What are the CareFirst Medicare Advantage Compliance Program Requirements?
It’s important that our FDRs are in compliance with applicable laws, rules and regulations. As an FDR you must comply with Medicare Compliance Program requirements. You may review the Code of Ethical Business Conduct and Compliance for First Tier, Downstream and Related Entities to make sure that you have internal processes to support your compliance with these requirements each calendar year.
What is the source of these requirements?
The Code of Federal Regulations (CFR) outlines these regulatory requirements from CMS. The training requirement and deemed status are noted at 42 CFR 422.503(b)(4)(vi)(C) for Medicare Advantage and 42 CFR 423.504(b)(4)(vi)(C) for Part D and further described within the Medicare Managed Care Manual, Chapter 21 – Compliance Program Guidelines and Prescription Drug Benefit Manual, Chapter 9 – Compliance Program Guidelines.
Is our organization required to have an FWA training and general compliance training?
As part of being an FDR, you/your organization will need to provide FWA and compliance training to all of your employees and downstream entities who provide administrative and/or healthcare services for our Medicare plans.
What kind of documentation is needed to show training was completed?
Evidence may be in the form of employee attestations, employee attendance/training logs, or other means determined by you to best represent fulfillment of your obligations. You should retain evidence of completion for at least 10 years. CareFirst Medicare Advantage and/or CMS may request this evidence to ensure completion of these requirements. If you and/or your employees are deemed to have met the FWA training requirements, you should retain proof of the deemed status.
How often is training required?
All required training must be completed within 90 days of initial hire or the effective date of contracting and at least annually thereafter.
If a violation has occurred either by an employee or by a Downstream Entity, how can we make a direct report?
You must make a report by taking any of the following actions:
CareFirst Medicare Advantage’s hotline is available 24 hours-a-day, seven days-a-week. The hotline is anonymous and calls are not traced and there is no caller ID. The hotline number is a voicemail number only. These reporting mechanisms are outlined in CareFirst Medicare Advantage’s Code of Ethical Business Conduct and Compliance for First Tier, Downstream and Related Entities. We enforce a zero-tolerance policy for retaliation or retribution against anyone who reports suspected misconduct.
Do we have to report non-compliance and FWA to CareFirst Medicare Advantage or does CareFirst Medicare Advantage consider reporting within our organization to be sufficient?
FDRs that partner with multiple Medicare Advantage and Medicare Prescription Drug Plans may train their employees on the FDR’s internal reporting processes including emphasis that reports must be made to our company. FDR’s internal processes must involve a system to promptly respond to compliance/FWA concerns as they are raised. They must also include thorough investigations, root cause analysis, actions for correction and prevention of reoccurrence and reporting to CareFirst Medicare Advantage and authorities, as applicable.
All concerns that affect CareFirst Medicare Advantage’s Medicare products must be reported to CareFirst Medicare Advantage’s Compliance Department, but may go through your process initially. It is mandatory to report any potential or actual non-compliance and/or FWA to CareFirst Medicare Advantage. There is a zero-tolerance policy for retaliation or retribution against anyone who reports suspected misconduct.
What is the difference between the OIG LEIE, General Services Administration (GSA) Excluded Parties List System (EPLS), and the System for Award Management (SAM) Websites?
GSA administers EPLS and SAM, both of which contain debarment actions taken by various Federal agencies, including exclusion actions taken by the OIG. The List of Excluded Individuals/Entities contains only the exclusion actions taken by the OIG.
How often do the exclusion/debarment checks have to be completed?
The checks must be completed initially before hire/contracting and then monthly thereafter.
What if an individual or entity is identified on one of the exclusion/debarment lists?
If you identify an excluded individual or entity employed or contracted by your organization, you must report this to CareFirst Medicare Advantage. This entity must be immediately removed from directly or indirectly servicing CareFirst Medicare Advantage’s Medicare plans.
What evidence should I submit to show that these checks are completed?
The documentation or evidence may vary depending on the system used to complete this checks. If you perform a manual search of the website lists, you may use a screen print of the results of the check. If you perform these checks using a more automated system or program, your documentation may be based on the information available within that system. Regardless of the process you use to perform these required checks, the documentation to evidence compliance with this requirement should clearly identify the name of the entity/individual checked, the date the check was performed, and the results of the check.