3d compliance for managed care vickie mccormick integrity officer - unitedhealth group mamie segall...
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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
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