Medicare Compliance

1

• Medicare Compliance
• Organizations contracted with the Centers for
  Medicare and Medicaid Services are Required to
  Create an effective Compliance Program
• The Compliance Program must include measure that
  prevent, detect and correct
• Non-compliance with State and Federal health
  program requirements
• Fraud, waste and abuse

2

• Medicare Compliance
• KelseyCare Advantages Compliance Department is
  led by the Compliance Officer that works to
  prevent, detect and correct non-compliance with
  Medicare rules.

3

• Medicare Compliance
• Our Compliance Program describes in detail
• How we operate our Compliance Department.
• How we meet each of the seven required elements
  of a compliance program prescribed by the Office
  of Inspector General.
• How we will monitor the effectiveness of our
  Compliance Program.

4

• Compliance Department
• Mission Statement
• The Compliance Department will
• Provide consistent, timely and proactive
  compliance services.
• Be vigilant and transparent in supporting our
  partnerships.
• Strive to maintain the integrity of the Plans
  operations.

5

• Medicare 2012
• Compliance Actions and Risk
• CMS has a more focused oversight methodology
  based on data.
• Data validation for reporting Part C and D data.
• Monitoring and oversight.

6

• Sanctions
• We may receive sanctions for not complying with
  CMS requirements.
• Sanctions may include
• Notice of Noncompliance
• Warning Letters
• Corrective Action Plans
• Suspension of Enrollment and Marketing
• Fines
• Contract Suspension

7

• Examples of Non-Compliance
• Anytime Kelseycare Advantage does not perform on
  its promises made to Medicare beneficiaries in
  the Evidence of Coverage, or anytime an agent
  markets a plan to a member in a way that violates
  the marketing rules, KCA is not complying with
  Medicare rules.
• Many times, noncompliance is unintentional - it
  may be the result of a computer issue that needs
  to be fixed. Intentional or not, the Compliance
  Department is responsible for identifying and
  correcting the noncompliance. While the
  department, as well as KCA as a whole, tries hard
  to prevent noncompliance, our goal is to identify
  and address problems as soon as possible.

8

• Your Responsibility
• As a plan employee or delegate you are required
  to report all suspected issues of FWA and
  non-compliance as outlined in the Code of Conduct
  to the Compliance Department .
• The plan will not reveal your identity unless
  your are party to the FWA or non-compliance and
  or it is totally necessary to do so as part of
  the investigation.

9

• Compliance Resources
• Fraud Hotline
• Report Fraud, Waste, Abuse and Other Compliance
  Violations to
• 713-442-9595 or medicarefraudhotline_at_kelseycaread
  vantage.com