ADMINISTRATIVE POLICY AND PROCEDURES MedStar Family Choice Medicare Advantage Plans

Transcription

1 ADMINISTRATIVE POLICY AND PROCEDURES MedStar Family Choice Medicare Advantage Plans DEPARTMENT: Medicare Compliance POLICY TITLE: RELATED DEPARTMENTS: All POLICY #: 700C VERSION #: 3 REVISION DATE: Medicare Compliance Committee 4/2016 EFFECTIVE DATE: PREPARED BY: PRODUCT: NEXT REVIEW DATE: 1/1/2013 Cathy Kajubi Medicare Advantage December 2016 Approved: David Finkel President, MedStar Family Choice Lesley Wallace Assistant Vice President, MedStar Family Choice PURPOSE To establish a Medicare Compliance Committee that meets regularly to monitor the implementation and effectiveness of the Medicare Compliance Plan and supporting policies and procedures and to ensure that inappropriate and unlawful conduct, privacy disclosures, fraudulent activities, and abusive patterns have been identified, reported and corrected. POLICY The MedStar Family Choice Medicare Compliance Committee will meet no less than quarterly to monitor adherence to the Medicare Compliance Plan and Privacy Manual, Policies and Procedures. In addition, the Medicare Committee shall review identified potential non-compliant activity, discuss the appropriate plan of action for potential and identified non-compliant activities and review corrective action plans for identified non-compliant activity.

2 PROCEDURE 1. The members of the MedStar Family Choice Medicare Compliance Committee include the Director of Medicare Compliance, the Medicare Compliance Officer, the Diversified Compliance Officer for MedStar Health, the Corporate VP of Managed Care, VP of Operations, Sr, Medical Director, and Asst. VP of Care Management. The Medicare Compliance Committee recommends approval of the Plan and receives quarterly compliance reports for the Medicare Advantage and Medicare Prescription Drug (PDP) plans. These quarterly reports summarize the overall compliance activities, including issues identified, investigated and resolved by the compliance program, and any changes that are recommended to improve compliance. The Board receives these quarterly reports summarizing compliance activity for the quarter. 2. The Committee may, in its discretion, delegate all or a portion of its duties and responsibilities to a subcommittee of the Committee, but shall retain ultimate accountability for the responsibilities described hereunder. The Committee shall have the resources and authority appropriate to discharge its responsibilities. 3. The Medicare Compliance Committee (MCC) is responsible for compliance strategy and oversight of the Medicare Compliance Program. The purpose of the Medicare Compliance Committee is to ensure that leadership is aware of the day to day issues associated with operating the program. This group consists of decision makers who can escalate issues, make strategic decisions, and identify and approve resource needs. 4. At least quarterly, a written report on Medicare compliance activities shall be presented to the Medicare Compliance Committee and the MedStar Family Choice Board of Directors. The report shall identify areas where corrective actions are needed and shall be used by the Director of Medicare Compliance and management to correct problems and prevent them from recurring. Subsequent reviews will be performed to ensure that corrective actions have been implemented and are successful. 5. The MFC Director of Medicare Compliance, the Medicare Compliance Officer, and members of OCBI (including the Diversified Compliance Officer), shall have the authority to review all documents and other information relevant to compliance activities, including, but not limited to, patient records, billing records, records concerning the marketing efforts of the organization and MFC s arrangements with other parties, including employees, professionals on staff, relevant independent contractors, suppliers, agents, supplemental staffing entities, and physicians. The Director of Medicare Compliance shall have the authority to consult with legal counsel when necessary. 6. Once a year, the Director of Medicare Compliance presents the Medicare Compliance Committee with an annual report. This report summarizes the key activities performed by the Medicare Compliance Department and discusses plans for the next year. The Director of Medicare Compliance will discuss the staff training and education that took place along with the outcomes of the auditing and monitoring activities. 7. The Medicare Compliance Committee will meet no less than quarterly and will maintain minutes.

3 The duties of the Medicare Compliance Committee include the following: 1. Supporting an appropriate infrastructure for the administration of the Medicare Compliance and Privacy Program including mechanisms and systems for long-term support; 2. Ensuring the periodic evaluation of Compliance and Privacy Program effectiveness, including the adequacy of resources, review of compliance plan and that appropriate changes or improvements are made to ensure Program effectiveness; 3. Analyzing the regulatory environment, the legal requirements with which MedStar Medicare plans must comply and specific risk areas; 4. Assisting and supporting the risk assessment on an annual basis to identify applicable laws and regulations and to identify MedStar Family Choice risks; and thereafter assisting in the review and validation of risk prioritization for appropriate corrective action such as policy development, training and education, and further auditing and monitoring; 5. Reviewing and approving policies and procedures that help to ensure the Compliance and Privacy Program and MedStar Family Choice Medicare operations comply with applicable laws and regulations and providing recommendations for additional policy development, updates and revisions as needed; 6. Recommending and monitoring the development of internal systems and controls to implement MedStar Family Choice s standards, policies and procedures as part of its daily operations; 7. Ensuring that Compliance and Privacy Program training and education occurs annually, heightens the awareness of compliance issues occur and supports entity and system wide initiatives and regulatory imperatives; 8. Monitoring open lines of communication within MedStar Family Choice to solicit, evaluate and respond to complaints and problems; 9. Ensuring that an annual compliance audit work plan is reviewed and approved so that auditing and monitoring activities are identified, conducted and reported; 10. Coordinating delegation management activities (FDRs) and making decisions pertaining to monitoring and auditing strategies and schedules; 11. Monitoring internal and external audits and investigations for the purpose of identifying problems and issues, and ensuring appropriate (preventive and correction) action has been taken.

4 Medicare Compliance Officer The MedStar Family Choice President shall designate a Medicare Compliance Officer. The Medicare Compliance Officer is responsible for the following: 1. Oversee the Medicare Compliance Program to ensure adherence to all appropriate regulations and program requirements. 2. Serve as Chair of the Medicare Compliance Committee 3. Reports Medicare issues and risks directly to the President on an ongoing basis and to the Board of Directors on no less than a quarterly basis regarding the status and activities of the compliance program, including compliance program outcomes, the results of internal and external audits and about all government compliance enforcement activity. 4. Reporting to the MFC President and the MedStar Health OCBI (via the Diversified Compliance Officer), or the MedStar Health Privacy Office any inquiries concerning improper billing practices or reports of non- compliance. Director of Medicare Compliance The MedStar Family Choice (MFC) Director of Medicare Compliance reports directly to the Medicare Compliance Officer and is responsible for the following: 1. Overseeing and monitoring the implementation of the Medicare Compliance plan 2. Providing an annual report summarizing the activities of the Medicare Compliance Committee during the calendar year. 3. Ensuring compliance guidance and education to MFC associates and working with OCBI to create a compliance/privacy education program and process that meets CMS requirements. 4. Acting as a liaison between MFC, OCBI or Corporate Privacy Office, to coordinate activities such as onsite compliance reviews or audits; 5. Acting as the liaison between MedStar Family Choice and CMS for all Medicare related issues and the OIG for fraud and abuse issues; 6. Maintaining MFC compliance policies and ensuring regular policy review and consistency with MedStar Health corporate standards;

5 7. Managing hotline inquiries pertaining to MFC in coordination with the Diversified Compliance Officer, in accordance with the specific processes outlined in the Integrity Hotline Protocols, and ensuring that anyone working on such investigations understand and follow the MedStar Integrity Hotline protocols; 8. Conducting investigations of compliance violations within MFC; 9. Handling and coordinating with OCBI or the Corporate Privacy Office when there are government investigations of MFC, including but not limited to the OIG; 10. Ensuring timely completion of risk assessments and related activities; 11. Directing corrective action plans resulting from compliance reviews, risk assessments, etc, and coordinating any necessary policy or procedure changes, repayments, etc. 12. Working closely with Human Resources when compliance violations occur to ensure consistent disciplinary standards are being met, in accordance with the corporate guidance; 13. Actively participating in the Corporate Compliance Leadership Team (CLT) meetings and projects, if appropriate; 14. Providing applicable reports to OCBI which identify compliance activities at MFC; 15. Providing education to MFC board and leadership groups on compliance-related initiatives and emerging issues; 16. Identifying key stakeholders and subject-matter experts within MFC to provide input or assistance for various compliance projects; 17. Ensuring that delegated entities, first tier, downstream entities and independent contractors who furnish services to MFC members are informed of MFC s standards of business conduct with respect to privacy, coding, billing, marketing, and other topics and conduct the appropriate compliance, FWA and privacy training;

6 18. Coordinating personnel issues with the appropriate Human Resources Office(s) to support corporate Human Resource policy that the National Practitioner Data Bank and OIG and GSA sanction listings have been checked with respect to all employees, medical staff, and independent contractors who order or provide services to patients. RECORD RETENTION Medical and business documents and records must be maintained in accordance with procedures and timeframes established by applicable laws, accreditation standards, and MedStar Health s Record Retention and Destruction Policy, whichever period is longer. For the Medicare line of business the record retention period is at least 10 years. Medical and business documents include paper documents such as letters and memoranda; computer-based information, such as or computer files on disk or tape; and any other medium that contains information about MedStar Health or its business activities. MFC maintains records of attendance, topic, certificates of completion (if applicable), and test scores of any tests administered to training of its employees for a period of at least 10 years. Further, MFC requires all FDRs to maintain records of the training of the FDRs employees for a similar period of time. FDRs who have met the FWA certification requirements through enrollment into Parts A or B of the Medicare program or through accreditation as a supplier of DMEPOS are deemed to have met the FWA training and education requirements. No additional documentation beyond the documentation necessary for proper credentialing is required to establish that an employee or FDR or employee of an FDR is deemed. In the case of chains, such as chain pharmacies, each individual location must be enrolled into Medicare Part A or B to be deemed. REGULATORY REFERENCES: 42 C.F.R. sections (b)(4)(vi) and (b)(4)(vi) RELATED DOCUMENTS MedStar Family Choice Medicare Compliance Plan MedStar Family Choice Medicare Compliance Charter REVIEW AND REVISION HISTORY DATE REVISION NO. REASON FOR CHANGE 7/15 2 Annual Policy Revision