Medicare Advantage Compliance

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Medicare Advantage Compliance

  1. 1. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />Presentation by: Cora Butler, JD, RN, CHC, CCEP<br />Ty Hubbard, MBA, MHA<br />
  2. 2. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />PRIMARIS<br />Quality Improvement Organization (QIO) for Missouri<br /><ul><li>Medicare Knowledge
  3. 3. Medicare Signals Direction Through Pilot Projects in Each Scope of Work:</li></ul>▪Transitions of Care ▪Primary Care Provider Adoption of Electronic Health Records<br /><ul><li>Quality Improvement Projects</li></ul>▪HEDIS ▪Core Measures ▪SNF Pressure Ulcer Reduction<br />Commercial Operations<br /><ul><li>Medicare Risk Adjustment
  4. 4. Core Measures Abstraction
  5. 5. HEDIS
  6. 6. Customized Medical Record Review
  7. 7. Health Information Technology Assistance Center</li></li></ul><li>MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />TAKE AWAY MESSAGES<br /><ul><li>Alignment of enterprise risk management and compliance through integration into business operations will drive decision-making and performance
  8. 8. Strategies to incentivize and motivate desired behaviors are essential to reach strategic goals
  9. 9. Vendors and business partners must share organizational goals
  10. 10. Silos are only good for storing grain</li></li></ul><li>MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />HISTORY OF MEDICARE PART C<br /><ul><li>1997: BBA (Balanced Budget Act)
  11. 11. 2000: Benefits Improvement Act (BIPA)
  12. 12. 2003: Medicare Prescription Drug, Improvement, and Modernization Act</li></li></ul><li>MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />Patient Protection and Affordable Care Act (PPACA) of 2010 as Amended by the Health Care Education and Reconciliation Act (HCERA) of 2010 Collectively Known as “Health Care Reform”<br />Health Insurance Reform<br />Expansion of Access to Healthcare Services<br />Medicare and Medicaid Part A & B Payment Reforms<br />Medicare Advantage (MA)<br />Congressional Budget Office combined scoring estimate, MA payment changes will result in approximately $135B reduction in direct federal spending over the next 10 years<br />One of the largest spending reduction line items in the Healthcare Reform Law.*<br />Medicare Part D<br />*Letter from Doulas W. Elmendorf, Director, CBO, to the Honorable Nancy Pelosi, Speaker, US House of Representatives. Table 5 (March 20, 2010), available at www.cbo.gov/doc.cfm?index=11379&type=1.<br />Source: American Health Lawyers Member Briefing June 2010.<br />
  13. 13. Common Themes Running Through The Health Care Reform Law<br />The Secretary . . .<br /><ul><li> Will adopt regulations . . .
  14. 14. May alter payment . . .
  15. 15. Will determine quality performance guidelines . . .
  16. 16. Will determine how funds will be allocated . . .
  17. 17. Will establish . . . that will provide for . . .
  18. 18. Will establish measures . . .</li></ul>Enhanced Medicare and Medicaid Program Integrity Provisions<br />Creating an environment of unknowns that makes ERM in healthcare extremely complicated<br />Phased in regulations will have ongoing impact on compliance plans and change risk<br />The Secretary (and her staff) will become among the most powerful <br /> people in the country<br />MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />
  19. 19. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />“Better get ready for a big bunch of ugly followed by a whole lot of stupid!” <br />– Queen Latifah<br />
  20. 20. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />RISK ADJUSTMENT<br /><ul><li>Purpose:
  21. 21. Pays plans accurately/appropriately
  22. 22. Diagnosis is measure of health status and demographic information
  23. 23. Quality of Care
  24. 24. Protection of Beneficiaries
  25. 25. Reduction of adverse selection</li></li></ul><li>MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />RISK ADJUSTMENT MODEL COMMON CHARACTERISTICS<br /><ul><li>Demographic Factors
  26. 26. Age
  27. 27. Sex
  28. 28. Entitlement (original reason)
  29. 29. Status (disabled)
  30. 30. Medicaid Status (Part C)
  31. 31. LIS and LTI Multipliers (Part D)</li></li></ul><li>MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />RISK ADJUSTMENT MODEL COMMON CHARACTERISTICS (cont.)<br /><ul><li>Disease Factors
  32. 32. Disease Groups
  33. 33. Diagnosis Source
  34. 34. Inpatient
  35. 35. Outpatient (hospital)
  36. 36. Physician setting</li></li></ul><li>MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />Enterprise Risk Management<br />“A process, affected by an entity’s board of directors, management & other personnel, applied in strategy setting & across the enterprise, designed to identify potential events that may affect the entity, and manage risks to be within its risk appetite, to provide reasonable assurance regarding the achievement of entity objectives.”<br />Enterprise Risk Management-Integrated Framework<br />http://www.erm.coso.org/Coso/coserm.nsf/vwWebSources/PDF_Manuscript/$file/COSO_Manuscript.pdf<br />
  37. 37. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />Enterprise Risk Management (ERM)<br />A discipline that engages professionals in the practice of identifying, managing, controlling, and monitoring all risks to an organization.<br />And….<br />American Health Lawyers Association. (2009) Enterprise Risk Management Handbook for Healthcare Entities, First Addition. Ellen L. Barton<br />
  38. 38. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />Enterprise Risk Management (ERM)<br />Is an ongoing business decision making process implemented and supported by the board of directors, executive administration, and medical staff leadership.<br />American Health Lawyers Association. (2009) Enterprise Risk Management Handbook for Healthcare Entities, First Addition. Ellen L. Barton<br />
  39. 39. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />ERM proactively identifies risks and recognizes the “synergistic” effects of risks across the continuum of business.<br />When considering areas of risk, ERM refers to each risk as “Risk Domains”.<br />American Health Lawyers Association. (2009) Enterprise Risk Management Handbook for Healthcare Entities, First Addition. Ellen L. Barton<br />
  40. 40. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />RISK DOMAINS<br /><ul><li>Operational
  41. 41. Financial
  42. 42. Human Capital
  43. 43. Strategic
  44. 44. Legal/Regulatory
  45. 45. Technological
  46. 46. Hazard</li></li></ul><li>MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />Operational Risk Domain<br />The strategy of healthcare emphasizes the delivery of care is safe, timely, and effective. <br />Risks associated with the business operation result from inadequate or failed internal processes, people, or systems. <br />American Health Lawyers Association. (2009) Enterprise Risk Management Handbook for Healthcare Entities, First Addition. Ellen L. Barton<br />
  47. 47. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />
  48. 48. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />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.<br />THE BOTTOM LINE<br />
  49. 49. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />Financial Risk Domain<br />Risks that affect the economic standpoint of an entity through business relationships or the timing & recognition of revenue expenses. Risks include:<br /><ul><li>Corporate compliance (fraud and abuse)</li></ul>American Health Lawyers Association. (2009) Enterprise Risk Management Handbook for Healthcare Entities, First Addition. Ellen L. Barton<br />
  50. 50. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />Financial/Regulatory Risk Domain(s)<br />Medicare Risk Adjustment – Upcoding – RADV Audit. RAC Audit. False Claims Act. FERA. Civil Monetary Penalties.<br />Medicare will pay Medicare Advantage plans 14% more per beneficiary than the cost of coverage in traditional Medicare.*<br />Overpayments average > $1100/beneficiary enrolled in a private plan.**<br />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.***<br />Overpayments weaken Medicare’s long term finances by advancing by 17 months the date upon which the Medicare Hospital Trust Fund will be insolvent.*<br />*Medicare Payment Advisory Commission, “Report to Congress: Medicare Payment Policy,” March 2009.<br />** Brian Biles, Jonah Pozen, and Stuart Guterman, “The Continuing Cost of Privatization: Extra Payments to Medicare Advantage Plans jump to <br />$11.4 Billion in 2009.” The Commonwealth Fund, May 4, 2009.<br />*** Rick Foster, “ Letter to Pete Stark on Medicare Advantage and the Hospital Trust Fund Solvency,” Centers for Medicare and <br />Medicaid Services, Office of the Actuary. June 2009<br />
  51. 51. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />April 15, 2010 CMS released the final rule related to MA and Part D Plan Sponsors. Requires Establishment of a Compliance Program*<br />Goal: Control of Fraud, Waste and Abuse in Medicare, currently the nation’s largest federally funded health insurance program. <br />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. <br />Waste: Failure to control costs or regulate payments associated with Federal program monies.<br />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.<br />*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<br />
  52. 52. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />Human Capital Domain<br />Risks related to the organizational workforce; associated with the recruitment, retention, and termination of health plan employees. Risks would include:<br /><ul><li>Cultural and environment risks
  53. 53. Sexual Harassment
  54. 54. Discrimination
  55. 55. Safety/Ergonomics</li></ul>American Health Lawyers Association. (2009) Enterprise Risk Management Handbook for Healthcare Entities, First Addition. Ellen L. Barton<br />
  56. 56. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />Strategic Domain<br />Risks associated with brand, reputation, and business strategies. Strategic risks would include:<br /><ul><li>Failure to adapt to market changes. (i.e. healthcare environment, changing customer needs, & competition)
  57. 57. Mergers, acquisitions, and divestitures
  58. 58. Managed care relationships
  59. 59. Antitrust</li></ul>American Health Lawyers Association. (2009) Enterprise Risk Management Handbook for Healthcare Entities, First Addition. Ellen L. Barton<br />
  60. 60. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />Legal & Regulatory Domain<br />Analyzes risks arising from licensure, accreditation, statutes, standards, and regulations. These risks include:<br /><ul><li>HIPAA
  61. 61. ARRA
  62. 62. DRA
  63. 63. FERA (Fraud Enforcement and Recovery Act)
  64. 64. False Claims Act
  65. 65. HITECH
  66. 66. Healthcare Reform (PPACA, HCERA)
  67. 67. Fraud, Waste, and Abuse</li></ul>American Health Lawyers Association. (2009) Enterprise Risk Management Handbook for Healthcare Entities, First Addition. Ellen L. Barton<br />
  68. 68. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />Technology Domain<br />Risks associated with the use of medical hardware or software. Examples include:<br /><ul><li>Privacy & Security
  69. 69. Record Retention
  70. 70. Disaster Recovery</li></ul>American Health Lawyers Association. (2009) Enterprise Risk Management Handbook for Healthcare Entities, First Addition. Ellen L. Barton<br />
  71. 71. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />Hazard Domain<br />Risks related to the physical loss of assets or a reduction in their value. Such as:<br /><ul><li>Facility management
  72. 72. Natural disasters</li></ul>American Health Lawyers Association. (2009) Enterprise Risk Management Handbook for Healthcare Entities, First Addition. Ellen L. Barton<br />
  73. 73. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />Risk Assessment & Evaluation <br />What do you do once organizational risks have been identified?<br />Understand & attempt to quantify the potential magnitude.<br />Consider the positive & negative consequences of events underlying those risks across the organization.<br />Incorporate at least two dimensions of risk “likelihood and severity”<br />Be aware of the different ranges of results associated with an event.<br />American Health Lawyers Association. (2009) Enterprise Risk Management Handbook for Healthcare Entities, First Addition. Ellen L. Barton<br />
  74. 74. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />Tools to Evaluate Risk<br /><ul><li>Failure Mode and Effects Analysis (FMEA)
  75. 75. Vulnerability Analysis
  76. 76. Quantitative Risk Modeling
  77. 77. Cost Benefit Analysis
  78. 78. Risk Scoring
  79. 79. Risk Maps/Heat Maps</li></li></ul><li>MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br /><ul><li>Evaluating the importance of risk vs. risk
  80. 80. (Probability + Time to Impact) X Severity =Risk Score</li></ul>“RISKY BUSINESS”<br />
  81. 81. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />
  82. 82. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />
  83. 83. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />
  84. 84. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />
  85. 85. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />
  86. 86. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />“Somebody has to do something, its just incredibly pathetic that it has to be us!” <br />–Jerry Garcia<br />
  87. 87. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />KEY:<br />COMPLIANCE PROGRAM<br />
  88. 88. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />Elements of a Compliance Program <br />Written Standards of Conduct – policies, procedures and other operating guidelines. <br />High Level Oversight –Designate a leader responsible for implementing and monitoring the Compliance Program.<br />Effective Compliance Training –development and implementation of regular and effective training, such as this one.<br />Monitoring and Auditing –use of risk evaluation and audits to monitor compliance.<br />Disciplinary Mechanisms – policies to consistently enforce standards.<br />Effective Lines of Communication – including a system to receive, record and respond to compliance questions or reports of potential non‐compliance.<br />Procedures for Responding to Detected Offenses – policies to respond and initiate corrective action including a timely and reasonable inquiry.<br />
  89. 89. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />Compliance Plan Element: High Level Oversight Required<br />Compliance officer must be an employee of the sponsoring/parent organization, or corporate affiliate. <br /> Compliance officer must be accountable to the governing body of the sponsor organization. <br /> Compliance officer may not be an employee of a first-tier, downstream, or related entity.<br /><ul><li>First Tier Entity: A first tier entity is any party that enters into a written arrangement acceptable to CMS with a Sponsor or applicant to provide administrative services 
  90. 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. 91. Related Entity: Any entity that is related to the Sponsor by common ownership or control and:
  92. 92. Performs some of the Sponsor’s management functions under contract or delegation;
  93. 93. Furnishes services to Medicare enrollees under an oral or written agreement; or
  94. 94. Leases real property or sells materials to the Sponsor at a cost of more than $2,500 during a contract period.</li></li></ul><li>MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />Structured Program<br /><ul><li>Integrated Team Coordinating Effort Throughout the Plan:
  95. 95. Compliance
  96. 96. Risk Adjustment Staff
  97. 97. Provider Community (Provider Relations)
  98. 98. Medical Management
  99. 99. Legal
  100. 100. Analytics/Informatics
  101. 101. Quality Improvement</li></li></ul><li>MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />Effective Lines of Communication<br /><ul><li>System to:
  102. 102. Retrieve
  103. 103. Record
  104. 104. Respond to compliance questions or reports of potential non-compliance</li></li></ul><li>MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />Compliance Plan Element<br />Written Standards of Conduct<br /><ul><li>Policies
  105. 105. Procedures
  106. 106. Other operating guidelines</li></li></ul><li>MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />Compliance Plan Element<br />Policies and Procedures Documenting:<br /><ul><li>Processes and Communications
  107. 107. Defined Roles and Responsibilities (Internal/External)
  108. 108. Training/Communication
  109. 109. Provider/Provider Staff
  110. 110. Medical Management/Clinical Documentation Requirements
  111. 111. Plan Staff
  112. 112. Adherence to CMS Contract Requirements
  113. 113. Provider/Vendor Data
  114. 114. Formal/Informal
  115. 115. Selection Criteria
  116. 116. Contract Compliance</li></li></ul><li>MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />Protecting EPHI<br />Accessing EPHI<br /><ul><li>Covered entities must develop and implement policies and procedures for authorizing EPHI access in accordance with the HIPAA Security Rule at §164.308(a)(4) and the HIPAA Privacy Rule at §164.508.</li></li></ul><li>MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />Protecting EPHI<br />Storing EPHI<br /><ul><li>Covered entities must develop and implement policies and procedures to protect EPHI that is stored on remote or portable devices, or on potentially transportable media.</li></li></ul><li>MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />Protecting EPHI<br />Transmitting EPHI<br /><ul><li>Covered entities must develop and implement policies and procedures to secure EPHI that is being transmitted over an electronic communications network.</li></li></ul><li>MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />Compliance Plan Element<br />HERE COMES TROUBLE!<br />
  117. 117. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />Compliance Plan Element<br /><ul><li>CMS
  118. 118. OIG
  119. 119. FBI
  120. 120. MFCU
  121. 121. Office of Consumer Information and Insurance Oversight
  122. 122. Audits (ie. RADV, RAC)
  123. 123. State insurance regulators
  124. 124. Sudden delays in reimbursement</li></li></ul><li>MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />ISSUES/CONCERNS<br />Marketing Misconduct<br />Look to state/federal laws<br />Complaints<br />Develop a plan for a response<br />Determine what depts./roles will be involved<br />Timelines<br />Records (identification/location)<br />Establish a process/resource identification<br />Denials <br />Appeals<br />Quality of Care<br />
  125. 125. MEDICARE ADVANTAGE FROM A COMPLIANCE PERSPECTIVE<br />

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