What are the Centers for Medicare & Medicaid Services’ (CMS) requirements for Medicare Advantage Organizations and Part D Plan Sponsors in regard to compliance programs?
Federal law requires Medicare Advantage Organizations (MAO) and Prescription Drug Plan (PDP) Sponsors to have a Compliance Plan to prevent, detect and correct Part C or D noncompliance as well as fraud, waste, and abuse. The plan must include:
What are First Tier, Downstream, Related Entities (FDRs)?
An example of a related entity would be one where a Sponsor is the parent company of its own in-house PBM.
What are my responsibilities as an FDR?
FDRs of Health First Health Plans shall implement policies and procedures that address fraud, waste and abuse, including:
FDRs of Health First Health Plans shall report any potential fraud, waste or abuse related to the MA-PD or PDP program immediately.
As an FDR already enrolled in the Medicare Program, is my organization still required to meet the annual MA-PDP fraud, waste and abuse training requirements?
No, FDRs who have met the fraud, waste, and abuse certification requirements through enrollment into the Medicare program are deemed to have met the training and educational requirements for fraud, waste, and abuse.
What should my organization do if we become aware of or suspect FWA?
Every person has the right and responsibility to report possible fraud, waste or abuse. HFHP encourages you to report issues or concerns of FWA by contacting the applicable plan sponsor(s) with whom you are contracted.
Why should I/my organization review the Health First Code of Ethics & Business Conduct?
FDRs are encouraged to adopt and follow a code of conduct particular to their own organization that reflects a commitment to detecting, preventing and correcting fraud, waste and abuse in the administration or delivery of MA and Part D benefits. As a result, CMS encourages plan sponsors to share their code of conduct with FDRs upon request in order to relay the sponsor’s own commitment and policies and procedures aimed at preventing, detecting and preventing fraud, waste and abuse.
What types of member fraud and abuse can occur in first tier, downstream, and related entities?
Changing, forging or altering any of the following: prescriptions, medical records, referral forms; any type of misrepresentation of eligibility status, including identity theft; resale of medications on the black market, medication stockpiling, or doctor shopping.
Who is responsible for identifying fraud and abuse?
All Health First Health Plans associates and those defined as a first tier, downstream, and related entities are responsible for identifying fraud and abuse.
What are some examples of first tier and downstream entities?
Part C examples include:
Part D examples include:
Last updated: 10/01/2014