18. Will establish measures . . .Enhanced Medicare and Medicaid Program Integrity Provisions Creating an environment of unknowns that makes ERM in healthcare extremely complicated Phased in regulations will have ongoing impact on compliance plans and change risk The Secretary (and her staff) will become among the most powerful people in the country MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE
19. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE “Better get ready for a big bunch of ugly followed by a whole lot of stupid!” – Queen Latifah
37. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE Enterprise Risk Management (ERM) A discipline that engages professionals in the practice of identifying, managing, controlling, and monitoring all risks to an organization. And…. American Health Lawyers Association. (2009) Enterprise Risk Management Handbook for Healthcare Entities, First Addition. Ellen L. Barton
38. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE Enterprise Risk Management (ERM) Is an ongoing business decision making process implemented and supported by the board of directors, executive administration, and medical staff leadership. American Health Lawyers Association. (2009) Enterprise Risk Management Handbook for Healthcare Entities, First Addition. Ellen L. Barton
39. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE ERM proactively identifies risks and recognizes the “synergistic” effects of risks across the continuum of business. When considering areas of risk, ERM refers to each risk as “Risk Domains”. American Health Lawyers Association. (2009) Enterprise Risk Management Handbook for Healthcare Entities, First Addition. Ellen L. Barton
48. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE Make sure the right care is provided in the right setting by the right provider type with the right documentation and that there are the right incentives to influence physician behavior. THE BOTTOM LINE
49.
50. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE Financial/Regulatory Risk Domain(s) Medicare Risk Adjustment – Upcoding – RADV Audit. RAC Audit. False Claims Act. FERA. Civil Monetary Penalties. Medicare will pay Medicare Advantage plans 14% more per beneficiary than the cost of coverage in traditional Medicare.* Overpayments average > $1100/beneficiary enrolled in a private plan.** Increased Medicare costs drive up premiums for beneficiaries in traditional Medicare even though those beneficiaries receive no additional coverage. The CMS Chief Actuary estimated the overpayments now raise premiums by $3.60/month per person or $86/year for a couple.*** Overpayments weaken Medicare’s long term finances by advancing by 17 months the date upon which the Medicare Hospital Trust Fund will be insolvent.* *Medicare Payment Advisory Commission, “Report to Congress: Medicare Payment Policy,” March 2009. ** Brian Biles, Jonah Pozen, and Stuart Guterman, “The Continuing Cost of Privatization: Extra Payments to Medicare Advantage Plans jump to $11.4 Billion in 2009.” The Commonwealth Fund, May 4, 2009. *** Rick Foster, “ Letter to Pete Stark on Medicare Advantage and the Hospital Trust Fund Solvency,” Centers for Medicare and Medicaid Services, Office of the Actuary. June 2009
51. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE April 15, 2010 CMS released the final rule related to MA and Part D Plan Sponsors. Requires Establishment of a Compliance Program* Goal: Control of Fraud, Waste and Abuse in Medicare, currently the nation’s largest federally funded health insurance program. Fraud: An intentional deception or misrepresentation made by an individual or entity, where they know the deception or misrepresentation could result in a benefit to which the individual or entity are not entitled. Waste: Failure to control costs or regulate payments associated with Federal program monies. Abuse: Any practice that is inconsistent with sound fiscal, business, or medical practices, and result in unnecessary cost to the health insurance payer, or in reimbursement for services that are not medically necessary, or that fail to meet professionally recognized standards or contractual obligations. There is no intent to deceive or misrepresent. *Summarized in the Prescription Drug Benefit Manual, Chapter 9 – Part D Program to Control Fraud, Waste and Abuse. Plan providers can access CMS regulations and guidance about fraud, waste, and abuse on the CMS website at www.cms.hhs.gov
67. Fraud, Waste, and AbuseAmerican Health Lawyers Association. (2009) Enterprise Risk Management Handbook for Healthcare Entities, First Addition. Ellen L. Barton
70. Disaster RecoveryAmerican Health Lawyers Association. (2009) Enterprise Risk Management Handbook for Healthcare Entities, First Addition. Ellen L. Barton
71.
72. Natural disastersAmerican Health Lawyers Association. (2009) Enterprise Risk Management Handbook for Healthcare Entities, First Addition. Ellen L. Barton
73. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE Risk Assessment & Evaluation What do you do once organizational risks have been identified? Understand & attempt to quantify the potential magnitude. Consider the positive & negative consequences of events underlying those risks across the organization. Incorporate at least two dimensions of risk “likelihood and severity” Be aware of the different ranges of results associated with an event. American Health Lawyers Association. (2009) Enterprise Risk Management Handbook for Healthcare Entities, First Addition. Ellen L. Barton
88. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE Elements of a Compliance Program Written Standards of Conduct – policies, procedures and other operating guidelines. High Level Oversight –Designate a leader responsible for implementing and monitoring the Compliance Program. Effective Compliance Training –development and implementation of regular and effective training, such as this one. Monitoring and Auditing –use of risk evaluation and audits to monitor compliance. Disciplinary Mechanisms – policies to consistently enforce standards. Effective Lines of Communication – including a system to receive, record and respond to compliance questions or reports of potential non‐compliance. Procedures for Responding to Detected Offenses – policies to respond and initiate corrective action including a timely and reasonable inquiry.
89.
90. Downstream Entity: Downstream entity means any party that enters into a written arrangement, acceptable to CMS, below the level of the arrangement between a Sponsor and a first tier entity.
91. Related Entity: Any entity that is related to the Sponsor by common ownership or control and:
92. Performs some of the Sponsor’s management functions under contract or delegation;
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