2012 Compliance: Fraud, Waste and Abuse (training - Ubhonline.com

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Overview, cont. • Contracted Entity Definitions: – First Tier: Any party that enters into a written agreement with a plan sponsor to provide administrative or health care services for a Medicare eligible individual under Medicare Advantage or Part D programs. • Examples include, but are not limited to: pharmacy benefit manager (PBM), contracted hospitals or providers. – Downstream: Any party that enters into a written agreement below the level of the arrangement between a sponsor and a first tier entity for the provision of administrative or health care services for a Medicare eligible individual under Medicare Advantage or Part D programs. • Examples include, but are not limited to: pharmacies, claims processing firms, billing agencies. – Related: Any entity that is related to the sponsor by common ownership or control and 1) performs some of the sponsor’s management of functions under a contract of delegation, 2) furnishes services to Medicare enrollees under an oral or written agreement, or 3) leases real property or sells materials to the sponsor at a cost of more than $2500 during a contract period. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 6
Compliance Expectations
Page 1 and 2: 2012 Compliance Fraud, Waste and Ab
Page 3 and 4: Overview, cont. • In regulations
Page 5: Overview, cont. • If you or your
Page 9 and 10: CMS Role and Definition • The Cen
Page 11 and 12: Seven Elements of an Effective Comp
Page 13 and 14: Effective Lines of Communication
Page 15 and 16: Exclusion and Debarment Review Requ
Page 17 and 18: CMS MLN FWA Training Materials
Page 19 and 20: Optum FWA Training Materials
Page 21 and 22: Fraud, Waste, and Abuse Policies
Page 23 and 24: Pertinent Laws and Regulations •
Page 31 and 32: Examples of Fraud, Waste, and Abuse
Page 33 and 34: Examples of Fraud, Waste, and Abuse
Page 35 and 36: Additional Resources • CMS’ Pre
Page 37 and 38: ANSWERS - Quiz and Self Assessment
Page 39: Documentation Requirements Attentio

2012 Compliance: Fraud, Waste and Abuse (training - Ubhonline.com

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