CurrentprominencehealthfirstoffloridaPolicy COMP.A&M.005
Routine Monitoring, Auditing, and Identification of Compliance Risks
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Establishes Prominence Health Plan's system for identifying compliance risks and for routine monitoring and auditing of Medicare Advantage and related operations; applies to all persons (management, staff, contractors, vendors) affiliated with Prominence Health Plan.
Policy Summary
Payerprominencehealthfirstofflorida
PolicyRoutine Monitoring, Auditing, and Identification of Compliance Risks
Policy CodePolicy COMP.A&M.005
Change TypeNo material changes
Effective DateJan 1, 2017
Last ReviewApr 30, 2021
Next Review DateJun 1, 2021
Key ActionDo not pay for services from persons or entities excluded by OIG or GSA; screen LEIE and SAM prior to hiring/contracting and monthly thereafter.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
annualrisk assessment frequency
quarterlyprogress reporting
monthlyexclusion checks
annuallyprogram audit
Monitoring and Auditing Requirements
Monitoring and Auditing Requirements
Operational requirements and procedures for the compliance monitoring and auditing program. Covered when ALL of the following are met:
Perform an annual risk assessment of operational areas to identify regulatory and fraud/waste/abuse risks and categorize findings as high, medium, or low.
Reference: risk assessment frequency = annual
Medicare Compliance Officer develops an annual Auditing and Monitoring Work Plan that defines objectives, scope, methodology, frequency/timing (including announced and unannounced), audit types (desk or on-site), responsible parties, and processes for corrective action and follow-up; the Work Plan is reviewed and approved by the Medicare Compliance Committee and the Board; progress is reported at least quarterly.
Work Plan must include response and follow-up procedures; corrective actions may include reporting to CMS or NBI MEDIC.
Monitoring activities: may be performed by operations and/or compliance on a regular basis (daily/weekly/monthly/quarterly) and include metric review, trending, interviews, and limited testing to detect and correct issues in real time.
Auditing activities: performed by reviewers independent of the audited department (Medicare Compliance staff, PHP management, or external third parties); audits include document review, personnel interviews, universe pulls and sample testing with extrapolation in accordance with generally accepted auditing standards; audits include first-tier entities.
Audit methodology must address sample selection, sample size, extrapolation, and use of targeted/stratified sampling.
Audit reports must describe objectives, scope, methodology, findings (results, criteria, cause, effect), and recommendations; business owners (internal or FDR) must submit corrective action plans with controls and verification processes; results are reported to senior management, the Medicare Compliance Committee, and the Board, and effectiveness of corrective actions is tracked.
Conduct follow-up reviews by auditing or monitoring areas previously found non-compliant to confirm that corrective actions fully addressed the underlying problem.
Audit the effectiveness of the compliance program at least annually; to avoid self-policing, auditors should be independent (non-compliance staff or external auditors); the compliance department may administer supplemental self-assessments in support of the formal audit.
Include first-tier entities in the annual Work Plan; require FDRs to submit specified reports and review those reports routinely as part of monitoring the compliance of first-tier entities and their downstream entities.
Do not use federal funds to pay for services, equipment, or drugs prescribed or provided by persons or entities excluded by the DHHS OIG or GSA; screen the DHHS OIG LEIE and the GSA/SAM exclusion lists prior to hiring/contracting and monthly thereafter.
Use data analysis of claims and other sources to identify unusual patterns or outliers indicative of potential fraud, waste, or abuse and refer potential cases as appropriate.
Compliance department performs Special Investigations Unit (SIU) functions: case development, referrals to NBI MEDIC and law enforcement, recommending provider exclusions, and supporting investigations; cooperate with CMS, OIG, federal auditors and extend similar contractual cooperation provisions to FDRs.
Exclusion Screening & Payment Prohibition
Prior Authorization
Exclusion screening and payment prohibition
Prominence Health Plan will not use federal funds to pay for services, equipment, or drugs prescribed by a provider, supplier, employee, or FDR who is excluded by the DHHS OIG or GSA. The plan reviews the DHHS OIG List of Excluded Individuals and Entities (LEIE) and the GSA Excluded Parties List (EPLS) (maintained by SAM) prior to hiring or contracting and on a monthly basis thereafter to ensure no excluded persons or entities are hired, contracted, or provide services.
- Do not pay for services, equipment, or drugs prescribed by excluded providers, suppliers, employees, or FDRs.
- Screen LEIE and SAM/EPLS before hiring or contracting any new employee, temporary employee, consultant, governing body member, or FDR.
- Perform exclusion checks monthly thereafter for existing personnel and contracted parties.
Key Definitions
CMS
DefinitionCenters for Medicare and Medicaid Services (CMS): The federal agency that runs the Medicare program and works to ensure beneficiaries receive high quality health care.
RoleAdministers Medicare and issues regulations and guidance referenced by this policy (e.g., 42 C.F.R. provisions).
Websitehttps://cms.gov/
Delegated Entity
DefinitionDelegated Entity: Any party, including an agent or broker, that enters into an agreement with a Qualified Health Plan (QHP) issuer to provide administrative services or healthcare services to qualified individuals, employers, or employees and their dependents (45 C.F.R. 156.20).
ExamplesMay include vendors, brokers, or contractors performing enrollment, claims administration, or clinical services under a delegation agreement.
Contracting requirementArrangement must be set out in a written agreement acceptable to CMS when applicable.
Downstream Entity
DefinitionDownstream Entity: Any party that enters into a written arrangement, acceptable to CMS, with persons or entities involved with the MA organization or Part D benefit, below the level of the arrangement between an MA organization or Part D plan sponsor (or applicant) and a first-tier entity; arrangements continue down to the ultimate provider of health and administrative services (42 C.F.R. 422.2, 423.4).
Placement in contract chainExists below first-tier entities and may include subcontractors and providers further down the arrangement chain.
Written arrangement requirementMust be an arrangement acceptable to CMS documenting responsibilities and expectations.
First-Tier Entity
DefinitionFirst-Tier Entity: Any party that enters into a written arrangement, acceptable to CMS, with the MA organization or Part D plan sponsor (or applicant) to provide administrative services or health care services to a Medicare-eligible individual under the MA organization or Part D program (42 C.F.R. 422.2, 423.4).
ExamplesEntities directly contracted by the MA organization or Part D sponsor to perform functions such as claims processing, utilization management, or provider network management.
Contract requirementArrangement must be in writing and acceptable to CMS, defining services and responsibilities.
Related Entity
DefinitionRelated Entity: Any entity that is related to an MA and/or Part D sponsor by common ownership or control.
ImplicationMay be subject to monitoring and reporting requirements due to common ownership or control relationships.
Contracting noteTransactions with related entities should be documented and comply with applicable regulations and oversight.
URAC
DefinitionURAC (Utilization Review Accreditation Commission): An independent organization that promotes health care quality through accreditation of organizations involved in medical care services; URAC accreditation is recognized by state and federal regulators.
RoleSets accreditation standards that appear in legislation and regulation at state and federal levels.
Websitewww.urac.org
NBI MEDIC
DefinitionNBI MEDIC (National Benefit Integrity Medicare Drug Integrity Contractor): A contractor established to detect and prevent fraud, waste, and abuse in the Part C (Medicare Advantage) and Part D (Prescription Drug Coverage) programs at the national level.
FunctionReceives referrals and collaborates on investigations of suspected FWA affecting Part C and D programs.
Referencehttp://www.healthintegrity.org/contracts/nbi-medic/
OIG
DefinitionOIG (Office of Inspector General): The HHS office responsible for enforcement of waste, fraud, and abuse efforts in Medicare, Medicaid, and other HHS programs; authorized to exclude providers, individuals, contractors, or businesses from Federal health care programs.
Exclusion authorityOIG may exclude parties for convictions, patient abuse, healthcare fraud, controlled substance abuse, license revocation, or other causes.
Websitehttps://oig.hhs.gov
Auditing
DefinitionAuditing: Retrospective review assessing compliance using a methodological approach and sampling of cases against standards such as policies, procedures, laws, and regulations.
MethodologyTypically includes document review, interviews, sampling, and extrapolation per auditing standards.
PurposeAssess compliance, identify deficiencies, and support corrective action planning and follow-up reviews.
Monitoring
DefinitionMonitoring: Periodic reviews performed as part of normal business operations to detect and correct issues in real time, confirm ongoing compliance, and ensure corrective actions were implemented and effective.
MethodsMay include metric review, trending, interviews, and limited testing as part of routine operations.
PurposeEarly detection and correction of issues and confirmation of sustained compliance between audits.
Policy Summary
Payerprominencehealthfirstofflorida
PolicyRoutine Monitoring, Auditing, and Identification of Compliance Risks
Policy CodePolicy COMP.A&M.005
Change TypeNo material changes
Effective DateJan 1, 2017
Last ReviewApr 30, 2021
Next Review DateJun 1, 2021
Key ActionDo not pay for services from persons or entities excluded by OIG or GSA; screen LEIE and SAM prior to hiring/contracting and monthly thereafter.
SourceLink
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