Medicare Advantage Compliance Training For First Tier, Downstream and Related Entities 2009

1. Medicare Advantage Compliance Training For First Tier, Downstream and Related Entities 2009

2. Purpose of These Training Materials In December 2007, CMS published a final rule that required Medicare Advantage- Prescription Drug Plans (MA-PDs) like Unison to apply certain training and communication requirements to all entities that they partner with (i.e. first tier, downstream and related entities). [72 FR 68700-68741]

3. Purpose of These Training Materials • MA-PDs are responsible for ensuring that all of their first tier, downstream and related entities are provided with the appropriate training. This PowerPoint Training has been prepared to meet that requirement. • Training must be completed by 12/31/09 and then annually thereafter. • Please maintain records of all training (dates, method of training, sign-in sheets, etc). Unison, CMS, or their agents may need to request such records to verify training occurred.

4. Medicare Medicare is a Federal program, administered by the Centers for Medicare and Medicaid Services (CMS), an agency within the U.S. Department of Health and Human Services. • CMS Implements Federal law. • CMS develops payment and quality standards. • CMS sets payment rates. • CMS enforces fraud and abuse laws.

5. 4 Parts of Medicare There are four parts to the Medicare law, including two categories of medical entitlements, and a pharmacy benefit. • Part A: primarily an inpatient benefit. Most Medicare beneficiaries automatically qualify for Part A. • Part B: pays for professional services, like physician’s office charges. This is a voluntary benefit. • Part C: Medicare Advantage (MA) plans offering Part A and B services are called Part C. • Part D: This is a voluntary prescription drug benefit, which began in 2006.

6. Medicare Advantage Plans Medicare Advantage (MA) plans are alternative ways to obtain Medicare coverage for Parts A, B and D (instead of from Medicare directly).Types of MA Plans: • Coordinated Care Plans are HMOs and PPOs. Most offer Part D pharmacy coverage. • Private Fee-For-Service Plans are products that permit beneficiaries to see any provider who will accept payment. • Medical Savings Accounts • Provider Sponsored Organizations.

7. Medicare Advantage Plans Plans that offer MA and Part D are referred to as MA-PDs. Plans that offer Part D only are referred to as PDPs. Unison is a MA-PD plan. • Part D plans are an option for beneficiaries who want to take advantage of their Original Medicare benefit, or who have an employer retirement plan without drug coverage.

8. Medicare Advantage Plans Special Needs Plans (SNPs) are a type of MA/MA-PD plan. SNPs are available for persons with Medicare and Medicaid (dual eligibles), institutionalized persons (for long term skilled nursing care) or persons with various chronic diseases. • SNPs must prove to CMS that they offer a specialized model of care for their unique population. • Unison offers an SNP plan for dual eligibles.

9. Fraud, Waste and Abuse • Fraud, Waste and Abuse are important concepts to Medicare. • There are several pertinent laws that are related to fraud, waste, and abuse.

10. What is Fraud, Waste and Abuse? Fraud • Committed when a dishonest provider or consumer intentionally submits, or causes someone else to submit, false or misleading information in determining the amount of health care benefits. For example, billing for services not rendered. Waste • The over-utilization of services not caused by criminally negligent actions but rather by the misuse of resources. Abuse • Provider practices that are inconsistent with professional standards of care, medical necessity, or inconsistent with sound fiscal, business, or medical practices. • Beneficiary practices that result in unnecessary costs to the healthcare program • For example, billing the wrong payer.

11. Federal Anti-Kickback Statute Prohibits anyone from knowingly paying anything of value to influence a referral to the Medicare or Medicaid program

12. Federal False Claims Act (FCA) • FCA prohibits knowingly submitting false claims for payment to federally funded program such as Medicare and Medicaid • Any violation can trigger potential liability • Intended to reach all types of fraud that might result in financial loss to the government

13. Federal False Claims Act (FCA) • Significant liability/treble damages • Use of whistle-blowers to bring suits; they can recover too • Whistle-blower protections for those with actual knowledge of false claims activity – no retaliation against whistleblowers

14. State False Claims Acts • Similar to federal FCA, but creates additional liability • More opportunity for whistle-blower recovery • Whistle-blower protections for those with actual knowledge of false claims activity

15. HIPAA Privacy Generally, covered entities (providers and plans) may not use or disclose protected health information (PHI) unless such disclosure is authorized by member or as required by the privacy rule.

16. HIPAA Privacy • These rules apply to any covered entity transmitting data electronically • Even when disclosure is permitted, it still must only be the minimum amount necessary

17. Notice of Medicare Non-Coverage (NOMNC) Obligations • A healthcare provider must deliver a completed NOMNC notice to members receiving skilled nursing, home health, or comprehensive O/P rehab facility services no later than 2 days prior to proposed termination of services. • Member must be able to understand it and sign for it. If member is unable understand it, it must be given to an authorized representative. • The process of presenting the NOMNC to the member (or representative) must be documented by the provider.

18. NOMNC Obligations • NOMNC outlines the member’s ability to appeal to the Quality Improvement Organization (QIO). • Provider should be sure to place a completed, dated copy of the NOMNC in the member’s file. • For more information on the NOMNC, refer to the CMS website: http://www.cms.hhs.gov/MMCAG/downloads/NOMNCInstructions.pdf • Unison’s NOMNCs are state-specific since they contain QIO contact information. You can find a copy of your state’s Unison CMS-approved NOMNC’s on www.unisonhealthplan.com. Go to Provider Forms under For Providers.

19. Medicare Compliance • Any entity doing business with Medicare, or receiving Medicare funds, must abide by CMS’s compliance rules and fraud, waste, and abuse guidelines. • This means understanding the reason for, and the elements of a compliance program, and understanding the fraud, waste, and abuse laws that impact Medicare Advantage.

20. Areas of Inherent Compliance Risks These topics should receive specific training • Sales and Marketing • Oversight of agents and brokers • Advertising accuracy • Enrollment • Reporting to CMS • Billing and payment • Calculation of TrOOP costs • Proper appeals decisions

21. Areas of Inherent Compliance Risks • Communicating to beneficiaries their exception and coverage determination rights • Drug transition activities • How beneficiaries can contact their plan regarding questions • How to report fraud, waste and abuse

22. Medicare Compliance MA Plans are required to have a Compliance Program. CMS expects this of a MA plan’s first tier, downstream and related entities too. A Compliance Program: • Identifies potential problems • Helps the MA plan and its delegates avoid ethical or legal enforcement actions • Builds a culture of performance improvement • May help improve operations, thereby reducing costs

23. Medicare Compliance The Office of the Inspector General (OIG) has identified seven essential elements to a Compliance Program. • Written Policies and Procedures • A Compliance Officer and Compliance Committee • Education/training • Effective communication • Enforcement/discipline • Monitoring, auditing and reporting • Regulatory responses and corrective actions

24. Medicare Compliance • Education and training are important elements of a Compliance Program. CMS expects organizations to train new hires, and reinforce compliance and fraud & abuse training annually. • Document all training activities, including the names of the participants. Effective training and education includes testing. • Training and successful testing should be a requirement for continued employment or contract.

25. Medicare Compliance CMS expects plans to perform internal performance monitoring and audits, including audits of the Compliance Program. This includes entities performing services under contract to the MA plan.

26. Medicare Compliance • The U.S. Dept. of Health and Human Services Office of the Inspector General (OIG) enforces most Fraud & Abuse laws. The U.S. Dept. of Justice prosecutes some criminal Fraud & Abuse actions. • There are serious penalties for Fraud & Abuse, for example, civil monetary penalties for false claims of $5,500 - $11,000 per claim, and criminal penalties that include fines and imprisonment. • The most serious penalty, often referred to in the industry as the “death penalty,” is exclusion from participation in the Federal health programs. Exclusion often puts providers out of business.

27. Unison Compliance and Fraud and Abuse Contact Information You can contact the Unison Compliance Officer regarding any questions regarding this training or the Unison Fraud and Abuse Dept. to report Fraud and Abuse activity that you are aware of at 1-877-766-3844 or 412-380-8025 (they are both at this number).They can also be reached by mail at Unison Plaza, 1001 Brinton Rd., Pittsburgh, PA 15221.