Medicare fraud, waste, and abuse compliance program
Both Chapter 21 of the Medicare Managed Care Manual and Chapter 9 of the Prescription Drug Benefit Manual, collectively referred as the Compliance Program Guidelines and last revised on January 11, 2013, contain requirements mandating Medicare Advantage plans and standalone Part D plans to apply compliance training and communications, including fraud, waste and abuse (FWA) requirements, to first-tier, downstream, and related entities.
The Compliance Program Guidelines also instruct Medicare Managed Care plans and their contractors (first-tier), subcontractors (downstream), and other related business entities on how to implement the regulatory requirements under 42 Code of Federal Regulations (C.F.R.) §423.504(b)(4)(vi)(H), and how to implement a comprehensive FWA compliance plan to detect, correct, and prevent fraud, waste, and abuse.
Components of a comprehensive program to detect, prevent, and control Medicare Fraud, Waste, and Abuse are included as part of our General Compliance Plan Requirements.
Serra Medical Group prohibits fraud, waste, and abuse and is committed to responding appropriately in the event that potential or suspected fraud, waste, or abuse is committed by its employees, vendors, subcontractors, contracted providers, or business associates.
The Compliance Program Guidelines provisions are integrated into each element of Serra Medical Group’s existing Medicare Compliance Program. Serra Medical Group’s FWA Program is organized to follow the core elements of a compliance plan in accordance with the Office of the Inspector General’s (OIG) Guidelines.
Fraud, waste and abuse component elements
The core elements involved in developing the fraud, waste, and abuse component of Blue Shield Promise’s Medicare Compliance Program include:
- Written policies and procedures
Blue Shield Promise has developed policies and procedures, including a Standard of Conduct, demonstrating its compliance and commitment as an entity that is contracted with the federal government.
- Compliance Officer and Compliance Committee
- Training and education
Serra Medical Group provides computer-based-training (CBT) and paper training to its employees and temporary/contracted workforce members, so as to comply with regulations and assist in fraud, waste, and abuse prevention efforts. CBT training addresses pertinent laws related to fraud and abuse (e.g., Anti-Kickback Statute, False Claims Act, etc.) and includes a discussion of Medicare vulnerabilities identified by Centers for Medicare & Medicaid Services (CMS), the Office of the Inspector General (OIG), the Department of Justice, and other organizations. In addition, Serra Medical Group provider communications also provide information to raise awareness of its fraud, waste, and abuse compliance requirements for its contracted and subcontracted entities.
- Effective lines of communication
Serra Medical Group has established a hotline to receive, monitor, process, and resolve non-compliant activities. Report any suspected or potential fraud, waste, or abuse to Serra Medical Group via the following methods:
- Enforcement standards through well-publicized disciplinary guidelines
Serra Medical Group uses various avenues to encourage reporting of incidents of unethical or noncompliant behavior via annual mandatory general compliance training, newsletters, and department staff and committee meetings.
- Corrective action procedures
Serra Medical Group corrects and mitigates, within set timelines, noncompliant activities or violations committed and identified. Detailed Corrective Action Plans (CAPs) are used to describe the actions that will be taken, including a targeted timeframe, to correct and complete the identified non-compliance violation.