Medicare Parts C and D General Compliance Training

Medicare Parts C and D General Compliance Training Complete prior to taking the post assessment

The Medicare Parts C and D General Compliance Training

The Medicare Parts C and D General Compliance Training

Web-Based Training course is brought to you by the Medicare Learning Network®, a registered trademark of the U.S. Department of Health & Human Services (HHS) 

This training course has been repackaged in a way that allows the Morehouse School of Medicine/ Morehouse Healthcare  community ease of access and completion. All content belongs to the Medicare Learning Network.

Medicare Parts C and D General Compliance Training Introduction

Completing this training module satisfies the Medicare Parts C and D plan Sponsors annual general compliance training requirements in the regulations and sub-regulatory guidance at:

  • 42 Code of Federal Regulations (CFR) Section 422.503(b)(4)(vi); 
  • 42 CFR Section 423.504(b)(4)(vi); 
  • Section 50.3 of the Compliance Program Guidelines (Chapter 9 of the “Medicare Prescription Drug Benefit Manual” and Chapter 21 of the “Medicare Managed Care Manual”); and
  • June 17, 2015, Health Plan Management System (HPMS) memo: Update – Reducing the Burden of the Compliance Program Training Requirements. (Keep up-to-date with the most recent memos on the CMS Compliance Program Policy and Guidance website.) 

While Sponsors are required to complete this training or use this module’s downloaded content to satisfy compliance training requirements, completing this training in and of itself does not ensure that a Sponsor has an “effective Compliance Program.” Sponsors are responsible for establishing and executing an effective compliance program according to the Centers for Medicare & Medicaid Services (CMS) regulations and program guidelines.

Medicare Parts C and D General Compliance Training Introduction

Why Do I Need Training?

Every year billions of dollars are improperly spent because of Fraud, Waste, and Abuse (FWA). It affects everyone – including you. This training helps you detect, correct, and prevent FWA. You are part of the solution.

Compliance is everyone’s responsibility. As an individual who provides health or administrative services for Medicare enrollees, your every action potentially affects Medicare enrollees, the Medicare Program, or the Medicare Trust Fund.

Medicare Parts C and D General Compliance Training Introduction

Course Content

 This  course consists of general compliance program training and a post-assessment. 

  • Anyone who provides health or administrative services to Medicare enrollees must satisfy general compliance and FWA training requirements. You must use this WBT course to satisfy general compliance training requirements. 
  • It should take approximately 20 minutes to complete this course.
  • Successfully completing the course requires completing the entire lesson and the questions in the Post-Assessment. After successfully completing the Post-Assessment, you’ll get instructions to print your certificate.

Course Objectives

Course Objectives

When you complete this course, you should be able to correctly: 

  • Recognize how a compliance program operates; and 
  • Recognize how compliance program violations should be reported. 


Medicare Parts C and D General Compliance Training Lesson: Compliance Program Training

Compliance Program Requirement

The Centers for Medicare & Medicaid Services (CMS) requires Sponsors to implement and maintain an effective compliance program for its Medicare Parts C and D plans. An effective compliance program should: 

  • Articulate and demonstrate an organization’s commitment to legal and ethical conduct; 
  • Provide guidance on how to handle compliance questions and concerns; and
  • Provide guidance on how to identify and report compliance violations.

Medicare Parts C and D General Compliance Training Lesson: Compliance Program Training

What Is an Effective Compliance Program?

An effective compliance program fosters a culture of compliance within an organization and, at a minimum:

  • Prevents, detects, and corrects non-compliance; 
  • Is fully implemented and is tailored to an organization’s unique operations and circumstances; 
  • Has adequate resources; 
  • Promotes the organization’s Standards of Conduct; and 
  • Establishes clear lines of communication for reporting non-compliance

An effective compliance program is essential to prevent, detect, and correct Medicare non-compliance as well as Fraud, Waste, and Abuse (FWA). It must, at a minimum, include the seven core compliance program requirements.

For more information, refer to:


Medicare Parts C and D General Compliance Training Lesson: Compliance Program Training

Seven Core Compliance Program Requirements

CMS requires that an effective compliance program must include seven core requirements:

1. Written Policies, Procedures, and Standards of Conduct 

These articulate the Sponsor’s commitment to comply with all applicable Federal and State standards and describe compliance expectations according to the Standards of Conduct.

2. Compliance Officer, Compliance Committee, and High-Level Oversight

The Sponsor must designate a compliance officer and a compliance committee that will be accountable and responsible for the activities and status of the compliance program, including issues identified, investigated, and resolved by the compliance program.

The Sponsor’s senior management and governing body must be engaged and exercise reasonable oversight of the Sponsor’s compliance program.

3. Effective Training and Education

This covers the elements of the compliance plan as well as prevention, detection, and reporting of FWA. This training and education should be tailored to the different responsibilities and job functions of employees.

Medicare Parts C and D General Compliance Training Lesson: Compliance Program Training

Seven Core Compliance Program Requirements (continued)

4. Effective Lines of Communication 

Effective lines of communication must be accessible to all, ensure confidentiality, and provide methods for anonymous and good-faith reporting of compliance issues at Sponsor and First-Tier, Downstream, or Related Entity (FDR) levels.

5. Well-Publicized Disciplinary Standards

Sponsor must enforce standards through well-publicized disciplinary guidelines.

 6. Effective System for Routine Monitoring, Auditing, and Identifying Compliance Risks 

Conduct routine monitoring and auditing of Sponsor’s and FDR’s operations to evaluate compliance with CMS requirements as well as the overall effectiveness of the compliance program.

NOTE: Sponsors must ensure that FDRs performing delegated administrative or health care service functions concerning the Sponsor’s Medicare Parts C and D program comply with Medicare Program requirements.

 7. Procedures and System for Prompt Response to Compliance Issues 

The Sponsor must use effective measures to respond promptly to non-compliance and undertake appropriate corrective action.

Medicare Parts C and D General Compliance Training Lesson: Compliance Program Training

Compliance Training‒Sponsors and their FDRs

CMS expects that all Sponsors will apply their training requirements and “effective lines of communication” to their FDRs. Having “effective lines of communication” means that employees of the Sponsor and the Sponsor’s FDRs have several avenues to report compliance concerns.

Medicare Parts C and D General Compliance Training Lesson: Compliance Program Training

Ethics–Do the Right Thing!

As part of the Medicare Program, you must conduct yourself in an ethical and legal manner. It’s about doing the right thing!

  •  Act fairly and honestly; 
  •  Adhere to high ethical standards in all you do;
  •  Comply with all applicable laws, regulations, and CMS requirements; and 
  •  Report suspected violations.

Medicare Parts C and D General Compliance Training Lesson: Compliance Program Training

What Is Non-Compliance?

Non-compliance is conduct that does not conform to the law, Federal health care program requirements, or an organization’s ethical and business policies.

 CMS has identified the following Medicare Parts C and D high risk areas: 

  • Agent/broker misrepresentation;
  • Appeals and grievance review (for example, coverage and organization determinations); 
  • Beneficiary notices; 
  • Conflicts of interest; 
  • Claims processing;
  • Credentialing and provider networks; 
  • Documentation and Timeliness requirements; 
  • Ethics;
  •  FDR oversight and monitoring; •Health Insurance Portability and Accountability Act (HIPAA); 
  • Marketing and enrollment; 
  • Pharmacy, formulary, and benefit administration; and 
  • Quality of care. 

For more information, refer to the Compliance Program Guidelines in the “Medicare Prescription Drug Benefit Manual” and “Medicare Managed Care Manual” on the CMS website.


Know the Consequences of Non-Compliance 

Failure to follow Medicare Program requirements and CMS guidance can lead to serious consequences including:

  • Contract termination;
  • Criminal penalties;
  • Exclusion from participation in all Federal health care programs; or
  • Civil monetary penalties.Additionally, your organization must have disciplinary standards for non-compliant behavior. Those who engage in non-compliant behavior may be subject to any of the following:
  • Mandatory training or re-training;
  • Disciplinary action; or
  • Termination.

Medicare Parts C and D General Compliance Training Lesson: Compliance Program Training

Non-Compliance Affects Everybody

Without programs to prevent, detect, and correct non-compliance, we all risk: 

Harm to beneficiaries, such as: 

  • Delayed services 
  • Denial of benefits 
  • Difficulty in using providers of choice
  • Other hurdles to care 

Less money for everyone, due to: 

  • High insurance co-payments 
  • Higher premiums 
  • Lower benefits for individuals and employers 
  • Lower Star ratings 
  • Lower profits

Medicare Parts C and D General Compliance Training Lesson: Compliance Program Training

How to Report Potential Non-Compliance

Employees of a Sponsor

  • Call the Medicare Compliance Officer; 
  • Make a report through the Morehouse School of Medicine (MSM) Hotline: www.msm.ethicspoint.com ; or 
  • Call the MSM Compliance Hotline: 855-279-7520

First-Tier, Downstream, or Related Entity (FDR) Employees

  • Talk to a Manager or Supervisor; 
  • Call your Ethics/Compliance Help Line: 855-279-7520; or 
  • Report to the Sponsor. 

Beneficiaries

Call the Sponsor’s Compliance Hotline or Customer Service; 

  • Make a report through the Sponsor’s website; or 
  • Call 1-800-Medicare. 

Don’t Hesitate to Report Non-Compliance

There can be no retaliation against you for reporting suspected non-compliance in good faith.

Each Sponsor must offer reporting methods that are:

  • Anonymous; 
  • Confidential; and 
  • Non-retaliatory.


Medicare Parts C and D General Compliance Training Lesson: Compliance Program Training

What Happens After Non-Compliance Is Detected?

After non-compliance is detected, it must be investigated immediately and corrected promptly.

However, internal monitoring should continue to ensure:

  • No recurrence of the same non-compliance;
  • Ongoing compliance with CMS requirements; 
  • Efficient and effective internal controls; and 
  • Enrollees are protected.

Medicare Parts C and D General Compliance Training Lesson: Compliance Program Training

What Are Internal Monitoring and Audits?

  • Internal monitoring activities are regular reviews that confirm ongoing compliance and ensure that corrective actions are undertaken and effective.
  • Internal auditing is a formal review of compliance with a particular set of standards (for example, policies and procedures, laws, and regulations) used as base measures.

Medicare Parts C and D General Compliance Training Lesson: Compliance Program Training

Lesson Summary

Organizations must create and maintain compliance programs that, at a minimum, meet the seven core requirements. An effective compliance program fosters a culture of compliance.

To help ensure compliance, behave ethically and follow your organization’s Standards of Conduct. Watch for common instances of non-compliance and report suspected non-compliance.

Know the consequences of non-compliance and help correct any non-compliance with a corrective action plan that includes ongoing monitoring and auditing.

Compliance Is Everyone’s Responsibility!

Prevent: Operate within your organization’s ethical expectations to prevent non-compliance!

Detect & Report: If you detect potential non-compliance, report it!

Correct: Correct non-compliance to protect beneficiaries and save money!

Medicare Parts C and D General Compliance TrainingLesson: Compliance Program Training

Lesson Review

Now that you have completed the Compliance Program Training lesson, let’s do a quick knowledge check. The following questions do not contribute to your overall course score in the Post-Assessment.

You discover an unattended email address or fax machine in your office that receives beneficiary appeals requests. You suspect that no one is processing the appeals. What should you do?

  • Contact law enforcement
  • Nothing
  • Contact your compliance department (via compliance hotline or other mechanism)
  • Wait to confirm someone is processing the appeals before taking further action
  • Wait to confirm someone is processing the appeals before taking further action Contact your supervisor

A sales agent, employed by the Sponsor’s First-Tier or Downstream entity, submitted an application for processing and requested two things: 1) to back-date the enrollment date by one month, and 2) to waive all monthly premiums for the beneficiary.

What should you do? 

  • Refuse to change the date or waive the premiums, but decide not to mention the request to a supervisor or the compliance department
  • Make the requested changes because the sales agent determines the beneficiary’s start date and monthly premiums
  • Tell the sales agent you will take care of it, but then process the application properly (without the requested revisions) – you will not file a report because you don’t want the sales agent to retaliate against you
  • Process the application properly (without the requested revisions) – inform your supervisor and the compliance officer about the sales agent’s request
  • Contact law enforcement and the Centers for Medicare & Medicaid Services (CMS) to report the sales agent’s behavior

You identified multiple enrollees for which the Sponsor is being paid, who are not enrolled in the plan. You spoke to your supervisor who said not to worry about it. This month, you have identified the same enrollees on the report again.

What should you do?


  • Decide not to worry about it as your supervisor instructed – you notified him last month and now it’s his responsibility
  • Although you have seen notices about the Sponsor’s non-retaliation policy, you are still nervous about reporting – to be safe, you submit a report through your compliance department’s anonymous tip line so you cannot be identified
  • Wait until the next month to see if the same enrollees appear on the report again, figuring it may take a few months for CMS to reconcile its records – if they are, then you will say something to your supervisor again
  • Contact law enforcement and CMS to report the discrepancy
  • Ask your supervisor about the discrepancy again

You are performing a regular inventory of the controlled substances in the pharmacy. You discover a minor inventory discrepancy. What should you do?

  • Call local law enforcement
  • Perform another review
  • Contact your compliance department (via compliance hotline or other mechanism)
  • Discuss your concerns with your supervisor
  • Follow your pharmacy’s procedures

Medicare Parts C and D General Compliance Training Lesson: Compliance Program Training

You’ve completed the lesson!

Now that you have learned about compliance programs, let’s take a post-assessment to see how much you’ve learned!


Post Assessment

Medicare Parts C and D General Compliance Training Post-Assessment

Post-Assessment

This assessment asks you 10 questions about Medicare Parts C and D compliance programs. It should take about 5 minutes to complete. Please choose the answer for each question by clicking on the button next to your answer. You may change your answer to a question until you click on the “SUBMIT ANSWER” button, at which time your answer is submitted. After you submit your answer, the “NEXT” button will appear, along with feedback on your answer. Click on the “NEXT” button to continue to the next question. You can only move forward in the Post-Assessment and you can answer each question only once.

Click the “NEXT” button to continue to the first Post-Assessment question

Compliance is the responsibility of the Compliance Officer, Compliance Committee, and Upper Management only.

  • True
  • False

Ways to report a compliance issue include:

  • Telephone hotlines
  • Report on the Sponsor’s website
  • In-person reporting to the compliance department/supervisor
  • All of the above

What is the policy of non-retaliation?

  • Allows the Sponsor to discipline employees who violate the Code of Conduct
  • Prohibits management and supervisor from harassing employees for misconduct
  • Protects employees who, in good faith, report suspected non-compliance
  • Prevents fights between employees

These are examples of issues that can be reported to a Compliance Department: suspected Fraud, Waste, and Abuse (FWA); potential health privacy violation, and unethical behavior/employee misconduct.

  • True
  • False

Once a corrective action plan begins addressing non-compliance or Fraud, Waste, and Abuse (FWA) committed by a Sponsor’s employee or First-Tier, Downstream, or Related Entity’s employee, ongoing monitoring of the corrective actions is not necessary.

  • True
  • False

Medicare Parts C and D plan Sponsors are not required to have a compliance program.

  • True
  • False

At a minimum, an effective compliance program includes four core requirements.

  • True
  • False

Standards of Conduct are the same for every Medicare Parts C and D Sponsor.

  • True
  • False

Correcting non-compliance ______________.

  • Protects enrollees, avoids recurrence of the same non-compliance, and promotes efficiency
  • Ensures bonuses for all employees
  • Both A. and B.

What are some of the consequences for non-compliance, fraudulent, or unethical behavior?

  • Disciplinary action
  • Termination of employment
  • Exclusion from participation in all Federal health care programs
  • All of the above

Medicare Parts C and D General Compliance Training Post-Assessment

Congratulations!

You successfully completed the course. Once you exit the course and return to the My Transcripts page, follow these directions to obtain your certificate. 

1. Select My Transcripts Transcripts on the Home Page of Cornerstone 


2. Click on Active which will open a drop down menu. Select Completed

3. Select view Certificate and print 

4. The certificate is a PDF. Either save or print your certificate for your records. 


APPENDIX A: RESOURCES RESOURCES PAGE 1 OF 1

APPENDIX A: RESOURCES RESOURCES PAGE 1 OF 1

 Disclaimers This Web-Based Training (WBT) course was current at the time it was published or uploaded onto the web. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference. This WBT course was prepared as a service to the public and is not intended to grant rights or impose obligations. This WBT course may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents. The Medicare Learning Network® (MLN) The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department of Health & Human Services (HHS). Glossary For the Centers for Medicare & Medicaid Services (CMS) Glossary, visit https://www.cms.gov/apps/glossary on the CMS website