risk assessment and monitoring plans
TRANSCRIPT
1/22/2016
1
Risk assessment and monitoring plansJanuary 2016
1
A deep dive
2
YOUR DIVERS:Steve Bunde –VP Integrity and Compliance & Internal Audit, HealthPartners
Laurena Lockner –Sr Manager Monitoring & Compliance, HealthPartners
Stephanie Moscetti –Program Manager, Integrity and Compliance, HealthPartners
AGENDA:
Developing and communicating the risk assessment
Aligning the monitoring plan to the risk assessment
Understanding risk areas
1/22/2016
2
3
Risk assessments
Risk
4
Template considerations• DETERMINE risk criteria• REVIEW risk equation• DETERMINE risk ratings• ENGAGE leaders• ANALYZE trends • REVIEW process
SHARE
DEVELOP
1/22/2016
3
Risk development
5
BOTH
‐Audit guides‐Regulatory guidance
‐Review topics
COMMERCIAL
‐Certification requirements‐CMS FFM compliance priorities
GOVERNMENTPROGRAMS
‐State contracts
Risk process
6
MEET with business areas
CREATE and distribute summary document
REVIEWwith Leadership
REVIEWwith Compliance Committee
MONITOR periodically
1/22/2016
4
7
Align monitoring plans to risk assessment
Resources
8
Limited resources
Determine monitoring strategy
Distinguish between auditing & monitoring
Identify all areas
1/22/2016
5
Work plans
9
Consider inherent vs. residual risks
Understand business
monitoring and results
Coordinate with internal
teams
Don’t forget FDRs and rotation planning
Align work plan with risks
Reporting
10
DETERMINE reporting format
(up front)
CONSIDER action plans in reports
PRESENT monitoring results to
business leaders, compliance and board committees
1/22/2016
6
11
Understand commercial and Government Programs risks
Defining high risk
12
BOTH
‐Financial risk‐Regulator
focus‐Audit protocol‐New rules
COMMERCIAL
‐False Claims Act
‐Litigation
GOVERNMENTPROGRAMS
‐Beneficiary impact
‐Audit findings‐Delegates
‐New contracts
1/22/2016
7
GP significant risks
13
PART D
DELEGATED ACTIVITIES
COVERAGE/ORG DETERMINATIONS
COMPLIANCE PROGRAM
Commercial significant risks
14
GENERALEdge Server, 3Rs, APTC/CSR, MLR/Risk Corridor, Taxes
FFM P&Ps, Provider Directories, Agent/Broker requirements
1/22/2016
8
15
QUESTIONS
?
?
Contact Information
16
Steve [email protected]
Stephanie [email protected]
Laurena [email protected]