A Vendor’s Oversight is Never Done

There are many industry voices adding their perspectives about the new administration and changes to come. However,  the Compliance Officers I know do not have the luxury of stopping and truly considering the potential impact as they are managing the continuous pressures of their daily directives. Today I address a group of very industrious Compliance professionals not often addressed, and those are the staff responsible for Compliance Programs at first tier, downstream and related entities, or “FDRs.” Under Medicare regulations, plan sponsors may enter into contracts with FDRs to provide administrative or healthcare service functions on their behalf.

Building the relationship between the sponsor and FDR, just like any marriage, is very important for the partnership to be fruitful.  In order to ensure a successful relationship, it is important for delegated entity Compliance staff to have a firm grasp on what the health plans face and to build a strong foundation to support those needs. So often we talk about the Centers for Medicare & Medicaid Services (CMS) Program Audit, so delegates supporting those services should already be in lock-step with their plan sponsor partners. However, that review methodology is a small subset of Medicare Advantage Prescription Drug (MA-PD) plan requirements.

One question we are often asked is: How are sponsors looking at FDRs? FDRs can be collaborative, cost-saving partners that bring significant value to an organization. However, we have also heard dozens of anecdotes of buyer’s remorse, some of which are in credit to the following:

• The sponsor’s Compliance Officer was informed months later that a business area contracted with an FDR.
• A key business owner did not ask the right probing questions during the sales presentation.
• No pre-delegation site visit was conducted to validate processes, or the right attendees were not included in the visit.
• The procurement process was not followed, and appropriate monetary penalties were not imposed for failure to perform.

As a Compliance professional at an FDR, what could you be doing to improve current relationships?

As a vendor, the sponsor is entrusting you to perform an activity on their behalf. If you are looking to partner for success, we recommend you take a look at current processes and evaluate if you are making the right impression from the beginning. You can be a proactive partner in supporting your sponsor, or you can be reactive, thereby weakening your product/service and increasing your and your sponsor’s oversight. Whether you are thinking of contracting with a plan sponsor for the first time or you are already in the thick of it, ask yourself these questions:

• Do you “speak” CMS? Can you and your business leaders hold a fruitful conversation about current industry issues, recent CMS releases, and agency focus?
• What is the state of your Compliance Program? Is it in good shape? Have you tested mechanisms and safeguards lately? Do you have an independent audit of your Compliance Program Effectiveness on an annual basis?
• Are your record-keeping tools equipped to handle the many sponsor requests received, such as attestation data, training information, and exclusion list checks documentation?
• How does your organization demonstrate knowledge of CMS requirements, and, more critically, how do you demonstrate meeting or exceeding those requirements?
• Are you restrictive in how often you allow plan sponsors to audit each year?

To be successful in fulfilling the daily rituals of a delegated entity Compliance Officer, it requires a very particular set of skills (thanks, Liam Neeson), as they are often communicating with multiple sponsor contacts at a time. They are not off the hook just because they are not CMS-facing. And as history has shown, when a potentially large-scale, pervasive problem occurs, CMS can and will contact a vendor directly. Think about the above questions and evaluate your current resources to ensure CMS never feels the need to do so.

Resources

Join Nilsa Lennig Rudisill, Gorman Health Group’s Vice President of Sales & Marketing Services, and colleague Diane Hollie, Senior Director of Sales & Marketing Services, on January 31, 2017, from 1:00 – 2:00 PM ET, as they outline how to analyze your market and the necessary steps to develop a successful growth strategy. Register Now >>

The Gorman Health Group 2017 Forum Conference Brochure and Preliminary Agenda Is Now Available! Download it now to see the topics we have in store for you at this year’s event. Register now for the Gorman Health Group 2017 Forum, April 26-27, 2017, at the JW Marriott New Orleans.

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