3D Compliance for 3D Compliance for Managed CareManaged Care

Vickie McCormick

Integrity Officer - UnitedHealth Group

Mamie Segall

Vice President, Compliance Operations - MedicaHealth Care Compliance Institute

The Compliance Evolution: Revealing the Opportunities

HCCA 2000 Compliance Institute

Introduction Three Dimensions to Building and

Sustaining

Compliance Organization Compliance Tools Partner/Vendor/Provider (“Extender”)

Organizations

Compliance Organization Model #1 -- Compliance Oversight

Operational/functional department primarily responsible for:

identifying compliance obligations implementing operational processes to promote compliance

Compliance primarily responsible for: providing coordination, resources and facilitation notifying operational/functional departments of compliance

obligations when identified facilitating cross-departmental issues conducting monitoring/auditing creating/maintaining metrics of functional departments’

compliance

Compliance Organization Model #2 -- Compliance Implementation

Compliance is primarily responsible for: identifying compliance obligations implementing operational processes to promote compliance facilitating cross-departmental issues conducting monitoring/auditing creating/maintaining metrics of functional departments’

compliance

Compliance Organization Model #3 -- Compliance Oversight and

Implementation

Compliance works in conjunction with functional/operational departments to:

identify compliance obligations implement operational processes to promote compliance

Compliance function: facilitates cross-departmental issues conducts monitoring/auditing creates/maintains metrics of functional departments’

compliance

Compliance Tools

Periodic Reporting on Compliance Activities

Confirming compliance organization structure Compliance Officer Compliance Committee

Identifying compliance-related activities Regulatory compliance Risk Analysis/Controls Training

Human Resource/Organizational Development Product Department Regulatory and Miscellaneous Compliance

Monitoring and Auditing Programs Corrective Action, including discipline

Compliance Tools Compliance Intranet

Description of compliance office responsibilities and staff

Code of Conduct Policies Q&A Compliance Hotline Information Compliance Notices/Articles/Newsletters Compliance Resources and Tools

Compliance Tools Accountability and Obligation Tracking

Define Mission Define Job Profile Create Intake Method Create Implementation Process Flow Track Assessments Monitor Obligation Summaries

Compliance Tools

Software Solutions

Goldmine Lotus Notes/Excell/Access/Web Database PricewaterhouseCoopers Compliance Office Ernst & Young Compliance Saver

Compliance Tools

Tool Box

UnitedHealth Group Quarterly Integrity and Compliance Reports

Sample Organization Charts Intranet Site Content Outline Regulatory Filing Tracking Tools

Extender Organizations MCO Accountability for Extender

Organization Compliance

OIG Guidance M+C Organizations responsible for provider organization

compliance

HCFA and State Regulators MCO can not avoid compliance obligation through delegation to

extender organizations, including providers and IPAs New York DOI position that MCOs are ultimately responsible for

actions (an inaction) of IPAs Maryland DOI decision regarding UnitedHealthCare of the

Midland’s obligation to pay claims not paid by capitated IPAs

Extender Organizations Standard MCO Extender Organizations

Medical Providers and Suppliers Providing medical services and supplies Information source (encounter data, special status, etc.)

Delegated Administrative Services/Clinical Services Claims Pharmacy Benefit Management Credentialing Utilization Management Quality

Information Systems Standard Business Vendors/Suppliers

Extender Organizations Agreement Provisions Regarding Compliance

General compliance with all laws clause no longer sufficient Addressing compliance in agreements with extender

organizations Standard 7 compliance program elements Flow-through to sub-contractors Consider excluded provider issue Extender organization reporting compliance issues to MCO

External organization attorney/client privilege issues Joint Defense Agreement?

MCO obligation to report to regulators/customers Violation of performance standards

MCO right/obligation to audit extender organization compliance program