Keeping a Pulse on potential CMS Risks

By Shelley Segal
CMS requires Medicare Advantage Plans, Medicare-Medicaid Plans, and stand-alone Prescription Drug Plan sponsors to implement an effective compliance program to foster a culture of transparency and compliance. Organizations can help prevent risks and non-compliant activities by educating or providing ongoing guidance to employees who support the Medicare line of business by taking the following measures:

  • Define Non-Compliance
    • Noncompliance is conduct that does not conform to the law, Federal health care program requirements, or to an organization’s ethical and business policies
  • Provide guidance on how to prevent, detect, and correct non-compliance:
    • How to handle compliance questions and concerns;
    • How to identify and report potential and substantiated compliance issues;
    • Ensure compliance issues are corrected and appropriate steps are taken to ensure that they do not re-occur.

An industry best practice is to implement a “Potential Compliance Risk Escalation Process,” which can be useful in reporting and tracking potential Medicare compliance issues, regardless of size or impact. Based on the severity of the issue, the issue is promptly escalated to Medicare Compliance and additional stakeholders, such as senior management and leadership teams.

A thorough investigation, root cause analysis, and appropriate corrective actions should be required by the business area.
Lastly, an organization should continuously demonstrate its commitment to legal and ethical conduct. Workforce members should be reminded continuously that they have a responsibility to report both potential and substantiated compliance issues, and that one shall not face retaliation for reporting. Ensure staff are aware of the option of reporting an issue anonymously, and, if any person engages in retaliation, disciplinary action will take place in accordance to your organization’s non-retaliation policy.
Don’t have a process and need help to keep a pulse on potential risks, especially if a CMS Program Audit is in the forecast?  Contact Medicare Compliance Solutions for assistance in developing an internal escalation process for reporting potential risks.
Compliance is EVERYONE’S responsibility!

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