Policy Policy Name: Compliance Training and Education Page: 1 of 6 Department: Medicare Compliance Policy Number: 3000_20M

Transcription

1 Policy Name: Compliance Training and Education Page: 1 of 6 PURPOSE: Pursuant to 42 CFR (b)(4)(vi), and (b)(4)(vi), Chapter 9 of the Medicare Prescription Drug Benefit Manual, and Chapter 21 of the Medicare Managed Care Manual, the Medicare Advantage plan (MCA) [here on out known as the Plan] is required to have an effective compliance program. The purpose of this document is to describe Medicare Compliance policies on requiring the completion of the annual Medicare Compliance training and education for all individuals that perform functions for the Plan. STATEMENT OF OBJECTIVE (Scope): This policy applies to the Plan employees, managers, governing body, and first tier, downstream, and related entities (FDR). Medicare Compliance will comply with all applicable Federal and State standards. Specifically, Medicare Compliance will adhere to standards for compliance training and education. DEFINITIONS: Employees Delegated Entity Governing body Medicare Compliance program Executive leadership, managers, employees and contingent workers employed by Aetna, supporting Mercy Care Advantage. A first tier, downstream or related (FDR) entity subcontracted to perform delegated functions on behalf of the health plan. The governing body is the Southwest Catholic Healthcare Network (SCHN) Board of Directors A formalized program of activities, training, policies and procedures designed, structured, and implemented to describe to objectives in meeting legal, regulatory, and contractual obligations for performing appointed responsibilities, and provide guidance for complying with federal, state, and local laws and regulations that apply to the services provided on behalf of the organization.

2 Policy Name: Compliance Training and Education Page: 2 of 6 POLICY: The Plan is committed to making Compliance a Core Competency for all employees and delegated entities. A key component to building and maintaining a culture of compliance is a strong program of education. Education and training begins with the annually required courses referenced below and is ongoing using different methods of communication. All employees who support the Plan, including the chief executive and senior administrators or managers; governing body members; and first tier, downstream, and related entities, are required to complete the Aetna Business Conduct and Integrity (BCI) Training, which includes the Aetna Code of Conduct, fraud, waste and abuse (FWA) training, and Corporate Compliance provisions upon hire and annually thereafter. Specialized training may be developed, delivered, and required based on an employee s job function and training needs as identified by Medicare Compliance and management to address operational and procedure requirements or education on regulatory and sub-regulatory requirements or a combination of both. In addition to the requirements set forth by Centers for Medicare and Medicaid Services (CMS) and the Office of Inspector General (OIG), the Plan must abide by the applicable provisions under Title 42 of the Code of Federal Regulations (CFR), Civil Rights Act, Age Discrimination Act, Rehabilitation Act of 1973 Genetic Information Nondiscrimination Act of 2008, and Americans with Disabilities Act. PROCEDURE: Aetna Business Conduct and Integrity (BCI) Training Employees-Under the Plan Management Services Agreement, executive leadership, managers, employees and contingent workers employed by Aetna, supporting the Plan will complete the Aetna Business Conduct and Integrity (BCI) Training at the time of hire and annually thereafter. The Aetna Business Conduct and Integrity (BCI) Training course contains an overall knowledge assessment, and must be completed with a mastery test score of at least 90% to reflect the requirement as complete. Aetna Corporate Compliance develops the training course and the course is administered via the Aetna Learning Center. Aetna Corporate Compliance also manages the training communication, monitoring of timely completion and maintenance of training records for audit purposes. Aetna Corporate Compliance notifies the Medicare Compliance Officer when an employee or contingent worker fails to complete training timely for required enforcement action. New hires and existing employees assigned to positions supporting Medicare products must complete the course within 7 days of hire/reassignment. New hire training completion is monitored monthly and reports are sent to Medicare Compliance identifying employees and delegates who have failed to complete this training timely. Medicare Compliance sends

3 Policy Name: Compliance Training and Education Page: 3 of 6 reminder notifications to employees and their respective manager when the course is not completed timely. Governing Body- Members of the Board of Directors complete the Code of Conduct applicable to the sponsoring organization they represent when appointed and annually thereafter. In addition, Compliance and FWA training will be provided to the members of the SCHN and MMIC governing body via a powerpoint training presentation prepared by the Medicare Compliance Officer. Medicare Compliance reviews and updates the training presentation on an annual basis. The Medicare Compliance Officer will distribute the training presentation to the existing governing body members electronically at the time of appointment and annually thereafter. The Medicare Compliance Officer will address questions related to the training provided. Existing governing body members are required to complete and return a training attestation to Medicare Compliance within 30-days of receiving the annual training for record maintenance. When changes to the members of the Board of Directors occur, Medicare Compliance will be notified by the internal Board of Directors Liaison. Medicare Compliance will provide newly appointed members with the required training electronically for completion within 90-days of appointment. Newly appointed governing body members will be required to complete and return a training attestation to Medicare Compliance within 30-days of receiving training for record maintenance. Delegated Entities- Delegated Entities- Delegated FDRs contracted to administer Part C and D benefits are provided with the Compliance and FWA training communication packet. The Compliance and FWA training communication packet includes copies of the Aetna Code of Conduct (COC), Medicare compliance policies, Medicare Compliance program, the Medicare Compliance Officer s contact information and instructions explaining how FDRs can access CMS FWA and General Compliance training module available on the CMS Medicare Learning Network. The Compliance and FWA training communication packet is provided to FDRs via electronic delivery at the time of contract and annually thereafter. FDRs have two (2) options for ensuring compliance with the general compliance and FWA training requirments: 1. FDRs can complete the web-based general compliance and FWA training modules located on the CMS Medicare Learning Network. 2. FDRs can incorporate the content of the CMS standardized training modules from the CMS website into their organizations existing training material. Contracted FDRs will be required to submit a completed Compliance and FWA attestation to the Medicare Compliance mailbox within 30 days of receipt for existing FDRs and within 60 days of receipt for new FDRs confirming their understanding and implementation of the required Compliance and FWA training, education and record retention requirements. The Delegation Oversight Committee, with support from the Medicare Compliance Officer is responsible to train and educate internal designated staff on the FDR contracting requirements. The Delegation Oversight Committee meets at least six times per year or more often as deemed necessary to track, monitor, and oversee contracted FDR arrangements with existing FDRs to validate performance results and compliance with applicable laws, rules and regulations with respect to Medicare Part C and D programs. The committee is also accountable to review and approve all new FDR arrangements proposed by the business. Timely delivery of the Compliance and FWA training communication packet and receipt of completed attestation forms

4 Policy Name: Compliance Training and Education Page: 4 of 6 will be tracked on the FDR Tracking Log maintained by the Delegation Oversight Committee. Copies of the communication sent to FDRs and completed FDR attestation forms will be maintained on the Delegation Committee Share Point site. FDRs are audited to confirm their ability to provide training dates and list of employees who completed the training. Additional Training: Model of Care (MOC) Training- As required under the Medicare Advantage Dual Eligible Special Needs Plan contract, the Plan is required to implement a Model of Care describing the following: Define Model of Care, Special Needs Plan, Interdisciplinary Team, and other terminology used Describe the targeted populations that meet the criteria for the Model of Care Review the SNP quality requirements based upon Medicare Improvements for Patients and Providers Act MIPPA regulations Recognize the key components that comprise the Model of Care Describe the integrated complex case management program Identify departments responsible for the management of the program Outline the benefits of this program for enrollees All employees, providers and delegates supporting the Plan are required to complete Model of Care training at time of hire and annually thereafter. CMS Training- Employees supporting the Plan contract are also required to take the following CMS online training courses: Part C Organization Determinations, Appeals & Grievance Part D Coverage Determinations, Appeals & Grievance OPERATING PROTOCOL: Systems Aetna Learning Center CMS Web-Based Training Portal Measurement Non-Applicable Reporting Aetna Corporate Compliance BCI Reporting

5 Policy Name: Compliance Training and Education Page: 5 of 6 Sales Management Agent Training Report Delegation Oversight Committee Project Log LEGAL/CONTRACT or SOURCE(S) REFERENCE: 42 CFR (b)(4)(vi), and (b)(4)(vi), 42 CFR (b) and 42 CFR (b) Medicare Compliance Program INTER-/INTRADEPENDENCIES: Internal Aetna Corporate and Aetna Medicare Compliance Medicare Compliance Employees Human Resources External Centers for Medicare and Medicaid Services First tier, downstream and related entities

6 Policy Name: Compliance Training and Education Page: 6 of 6 SIGNATURE ON FILE Mark Fisher Chief Executive Officer SIGNATURE ON FILE Charlton Wilson, MD Chief Medical Officer Reviewed and Revised: Date Reason for Review Revision Description 01/17 Annual review Update the FDR training requirements and removed related desktops and policy section 02/16 Annual Review Removal of MMA 11/15 Policy revised to reflect that we are no Revised policy by removing MMA. longer contracted with MMA. 3/15 Policy revised to incorporate changes required based on the CMS audit. Updated to the new policy template. QB 2818