Three Reasons Why Compliance Program Effectiveness Needs Evaluation Now

Happy New Year! It’s a time when your organization may be evaluating whether or not to submit a new application or a service area expansion. This may be when annual training kicks off once again. You may be reviewing attestations to determine which vendors need to provide you with new documentation.  And don’t forget to ensure the Claims Department has updated systems to reflect the current prompt payment interest rate.

For those of you in Compliance, all of the above might be on your radar, in addition to the day-to-day.  If you have not tested or evaluated the effectiveness of your Compliance Program lately, now is the time to do it.  Here are three reasons why:

• Major pharmacies cited for repeat violations of privacy violations.  Pharmacies arguably make up the largest group of downstream entities for Sponsors. Those contracted pharmacies have been subject to hundreds of Sponsor-specific general compliance and fraud, waste, and abuse (FWA) training in the past, as well as the trainings created by the pharmacy benefit managers (PBMs). (Starting this year, Sponsors must require first tier, downstream, and related entities (FDRs) to take the Centers for Medicare & Medicaid Services (CMS) training and accept the certificate of completion.)  As you can see from the article, health information privacy complaints are on the rise.  Sponsors should not simply check a box confirming a PBM attested that all pharmacies took training — this should be tested and sampled as part of auditing and monitoring. Furthermore, if and when a potential pattern of issues is identified, a deeper investigatory dive and escalation of corrective actions should be pursued.
• The new season of audits is approaching. At the end of October, CMS released their revised 2015/2016 protocols.  Recently, CMS released a memo stating they continue to receive inquiries and concerns not only from Sponsors but also from FDRs regarding the difficulties encountered with adopting the new training requirement. While they have not delayed or retracted the requirement, CMS has decided to suspend their review of the FDR training certification aspect in their program audit protocol. Having this suspended in the audit protocol is by no means a free pass — it only highlights CMS’ acknowledgement that implementing their guidance has been a challenge. Plan Sponsors still have the responsibility of ensuring those contracted to service their members understand their obligations, because it doesn’t only take an audit for CMS to take action over FDR issues — it could be one call to a Regional Office or an escalated number of Complaints Tracking Module (CTM) cases that places your organization on CMS’ radar.
• You may already know where your weaknesses are — evaluate the program and get those weaknesses and corrections documented.  CMS has placed the onus on Sponsors to hire independent auditors to validate program audit corrections.  If you are targeted this year, why not be as prepared as you possibly can be? Some things you cannot change — but it is of utmost importance you make time to conduct a Compliance Program Effectiveness (CPE) audit.

CMS has never said they are looking for a perfect audit.  They expect to find things; therefore, you should also expect to find things in your own CPE audit.  By virtue of regularly testing and evaluating the effectiveness, you make strides to strengthen your organization as a whole.

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In addition to monitoring your operations and auditing the organization’s performance, CMS also audits the compliance function.  In recent years many CMS sanctions have been issued as the result of a Compliance Program that was determined to be ineffective. Learn how GHG can help >>

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