Page 1 of 5 National Policy Library Document Policy Name: Medicare Compliance: Compliance Officer and Compliance Committee Policy No.: HR328-133757 Policy Author: Author Title: Author Department: Sheryl D Pessah Mgr Compliance & Reporting 4002-Medicare Compliance and C Phone: Cost Center: 818/676-8767 11709 Functional Owner: Nancy A Starts Executive Owner: Gay Ann Williams Blank This Policy is applicable to the following: Department(s): Business Unit(s): Regions: Products/LOB's: All Departments HN Life, HNAZ, HNCA, HNI, HNNE, HNOR, HNPS N/A Medicare Advantage, Medicare Part D Date Created: Effective Date: Version: 03/28/2007 01/01/2007 2 Blank Policy Statement: Health Net 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). CMS requires Medicare Advantage (MA) organizations and Part D Sponsors have a compliance officer and compliance committee in place as described in 42 CFR 422.503 (b)(4)(vi), Chapter 11 Section 20.1 of the Medicare Managed Care Manual as well as in the CMS Prescription Drug Benefit Manual Chapter 9 Part D Program to Control Fraud, Waste and Abuse (Sections 50.2.2 through 50.2.2.2). A. Medicare Compliance Officer The Medicare Compliance Officer is responsible for ensuring compliance with the MA and Part D program requirements. 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) Participating with the Medicare Oversight Committee, which functions as the Medicare compliance committee.
Page 2 of 5 c) Reporting, at least on a quarterly basis, or more frequently as necessary, to Health Net s Chief Compliance Officer and compliance committee, on the status of Health Net s compliance program, the identification and resolution of potential or actual instances of noncompliance, and Health Net s oversight and audit activities. d) Ensuring consistent and timely reporting of relevant Medicare Compliance issues to management, to the Chief Executive Officer and President of Health Net, Inc., and to the Audit Committee of the Health Net Board of e) 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 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 the applicable statutory, regulatory, and other requirements. f) Ensuring that first tier, downstream, and related entities, particularly those involved in sales and marketing activities, are aware of and follow the requirements for MA and Part D sales and marketing activities. g) Briefing the compliance committees and governing body on the status of compliance training. h) Developing, implementing and maintaining a system for Health Net s officers, directors, managers, associates and first-tier, downstream and related entities to ask compliance questions, and report suspected instances of non-compliance or potential instances of fraud, waste or abuse confidentially or anonymously without fear of retaliation. i) Maintaining the compliance reporting mechanism and closely coordinating with the Special Investigations Unit (SIU), where applicable. j) 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). k) Coordinating personnel issues with Health Net s Organization Effectiveness (OE) Department to ensure that the DHHS OIG and GSA exclusion lists have been checked to ensure no officers, directors, managers, associates or first-tier, downstream and related entities are included on such lists. l) Reporting any potential fraud or misconduct related to the MA or Part D program to CMS, its designee and/or law enforcement. m) Ensuring documentation is maintained for each report of potential fraud, waste or abuse received through any of the reporting methods (i.e., 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. n) Overseeing the development, implementation and monitoring of corrective action plans. o) Ensuring potential fraud investigations are referred to the MEDIC (Part D), as appropriate, and facilitating any documentation or procedural requests that the MEDIC make of the Part D plan. Similarly, the Medicare Compliance Officer will collaborate with other other applicable organizations when a fraud, waste or abuse issue is discovered to involve multiple parties. p) The Medicare Compliance: Officer has the authority to: Report directly to the Chief Compliance Officer, who has the authority to report directly to the Board of 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. Seek advice from legal counsel. Report misconduct to CMS, its designee and/or law enforcement. Conduct and direct internal audits and investigations of any first tier, downstream, or related entities. 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. Interpreting Federal policy and providing guidance to the Health Net business units responsible for administering the MA and Part D program.
Page 3 of 5 Analyzing CMS memos and new or revised guidance and distributing such memos to the Health Net business units responsible for administering the MA and Part D program. 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 audits 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. Developing, implementing and maintaining Medicare Compliance policies and procedures. B. Compliance Committee The Health Net Medicare Oversight Committee is responsible for setting the Medicare Program s direction; resolving compliance actions and other critical issues requiring executive decisions such as resources, budgets, interdependencies, resource deployment; monitoring the status and progress of critical projects; and addressing organizational obstacles for the subcommittees. The Medicare Oversight Committee is functionally the Medicare Compliance committee and is responsible to the Chief Government Programs Officer. Responsibilities of the Medicare Oversight Committee include, but are not limited to: a) Meeting not less than semi-monthly or with greater frequency as business conditions require. b) Developing strategies to promote compliance and the detection of any potential violations. c) Ensuring that training and education are appropriately completed. d) Assisting in the creation of effective corrective action plans and ensuring that they are implemented and monitored. e) Ensuring the business units that administer the Health Net MA and Part D products have appropriate, up-todate compliance policies and procedures. f) Reviewing and addressing reports of monitoring and auditing of areas in which Health Net is at risk of fraud, waste or abuse and ensuring that corrective action plans are implemented and monitored. Providing regular and ad hoc reports on the status of compliance with recommendations to Health Net s Board of 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. Related Policies: Associate Policy: Designation of Chief Compliance Officers and Obligation of Associates to Support the Compliance Mission (MP927-9829) Medicare Compliance: Comprehensive Fraud, Waste and Abuse Plan (HR328-151041) Medicare Compliance: Corrective Action Procedures (EJ44-83932) Medicare Compliance: Effective Lines of Communication ( HR329-81145) Medicare Compliance: Enforcement of Standards ( HR329-83126) Medicare Compliance: Medicare Compliance Plan (HR328-1543) Medicare Compliance: Monitoring and Auditing (HR810-84520) Medicare Compliance: Training and Education ( HR329-81145) Medicare Compliance: Written Policies and Procedures and Standards of Conduct (PS729-65015) References: Title 42 Code of Federal Regulations (CFR) 42 CFR 422.503(b)(4)(vi), 42 CFR 423.504(b)(4)(vi) 42 CFR 423.504(b)(4)(vi)(A-G)
Page 4 of 5 42 CFR 423.504(b)(4)(i and iii) CMS Medicare Managed Care Manual Chapter 11 - Medicare Advantage Application Procedures and Contract Requirements Section 20.1 Chapter 9 Part D Program to Control Fraud, Waste and Abuse MA-PD Sponsor Part D Audit Guide V 3.0 CP02 - Designation of Compliance Officer and Committee CP09 - Executive Manager and Policy-Making Body PDP Sponsor Part D Audit Guide V 3.0 CP02 - Designation of Compliance Officer and Committee CP09 Executive Manager and Policy Making Body Health Net Medicare Compliance Plan 2010 Definitions: Centers for Medicare and Medicaid Services (CMS) The federal agency within the Department of Health and Human Services that administers the Medicare program. Chief Compliance Officer An associate responsible for the overall compliance program for Health Net, Inc. Compliance Program A program that promotes regulatory compliance and legal conduct to provide guidance to prevent, detect and help resolve non-compliant and illegal conduct, including fraud, waste or abuse. The Department (DHHS) of Health and Human Services 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. 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. Health Net 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 Medicare Advantage (MA) and Part D lines of business. 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) Also referred to as Medicare Part C, is a program offered to Medicare beneficiaries by private companies which work in conjunction with Medicare and cover the full range of hospital and doctor services covered in Original Medicare. Medicare Advantage (MA) Organization
Page 5 of 5 A public or private entity organized and licensed by a state as a risk-bearing entity (with the exception of provider sponsored organization receiving waivers) that is certified by CMS as meeting the Medicare Advantage contract requirements. Medicare Advantage Prescription Drug Plan (MA-PD) An MA plan that provides qualified prescription drug coverage. 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 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 Refers to an organization offering a PDP, MA or MA-PD plan, a PACE organization offering a PACE plan including qualified prescription drug coverage, and a cost plan offering qualified prescription drug coverage. This includes employer- and union-sponsored plans. Prescription Drug Plan (PDP) Prescription drug coverage that is offered under a policy, contract, or plan that has been approved as specified in 42 C.F.R. 423.272 to offer qualified 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, furnishes services to Medicare enrollees under an oral or written agreement. Subsidiaries Legal entities that report to or are owned by a parent company. Approvers: Functional Owner: Nancy A Starts - Approved on 0 Executive Owner: Gay Ann Williams - Approved on 0 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 09:28:22 AM