Is This Condition For Real? CMS Compliance Program Audit Findings Tied to FDR Oversight

There is no shortage of concern when it comes to awareness of first tier, downstream and related entity (FDR) oversight. In fact, during a recent webinar hosted by John Gorman, Executive Chairman at GHG, on “The Top 10 Things Killing Your Organization”, we shared survey results showing the number one Compliance Program risk, from a health plan’s perspective, is FDR oversight.

A number of compliance specialists recently asked us about a CMS condition that either they have received as part of a program audit, or have heard about others receiving. Specifically, the condition pertains to the failure to provide evidence that a Plan Sponsor’s FDR employees received fraud, waste and abuse (FWA) training within 90 days of hiring or contracting and annually thereafter.

The citations previously referenced in this condition include 42 CFR § 422.503(b)(4)(vi)(C) and 42 CFR § 423.504(b)(4)(vi)(C), as well as the Compliance Program Guidelines, Section 50.3.2 (dated 1/1/2013). In summation, the CFR required MA organizations to establish and implement effective training and education, and the sub-regulatory guidance supported the regulation, also stating that:

• Sponsors may choose to tailor the training;
• Sponsors must provide the FWA training directly or provide FWA training materials to their FDRs; and
• Sponsors may have FDRs access CMS’ standardized FWA training and education module

It is important that all Plan Sponsors are aware of the regulation change made effective as part of the Final Rule released May 24, 2014. In summary, 42 CFR § 422.503(b)(4)(vi)(C)(3) now states as follows: “A MA organization must require all of its first tier, downstream, and related entities to take the CMS training and accept the certificate of completion of the CMS training as satisfaction of this requirement. MA organizations are prohibited from developing and implementing their own training or providing supplemental training materials to fulfill this requirement.”  The corresponding update was also made to Part 423 for Part D.

For some organizations, this is business as usual. However, for those organizations that were providing their own training and delivering to their FDRs, this is no longer permissible as of 1/1/2016.Therefore, it is recommended that organizations implement this new requirement now. Make sure that any policies and procedures documenting this process are updated, especially since the Compliance Program Guidelines require update. For reference, the Medicare Learning Network is here and the link to the web based training courses is near the end of the page.

Have Questions? Contact me directly at rpennypacker@ghgadvisors.com

Resources

Gorman Health Group’s solution, the Online Monitoring Tool (OMT™), streamlines vital compliance activities, such as the implementation of new requirements and corrective actions. Read our recent White paper to learn more.

The external audit program process is fully customizable according to your organization’s needs and can encompass both internal and delegated functions, CMS audit protocol, as well as the inclusion of other audit elements that are not part of the current protocol (e.g. enrollment, credentialing, member services).  Don’t let CMS be the first to tell you where your deficiencies are. Visit our website to learn more >>

Gorman Health Group’s Summary and Analysis of the 2016 Draft Call Letter and the Medicare Advantage (MA) Advance Notice is now available. Download it today >>