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Medicare Compliance

Explore how KelseyCare Advantage ensures adherence to Medicare regulations, identifies and rectifies non-compliance issues, and promotes integrity in operations through a comprehensive Compliance Department. Learn about compliance actions, risks, and your responsibilities in reporting violations.

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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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