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For Medicare programs, we must ensure compliance in these key areas:
1. Beneficiaries receive all medically necessary services to which they are entitled.
2. The organization does not selectively market its program (i.e., market only to those healthier beneficiaries who utilize less services, representing lower than average annual cost).
3. Provider compensation, and especially the risk-sharing mechanisms, are not structured to provide incentives to withhold medically necessary services.
4. Marketing and sales materials provide important beneficiary information in a clear and succinct manner, neither over- or under-promising, nor excluding key components of the benefit package and requirements.
5. Providers or medical personnel do not initiate discussions concerning disenrollment.
These issues seem straightforward but, given the many participants in the Medicare Risk program, all of MCHP's staff members, our written materials, and the employees of our provider network, it is obvious that there are many places where inaccu-rate information could be given to members and providers, many oppor-tunities to err in communications or actions, and the need to pay careful attention to all aspects of program-matic requirements. Unfortunately, there are managed care organizations that are not fully in compliance. This creates a negative public perception about all of us, placing us under extreme regulatory and public scrutiny and suspicion, making our jobs even more difficult.
CH: Why is compliance so important?
LP: Managed care organizations that contract with HCFA have been delegated the federal government's responsibility to serve and protect beneficiaries. These are contractual requirements and must be followed to the letter of the law and/or regulation.
CH: What is the most important issue that supports your efforts as compliance officer?
LP: The support of the CEO, the board of directors and the entire man-aged care organization staff is critical for a compliance program to be successful. All must understand that compliance is critically important and that it needs to be taken seriously.
CH: What other aspects of the program are you responsible for?
LP: I am responsible for disclosing to HCFA any action or issue that would cause MCHP to be non-compliant with our contract. I am also an inter-nal resource for MCHP staff and con-tracted providers and vendors. I have the responsibility for developing the compliance program, overseeing audits, monitoring activities and reporting to HCFA on an established calendar.
CH: What makes you effective in your role?
LP: I am very visible and available to MCHP staff, keeping an open door policy, encouraging everyone to bring to my attention any real, perceived or potential violation. By reporting directly to the CEO and having the ear of the board of directors, I have the authority to act immediately and decisively if an issue arises. I inform management, staff and the board of the status of issues. I am an "expert" resource to them in explaining and operationalizing requirements. I believe in continuous education and training of the staff and board of directors.
CH: What are some pointers you would give to others who are in the process of establishing a compliance function in their organization ?
LP: Here are a few necessary components for a good working compliance program:
1. Hire an experienced consultant who knows about compliance and has an established track record of implementing successful programs. It is difficult to establish the function, educate the staff, and complete the auditing, monitoring and reporting all at the same time you are learning yourself what is expected.
2. The compliance officer needs to report at the highest level of the organization, to either the CEO and/or the board of directors.
3. There needs to be adequate financial support for the department, especially in terms of personnel. It is too critical a function to under-staff. The potential fines justify this alone. One person cannot provide the necessary compliance functions.
4. Buy-in from the staff, CEO and board to facilitate the adoption of the code of conduct required for its compliance program.
5. Continuous education and training, including the use of video's that provide examples of issues for staff and providers.
6. Audit, monitor, and report on a regular basis and in a timely manner.
7. Keep the compliance program in front of the staff and board of directors.
8. Keep current; focus on the key areas of vulnerability or liability.
9. Utilize the HCFA and OIG websites on the Internet daily.
10. Form a compliance committee that meets on a regular basis and represents all key areas of the organization, especially those most vulnerable to non-compliance.
CH: Have you found it an asset to be an attorney in your role as compliance officer?
LP: Yes, it has been helpful. There probably are organizations where the "inside" counsel acts also as the compliance officer, but I believe that asking one person to have responsibility for these two major roles is a very difficult challenge. With my legal training and experience, I understand the federal and state regulations and can do the necessary research. However, this has drawbacks, in that part of my time is taken by doing what an external counsel could do in interpreting legal/regulatory documents. Therefore I have less time to establish and maintain the operational processes and procedures for the organization.
CH: What is your focus in the near future?
LP: My focus will be on finalizing our compliance program and making changes in our current program to meet new regulatory requirements. Since MCHP is owned by a hospital system, we can take advantage of the hospital's policies, processes and mechanisms for compliance (e.g., the hospital system already has a "hot line" for reporting), but there are inherent differences between the hospital system's focus and requirements, and those of a managed care organization.
CH: What do you think are the important elements of staff education?
LP: I found that providing information about the Medicare program is the first step so that all staff will have a common understanding of why HCFA believes compliance is so important. Understanding that MediCare is an entitlement, with a trust fund for beneficiaries, provides the essential framework that is an important distinction in managed care organizations that offer both MediCare+Choices programs and other products. Using this approach, I found that the staff were receptive to these educational sessions. They have expressed their appreciation for providing this perspective about why certain steps must be taken to protect the beneficiaries. Another method I use is "train the trainers." By training the managers and directors, they can in turn train their staff and any new staff who are hired.
CH: Do you see areas for compliance that HCFA is not yet monitoring?
LP: No, I believe HCFA has identified and is monitoring all areas that are critical to protecting beneficiaries.
Editor's Note: Other managed care organizations need to take into consideration the statutory and other requirements of other payors as well, e.g., Medicaid, Workers Compensation and commercial insurers, and structure their operations to include these essential requirements.
Comments From Readers?
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