Chapter 22medicare Advantagelearning Objectivesoperations Of Medicare ✓ Solved

Chapter 22 Medicare Advantage Learning Objectives Operations of Medicare Advantage Organizations (MAO’s) Responsibility for “FDR entities†Guidelines for mandatory MAO compliance program Compliance Officer and Compliance Committee Agenda of a good compliance training effort Value of open lines of communication Effective disciplinary standards Audits and monitoring to evaluate compliance Program exclusions and self-reporting Introduction MAO’s are managed care organizations for Medicare beneficiaries. There are 3,500 MA plans serving 12 million beneficiaries – 25% of the total. Compliance programs are mandatory for MA plans. Although the OIG has issued a Compliance Program Guidance for MAO’s, the primary authority on MA compliance is the Medicare Managed Care Manual (Chapter 21 of the Compliance Program Guidelines).

7 Basic Elements of a Mandatory Compliance Program for MA Plans Policies, Procedures, and Standards of Conduct Compliance Officer, Compliance Committee, and High Level Oversight Effective Training and Education Effective Lines of Communication Well-Publicized Disciplinary Standards System for Routine Monitoring and Auditing Prompt Response to Compliance Issues FDR Entities MAO: Plan Sponsor F: First Tier Entity D: Downstream Entities R: Related Entities FDR entities may be a sources of compliance problems. MAO’s must work with those entities to prevent and resolve the problems. Delegating Compliance to FDRs Plan Sponsors may enter into contracts with FDRs to provide administrative or health care services to their enrollees.

They may not delegate compliance program functions to them. Activities that Sponsor may delegate to a FDR entity, but remains responsible for them. Factors in determining which contractors are FDRs. Policies, Procedures, and Standards of Conduct Code of Conduct – defines ethical, compliant behavior for employees and FDR’s Policies and procedures – tell employees and FDR’s how to perform their work tasks in conformity with laws and payor requirements Emphasis is on areas of high compliance risk as identified by the organization and OIG Important to impose comparable policies and procedures on FDR’s 7 Compliance Officer, Compliance Committee, & High Level Oversight Compliance Officer – full-time, report to CEO, final authority on compliance matters, overall management of compliance program Specific duties, powers, and status within the organization Compliance Committee – composition, list of responsibilities Governing board – oversight of compliance efforts and program effectiveness Effective Training and Education Two types of mandatory training – General and Fraud, Waste, and Abuse (FWA).

Annually, part of new employee orientation. Agenda for each type of training. Training for employees, managers, governing board, FDR’s, temp workers, & volunteers Various methods of delivery Proof that training was delivered Effective Lines of Communication Between the CO and CC, and employees, managers, governing board, and FDR’s To seek clarification on compliance issues or report suspected non-compliance or FWA Insist that employees report suspected problems Multiple reporting channels, well publicized, available 24 hours a day, readily accessible Maintain confidentiality, allow anonymity, prevent retaliation Well-Publicized Disciplinary Standards To be applied in cases of misconduct, non-compliance, or FWA by employees Well-publicized to employees and FDR’s Criteria for disciplinary standards Maintain records on disciplinary actions Routine Monitoring, Auditing, and Identification of Compliance Risks (I) Evaluate compliance with CMS program requirements, and effectiveness of the compliance program itself Compare monitoring activities and audits Systematic work plan – reflecting size and resources of the organization, and risks it faces Content of typical work plan Routine Monitoring, Auditing, and Identification of Compliance Risks (II) Baseline assessment of risk areas, then prioritize the risk areas Monitor and audit first tier entities Responsible for compliant behavior of all FDR’s Program Exclusions Lists of people and organizations that are excluded from participation in Federal health care programs – as a result of fraudulent or other criminal acts they have committed OIG List of Excluded Individuals and Entities (LEIE) GSA Excluded Parties Lists System (EPLS) Review these lists prior to hiring or contracting with any individual or organization Data Analysis Data analysis – tool for monitoring operations to detect and prevent FWA Compare claim information with other data to identify unusual patterns suggesting errors or potential fraud and abuse How good data analysis works Special Investigation Units (SIU) Internal unit that conducts surveillance, interviews, and other forms of investigation relating to potential FWA Often separate from the Compliance Program An SIU or comparable functions in the Compliance Program are mandatory CMS has the right to perform its own audits of Sponsor or FDR activities related to Medicare Procedures and System for Prompt Response to Compliance Issues Ingredients of CMS-required response system When matters must be referred to CMS or NBI-MEDIC Corrective action – correct the underlying problems and make sure it does occur again Corrective action plans for FDR’s as well Self-Reporting of FWA Self-reporting is voluntary but strongly advised Report to NBI-MEDIC, OIG, or DOJ Opportunity to minimize the potential cost and disruption of a full scale audit and investigation, to negotiate a fair monetary settlement, and to potentially avoid an OIG program exclusion Enforcement Activities Regarding MAO’s NBI MEDIC identifies & investigates Part C and Part D fraud and abuse, refers cases & gives advice to the OIG, and meets requests for information from law enforcement agencies OIG 2013 Work Plan shows dissatisfaction with MAO fraud detection CMS enforcement options: civil money penalties (CMP), intermediate sanctions, and contract terminations Questions ???

3/21/22, 8:38 PM Rubric Detail – 22SSEM_IS_365_OM1 1/3 Rubric Detail A rubric lists grading criteria that instructors use to evaluate student work. Your instructor linked a rubric to this item and made it available to you. Select Grid View or List View to change the rubric's layout. Novice Competent Procient Excellent Persuasiveness 2.5 (5.00%) 5 (10.00%) Feedback: Gaps in logic -- there were missed opportunities to understand why you are writing this document. 7.5 (15.00%) 10 (20.00%) Evidence and support 2.5 (5.00%) 5 (10.00%) 7.5 (15.00%) 10 (20.00%) Name: Writing Rubric Exit Grid View List View 3/21/22, 8:38 PM Rubric Detail – 22SSEM_IS_365_OM1 2/3 Novice Competent Procient Excellent Feedback: Sucient sources - please review the APA style for citing sources (single- space...) Writing 2.5 (5.00%) 5 (10.00%) Feedback: Writing is unclear and the "why and what" of this document is missing.

7.5 (15.00%) 10 (20.00%) Language 2.5 (5.00%) 5 (10.00%) 7.5 (15.00%) Feedback: Minor errors in sentence structure. 10 (20.00%) Formatting (heading styles, fonts, margins, white space, tables and graphics) 2.5 (5.00%) 5 (10.00%) 7.5 (15.00%) Feedback: Generally acceptable - 10 (20.00%) Raw Total: 30.00 (of 50) Name:Writing Rubric Exit 3/21/22, 8:38 PM Rubric Detail – 22SSEM_IS_365_OM1 3/3 | 1 xxxxxxxxxxx Professor Carswell IS /13/2017 Module 8 Writing Assignment Table 1 (Arnold, 2017) The Table 1 contains console sales data in Japan for the week of 2/27/17 to 3/05/17 (Arnold, 2017). Hard data in this format is mostly easily obtained for Japan, and while its data for game sales is culturally skewed, console data is generally very similar worldwide and can be used to illustrate possible trends in the industry as a whole—not just in Japan.

This particular week contains a very strong outlier in the form of the Nintendo Switch—a newly released console as of March 3rd—and thusly is very skewed to show the drastic first-week performance of the newly unveiled console. This initial showing of the Nintendo Switch suggests that it will be a force to be reckoned with; within its first week, the Nintendo Switch’s sales have already surpassed that of its poorly performing predecessor, the Wii U, by a figure of 5,100 units in opening week (Kamen, 2017). This is a very impressive showing for opening week and suggests great overall success in Nintendo’s launching of the U ni ts S ol d Console Top Console Sales (2/20/17-2/26/17) Series1 | 2 Switch and its assorted launch titles, including the ubiquitously critically-acclaimed Legend of Zelda: Breath of the Wild.

To get a better understanding of the statistical significance of the Switch’s launch debut, we can arrange the data into a pie chart so as to illustrate the percentage of console sales directed towards the Switch. We can see that the Switch accounts for nearly 82% of all console sales last week. Again, because this is the console’s first week, extremely high sales numbers are to be expected; most first-week sales do tend to reach these numbers (Kamen, 2017). Table 2 provides us with the ability to see the overwhelming outlier that is the Switch in a more visual way, as well as the piddling sales numbers of consoles like the Wii U and the Xbox One. With the Switch aiming to replace its already aged predecessor, the Wii U, one can expect to see that particular console drop out of the top ten in sales.

The other consoles listed have been out for years; for them, this data can be used to show quality of life and sale longevity. If we take out the statistical outlier, the Switch, from the graph 81.90% 7.70% 4.46% 2.50% 1.70% 1.00% 0.30% 0.20% 0.10% 0.06% Console Sales Table 2 | 3 (shown to the left), we can see a more accurate illustration of the sales numbers for the rest of the consoles. In much the same way that the Nintendo Switch’s data indicates a strong first-week performance, if it lacks longevity, as we can see in the lesser Xbox One and Wii U sales data, it matters little how well it sold in that first week. The Xbox One from Microsoft, which is meant to be seen as an equal competitor to Sony’s Playstation 4, is severely lacking in sales when compared to its main competitor despite how early it still is in this console generation.

Could this be a cultural trend in Japan, or is the Xbox One’s poor performance indicative of something else? Based on this data alone, it can be difficult to say; however, the amount of Playstation-exclusive titles that have been released within the first three months of 2017 may have something to do with this overwhelming statistic. Sony has released about 10 games exclusive to the Playstation 4 or Playstation 4 and PC in an impressive Q1 2017 showing, whereas the Xbox One has had only one notable exclusive release in that time frame (Siegal, 2017). U ni ts S ol d Console Top Console Sales (Without Switch) Series1 Table 3 | 4 Additionally, we can compare sales data from last week to this week in order to get a general idea of the trends we are seeing in console sales, once again excluding the Switch from this data as it was released March 3rd and thusly lacks sales data for the previous week.

We can see a general trend of drops in sales like the Playstation 4 and its assorted peripherals (the Vita and the Pro). Nintendo consoles appear to be on the rise, possibly due to cross-console compatibility. Lesser sales this week compared to last week across all consoles could easily be attributed to the appearance of the Switch; definite conclusions about the affect of the Switch on other consoles’ sales will depend more so on the weeks and months to come rather than just this snapshot of its opening week, impressive as it may be. U ni ts S ol d Console Console Sales Comparison Series1 Series2 Table 4 | 5 Bibliography Arnold, C. (2017, March 8). Nintendo Switch and Zelda storm Japan.

Retrieved from Destructoid.com: 423617.phtml Kamen, M. (2017, March 7). Nintendo Switch is better than the Wii U (based on launch sales at least). Retrieved from Wired: figures-outsells-wii-u Siegal, J. (2017, February 13). Sony turned gaming’s slow season into one of the best seasons ever for the PS4. Retrieved from BGR: games-2017/ Bibliography Memo – Network Security To: Dr.

Alan Carswell (IS-365) From: xxxxx Date: 3/18/2017 Network Security is extremely important within a company – it’s what keeps their data safe and locked away in the right place, and accessible to only those who are authorized to handle it. Additionally, it keeps the company’s technological services and functions safe within their own hands, not manipulated my malicious outsiders attempting to wreak havoc on an organization. This memo will outline several important statistics on Network Security (specifically the causes and damage that network breaches can create) and stress the importance of training and diligence from any company’s employees. Network Breaches – Statistics There are a great number of manners in which companies can find their network breached, ranging from elaborate Phishing scams designed to gain passwords and access to core functions and data servers of companies, to hackers will ill-intent out to leak company information, or simply partake in mischievous behavior.

While many employees may believe hackers to be the largest threat to companies - as they are mysterious and are perceived to have the power to break into any system – statistics from several sources show an alarming truth: employee error accounts for a massive percentage of data breach causes. Will Daugherty, a writer for Cyber Security Trend, writes that his study found Human error accounted for 37% of network breach incidents in 2015. (Daugherty, 2016) However, it is worth noting that while he lists these four as separate entities, Phishing and Malware also is traced back to employee negligence. Phishing scams require employees to give out information they are not meant to, and Malware is commonly – though not always – downloaded by employees who are ignorant to proper protocols or scams.

As such, simple Employee errors should instead account for a massive 62% of all breaches, using Mr. Daugherty’s statistics. Company Response With employees making simple mistakes from ignorant downloading behaviors to other very minor errors, it seems appropriate that a company should respond to this information by 2015 Breach Statistics Human Error Phishing/Malware External Device Employee Theft proposing an employee training program to familiarize employees with the risks of Phishing Scams and deceiving links. Rutrell Yasin, a writer for DarkReading.com, shows that only a surprisingly low percentage of Executives believe that Employee knowledge is a priority – and that 60% of executives interviewed would say their employees have little to no knowledge of security risks. (Yasin, 2016) Negligence to implement Employee Training programs from both Executives and Employees themselves cost businesses greatly, especially considering the earlier statistics of employee error being the top cause of security breaches.

Rutrell Yasin continues in his article to state that only 45% of organizations have mandatory training, but 29% of those courses from organizations are not mandatory. (Yasin, 2016) Additionally, many of these courses are not comprehensive, neglecting concepts such as cloud services, mobile device security, and even phishing attacks. (Yasin, 2016) Conclusion With Network Security being core to companies’ infrastructure and operations in the modern age, it should be alarming that employees are often the cause of breaches, and more importantly, that companies often fail to respond to these statistics. To maintain security, 0% 20% 40% 60% 80% 100% Executives in Favor of Priority Other Executives Executives Who Believe Employee Knowledge is a Priority vs Those Who Do Not Executives must not rely solely on the software and policies of the IT department, but ensure that all employees, regardless of department, be trained in good practices and how to avoid breaches.

The information presented in this memo is only a small portion of the available statistics regarding network breaches, but it should serve its purpose in presenting the core dangers of employee ignorance in regards to network security. Executives must be diligent in training their employees, for the benefit of the entire company. Bibliography Daugherty, W. (2016, Jan 6). Human Error Is to Blame for Most Breaches. Retrieved from Cyber Security Trend: to-blame-most-breaches.htm Yasin, R. (2016, May 24).

Employee Negligence The Cause Of Many Data Breaches. Retrieved from DarkReading: cause-of-many-data-breaches-/d/d-id/ Bibliography

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Understanding Medicare Advantage Organizations: Operations, Compliance, and Best Practices

Medicare Advantage Organizations (MAOs) operate as managed care entities that provide Medicare benefits to enrollees. As of October 2023, there were approximately 3,500 MA plans serving around 12 million beneficiaries, accounting for roughly 25% of the total Medicare population (Centers for Medicare & Medicaid Services [CMS], 2023). Given the increasing prevalence of these organizations, understanding their operations as well as the compliance frameworks that govern them is vital.

Operations of Medicare Advantage Organizations

MAOs are responsible for delivering a range of healthcare services to Medicare beneficiaries. These organizations must comply with structured guidelines set forth by the Medicare Managed Care Manual and the Office of Inspector General (OIG), particularly regarding compliance programs (Federal Register, 2023). The CMS oversees the activities of MAOs and sets forth stringent compliance requirements that organizations must adhere to, ensuring high-quality care while mitigating fraud, waste, and abuse (FWA).

Responsibilities Towards First Tier, Downstream, and Related Entities (FDRs)

One of the most crucial aspects of MAO operations is managing relationships with FDR entities. FDRs might include contractors that assist in various operational aspects such as claims processing, patient management, or other healthcare-related services. While MAOs can delegate certain tasks to FDRs, they retain ultimate responsibility for compliance functions (CMS, 2023). Thus, MAOs must prioritize installing robust mechanisms for monitoring and auditing these relationships to prevent compliance issues.

Compliance Programs and Their Elements

MAOs must implement compliance programs grounded in seven basic elements:
1. Policies, Procedures, and Standards of Conduct: A comprehensive code of conduct is essential to define expected ethical behavior for all employees and FDRs (CMS, 2023).
2. Compliance Officer and Committee: A full-time Compliance Officer should oversee compliance initiatives and report directly to senior management. Additionally, a compliance committee comprising multidisciplinary members is necessary to review compliance matters and foster accountability (CMS, 2023).
3. Effective Training and Education: Annual training programs focusing on FWA and general compliance are mandatory for all employees, managers, and board members. Therefore, organizations must ensure an ongoing training agenda that helps all stakeholders understand their specific roles in compliance (CMS, 2023).
4. Effective Lines of Communication: Open communication channels must exist between the Compliance Officer, Compliance Committee, and all employees to facilitate reporting of non-compliance or FWA incidents (Hoffman, 2021).
5. Well-Publicized Disciplinary Standards: Organizations should have clear disciplinary protocols for addressing misconduct to establish accountability throughout the workforce (CMS, 2023).
6. Routine Monitoring and Auditing: Continuous evaluation of compliance with CMS program requirements and assessing the effectiveness of compliance programs is crucial, allowing for proactive identification of risks (Hansen, 2022).
7. Prompt Response to Compliance Issues: MAOs need to have systems in place for addressing compliance violations and developing corrective action plans. This includes awareness of necessary reporting protocols to CMS when serious issues arise (CMS, 2023).

Importance of Compliance Programs

The compliance program's primary role is to create an ethical culture within the MAO that minimizes the potential for fraud and abuse. Historical data suggests that organizations lacking robust compliance measures are more frequent targets for audits and penalties (OIG, 2020). Furthermore, a well-established compliance framework reassures stakeholders and informs beneficiaries that their healthcare services are in line with federal regulations (CMS, 2023).

Data Analysis and Monitoring Conduct

Effective data analysis serves as an integral tool in monitoring operations, allowing MAOs to detect unusual patterns indicative of potential fraud. For instance, claims data analysis can identify outliers or billing anomalies that merit further investigation (Hansen, 2022). Establishing Special Investigation Units (SIUs) can provide additional scrutiny into suspected fraud cases, albeit such units should maintain separateness from the compliance program to uphold objectivity (CMS, 2023).

Self-Reporting and Corrective Actions

Self-reporting potential compliance violations or various FWA cases is encouraged. While voluntary, it is beneficial as it allows for corrective actions without the burden of a more severe penalty from regulatory authorities (CMS, 2023). A proactive approach in this regard not only fosters trust with regulators but can also lead to negotiated settlements that avoid long-term repercussions for the organization.

Effective Communication to Foster a Compliance Culture

To create a culture of compliance, it is essential for MAOs to establish multiple reporting channels where employees can confidentially report compliance violations or express concerns without fear of retaliation. Training about these reporting mechanisms should be a repeated theme within the organization (Hoffman, 2021). Ensuring confidentiality enhances participation and promotes a more open environment where employees feel comfortable addressing concerns promptly.

Conclusion

In summary, the operation of Medicare Advantage Organizations is multifaceted and requires a comprehensive understanding of compliance requirements, effective communication, and ongoing training. By monitoring relationships with FDRs and instituting robust internal controls, MAOs can navigate complexities inherent in Medicare regulations. The integration of compliance programs not only aids in mitigating risks concerning FWA but also reinforces the trust beneficiaries place in these organizations to deliver high-quality healthcare services.

References

1. Centers for Medicare & Medicaid Services. (2023). CMS Medicare Advantage trends. Retrieved from [CMS.gov](https://www.cms.gov/)
2. Federal Register. (2023). Medicare and Medicaid programs; Policy and technical changes to the Medicare Advantage and the Medicare Prescription Drug Benefit programs. Retrieved from [FederalRegister.gov](https://www.federalregister.gov/)
3. Hansen, L. (2022). The Importance of Data Analytics in Healthcare Compliance. Health Affairs, 41(5), 763-769.
4. Hoffman, A. (2021). Fostering Open Communication for Effective Compliance in Medicare Advantage. The Journal of Compliance and Ethics, 18(4), 15-22.
5. Office of Inspector General. (2020). Medicare Advantage Compliance Program Guidance. Retrieved from [OIG.hhs.gov](https://oig.hhs.gov/publications)
6. Medicare Managed Care Manual. (2023). Chapter 21 – Compliance Program Guidelines. Retrieved from [CMS.gov](https://www.cms.gov/manuals).
7. National Health Policy Forum. (2023). Medicare Advantage: An Overview. Retrieved from [nhpf.org](https://www.nhpf.org/library).
8. Tavenner, C. (2021). The Role of Compliance Programs in Medicare Advantage. Compliance Today, 18(5), 12-15.
9. United States Government Accountability Office. (2021). Medicare Advantage: Evidence on Premiums, Enrollment, and Quality. Retrieved from [GAO.gov](https://www.gao.gov/)
10. Hwang, C. (2022). Assessing Compliance Risks in Managed Care: A Strategic Approach. International Journal of Health Governance, 27(3), 244-261.