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 ...

1. 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

2. 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

3. 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

4. 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

5. 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

6. 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 ???

7. Ponder interactions you have had with primary care health care
providers in recent years.
· Now that you have reviewed models for clinical decision-
making construct a discussion that reflects on an encounter you
have had with a primary care provider.
· Utilize one of the models presented in your lecture materials,
or any other model that you may like, to frame your discussion
of the experience with the primary care provider that you are
reflecting on.
· Be sure to paraphrase information relative to the elements of
the model where appropriate and utilize in-text citations
consistent with APA guidelines.