Compliance Corner

Garity Advantage Annual Downline Compliance


 

Background

The Centers for Medicare & Medicaid Services (CMS) requires that we communicate general compliance program information and requirements, as well as provide training and education and monitor specific Compliance and Fraud, Waste and Abuse (FWA) requirements to our employees, first tier, downstream, and related entities. (FDR)

Action Required

Review the following compliance and FWA requirements now to make sure you, your employees and any applicable affiliate organizations meet all the requirements. Employees are defined as hired staff, management and temporary workers for your company or subcontractors that have involvement in or responsibility for a core function in the administration or delivery of Medicare Advantage Part C, Part D, or Medicaid health plan benefits and have access to personal health information/personally identifiable information (PHI/PII).

  • Code of Conduct Distribution

    Downline Entities must distribute their own written policies, procedures or standards of conduct or the GarityAdvantage Code of Conduct to employees who support the administration or delivery of program benefits or services.

    • Must be distributed within 90 days of hire and annually thereafter.
    • Downline Entities must retain proof of distribution for each
    • Resource: Generic Code of Conduct
  • FWA and General Compliance Training Completion

    All FDR’s are required to know, understand and follow all FWA and General Compliance regulations and requirements.

    We all have the obligation to combat FWA and should be aware of how to identify and report FWA and non- compliance  – if you need assistance in training, or more info on FWA and general compliance guidance, please review the information provided on these website.

  • OIG/GSA/State Exclusion Checks
    CMS and other federal and state regulators prohibit you from hiring, employing or making payments to any person or business excluded or debarred from federal or state health care programs. You are only required to complete these pre-hire and monthly exclusion checks on your non-agent staff and Medicare Supplement only agents. This could include your administrative staff and others who are not licensed. Failure to perform checks against the Office of Inspector General (OIG), General Services Administration (GSA) federal exclusion and state exclusion lists prior to hire and monthly thereafter are not in compliance with applicable laws, regulations and guidance.

    If you sell products that service Medicaid program memberships (for example DSNP products), you may also be required to check additional State exclusion lists.  Not all States have this requirement, however if you sell to members, or have employees who reside in a State that has this additional requirement you must check all applicable lists both prior to hire and monthly thereafter. Please note that you must check the states where both the Member and Employee reside, so if you have employees in one State, but sell to members in multiple states, you must check your employees against all States you sell in that have this requirement regardless of where your employees are located.

    Resources:

    1. Health and Human Services Office of Inspector General List of Excluded Individuals and Entities (LEIE)
    2. General Services Admission (GSA) System for Award Management (SAM)
  • Exclusion review requirement: is listed under Title 42 Public Health CFR §1001.1901(b). The state exclusion list requirement is listed under Title 42 Public Health CFR 1002.2; Authority also includes applicable state law and state Medicaid contracts.

  • Notification of All Offshoring ‒ Requires you contact us for approval prior to sharing members’ protected health information (PHI) with an offshore third

    Reporting Medicare: To report Medicare offshoring, email kfennessy@garityadvantage.com.

  • Document Retention ‒ You must keep all CMS documentation a minimum of 10

  • Monitoring and/or Auditing of Subcontracted Delegates/Vendors ‒ Downstream entities or subcontractors that support the delivery or administration of program benefits or services are held to the same Compliance Program requirements.

Reporting a CMS Violation

If you suspect misconduct or identify an excluded individual, report it to us immediately so we may investigate and respond appropriately. Go to GarityAdvantage.com/compliancecorner and click on “report a CMS violation”. This is an anonymous communication and GarityAdvantage prohibits retaliation for reports made in good faith.

 

GarityAdvantage

Compliance Team

17 Accord Park Drive | Norwell, MA 02066

Email: kfennessy@garityadvantage.com