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1Anthem Medicare FDR Program (Rev_12182018)

Overview Information

FDR Oversight – High Level Overview

Appendix – Overview of FDR Compliance Requirements

1. General Compliance Information

2. Standards of Conduct Checklist

3. OIG/GSA Exclusion Screening

4. Record Retention

5. Monitoring of Downstream Entities

6. Offshore/Locations

7. Anthem’s Methods of Reporting Compliance

and Fraud, Waste and Abuse

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121314 – 1819202122-23

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Policy & Procedure Templates

OIG/GSA Exclusion List Policy and Procedure

Record Retention Policy and Procedure

25-26

27

Forms

2019 Offshore Subcontract Attestation Template

FDR Disciplinary Actions Information Form

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31-32

General FDR Information

2019 Anthem Contract Listing

FDR Audit Readiness

Medicare Regulatory Exhibit and Attachment One (1)

(i.e. FDR Monitoring Survey)

Anthem’s FDR Annual Monitoring Survey

Ariba System New User Access Guide

TABLE OF CONTENTS

FDR OVERSIGHT SUPPORT

TOOLS YOU CAN USE!

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First Tier, Downstream and Related Entity (FDR) Oversight - High Level Overview


The FDR Oversight Program maintains high-level

oversight of Anthem’s contracted First Tier, Downstream

and Related Entities (FDRs) to ensure each FDR meets

applicable CMS requirements.

Meeting CMS Requirements

Business areas contracting FDRs maintain day to day

oversight.

FDR Oversight Program aims to provide high level

oversight of FDR with assistance of business

owners/business unit via:

Annual monitoring, auditing, and

communication/education/ training efforts.

The Appendix of this document contains a high level

overview of Centers for Medicare and Medicaid

Services (CMS) requirements.

Requirements are also covered in the Medicare

Regulatory Exhibit (MRE) of the FDR’s contract with

Anthem.


Medicare FDR Oversight - Monitoring

FDR Monitoring Schedule

All FDRs are assigned a monitoring month via the

FDR Monitoring Schedule.

Monitoring reviews begin the first (1st) day of assigned

month and have a 30-day due date.

Monitoring Survey Features

The Monitoring Survey is issued electronically via

Ariba a web-based tool.

The Monitoring Survey is a compliance

questionnaire with support documentation requests.

A signed FDR Attestation upon submission of the

Monitoring is required from FDR Representatives.

- Contract Information

Business Owner Section FDR Section

- Corrective Action Plans

(CAPs)/Compliance

Communication Center

(CCC)

- Performance Metrics &

Reporting Requirements

- Readiness Activities

- FDR Locations- FDR Offshore Locations- Code of Conduct/

Compliance Policies- Reporting Compliance or

FWA Concerns

- OIG/GSA Federal Exclusions

- Record Retention

- Monitoring of Downstream

Entities

- FDR Attestation

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FDR Monitoring Form Features

Anthem Medicare FDR Program (Rev_12182018)




Compliance Categorization

Corrective Action Process

• FDR Oversight Team reviews the submitted

Monitoring Survey.

• Feedback is issued via a web-based

Remediation Survey.

• All follow-up items and/or compliance gaps must be

remediated before the FDRs monitoring cycle is

closed.



FDR Oversight Workflow


Medicare FDR Oversight – Audit

Audit Process

Focused FDR Audits are conducted to validate FDRs

fulfilling CMS compliance program requirements, CMS

requirements specific to services provided and Anthem

FDR expectations.

• The annual Medicare FDR Oversight Audit

Schedule is approved by the FDR Compliance

Committee and announced at the beginning of

each year.

• The Audit Survey and requests are issued via

Ariba a web-based system.

Corrective Action Process

• FDR Oversight Team tracks and documents audit

progress.

• All information and documentation is reviewed by

the FDR Oversight Team.

• Initial feedback and additional requests are issued

via a web-based Remediation Survey.

• Final audit report is issued to the Anthem Business

Owner and FDR. All audit findings and/or additional

supporting documentation requests must be

addressed by the Anthem Business Owner and FDR.


Medicare FDR Oversight - Communication

Kick-Off

Packet

FDR

Newsletter

Business Owner

Meeting/

FDR Training

Monthly FDR

Oversight

Clinic

• Monthly meeting with open invitation

to Anthem Business Owners and

FDRs.

• Used to provide education, training,

and answer oversight questions.

• Packet of documentation and tools to aid

FDRs in compliance and understand

oversight requirements• Includes Anthem’s Standards of Ethical

Business Conduct, Anthem’s Medicare

Compliance Plan and FDR Oversight Tool

Kit.

• Quarterly electronic distribution to all

Anthem Business Owners and FDRs.

• Content includes compliance information,

updates to requirements, helpful tips and

examples.

• Periodic meeting with open invitation to

Anthem Business Owners and FDRs.

• Used to provide education, training and

address oversight questions.

• To all FDRs at the start of a new year.

• During the FDR on-boarding process.

• The document includes a copy of the FDR Annual Monitoring Survey.

• Distributed whenever new documentation is issued by Anthem (i.e. Compliance Plan, etc.)

Packet Also Includes

• Anthem’s Standards of Ethical Business Conduct (SOEBC)

• Anthem’s Medicare Compliance Plan

• FDR Oversight Support “Tools you Can Use” Kit.


Medicare FDR Oversight – Communication

Kick-Off Packet

Distribution Schedule

Newsletter Quarterly Distribution

• FDRs and internal business owners receive electronically on a quarterly basis.

• Educates stakeholders on key compliance updates to requirements and processes

• Features multiple articles, external links, and includes methods of reporting compliance issues.

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Articles in Action

Reporting for Duty: The

Requirement to Report Non-

Compliance and FWA.

Keep Your Policies Healthy:

A Check-Up for your P&Ps

Checking in on OIG & GSA

Federal Exclusion Checks

Set your Standards High:

Comply with Standards of

Conduct, Policies &

Procedures Requirements

Read All About It! Highlights

HPMS memos released by

CMS pertaining to FDRs.


Medicare FDR Oversight – Communication

Quarterly FDR Newsletter

Appendix – Overview of FDR Compliance Requirements

11

CMS Requirement

• Compliance Policies and Standards of Conduct must be distributed to employees who support Medicare Business.

• Distribution must occur:

• Within 90 days of hire

• When policy updates occur, and

• Annually thereafter

• Sponsors should ensure that standards of Conduct and policies are distributed to FDR’s employees.

• Sponsors may make their Standards of Conduct and policies available to their FDRs.

• Alternatively, the Sponsor may ensure that the FDR has comparable policies and Standards of Conduct of their own.

FDRExpectation

• Anthem distributes our Standards of Ethical Business Conduct (SOEBC) and Medicare Compliance Plan to all FDRs. Distribution occurs through Kick-Off Packet and FDR Monitoring Survey.

• FDRs must make Anthem’s SOEBC and Compliance Plan available to all associates supporting Medicare, or alternatively, make their own comparable documents available. Distribution methods can include:

• An email blast,

• Placement on an associate portal,

• Training content, etc.

• FDRs must be able to demonstrate distribution to staff. In example:

• Email with visible distribution listing staff, or

• Communication sent to staff with Web location, etc.


General Compliance Information


Standards of Conduct

• Sponsors must review the OIG list of Excluded Individuals and Entities (LEIE) and the GSA Excluded Parties Lists System (EPLS prior to the hiring or contracting of any new employee, volunteer, consultant, governing body member, or FDR, and monthly thereafter, to ensure that none of these persons or entities are excluded or become excluded from participating in federal programs.

• Sponsors shall not use federal funds to pay for services, equipment or drugs prescribed or provided by a provider, supplier, employee or FDR excluded by the DHHS OIG or GSA.

MMCM Ch. 21 &

PDBM Ch. 9 Sect. 50.6.8

• FDRs must screen all employees supporting Medicare business prior to hire and monthly thereafter against both the OIG and GSA exclusion lists.

• FDR must maintain documentation to evidence all pre-hire and monthly employee screenings.

• Proof of Screenings will be required during Annual Monitoring and may include exclusion screening screenshots, system generated reports, etc.

• At a minimum, evidence should show associate name (or identifier), date of screening, and results.

• FDRs must have policies in place for immediate removal of staff verified as excluded.


OIG/GSA Federal Exclusion Screening

CMS

REQUIREMENT

ANTHEM

EXPECTATIONS

Anthem Medicare FDR Program (Rev_12182018) 15




OIG/GSA Exclusion Verifications – Sample of Support Documentation

• Medicare RegulatoryExhibit (MRE) Section“Inspection of Books andRecords” requires allrecords related to Medicareactivity must be maintainedfor a period of 10 years.

• 42 C.F.R. 422.504(i) and/or42 C.F.R. 423.505(i))

• Sponsors are accountablefor maintaining records fora period of 10 years of thetime, attendance, topic,certificates of completion (ifapplicable), and test scoresof any tests administered totheir employees, and mustrequire FDRs to maintainrecords of the training ofthe FDR’s employees

• FDRs should have policiesin place requiring at least10 years retention of allrecords, compliancerecords, records specific tofunction provided).

• Policy should include the method of retention (i.e. electronic, offsite storage, etc.)


Record Retention


Monitoring Downstream Entities

• The sponsor must

develop a strategy to

monitor and audit its first

tier entities to ensure they

are in compliance with all

applicable laws and

regulations, and to ensure

that the first tier entities

are monitoring the

compliance of the entities

with which they contract.

• Monitoring of first tier

entities for compliance

program requirements

must include an

evaluation to confirm

that the first tier entities

are applying

appropriate compliance

program requirements

to downstream entities

with which the first tier

contracts.

• If the FDR subcontracts

services to a delegated

vendor (in support of

Anthem’s Medicare

business), the FDR must

be monitoring all

subcontractors to ensure

they are in compliance

with CMS requirements.

• FDRs will be required to

provide a listing of all

subcontractors

supporting Anthem’s

Medicare business during

annual monitoring.

- FDRs should ensure

they can demonstrate

monitoring of

subcontractors and be

able to provide supporting

documentation as part of

the FDR Monitoring

Cycle.

• If the FDR has facilities performing Anthem Medicare work that are located offshore (outside of U.S), CMS requires an Offshore Attestation to be submitted.

• Information must be submitted within 30-days of contracting, including specific information about the FDR, its offshore locations, and the privacy protections in place to address risks associated with the use of offshore subcontractors.

• If a contracted FDR is intending to transition onshore services to an offshore location the FDR must notify Anthem immediately and receive approval prior to any changes.

HPMS Memo 7/23/07, 09/20/07, and 08/26/08

• Anthem will work with the FDR wishing to perform services outside of the United States to complete an Offshore Attestation and ensure necessary information is submitted to CMS within the required 30-days.

• After the initial information is submitted to Anthem and CMS, FDRs will be required to confirm offshore information via Anthem’s annual FDR Monitoring Survey. This includes the submission of an Offshore Attestation each year. All offshore information will be reviewed and updated with CMS on an annual basis.

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Offshore Subcontracting/Locations

• The Sponsor’s written Standards of Conduct and/or policies must require all employees, members of the governing body, and FDRs to report compliance concerns and suspected or actual violations related to the Medicare program to the sponsor.

• Sponsors must adopt, widely publicize, and enforce a no-tolerance policy for retaliation or retribution against any employee or FDR who in good faith reports suspected FWA.

MMCM Ch. 21 & PDBM Ch. 9 Section 50.4.2

• FDRs should be aware of the requirement to report compliance or FWA concerns, methods of reporting, and non-retaliation policy for reporting issues.

• If an FDR discovers evidence of misconduct related to payment or delivery of items or services under the contract, the FDR must conduct a timely, reasonable inquiry into that conduct.

• FDRs must conduct appropriate corrective actions (for example, repayment of overpayments, disciplinary actions against responsible employees) in response to the potential violation.

• FDRs are required to have procedures in place to voluntarily self-report potential fraud or misconduct related to the MA program to Anthem.


Reporting Compliance and Fraud, Waste

and Abuse Issues


You can easily and confidentially report a known or suspected violation by:

• Calling the Helpline at 877.725.2702

• Using the Helpline online tool: www.anthemethicshelpline.com

• Sending an email to: [email protected]

• Calling the Medicare Compliance Officer, Angela Canton 805.557.6467

• Calling the Corporate Privacy Officer, Michelle Nader at 513.336.2703

Anthem enforces strict Policy of non-retaliation:

• Retaliation against anyone who reports a compliance issue in good faith is strictly prohibited, including reports made by contracted vendors (first tier, downstream and related entities).

• If you see retaliation or believe that retaliation has occurred, you must report it

Confidential Reporting

http://www.anthemethicshelpline.com/

mailto:[email protected]

Policy and Procedure Document Samples

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OIG/GSA Federal Exclusion Policy and

Procedure Sample


OIG/GSA Federal Exclusion Policy and

Procedure Sample Continued


Record Retention Policy and Procedure Sample

28

Offshore Subcontract and Attestation


2019 Offshore Subcontract Information and

Attestation


2019 Offshore Subcontract Information

and Attestation - Continued

Disciplinary Actions Information Request Form



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FDR Audit Readiness

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Audit readiness is an important part of Anthem’s commitment to compliance. As anAnthem FDR, we want to ensure you are prepared for regulatory audits. Below arejust a few questions to consider when thinking through audit readiness:

Am I current with Anthem’s FDR monitoring and auditing requests? Are allnoted compliance issues fully addressed and remediated?

Do my policies and procedures supporting FDR Compliance requirementsaccurately reflect processes to meet CMS laws/ regulations? Has appropriatestaff been trained on Policies and Procedures (P&Ps)? Are P&Ps up to date andreviewed at least annually? Are P&Ps being monitored for compliance?

Do I provide Claims and/or utilization management services on Anthem’sbehalf? If so, am I familiar with CMS’ audit protocols and universe requests forclaims and UM? Would I be able to pull appropriate data for the universerequest and provide to Anthem within the required timeframe?

Do our employees know who Anthem’s Medicare Compliance Officer is nowand how to reach out to her (hint: refer to Anthem’s Methods of ReportingCompliance/FWA issues section of this tool kit)

What about downstream entities, if applicable? Can these questions beappropriately answered by each of your downstream? Have contacts beenidentified for each?

Remember, audits may be performed by CMS, the office of Inspector General(OIG), or federally contracted vendors. In the event your organization is included ina CMS or other regulator audit, Anthem’s Medicare Compliance will work with youto coordinate all meetings and submission of audit materials consistent with CMSaudit protocols and processes. You will be required to comply and providedocumentation timely, and we will be available to support you through the auditprocess!

Additional Audit Resources:

• CMS Audit Protocols:

https://www.cms.gov/Medicare/Compliance -and-Audits/Part-C-and-Part-D-Compliance-and-Audits/ProgramAudits.html

• Medicare Managed Care Manual, Chapter 21 and Prescription Drug Benefit Manual Chapter 9:

www.cms.gov/Regulations-and-Guidance/Manuals/Downloads/mc86c21.pdf


FDR Audit Readiness - Assessment

https://www.cms.gov/Medicare/Compliance -and-Audits/Part-C-and-Part-D-Compliance-and-Audits/ProgramAudits.html

http://www.cms.gov/Regulations-and-Guidance/Manuals/Downloads/mc86c21.pdf

Anthem’s Medicare Regulatory Exhibit (MRE)



Anthem’s Medicare Regulatory Exhibit

(MRE)- Continued



(MRE) - Continued


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2019 FDR Monitoring Survey

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FDR Monitoring Survey – Business OwnerSection


FDR Monitoring - FDR Section



FDR Monitoring - FDR Section- Continued

ARIBA System - New User Access & Getting Help



Steps to Access Ariba


Ariba Assistance


Confidential Reporting

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