Medicare Parts C and D General Compliance Training
January 2018
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Medicare Parts C and D General Compliance Training |
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Medicare Learning Network® |
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TABLE OF CONTENTS |
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TABLE OF CONTENTS
Medicare Parts C and D Compliance Training
Medicare Learning Network®
ACRONYMS
The following acronyms are used throughout the course.
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CFR |
Code of Federal Regulations |
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CMS |
Centers for Medicare & Medicaid Services |
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FDR |
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FWA |
Fraud, Waste, and Abuse |
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HHS |
U.S. Department of Health & Human Services |
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MA |
Medicare Advantage |
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MAO |
Medicare Advantage Organization |
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MA Prescription Drug |
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MLN |
Medicare Learning Network® |
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OIG |
Office of Inspector General |
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PDP |
Prescription Drug Plan |
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ACRONYMS
Medicare Parts C and D Compliance Training
Medicare Learning Network®
TITLE
TITLE PAGE
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TITLE
Medicare Parts C and D Compliance Training
Medicare Learning Network®
INTRODUCTION
INTRODUCTION PAGE 1
The Medicare Parts C and D General Compliance Training course is brought to you by the Medicare Learning Network®
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INTRODUCTION
Medicare Parts C and D Compliance Training
Medicare Learning Network®
INTRODUCTION PAGE 2
The Medicare Learning Network® (MLN) offers free educational materials for health care professionals on the Centers for Medicare
&Medicaid Services (CMS) programs, policies, and initiatives. Get quick access to the information you need.
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Publications & Multimedia |
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Events & Training |
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Newsletters & Social Media |
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Continuing Education |
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INTRODUCTION
Medicare Parts C and D Compliance Training
Medicare Learning Network®
INTRODUCTION PAGE 3
This training assists Medicare Parts C and D plan Sponsors’ employees, governing body members, and their
•42 Code of Federal Regulations (CFR) Section 422.503(b)(4)(vi)(C)
•42 CFR Section 423.504(b)(4)(vi)(C)
•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)
•The “Downloads” section of the CMS Compliance Program Policy and Guidance webpage
Completing this training in and of itself does not ensure a Sponsor has an “effective Compliance Program.” Sponsors and their FDRs are responsible for establishing and executing an effective compliance program according to the CMS regulations and program guidelines.
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42 Code of Federal Regulations (CFR) Section 422.503 |
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42 CFR Section 423.504 |
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bin/retrieveECFR?gp=&SID=5cff780d3df38cc4183f2802223859ba&mc=true&r |
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Chapter 9 of the Medicare Prescription Drug Benefit Manual |
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Chapter 21 of the Medicare Managed Care Manual |
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CMS Compliance Program Policy and Guidance webpage |
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INTRODUCTION
Medicare Parts C and D Compliance Training
Medicare Learning Network®
INTRODUCTION PAGE 4
Why Do I Need Training?
Every year, billions of dollars are improperly spent because of fraud, waste, and abuse (FWA). It affects
Compliance is everyone’s responsibility! As an individual who provides health or administrative services for Medicare enrollees, every action you take potentially affects Medicare enrollees, the Medicare Program, or the Medicare Trust Fund.
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INTRODUCTION
Medicare Parts C and D Compliance Training
Medicare Learning Network®
INTRODUCTION PAGE 5
Training Requirements: Plan Employees, Governing Body Members, and
Certain training requirements apply to people involved in Medicare Parts C and D. All employees of Medicare Advantage Organizations (MAOs) and Prescription Drug Plans (PDPs) (collectively referred to in this course as “Sponsors”) must receive training about compliance with CMS program rules.
You may need to complete FWA training within 90 days of your initial hire. More information on other Medicare Parts C and D compliance trainings and answers to common questions is available on the CMS website. Please contact your management team for more information.
Learn more about Medicare Part C
Medicare Part C, or Medicare Advantage (MA), is a health insurance option available to Medicare beneficiaries. Private,
MA plans must cover all services Medicare covers with the exception of hospice care. They provide Part A and Part B benefits and may also include prescription drug coverage and other supplemental benefits.
Learn more about Medicare Part D
Medicare Part D, the Prescription Drug Benefit, provides prescription drug coverage to Medicare beneficiaries enrolled in Part A and/or Part B who enroll in a Medicare Prescription Drug Plan (PDP) or an MA Prescription Drug
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Medicare Parts C and D compliance trainings and answers to |
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INTRODUCTION
Medicare Parts C and D Compliance Training
Medicare Learning Network®
INTRODUCTION PAGE 6
Navigating and Completing This Course
Anyone who provides health or administrative services to Medicare enrollees must satisfy general compliance and FWA training requirements. You may use this course to satisfy the general compliance training requirements.
This course consists of one lesson and a
do not successfully complete the course, you can review the course material and retake the
This course uses cues at various times to provide additional information and functionality. For more information on using these cues, adjusting your screen resolution, and suggested browser settings, select “HELP”.
You do not have to complete this course in one session; however, you must complete the lesson before exiting the course. You can complete the entire course in about 25 minutes. After you successfully complete this course, you receive instructions on how to print your certificate.
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INTRODUCTION
Medicare Parts C and D Compliance Training
Medicare Learning Network®
INTRODUCTION PAGE 7
Course Objectives
After completing this course, you should correctly:
•Recognize how a compliance program operates
•Recognize how compliance program violations should be reported
Select the “MAIN MENU” button to return to the Main Menu. Then, select “Lesson: Compliance Program Training.”
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INTRODUCTION
Medicare Parts C and D Compliance Training
Medicare Learning Network®
LESSON: COMPLIANCE PROGRAM TRAINING
LESSON PAGE 1
Introduction and Learning Objectives
This lesson outlines effective compliance programs. It should take about 15 minutes to complete.
After completing this lesson, you should correctly:
•Recognize how a compliance program operates
•Recognize how compliance program violations should be reported
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LESSON: COMPLIANCE PROGRAM TRAINING
Medicare Parts C and D Compliance Training
Medicare Learning Network®
LESSON PAGE 2
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 must:
•Articulate and demonstrate an organization’s commitment to legal and ethical conduct
•Provide guidance on how to handle compliance questions and concerns
•Provide guidance on how to identify and report compliance violations
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LESSON: COMPLIANCE PROGRAM TRAINING
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LESSON PAGE 3
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
•Is fully implemented and is tailored to an organization’s unique operations and circumstances
•Has adequate resources
•Promotes the organization’s Standards of Conduct
•Establishes clear lines of communication for reporting
An effective compliance program is essential to prevent, detect, and correct Medicare
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LESSON: COMPLIANCE PROGRAM TRAINING
Medicare Parts C and D Compliance Training
Medicare Learning Network®
LESSON PAGE 4
Seven Core Compliance Program Requirements
CMS requires an effective compliance program to 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
The Sponsor must designate a compliance officer and a compliance committee 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 preventing, detecting, and reporting FWA. Tailor this training and education to the different employees and their responsibilities and job functions.
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LESSON: COMPLIANCE PROGRAM TRAINING
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Medicare Learning Network®
LESSON PAGE 5
Seven Core Compliance Program Requirements (continued)
4.Effective Lines of Communication
Make effective lines of communication accessible to all, ensure confidentiality, and provide methods for anonymous and good- faith compliance issues reporting at Sponsor and
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Sponsor must enforce standards through
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 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
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LESSON: COMPLIANCE PROGRAM TRAINING
Medicare Parts C and D Compliance Training
Medicare Learning Network®
LESSON PAGE 6
Compliance Training: Sponsors and Their FDRs
CMS expects all Sponsors will apply their training requirements and “effective lines of communication” to their FDRs. Having “effective lines of communication” means employees of the Sponsor and the Sponsor’s FDRs have several avenues to report compliance concerns.
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LESSON: COMPLIANCE PROGRAM TRAINING
Medicare Parts C and D Compliance Training
Medicare Learning Network®
LESSON PAGE 7
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
•Report suspected violations
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LESSON: COMPLIANCE PROGRAM TRAINING
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Medicare Learning Network®
LESSON PAGE 8
How Do You Know What Is Expected of You?
Now that you’ve read the general ethical guidelines on the previous page, how do you know what is expected of you in a specific situation?
Standards of Conduct (or Code of Conduct) state the organization’s compliance expectations and their operational principles and values. Organizational Standards of Conduct vary. The organization should tailor the Standards of Conduct content to their individual organization’s culture and business operations. Ask management where to locate your organization’s Standards of Conduct.
Reporting Standards of Conduct violations and suspected
An organization’s Standards of Conduct and Policies and Procedures should identify this obligation and tell you how to report suspected
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LESSON: COMPLIANCE PROGRAM TRAINING
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LESSON PAGE 9
What Is
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Agent/broker misrepresentation |
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Ethics |
• Appeals and grievance review (for example, coverage |
• FDR oversight and monitoring |
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• Health Insurance Portability and Accountability Act |
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Beneficiary notices |
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Conflicts of interest |
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Marketing and enrollment |
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Claims processing |
• Pharmacy, formulary, and benefit administration |
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Credentialing and provider networks |
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Quality of care |
•Documentation and Timeliness requirements
For more information, refer to the Compliance Program Guidelines in the Medicare Prescription Drug Benefit Manual and Medicare Managed Care Manual.
Know the Consequences of
Failure to follow Medicare Program requirements and CMS guidance can lead to serious consequences, including:
•Contract termination
•Criminal penalties
•Exclusion from participating in all Federal health care programs
•Civil monetary penalties
Additionally, your organization must have disciplinary standards for
•Mandatory training or
•Disciplinary action
•Termination
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LESSON: COMPLIANCE PROGRAM TRAINING
Medicare Parts C and D Compliance Training
Medicare Learning Network®
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Medicare Prescription Drug Benefit Manual |
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Medicare Managed Care Manual |
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LESSON: COMPLIANCE PROGRAM TRAINING
Medicare Parts C and D Compliance Training
Medicare Learning Network®
LESSON PAGE 10
Without programs to prevent, detect, and correct
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 copayments
•Higher premiums
•Lower benefits for individuals and employers
•Lower Star ratings
•Lower profits
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LESSON: COMPLIANCE PROGRAM TRAINING
Medicare Parts C and D Compliance Training
Medicare Learning Network®
LESSON PAGE 11 |
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How to Report Potential |
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Employees of a Sponsor |
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Don’t Hesitate to Report |
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• Call the Medicare Compliance Officer |
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When you report suspected |
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• Make a report through your organization’s website |
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good faith, the Sponsor can’t retaliate against you. |
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• Call the Compliance Hotline |
Each Sponsor must offer reporting methods that |
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• Talk to a Manager or Supervisor |
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• Call your Ethics/Compliance Help Line |
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• Report to the Sponsor |
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Beneficiaries |
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•Call the Sponsor’s Compliance Hotline or Customer Service
•Make a report through the Sponsor’s website
•Call
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LESSON: COMPLIANCE PROGRAM TRAINING
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LESSON PAGE 12
What Happens After
Internal monitoring should ensure:
•No recurrence of the same
•Ongoing CMS requirements compliance
•Efficient and effective internal controls
•Protected enrollees
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LESSON: COMPLIANCE PROGRAM TRAINING
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Medicare Learning Network®
LESSON PAGE 13
What Are Internal Monitoring and Audits?
Internal monitoring activities include regular reviews confirming ongoing compliance and taking effective corrective actions.
Internal auditing is a formal review of compliance with a particular set of standards (for example, policies, procedures, laws, and regulations) used as base measures.
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LESSON: COMPLIANCE PROGRAM TRAINING
Medicare Parts C and D Compliance Training
Medicare Learning Network®
LESSON PAGE 14 |
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Lesson Summary |
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Compliance Is Everyone’s Responsibility! |
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Organizations must create and maintain compliance programs that, at a |
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minimum, meet the seven core requirements. An effective compliance program |
Prevent: Operate within your organization’s |
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fosters a culture of compliance. |
ethical expectations to prevent |
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To help ensure compliance, behave ethically and follow your organization’s |
Detect & Report: Report detected potential non- |
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Standards of Conduct. Watch for common instances of |
compliance! |
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report suspected |
Correct: Correct |
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Know the consequences of |
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beneficiaries and save money! |
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compliance with a corrective action plan that includes ongoing monitoring and |
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auditing. |
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LESSON: COMPLIANCE PROGRAM TRAINING
Medicare Parts C and D Compliance Training
Medicare Learning Network®
LESSON PAGE 15
Lesson Review
Now that you completed the lesson, let’s do a quick knowledge check. The
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LESSON: COMPLIANCE PROGRAM TRAINING
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LESSON PAGE 16
Knowledge Check
Select the correct answer.
You discover an unattended email address or fax machine in your office receiving beneficiary appeals requests. You suspect no one is processing the appeals. What should you do?
○A. Contact law enforcement
○B. Nothing
○C. Contact your compliance department (via compliance hotline or other mechanism)
○D. Wait to confirm someone is processing the appeals before taking further action
○E. Contact your supervisor
CORRECT
ANSWER
C
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LESSON: COMPLIANCE PROGRAM TRAINING
Medicare Parts C and D Compliance Training
Medicare Learning Network®
LESSON PAGE 17
Knowledge Check
Select the correct answer.
A sales agent, employed by the Sponsor’s
○A. Refuse to change the date or waive the premiums but decide not to mention the request to a supervisor or the compliance department
○B. Make the requested changes because the sales agent determines the beneficiary’s start date and monthly premiums
○C. Tell the sales agent you will take care of it but then process the application properly (without the requested
○D. Process the application properly (without the requested
○E. Contact law enforcement and the Centers for Medicare & Medicaid Services (CMS) to report the sales agent’s behavior
CORRECT
ANSWER
D
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LESSON: COMPLIANCE PROGRAM TRAINING
Medicare Parts C and D Compliance Training
Medicare Learning Network®
LESSON PAGE 18
Knowledge Check
Select the correct answer.
You work for a Sponsor. Last month, while reviewing a Centers for Medicare & Medicaid Services (CMS) monthly report, you identified multiple individuals not enrolled in the plan but for whom the Sponsor is paid. You spoke to your supervisor who said don’t worry about it. This month, you identify the same enrollees on the report again. What should you do?
○A. Decide not to worry about it as your supervisor
○B. Although you know about the Sponsor’s
○C. 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
○D. Contact law enforcement and CMS to report the discrepancy
○E. Ask your supervisor about the discrepancy again
CORRECT
ANSWER
B
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LESSON: COMPLIANCE PROGRAM TRAINING
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LESSON PAGE 19
Knowledge Check
Select the correct answer.
You are performing a regular inventory of the controlled substances in the pharmacy. You discover a minor inventory discrepancy. What should you do?
○A. Call local law enforcement
○B. Perform another review
○C. Contact your compliance department (via compliance hotline or other mechanism)
○D. Discuss your concerns with your supervisor
○E. Follow your pharmacy’s procedures
CORRECT
ANSWER
E
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LESSON: COMPLIANCE PROGRAM TRAINING
Medicare Parts C and D Compliance Training
Medicare Learning Network®
LESSON PAGE 20
You’ve completed the lesson!
Now that you have learned about compliance programs, it’s time to assess your knowledge. Select the “MAIN MENU” button to return to the course Main Menu. Then, select
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LESSON: COMPLIANCE PROGRAM TRAINING
Medicare Parts C and D Compliance Training
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This brief
Choose an answer for each question by selecting the button next to your answer. You must select an answer before advancing to the next question. You can only move forward in the
You may print your score when you finish the
Select the “NEXT” button to begin the
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Medicare Parts C and D Compliance Training
Medicare Learning Network®
Question 1 of 10
Select the correct answer.
Compliance is the responsibility of the Compliance Officer, Compliance Committee, and Upper Management only.
○A. True
○B. False
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Medicare Parts C and D Compliance Training
Medicare Learning Network®
Question 2 of 10
Select the correct answer.
Ways to report a compliance issue include:
○A. Telephone hotlines
○B. Report on the Sponsor’s website
○C.
○D. All of the above
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Medicare Parts C and D Compliance Training
Medicare Learning Network®
Question 3 of 10
Select the correct answer.
What is the policy of
○A. Allows the Sponsor to discipline employees who violate the Code of Conduct
○B. Prohibits management and supervisor from harassing employees for misconduct
○C. Protects employees who, in good faith, report suspected
○D. Prevents fights between employees
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Medicare Parts C and D Compliance Training
Medicare Learning Network®
Question 4 of 10
Select the correct answer.
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.
○A. True
○B. False
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Medicare Parts C and D Compliance Training
Medicare Learning Network®
Question 5 of 10
Select the correct answer.
Once a corrective action plan begins addressing
○A. True
○B. False
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Medicare Parts C and D Compliance Training
Medicare Learning Network®
Question 6 of 10
Select the correct answer.
Medicare Parts C and D plan Sponsors are not required to have a compliance program.
○A. True
○B. False
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Medicare Parts C and D Compliance Training
Medicare Learning Network®
Question 7 of 10
Select the correct answer.
At a minimum, an effective compliance program includes four core requirements.
○A. True
○B. False
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Medicare Parts C and D Compliance Training
Medicare Learning Network®
Question 8 of 10
Select the correct answer.
Standards of Conduct are the same for every Medicare Parts C and D Sponsor.
○A. True
○B. False
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Medicare Parts C and D Compliance Training
Medicare Learning Network®
Question 9 of 10
Select the correct answer.
Correcting
○A. Protects enrollees, avoids recurrence of the same
○B. Ensures bonuses for all employees
○C. Both A. and B.
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Medicare Parts C and D Compliance Training
Medicare Learning Network®
Question 10 of 10
Select the correct answer.
What are some of the consequences for
○A. Disciplinary action
○B. Termination of employment
○C. Exclusion from participating in all Federal health care programs
○D. All of the above
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Medicare Parts C and D Compliance Training
Medicare Learning Network®
APPENDIX A: RESOURCES
RESOURCES PAGE 1 OF 1
Disclaimers
This
This course was prepared as a service to the public and is not intended to grant rights or impose obligations. This 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).
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APPENDIX A: RESOURCES
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Glossary
For glossary terms, visit the Centers for Medicare & Medicaid Services Glossary.
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Centers for Medicare & Medicaid Services Glossary |
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APPENDIX A: RESOURCES
Medicare Parts C and D Compliance Training
Medicare Learning Network®
APPENDIX B: JOB AIDS
Job Aid A: Seven Core Compliance Program Requirements
The Centers for Medicare & Medicaid Services (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
The Sponsor must designate a compliance officer and a compliance committee to 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 fraud, waste, and abuse (FWA). This training and education should be tailored to the different responsibilities and job functions of employees.
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
5.
Sponsor must enforce standards through
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 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
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APPENDIX B: JOB AIDS
Medicare Parts C and D Compliance Training
Medicare Learning Network®
Job Aid B: Resources
Compliance Education Materials: Compliance 101
Health Care Fraud Prevention and Enforcement Action Team Provider Compliance Training
Office of Inspector General’s (OIG’s) Provider
Part C and Part D Compliance and Audits - Overview
Avoiding Medicare Fraud & Abuse: A Roadmap for Physicians
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Compliance Education Materials: Compliance 101 |
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Health Care Fraud Prevention and Enforcement Action Team |
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Provider Compliance Training |
Office of Inspector General’s (OIG’s) Provider |
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Part C and Part D Compliance and Audits - Overview |
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Physician |
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Avoiding Medicare Fraud & Abuse: A Roadmap for Physicians |
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Safe Harbor Regulations |
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APPENDIX B: JOB AIDS