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Medicare Compliance

Medicare Compliance Organizations contracted with the Centers for Medicare and Medicaid Services are Required to Create an effective Compliance Program The Compliance Program must include measure that prevent, detect and correct:

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Medicare Compliance

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  1. Medicare Compliance • Organizations contracted with the Centers for Medicare and Medicaid Services are Required to Create an effective Compliance Program • The Compliance Program must include measure that prevent, detect and correct: • Non-compliance with State and Federal health program requirements • Fraud, waste and abuse

  2. Medicare Compliance • KelseyCare Advantage’s Compliance Department is led by the Compliance Officer that works to prevent, detect and correct non-compliance with Medicare rules.

  3. Medicare Compliance • Our Compliance Program describes in detail • How we operate our Compliance Department. • How we meet each of the seven required elements of a compliance program prescribed by the Office of Inspector General. • How we will monitor the effectiveness of our Compliance Program.

  4. Compliance Department • Mission Statement • The Compliance Department will: • Provide consistent, timely and proactive compliance services. • Be vigilant and transparent in supporting our partnerships. • Strive to maintain the integrity of the Plan’s operations.

  5. Medicare 2012 • Compliance Actions and Risk • CMS has a more focused oversight methodology based on data. • Data validation for reporting Part C and D data. • Monitoring and oversight.

  6. Sanctions • We may receive sanctions for not complying with CMS requirements. • Sanctions may include • Notice of Noncompliance • Warning Letters • Corrective Action Plans • Suspension of Enrollment and Marketing • Fines • Contract Suspension

  7. Examples of Non-Compliance • Anytime Kelseycare Advantage does not perform on its promises made to Medicare beneficiaries in the Evidence of Coverage, or anytime an agent markets a plan to a member in a way that violates the marketing rules, KCA is not complying with Medicare rules. • Many times, noncompliance is unintentional - it may be the result of a computer issue that needs to be fixed. Intentional or not, the Compliance Department is responsible for identifying and correcting the noncompliance. While the department, as well as KCA as a whole, tries hard to prevent noncompliance, our goal is to identify and address problems as soon as possible.

  8. Your Responsibility • As a plan employee or delegate you are required to report all suspected issues of FWA and non-compliance as outlined in the Code of Conduct to the Compliance Department . • The plan will not reveal your identity unless your are party to the FWA or non-compliance and or it is totally necessary to do so as part of the investigation.

  9. Compliance Resources • Fraud Hotline • Report Fraud, Waste, Abuse and Other Compliance Violations to: • 713-442-9595 or medicarefraudhotline@kelseycareadvantage.com

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