (e.g., policies and procedures, laws and regulations used as base measures)

Prevent

Detect

Report Correct

Monitor/ Audit


Know the Consequences of Noncompliance

ASH has disciplinary standards in place to address noncompliant behavior. Those who engage in noncompliant behavior may be subject to any of the following:

1. Mandatory training or re-training

2. Disciplinary action

3. Termination


Compliance is Everyone’s Responsibility!

PREVENT

Operate within contractual requirements

to prevent noncompliance!

If you detect potential noncompliance,

report it! CORRECT

Correct noncompliance to protect members

and to promote quality and efficiency!

DETECT & REPORT


Noncompliance with this Training Requirement CMS requires that all Medicare Advantage plan sponsors, first-tier, and downstream entities complete an annual fraud, waste, and abuse training program. Training must occur upon initial hiring and annually thereafter, so long as you remain a Contracted Facility that provides services to Medicare beneficiaries.

At the completion of the training, the contracted fitness facility must complete the attestation that all key employees (as defined in this training) who may interface with Medicare beneficiaries have completed fraud, waste, and abuse training. You must also maintain training logs and information regarding who completed the training and the date on which the training was completed.

Please keep a copy of the signed attestation

for 10 years.


Consequences for Noncompliance with this Training Requirement

• Fitness facilities who are not compliant will initially be contacted by telephone by a Contract Services representative

• If the fitness facility does not comply after this outreach, the Contract Determination Committee (CDC) will issue a Corrective Action Plan (CAP) inquiry letter to encourage compliance

• If, after the CDC has issued a CAP inquiry letter, the fitness facility is still not in compliance, the CDC will issue a formal CAP with the expectation that the fitness facility comply

• Failure to reply or comply with the CAP will result in the fitness facility being excluded from participation in all Medicare Advantage health plan payors who provide the Silver&Fit benefit through ASH


What Governs Compliance?

Social Security Act: • Title 18

Code of Federal Regulations: • 42 CFR Parts 422 (Part C) and 423 (Part D)

CMS Guidance: • Manuals • HPMS memos

Contracts: • Private entities apply and contracts are

renewed/non-renewed each year • ASH’s contracts with its health plan clients,

practitioners, and fitness facilities

Other Sources: • OIG/DOJ (fraud, waste and abuse (FWA)) • HHS (HIPAA privacy)

State Laws: • Licensure • Financial solvency


Additional Resources For more information on laws governing the Medicare program and Medicare noncompliance, or for additional healthcare compliance resources please see:

• Title XVIII of the Social Security Act

• Medicare Regulations governing Parts C and D (42 C.F.R. §§ 422 and 423)

• Civil False Claims Act (31 U.S.C. §§ 3729-3733)

• Criminal False Claims Statute (18 U.S.C. §§ 287,1001)

• Anti-Kickback Statute (42 U.S.C. § 1320a-7b(b))

• Stark Statute (Physician Self-Referral Law) (42 U.S.C. § 1395nn)

• Exclusion entities instruction (42 U.S.C. § 1395w-27(g)(1)(G))

• The Health Insurance Portability and Accountability Act of 1996 (HIPAA) (Public Law 104-191) (45 CFR Part 160 and Part 164, Subparts A and E)

• OIG Compliance Program Guidance for the Healthcare Industry: http://oig.hhs.gov/compliance/ compliance-guidance/index.asp


Questions

• If you have any questions regarding this reporting requirement and the procedures that must be followed, please contact the Practitioner Contract Services department by calling 800-972-4226, option 4, between 7:00 AM and 5:00 PM Pacific.


Attestation and Sample Log


General Medicare Compliance Training Requirement Attestation As required by the Centers for Medicare & Medicaid Services (CMS) all Contracted Facilities

who provide health care services to Medicare beneficiaries and their employees who interface

with Medicare beneficiaries, must complete a General Medicare Compliance training program.

An “authorized representative” (either the Contracted Facility’s owner or manager) must attest

to the completion of this training program. Training must be conducted annually, and upon hire

of new employees who interface with Medicare beneficiaries. Failure to do so could result in

you no longer being eligible for reimbursement for services provided to Medicare Advantage

beneficiaries. Employees that must be trained include, but are not limited to the following:

1. Owner

2. Front-desk attendees that track Silver&Fit member utilization,

3. Sales associates, and

4. Individual fitness instructors that lead Silver&Fit themed group exercise classes. Attestation Statement

By checking this box and signing below, I hereby certify that I am the authorized

representative of my organization having responsibility directly or indirectly for all

employees of my organization who have direct contact with Medicare business and

hereby certify all of the aforementioned individuals have completed a General Medicare

Compliance Training as mandated by the Centers for Medicare & Medicaid Services (42

CFR § 422.503(b) (4) (vi), § 423.504(b) (4) (vi)). Fitness Facility Owner or Designee Attesting (signature) Date

Fitness Facility Owner or Designee Attesting name (print)

Name of Contracted Facility (print)

For audit purposes please maintain a copy of this signed attestation along with the training

program completed and a log of staff trained each year. If you’d like to submit your attestation and

training materials to ASH, please fax them to 866.545.2746.

Fitness GMC Training Attestation Page 1 of 2 06/05/2013

Medicare Compliance Training Log Name of Contracted Facility:

Name of Contracted Facility Owner or Designee:

#

Employee Name

Department

Date of Training

Employee Signature

Fitness GMC Training Attestation Page 2 of 2 06/05/2013

Reportable Medicare Issue Write-Up Form INSTRUCTIONS for FITNESS FACILITIES

All descriptions must be written in CONCISE and CLEAR. As the recipients of the write-up may not know ASH’s systems or internal processes, all write ups must present issues in a logical, understandable way.

• Use clear language. Anyone reading any section of the write up should be able to understand the systems issues, updates and dates actions have or will be taken.

• Identify systems involved such as grievances, facility access, etc. • Use only widely accepted abbreviations (i.e. S&F for Silver&Fit, etc.) after completely

spelling out the term the first time. Explain all acronyms. • Don't lay blame on external sources. ASH is ultimately responsible even if the issue

involved an external source (e.g., Centers for Medicare and Medicaid Services (CMS), vendor, provider, etc.).

Consider the following when drafting the issue for Regulatory & Program Compliance department review:

Who: Were members impacted?

How many members were directly/indirectly impacted? What: What occurred?

What system(s) failed? What oversight protocols were in place and/or will be put in place?

When: When did the issue occur?

When was the issue identified? When will the issue be resolved? What are the key dates for addressing issue/resolving problem and to ensure follow up occurs? (Remember to keep the dates realistic)

Why: Why did the issue occur?

Why did the system(s) or process(es) fail? Why did existing oversight protocols fail?

How: How were members impacted?

How was the issue identified? How will the issue be resolved? How and when will members be contacted? (If access to benefits were denied members need to be contacted immediately).

IMPORTANT: If you do not provide a manageable due date for completing Action Steps or Follow-Up items, one may be assigned for you.

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Please Note: If you need assistance in completing items A through G, please call a Contract Services department representative at 800.972.4226, option 4 between 7 am and 5 pm Pacific Time.

A. Issue Summary (Provide a short clear description of the issue)

B. Description of Incidence (Include specifics such as contracted facility name, what

happened, where it happened)

C. Root Cause Analysis (Describe the primary reason for issue and the steps taken

to reach that conclusion)

D. Description of Similar Incidents in the past with dates (If there were no similar

incidents– just note – “None known that are similar”)

E. Actions Taken with Dates F. Next Steps (Describe what steps you will take to resolve the issue. Provide dates

by which each step will be accomplished. If you don’t know when the action steps will be completed, state when you will be able to provide a completion date for the action steps)

G. Follow-Up (State how you will follow up to ensure the issue is resolved. Provide

dates. Include information regarding how you will test to ensure compliance is achieved and monitor/validate to ensure compliance is maintained and issue won’t recur)

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Medicare Compliance Training 1 of 2

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