Situation:
On February 8, 2006 the Centers for Medicare and Medicaid Services (CMS) issued updated guidance clarifying the responsibilities of Medicare Part D plan Sponsors specific to detecting and preventing fraud, waste and abuse. The new draft guidance appears in the Prescription Drug Benefit Manual in Chapter 9 – Part D Program to Control Fraud, Waste and Abuse.
Chapter 9 provides an extensive discussion of the methods Part D Sponsors can use to meet statutory and regulatory requirements so that they have a plan in place for detecting, correcting, and preventing fraud, waste and abuse as an element of their overall compliance programs. This chapter also offers implementation recommendations, including a discussion of basic program elements, training and education, and recommended procedures for self-reporting fraud, waste, and abuse. It outlines CMS’ guidelines for operational issues such as handling complaints, and coordinating with CMS and law enforcement.
Chapter 9, Section 50.2.4.2 – Establishing a Mechanism to Field Compliance Questions and Concerns from Employees and Subcontractors recommends that one of the most common methods of fielding and compiling compliance questions/concerns is through the establishment of a hotline. As stated in the chapter, the sponsor organization may employ an independent contractor to operate the hotline and should ensure that it is easily available and accessible for employees and subcontractors. The chapter emphasizes that the communication of the reporting mechanism’s existence should be very clear for employees and subcontractors.
Section 50.2.4.2 states that the effectiveness of hotlines relies on confidentiality, accessibility, intake and follow-up and also includes a recommendation that Sponsors should implement prompt follow-up investigation procedures in response to hotline inquiries and other complaints. Lastly, the section indicates that Sponsors should establish a process to document and track reported concerns and issues, including the status of related investigations and corrective actions.
Solution:
Global Compliance™ provides integrated, turnkey offerings for compliance with Chapter 9 of the Medicare Part D program:
- Hotline and web reporting vehicles for 24/7, confidential and anonymous reporting of fraud, waste, and abuse. Employees’, subcontractors’, and agents’ reports are submitted to Global Compliance, a fully independent, third party provider offering interpretation in up to 150 languages
- Online information management system seamlessly integrates both hotline and web reports and enables real-time access to a centralized data repository to efficiently manage allegation reports
- Case Management service facilitates case assignment, investigative notes, communication between case managers and investigators, attachment of supporting documentation, and designation of case status to properly manage investigations
- Report Writer service enables query of all data in the repository for charting, trending, analysis and upward reporting to executive management and the Board
- Web-based training programs educate and certify on statutory and regulatory requirements and the process of reporting fraud, waste and abuse . Built-in quizzes validate review and comprehension of information and online management reports provide details on employee participation and scoring. An optional interactive voice response (IVR) capability can provide testing and certification for non-enabled web personnel.
Outcome:
A Medicare Part D compliance program inclusive of information intake, information management and awareness and education satisfies the requirements of Chapter 9 and can be implemented separately from other ethics and compliance programs or integrated within. Plan Sponsors will be prepared to demonstrate a fraud, waste, and abuse detection and prevention plan upon request by CMS or CMS Medicare Drug Integrity Contractors (MEDIC) and mitigate the risk of losing funding by proactively following recommended guidance from the Centers for Medicare and Medicaid Services.
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