National Policy Library Document

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1 Page 1 of 11 National Policy Library Document Policy Name: Medicare Compliance: Compliance Officer and Compliance Committee Policy No.: HR Policy Author: Author Title: Author Department: Sheryl D Pessah Mgr Compliance & Reporting 4002-Medicare Compliance and C Phone: Cost Center: 818/ Functional Owner: Gay Ann Williams Executive Owner: Patricia T Clarey This Policy is applicable to the following: Department(s): Business Unit(s): Products/LOB's: All Departments HN Life, HNAZ, HNCA, HNI, HNNE, HNOR, HNPS Medicare Advantage and Medicare Part D, Dual Eligible Date Created in NPL: Date Last Reviewed : Date Approved: Version: 03/28/ /11/ /11/ Policy Statement: Health Net, Inc. follows the Centers for Medicare & Medicaid Services (CMS) requirements contained in the Medicare Managed Care Manual Chapters, the Prescription Drug Benefit Manual Chapter 9 Part D Program to Control Fraud, Waste and Abuse Guidance as well as Parts 422 and 423 of Title 42 of the Code of Federal Regulations (CFR). Medicare Advantage (MA) organizations and Medicare Prescription Drug Plan (Part D) Sponsors must designate a compliance officer and compliance committee who report directly to and are accountable to the organization s chief executive or other senior management as described in 42 CFR (b)(4)(vi)(b), 42 CFR (b)(4)(vi)(B), Medicare Managed Care Manual Chapter 11 - Medicare Advantage Application Procedures and Contract Requirements 20.1 and Prescription Drug Benefit Manual Chapter 9 Part D Program to Control Fraud, Waste and Abuse through A. Medicare Compliance Officer

2 Page 2 of 11 The Medicare Compliance Officer: 1. Is a full time employee of Health Net, Inc.; 2. Reports to the Corporate Compliance Officer; 3. Is a member of Health Net, Inc., senior management; 4. Is dedicated principally to the Medicare Compliance Program; 5. Does not serve dual roles in both compliance and in operational areas; and 6. Is responsible for implementation of the Compliance Program. The Medicare Compliance Officer defines the compliance program structure, educational requirements, reporting and complaint mechanisms, response and correction procedures, and compliance expectations of all personnel and FDRs As some duties of the Medicare Compliance Officer are delegated, the Medicare Compliance Officer maintains appropriate oversight of those delegated duties. Responsibilities of the Medicare Compliance Officer include, but are not limited to: a) Developing and monitoring the implementation of and compliance with MA and Part D related policies and procedures through the creation and implementation of a monitoring and auditing program; b) Oversight of the Medicare Compliance Committee; c) Reporting, at least on a quarterly basis, or more frequently as necessary, to the Health Net Board of Director or the Health Net Board of Director s Audit Committee, on the status of Health Net s Medicare compliance program, the identification and resolution of potential or actual instances of noncompliance, and Health Net s oversight and audit activities, and will be documented in meeting minutes; d) Creating and coordinating, or appropriately delegating, educational training programs to ensure that Health Net s officers, directors, managers, associates and first-tier, downstream and related entities (FDR) working on the MA and Part D programs are knowledgeable of Health Net s compliance program; its written standards of conduct, policies, and procedures; and applicable statutory, regulatory, and other requirements; e) Ensuring that FDRs, particularly those involved in sales and marketing activities, are aware of and follow the requirements for MA and Part D sales and marketing activities; f) Ensuring the Medicare Compliance Committee and the Health Net Board of Director or the Health Net Board of Director s Audit Committee are briefed on the status of compliance training; g) Developing and implementing methods and programs that encourage Health Net s officers, directors, managers, associates and FDRs to ask compliance questions, and report instances of Medicare program non-compliance and suspected fraud, waste or abuse and other

3 Page 3 of 11 misconduct without fear of retaliation; h) Maintaining the compliance reporting mechanism and closely coordinating with the Internal Audit department and the Special Investigations Unit (SIU), where applicable; i) Responding to reports of potential instances of MA and Part D fraud, waste or abuse, including the coordination of internal investigations and the development of appropriate corrective or disciplinary actions, if necessary. To that end, the Medicare Compliance Officer has the flexibility to design and coordinate internal investigations (e.g., responding to reports of problems or suspected violations) and execute any resulting corrective action (e.g., making necessary improvements to policies and practices and taking appropriate disciplinary action); j) Ensuring processes are in place to check the HHS OIG exclusion list and GSA debarment list with respect to all officers, directors, associates and FDRs monthly; k) Ensuring applicable Health Net business units responsible for oversight of FDRs, have processes in place to ensure that the HHS OIG exclusion list and GSA debarment list have been checked with respect to all FDR officers, directors, employees and contractors monthly; l) Ensuring documentation is maintained for each report of potential non-compliance, fraud, waste, abuse received through any source, including any of the reporting methods (i.e., the Health Net Integrity Line, the Health Net Fraud Hotline, mail, in-person), which describes the initial report of non-compliance, the investigation, the results of the investigation, and all corrective and/or disciplinary action(s) taken as a result of the investigation as well as the respective dates when each of these events and/or actions occurred and the names and contact information for the person(s) who took and documented these actions; m) Overseeing the development, implementation and monitoring of corrective action plans; n) Ensuring potential fraud investigations are referred to the MEDIC (Part D), as appropriate, and facilitating any documentation or procedural requests that the NBI MEDIC makes of Health Net. Ensuring collaboration with other applicable organizations when a fraud, waste or abuse issue is discovered to involve multiple parties; and o) The Medicare Compliance Officer has the authority to: Report directly to the Board of Directors; Interview or delegate the responsibility to interview Health Net s employees and other relevant individuals; Review and retain company contracts and other documents pertinent to the MA and Part D programs; Review or delegate the responsibility to review the submission of data to CMS to ensure that it is accurate and in compliance with CMS reporting requirements; Independently seek advice from legal counsel;

4 Page 4 of 11 Report misconduct to CMS, its designee and/or law enforcement; and Conduct and direct internal audits and investigations of any FDR. Health Net Medicare Compliance Department The Health Net Medicare Compliance department reports to the Medicare Compliance Officer and assists in promoting ethical conduct, instilling a company-wide commitment to Medicare Compliance, and exercising diligence in detecting and preventing misconduct. Responsibilities of the Medicare Compliance department include, but are not limited to: Maintaining the Health Net Medicare Compliance Plan; Interacting with Health Net s operational business units responsible for administration of the MA and Part D programs and being involved in and aware of their daily business activities; Interpreting Federal policy and providing guidance to the Health Net business units responsible for administering the MA and Part D programs; Analyzing CMS memos and new or revised guidance and ensuring distribution of such memos to the Health Net business units responsible for administering the MA and Part D programs; Tracking to ensure appropriate actions are taken by the applicable business unit(s) in response to CMS memos and new or revised guidance; Conducting routine monitoring and focused reviews of high-risk areas; Maintaining the Medicare Compliance intranet site on Health Net Connect as a source of education and information to all associates; Developing training products to educate associates about the Compliance Program and associates responsibility for administering the MA and Part D plans in a compliant and ethical manner; Reporting significant and material compliance issues to the Medicare Compliance Officer; and Developing, implementing and maintaining Medicare Compliance policies and procedures. B. Compliance Committee The Health Net Medicare Compliance Committee is charged with assisting the Board of Directors and senior management in overseeing the Company s compliance program with respect to: (i) compliance with the laws and regulations applicable to the MA and Part D programs; and (ii) compliance with the Company s Code of Business Conduct and Ethics and related policies, as applicable to the MA and Part D lines of business, by employees, officers, directors and other agents and associates of the Company.

5 Page 5 of 11 The Medicare Compliance Committee is composed of the Medicare Compliance Officer, Chief Medicare Officer, Ethics Officer, Privacy Officer, and Legal Counsel. The Committee also includes representatives from, but not limited to, the following departments: Appeals and Grievances, Claims Operations, Customer Contact Center, Finance, Health Care Services, Health Net Pharmaceutical Services, Information Technology, Marketing, Medicare Operations, Membership Accounting, Organizational Effectiveness, Provider Network Management, Quality Improvement, Sales and the Special Investigations Unit. The Medicare Compliance Committee is chaired by the Medicare Compliance Officer or a designee of the Medicare Compliance Officer. The Medicare Compliance Committee meets at least quarterly, or more frequently as the Committee members may determine. The Medicare Compliance Officer reports to the Board of Director s Audit Committee regularly, but no less than once per quarter, regarding the Medicare Compliance Committee s activities and actions and any matter of material concern to Health Net. Responsibilities of the Medicare Compliance Committee include, but are not limited to: a) Reviewing and approving the Medicare Compliance Plan including the policies and procedures that support the seven elements of the Medicare Compliance Plan at least annually, or more frequently depending upon business needs or changes to the MA and/or Part D program requirements; b) Developing strategies to promote compliance and the detection of any potential violations; c) Ensuring that compliance training and education are effective and appropriately completed; d) Authorizing, reviewing, and approving a Medicare compliance risk assessment at least annually, or more frequently as needed; e) Reviewing and making recommendations regarding Internal Audit s annual audit plan to the Board of Director s Audit Committee; f) Assisting with creation and implementation of the Medicare Advantage and Part D Monitoring Work plan; g) Assisting in the creation of effective corrective and preventive action plans and ensures that they are implemented and monitored; h) Overseeing a system of internal controls designed to ensure compliance with Medicare regulations in daily operations; i) Supporting the Medicare Compliance Officer s needs for sufficient staff and resources to carry out her duties; j) Ensuring Health Net has appropriate, up-to-date Medicare compliance policies and procedures;

6 Page 6 of 11 k) Ensuring Health Net has a system for employees and FDRs to ask compliance questions, and report potential instances of Medicare program non-compliance and fraud, waste or abuse confidentially or anonymously (if desired) without fear of retaliation; l) Reviewing and addressing reports of monitoring and auditing of areas in which Health Net is at risk for program non-compliance or fraud, waste or abuse and ensures corrective action plans are implemented and monitored for effectiveness; and m) Providing regular and ad-hoc reports on the status of compliance with recommendations to the Board of Director s Audit Committee. C. Governing Body The Health Net, Inc., Board of Directors is ultimately accountable for compliance within Health Net, and is obligated to oversee Health Net s Medicare Compliance Program. The Board of Directors delegates Medicare Compliance Program oversight to the Audit Committee, but the Board of Directors as a whole remains accountable for ensuring the effectiveness of the Medicare Compliance Program. The Board of Directors for each of the Health Net subsidiaries that hold contracts with CMS are also obligated to oversee the Medicare Compliance program for the MA and Part D contracts under their purview. When compliance issues are presented to Health Net, Inc., or subsidiary Boards of Directors or the Audit Committee, further inquires are made and appropriate action is taken to address and satisfactorily resolve those issues. The Medicare Compliance Officer has unfettered access to the Health Net, Inc. and subsidiary Boards of Directors and the Audit Committee. As required by Federal regulations, the Health Net, Inc. and subsidiary Boards of Directors are knowledgeable on the content and operations of the Medicare Compliance Program. The Health Net, Inc. and subsidiary Boards of Directors and the Audit Committee receive compliance training and education as to the structure and operation of the Medicare Compliance and FWA Program to enable them to be engaged, to ask questions and to exercise independent judgment over the compliance issues with which it is presented. The Health Net, Inc. and subsidiary Boards of Directors and the Audit Committee are knowledgeable about compliance risks and strategies, understand the measurements of outcome, and are able to gauge effectiveness of the Medicare Compliance Program. Responsibilities of the Health Net, Inc. Board of Directors, directly or through delegation to the Audit Committee, include, but are not limited to: a) Reviewing and approving the Health Net Code of Business Conduct and Ethics; b) Endorsing the Medicare Compliance Plan and the Medicare Compliance Program policies and procedures; c) Reviewing and approving internal audit work plans;

7 Page 7 of 11 d) Reviewing outcomes from internal audits; e) Approving corrective action plans resulting from internal audits; f) Regularly scheduling updates from the Medicare Compliance Officer; and g) Overseeing the senior management team s commitment to ethics and the Medicare Compliance Program. Responsibilities of the subsidiary Boards of Directors include, but are not limited to: a) Reviewing and approving the Health Net Code of Business Conduct and Ethics; b) Reviewing and approving the Medicare Compliance Plan and the Medicare Compliance Program policies and procedures; c) Approving Medicare compliance and FWA training; d) Reviewing, approving and reporting to the Audit Committee on the Medicare Compliance Program structure and operations; e) Reviewing and approving the Medicare Advantage and Part D risk assessment; f) Reviewing and approving external audit work plans and internal monitoring work plans; g) Reviewing outcomes from external audits and internal monitoring activities; h) Approving corrective action plans resulting from external audits and internal monitoring activities; i) Regularly scheduling updates from the Medicare Compliance Officer; j) Reviewing and approving the Medicare Compliance Officer s performance goals; and k) Reviewing and evaluating and reporting to the Audit Committee on the performance of the Medicare Compliance Program on at least an annual basis. The Health Net, Inc. and subsidiary Boards of Directors Boards of Directors and Audit Committee meeting minutes document the level of their engagement in oversight of the Medicare Compliance Program. D. Senior Management The CEO and other senior management are engaged in the Medicare Compliance Program. The CEO and senior management ensure the Medicare Compliance Officer is integrated into the organization and has the resources necessary to operate a robust and effective Medicare Compliance Program. The CEO receives regular reporting from the Medicare Compliance Officer and/or Corporate Compliance Officer of risk areas facing the organization, the strategies being implemented to address them and the results of those strategies. The CEO receives regular reporting of all compliance enforcement, from Notices of Noncompliance to

8 Page 8 of 11 formal enforcement action. Policy Purpose: A. To ensure the designation of a Medicare Compliance Officer responsible for developing, operating and monitoring the MA and Part D compliance program. B. To ensure a Medicare compliance committee is in place. Scope/Limitations: This policy and procedure applies to all associates employed, contracted, or otherwise representing Health Net, Inc. and its subsidiaries and those of any FDRs, who participate in the administration of Health Net s Medicare Advantage and/or Part D programs. Related Policies: Associate Policy: Designation of Chief Compliance Officers and Obligation of Associates to Support the Compliance Mission (MP ) Medicare Compliance: Prompt Response to Detected Offenses (EJ ) Medicare Compliance: Effective Lines of Communication ( HR ) Medicare Compliance: Enforcement of Standards ( HR ) Medicare Compliance: Medicare Compliance Plan (HR ) Medicare Compliance: Monitoring and Auditing (HR ) Medicare Compliance: Training and Education ( HR ) Medicare Compliance: Written Policies and Procedures and Standards of Conduct (PS ) References: Title 42 Code of Federal Regulations (CFR) 42 CFR (b)(4)(vi)(B) 42 CFR (b)(4)(vi)(B) CMS Medicare Managed Care Manual Chapter 11 - Medicare Advantage Application Procedures and Contract Requirements 20.1 Prescription Drug Benefit Manual Chapter 9 Part D Program to Control Fraud, Waste and Abuse Health Net Medicare Compliance Plan 2012 Definitions: Audit Committee The Board of Directors of Health Net has established an Audit Committee, which is directly responsible for, among other things, the appointment, retention, compensation and oversight of the Company s Internal Audit Officer who works directly for the Committee. This oversight extends to the internal audit function taken as a whole, the internal audit plan, audit results, and management actions to strengthen control procedures, processes and standards. Centers for Medicare & Medicaid Services (CMS) The Federal agency within the Department of Health and Human Services (DHHS) that administers the Medicare program. Compliance Program A program that promotes regulatory compliance and legal conduct to provide guidance to

9 Page 9 of 11 prevent, detect and help resolve non-compliant and illegal conduct, including fraud, waste or abuse. The Department of Health and Human Services (DHHS) The Federal department that oversees CMS, and administers many of the "social" programs at the Federal level dealing with the health and welfare of the citizens of the United States. Downstream Entity Any party that enters into a written arrangement, acceptable to CMS, below the level of the arrangement between Health Net and a first tier entity. These written arrangements continue down to the level of ultimate provider of health, pharmacy and/or administrative services to members. First Tier Entity Any party that enters into a written arrangement acceptable to CMS with Health Net to provide administrative services or health care or pharmacy services for a Medicare eligible individual under a MA or Part D Plan. General Services Administration's (GSA) Excluded Parties List System (EPLS) an electronic, web-based system that identifies parties suspended, debarred, proposed for debarment or otherwise excluded from receiving Federal contracts, certain subcontracts, and certain types of Federal financial and non-financial assistance and benefits. Health Net The term Health Net for the purpose of this policy and procedure is applicable for Health Net, Inc and its various subsidiaries. The term will also include delegates, such as providers, third party administrators, or other entities who have been delegated responsibility for activities defined in this policy. Health Net Inc. is the parent company. Medicare The federal health insurance program for people 65 years of age or older, certain younger people with disabilities, and people with End Stage Renal Disease (ESRD). Medicare Advantage (MA) A program offered to Medicare beneficiaries by private companies that work in conjunction with Medicare and cover the full range of hospital and doctor services covered under Original Medicare. Also referred to as Medicare Part C. Medicare Advantage (MA) Organization An organization that is a public or private entity organized and licensed by a State as a riskbearing entity that is certified by CMS as meeting the requirements to offer an MA plan.

10 Page 10 of 11 Medicare Compliance Officer A Health Net associate responsible, either directly or through delegation, for overseeing the MA and Part D compliance program and operations and for developing, operating, and monitoring the fraud, waste and abuse program. Medicare Compliance Plan A written document that defines the specific manner in which the enterprise-wide Compliance Program is implemented across the organization for the MA and Part D programs. Medicare Drug Integrity Contractor (MEDIC) An organization that the CMS has contracted with to perform specific program integrity functions for Part D under the Medicare Integrity Program. The MEDIC is CMS designee to manage CMS audit, oversight, and anti-fraud and abuse efforts in the Part D benefit. Office of the Inspector General (OIG) The OIG conducts and supervises audits and investigations relating to programs and operations of the DHHS. Part D Also referred to as Medicare prescription drug coverage, is a voluntary program offered to Medicare beneficiaries by private companies to subsidize the cost of prescription drugs. Part D Plan Sponsor An entity that has a contract with the Federal Government to offer Medicare prescription drug coverage. Related Entities Any entity that is related to Health Net by common ownership or control and performs some of Health Net s management functions under contract or delegation, and furnishes services to Medicare enrollees under an oral or written agreement. Subsidiaries Legal entities that report to, or are owned by, a parent company. Disclaimer: Deviations: Approvers: Policy Author: Sheryl D Pessah - Approved on 05/05/2012

11 Page 11 of 11 Functional Owner: Gay Ann Williams - Approved on 05/06/2012 Executive Owner: Patricia T Clarey - Approved on 05/11/2012 Active Policy Disclaimer Please note: This copy of this policy is current as of the date printed. To be assured that you are viewing the currently active policy, please refer to Health Net's National Policy Library site. Date Printed: 0 10:32:21 AM