Ritter Insurance Marketing, Craig Ritter

2016 Medicare Parts C & D Audit & Enforcement Findings

Last Tuesday, the Centers for Medicare and Medicaid Services (CMS) released their 2016 Medicare Parts C and Part D Program Audit and Enforcement Report.

This report summarizes the audit findings on carriers’ Compliance Program Effectiveness (CPE), Part D Formulary and Benefit Administration (FA), Part D Coverage Determinations, Appeals, and Grievances (CDAG), Part C Organization Determinations, Appeals, and Grievances (ODAG), and Special Needs Plans Model of Care (SNP-MOC).

Agents and agencies should be aware that the most commonly cited deficiencies related to carriers’ CPE in 2016 were:

  1. Sponsor did not review OIG/GSA exclusion lists prior to hire and monthly after for new employees, temporary employees, volunteers, consultants, or governing body members.
  2. Sponsor did not provide evidence of it auditing the effectiveness of its compliance program at least annually and that the results are shared with the governing body.
  3. Sponsor did not establish, implement, and provide timely and effective compliance and Fraud, Waste and Abuse (FWA) training and education to their employees.
  4. Sponsor did not establish and implement effective lines of communication for confidential and anonymous reporting of potential compliance and FWA issues.
  5. Sponsor did not conduct monitoring and/or auditing of first tier entities to ensure they fulfill compliance requirements.

What This Means for You

These findings may trigger more First Tier, Downstream, and Related Entity (FDR) auditing activities by carriers, which may trickle down to those below the FMO level. To stay compliant, all downstream entities (e.g, Ritter’s downline agencies) must ensure they do the following:

  1. Disseminate either the applicable insurance company’s Code of Business Conduct (COBC) or its own comparable COBC and/or compliance program policies to all employees within 90 days of hire, upon revision, and annually thereafter.
    • Such information should include how to report suspected or detected non-compliance or potential fraud, waste, and abuse matters.
    • You may request employees report concerns either directly to the applicable insurance company, to your own organization’s reporting mechanisms, or to your FMO.
  2. Review the DHHS OIG List of Excluded Individuals and Entities (LEIE List) and the GSA Excluded Parties List System (EPLS) prior to hiring non-agent employees, management, temporary workers, or subcontractors, if applicable, and monthly during the term thereafter to ensure these persons are not on these exclusion lists.
    • You must retain documentation that confirms the screening was conducted.
    • If your supporting staff members are licensed insurance agents who are appointed with the specific insurance companies your agency supports and your agency does not have any other non-licensed staff/contractors, this requirement is met as contracted agents are required to be screened as part of the agent onboarding process.
  3. Provide and document Medicare General Compliance and FWA training for their non-agent employees, management, temporary workers, or subcontractors, if applicable.
    • Downstream entities must utilize the training content located on the CMS Medicare Learning Network to satisfy the General Compliance and FWA training requirements.
    • If your supporting staff members are licensed insurance agents who are appointed with the specific insurance companies your agency supports and your agency does not have any other non-licensed staff/contractors, this requirement is met as contracted agents are required to be screened as part of the agent onboarding process.
  4. Avoid offshoring any of their Medicare Advantage activities unless prior approval is obtained from the insurance company.
  5. Oversee all third parties you use to support any of your FMO contracts.

Ritter agents can find additional information on how to stay compliant with CMS’ regulations at by logging in to RitterIM.com and clicking on the “Compliance” tab.

Posted by filed under CMS, Medicare .


© Ritter Insurance Marketing