Medicare compliance training

Regence contracts with the Centers for Medicare & Medicaid Services (CMS) to provide health care services to Medicare members through our Medicare Advantage Plans and Medicare Part D prescription drug products, and the exchanges through the Qualified Health Plans (QHP). As a part of these contracts, CMS requires us to oversee our first tier, downstream, and related entities (FDRs) and Downstream and Delegated Entities (DDEs) that assist us in providing services for our Medicare and QHP beneficiaries. Examples of FDRs and DDEs include providers, producers, pharmacies, claims processors, health care facilities and other vendors who help us deliver benefits.

As an FDR in Regence Medicare Advantage and Part D plans or DDE in the QHP programs, you are an important partner in the continued success of our government programs. Payment received for services, are in whole or in part, from federal funds. As such, CMS requires FDRs/DDEs to participate in our government compliance program.

Regence provides you with the tools needed to ensure you meet the obligations under our government compliance program. We provide our standards of conduct, resources for reporting concerns or issues, and more.

Expectations

Fraud, waste, and abuse and general compliance training

Fraud, waste, and abuse and general compliance training should be completed by FDR/DDE employees within 90 days of hire and annually thereafter.

Completed certificates or training logs must be made available for review, upon request.

CMS may update these training modules on an annual basis. Ensure you are using the most current training by following the links above.

If you have any questions about whether your organization is required to complete these trainings, contact your Regence representative.

Code of business conduct and Medicare compliance principles

CMS expects Regence to share our standards of conduct and compliance principles with our FDRs/DDEs. We must ensure that our FDRs/DDEs adopt and follow either our or their own standards and principles that reflect a commitment to detecting, preventing and correcting noncompliance with Medicare requirements, including those regarding fraud, waste, and abuse.

Sample conflict of interest disclosure certification

CMS expects Regence to regularly audit conflict of interest certifications (COI) from our FDRs/DDEs. Regence requires upon-hire and annual completion of these certifications. This ensures that each FDR/DDE has effectively screened managers, officers and directors responsible for the administration or delivery of Medicare Advantage and Part D benefits and/or QHP program. Signed conflict of interest statements attest that the FDR/DDE staff is free from any conflict of interest in administering or delivering these benefits.

Completed COI disclosure forms must be made available for review, upon request.

OIG and GSA exclusion lists

All FDRs/DDEs must review the exclusion databases listed below prior to hire, and monthly thereafter, for current employees, officers and directors, board members, subcontractors, consultants and vendors, as applicable. You must notify Regence immediately if an exclusion is identified. Excluded persons or entities are prohibited from receiving payment.

Exclusion logs must include employee name, date each database was checked and whether or not an exclusion was found. These logs must be made available for review, upon request.

Review this FDR FAQ to determine if your Government Compliance program and documentation meet current guidelines.

Medicare program guidance may be reviewed in CMS Health Plan Management System (HPMS) memos. Access HPMS memos directly.

Member appeals and grievances

Members who indicate dissatisfaction to you or your employee regarding any aspect of their Medicare experience must be immediately directed to the health plan. If you are dealing directly with our Medicare members and receive a grievance and/or appeal request, send the member's name, member ID, date, time of contact and description of issue to:

Medicare Appeals and Grievances Department
PO BOX 12625
Mail Station S5D
Salem, OR 97309

FAX (888) 309-8784

Phone (866) 749-0355

Email: FAX_Medicare_Appeals_and_Grievances@regence.com

Reminder: Providing information that identifies a member is considered protected health information and must be sent in a secure format.

Ethics, compliance and fraud

Regence is committed to ethical business practices and complying with all Medicare requirements. This includes detecting, preventing and correcting fraud, waste, and abuse. If you have concerns about ethics, compliance or fraud, consult the following resources and report through one of these confidential options:

Anonymous reporting line: (888) 384-3577

Call (877) 878-2273 for questions or concerns related to:

Fraud, Waste, and Abuse: (800) 323-1693