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3D Compliance for Managed Care

HCCA 2000 Compliance Institute. 3D Compliance for Managed Care. Vickie McCormick Integrity Officer - UnitedHealth Group Mamie Segall Vice President, Compliance Operations - Medica Health Care Compliance Institute The Compliance Evolution: Revealing the Opportunities. Introduction.

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3D Compliance for Managed Care

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  1. HCCA 2000 Compliance Institute 3D Compliance for Managed Care Vickie McCormick Integrity Officer - UnitedHealth Group Mamie Segall Vice President, Compliance Operations - Medica Health Care Compliance Institute The Compliance Evolution: Revealing the Opportunities

  2. Introduction • Three Dimensions to Building and Sustaining • Compliance Organization • Compliance Tools • Partner/Vendor/Provider (“Extender”) Organizations

  3. Compliance Organization • Model #1 -- Compliance Oversight • Operational/functional department primarily responsible for: • identifying compliance obligations • implementing operational processes to promote compliance • Compliance primarily responsible for: • providing coordination, resources and facilitation • notifying operational/functional departments of compliance obligations when identified • facilitating cross-departmental issues • conducting monitoring/auditing • creating/maintaining metrics of functional departments’ compliance

  4. Compliance Organization • Model #2 -- Compliance Implementation • Compliance is primarily responsible for: • identifying compliance obligations • implementing operational processes to promote compliance • facilitating cross-departmental issues • conducting monitoring/auditing • creating/maintaining metrics of functional departments’ compliance

  5. Compliance Organization • Model #3 -- Compliance Oversight and Implementation • Compliance works in conjunction with functional/operational departments to: • identify compliance obligations • implement operational processes to promote compliance • Compliance function: • facilitates cross-departmental issues • conducts monitoring/auditing • creates/maintains metrics of functional departments’ compliance

  6. Compliance Tools • Periodic Reporting on Compliance Activities • Confirming compliance organization structure • Compliance Officer • Compliance Committee • Identifying compliance-related activities • Regulatory compliance • Risk Analysis/Controls • Training • Human Resource/Organizational Development • Product • Department • Regulatory and Miscellaneous Compliance • Monitoring and Auditing Programs • Corrective Action, including discipline

  7. Compliance Tools • Compliance Intranet • Description of compliance office responsibilities and staff • Code of Conduct • Policies • Q&A • Compliance Hotline Information • Compliance Notices/Articles/Newsletters • Compliance Resources and Tools

  8. Compliance Tools • Accountability and Obligation Tracking • Define Mission • Define Job Profile • Create Intake Method • Create Implementation Process Flow • Track Assessments • Monitor Obligation Summaries

  9. Compliance Tools • Software Solutions • Goldmine • Lotus Notes/Excell/Access/Web Database • PricewaterhouseCoopers Compliance Office • Ernst & Young Compliance Saver

  10. Compliance Tools • Tool Box • UnitedHealth Group Quarterly Integrity and Compliance Reports • Sample Organization Charts • Intranet Site Content Outline • Regulatory Filing Tracking Tools

  11. Extender Organizations • MCO Accountability for Extender Organization Compliance • OIG Guidance • M+C Organizations responsible for provider organization compliance • HCFA and State Regulators • MCO can not avoid compliance obligation through delegation to extender organizations, including providers and IPAs • New York DOI position that MCOs are ultimately responsible for actions (an inaction) of IPAs • Maryland DOI decision regarding UnitedHealthCare of the Midland’s obligation to pay claims not paid by capitated IPAs

  12. Extender Organizations • Standard MCO Extender Organizations • Medical Providers and Suppliers • Providing medical services and supplies • Information source (encounter data, special status, etc.) • Delegated Administrative Services/Clinical Services • Claims • Pharmacy Benefit Management • Credentialing • Utilization Management • Quality • Information Systems • Standard Business Vendors/Suppliers

  13. Extender Organizations • Agreement Provisions Regarding Compliance • General compliance with all laws clause no longer sufficient • Addressing compliance in agreements with extender organizations • Standard 7 compliance program elements • Flow-through to sub-contractors • Consider excluded provider issue • Extender organization reporting compliance issues to MCO • External organization attorney/client privilege issues • Joint Defense Agreement? • MCO obligation to report to regulators/customers • Violation of performance standards • MCO right/obligation to audit extender organization compliance program

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