medicare compliance checklist

Since 2008, the OIG Office of Evaluation and Inspections has conducted a series of studies regarding adverse events, defined as patient harm resulting from medical care. WebCMSrecommends that organizations review this checklist and take the necessary steps to ful fill requirements for the 2022 contract year. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. In this role, he has been involved in projects for product strategy, market and feasibility analyses, bid review, new health plan implementation, risk adjustment, revenue maximization, and financial reconciliations. Use your online accounts to monitor your coverage and claims, pay your bill, and find providers. How to join a Medicare Advantage plan. Make sure you know when your enrollment window begins and ends. With physical, occupational and speech therapy under review by Medicare auditors, its important to ensure the medical necessity of your services (With Payment Changes and Medicare Audits, Therapy Services End users do not act for or on behalf of the CMS. Secure .gov websites use HTTPSA portalId: "4332662", Kate is a Clinical Nurse Specialist with expertise in oncology and infectious diseases, and a focus on caring for vulnerable populations. This guide includes ways to measure the effectiveness of compliance programs. Anita has a proven track record in developing various quality assurance programs, public health online web-base, and written educational tools. If you miss an enrollment period, you may pay extra fees, and some of these penalties last as long as you have Medicare. 7500 Security Boulevard, Baltimore, MD 21244, An official website of the United States government, Part C and Part D Compliance and Audits - Overview, Pharmaceutical Manufacturer Enforcement Actions, 2023 Program Audit Process Overview (PDF), 2022 Program Audit Process Overview (PDF), Final Protocols for the Medicare Part C and Part D Program Audits and Industry-Wide Part C Timeliness Monitoring Project (CMS-10717) (ZIP), 2022 MMP Audit Protocols And Data Requests (ZIP), 2020 MMP Audit Protocols And Data Requests (ZIP), 2021 Program Audit Enforcement Report (PDF), 2020 Program Audit Enforcement Report (PDF), 2020 Medicare Parts C and D Program Audit Protocols (ZIP), Medicare Prescription Drug Eligibility and Enrollment, Medicare Managed Care Eligibility and Enrollment. WebBefore using the self-audit checklist, gather the following information and review the documentation: Licensespharmacist, intern, and technician; Pre-hire screening and With her varied background, she is able to work cross-departmentally to identify both opportunities and areas of risk. Jennifer brings GHG clients more than 20 years of experience as a HEDIS and health plan quality management professional, working with Medicare, Special Needs Plans, Commercial, Medicaid, and Exchange populations. Tina is certified in Compliance and Ethics from the Health Care Compliance Association. Youll also need to provide Social Security and Medicare with some information that proves youre eligible. However, the agency also conducts a teleconference with Sponsors to understand any potential challenges and obtain feedback about a plans process improvements to mitigate any risks or gaps in meeting obligations. His experience includes developing strategies and initiatives to optimize health plan and provider risk adjustment operations and ensure compliance with Federal and State regulations. He has been responsible for a variety of turnkey health initiatives spanning the continuum from HIPAA compliance to operational managed care initiatives for Medicare, Medicaid, Marketplace Co-Ops, and Commercial throughout the country. Youll need to take some actions when you first become eligible for Medicare. Measuring compliance program effectiveness is recommended by several authorities, including the United States Sentencing Commission. Before GHG, Sandy served in multiple Compliance and Regulatory Affairs roles with responsibility for creation and implementation of compliance programs, delegation oversight, risk assessments, monitoring and auditing, and creation of P&Ps. Contact GHG Advisors today to learn how we can help you be best prepared. NOTE: To access Program Audit Results data, please click on Program Audit Results in the left navigation pane. Further, Jean served as Senior Advisor in the Employer Operations and Policy Group, implementing employer provisions of the Medicare Modernization Act. Know that if you choose to enroll in Part D at a later date and go without Part D coverage, youll face a permanent late enrollment penalty. Audit Submission Checklist (XLSX) Audit Submission Checklist (PDF) 2022 MMP Audit Protocols And Data Requests (ZIP) 2020 MMP Audit Protocols And Data In addition to her expertise in Medicare, Miru has assisted the Medicaid and commercial books of business through quality initiatives for formulary testing/automation development, claim analytics, claim processing, and quality assurance of client migrations and implementations. Eric received his masters degree in Public Administration from New York University specializing in Healthcare Policy and a bachelors degree from Indiana University with a concentration in Health Administration. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements. Sponsors should carefully review the Checklist for regulatory changes and updates that may have occurred since the previous year. Contact GHG Advisors today to learn how we can help you be best prepared. You can skip down to the next section in the checklist. Angela was also a distinguished member of GHGs Enrollment and Reconciliation team, analyzing and resolving thousands of organization discrepancies, and working with clients Enrollment and Compliance teams to appropriately process beneficiary enrollment requests. Compliance and eligibility requirements apply to health practitioners who bill, claim, dispense and prescribe under the: Medicare Benefits Schedule (MBS) Pharmaceutical Benefits Scheme (PBS) Child Dental Benefits Schedule (CDBS) Practitioner Incentives Program (PIP). Compliance Programs O. 422.503 and 423.504 specify the requirements for Medicare Plans to implement an effective Compliance Program. While at GHG, Anita has guided plans in development and readiness for CMS audits, review of Models of Care and Chronic Care Improvement Programs. Cynthia Pawley-Martin is a Senior Clinical Consultant at GHG Advisors. WebTrying to understand the Medicare process can feel overwhelming. She has experience with CMS audit preparation, mock audits, and application filing. Clinical evaluation following enrollment in FFS Medicare, the beneficiary must have a F2F . 2. Jessica has been asked to speak at many national healthcare conferences on the topics of Star Ratings, social determinants of health, health plan operations, and beneficiary experience. In this role, he has designed and developed Medicare Advantage (MA) and Medicare-Medicaid provider networks and reimbursement strategies. John graduated from Seton Hall University and completed executive education programs at the University of North Carolina at Chapel Hill, Babson College, the Kellogg School of Management at Northwestern University, and the Center for Creative Leadership. Here are facts to help you decide. Jim Clark is a Senior Consultant with GHG Advisors. As a sales and marketing executive, Keitha drove a successful and sustainable $2 billion product suite serving Medicare, Individual, Small Group, and Federal Employee Program markets by developing new products and new sales distribution channels. While Summers background holds an overall emphasis in sales and marketing compliance, her forte has been agent/broker guidelines, certification and training requirements, and strategic compliance support to collaborative initiatives. This tool and others can be found on the Home Health Quick Resource Tools web page. Applications are available at the AMA website. All rights reserved. Kates past clinical experience includes acute inpatient, ambulatory care, home care/hospice, and specialty pharmacy. ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. Tina has also held management positions with several MAOs in the greater Los Angeles and Orange County markets. Official websites use .gov He managed the health plan strategy, redesign, and execution of a comprehensive end-to end risk adjustment program across Medicare Advantage, Medicaid, and ACA membership. Make sure your doctor and other providers accept Medicare. Is your MA Plan ready for 2021? Mirus comprehensive knowledge and proficiency with respect to Medicare Part D extends to formulary configuration and analysis, benefit design and testing, claims processing, data management, reporting, prescription drug event, member Explanation of Benefits, and other Medicare-required programs and audits. Bringing GHG clients 30+ years of experience with the Centers for Medicare & Medicaid Services (CMS), Jeans focus includes health policy and health care reform. The ACA also includes provisions intended to create a seamless, no wrong door, coordinated Medicare Part D, Make sure both plans fit into your budget. Tina is certified in Compliance and Ethics from the Health Care Compliance Association. Apply for coverage along with your initial enrollment in Medicare. Heres how you know. }); Jean LeMasurier is Senior Vice President of Public Policy at GHG. BY CLICKING BELOW ON THE BUTTON LABELED "I ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT. Prior to joining GHG, he enjoyed a diverse career providing interim executive outsourcing and short-term consulting services with emphasis in project planning and implementation, medical delivery, operations, sales, and marketing. Cheri brings GHG clients more than 10 years of experience in Medicare Advantage Operations. If the plan includes Part D coverage, make sure it covers any medications you take. She shares responsibility for leading GHGs efforts to advance the next generation of population health management and clinical innovation. Roshan also oversaw product design and worked with outside actuaries on bid development. An articulate interpreter of the complexities of todays healthcare environment, she navigates fluidly from strategy to execution and from the big picture to day-to-operations. WebMedicare Benefit Policy Manual, chapter 15, section 80.6.1, state that if the order for the clinical diagnostic test is unsigned, there must be medical documentation by the treating physician (e.g., a progress note) that he/she intended the Most recently she assisted plans with process improvements for Star Ratings in appeal and grievances. Use the Home Health Documentation Checklist Tool to ensure you have all the following documentation you need! Prior to joining GHG, Jessica led the Medicare, Marketplace and Medicaid Star Ratings Programs and Quality Ratings Systems for an independent, nonprofit health plan in Minnesota, successfully achieving 4-, 4.5- and 5-Star Ratings for multiple Medicare and Marketplace contracts and product lines. Her areas of experience include Medicare and State clinical operations compliance, managed care, case and disease management, quality management and improvement, clinical practice, and government audits. Stephen served as Interim President and Chief Executive Officer with direct responsibility and oversight for the development and implementation of several health plans in New York as well as plans in Louisiana, Dallas/Ft. He has held executive leadership with responsibility for P&L, strategic planning, revenue growth, product development and management, sales and marketing, vendor management, project management, compliance, and ancillary network contracting and quality. All Rights Reserved (or such other date of publication of CPT). portalId: "4332662", CPT is a trademark of the AMA. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. You may also want to research which Medicare parts you want and what coverage is available in your area before enrollment. If youre applying through your local office, you can visit in person or send them a letter with your name, your Social Security number, and the date youd like to enroll. portalId: "4332662", He has directed start-up operations for companies desiring to enter the Medicare Advantage market as well as service area expansions of existing plans. Apply for your selected Medigap plan and pay your first premium. Medicare covers most of the cost if you need a PET scan. 0 Jennifer Beckett is a Senior Consultant at GHG Advisors. Her areas of expertise include compliance, applications,audits, readiness, delegation oversight, marketing materials, bid development, new plan implementation as well as appeal and grievance expertise. Healthline Media does not recommend or endorse any third parties that may transact the business of insurance. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials. The Readiness Checklist is not only a great reminder for existing Sponsors, but is also an excellent guide for plans that are new to the MA market. Her leadership skills allow her to effectively communicate across all organizational levels and enables those teams to reach consensus among diverse stakeholders to deliver better services for GHG healthcare clients. All rights reserved. Tina Bailey began her tenure at GHG in 2011 and was appointed Vice President, Compliance Solutions in August 2018. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. There she was responsible for Medicare Advantage (MA) application review, and audit and oversight of MA plans and was part of CMS national teams who developed audit protocols and application requirements for Private Fee-for-Service contractors. She is fluent in developing the working tools and training programs for future success within the market and with CMS. Cheri Shortridge is a Senior Consultant at GHG Advisors. Also, applicable integrated plans should implement the integrated appeal and grievance processes and. WebThis Accountable Care Organization (ACO) checklist identifies top issues to consider early in the due diligence and negotiation process, and can serve as a guide to the terms of Debra Sullivan, Ph.D., MSN, R.N., CNE, COI, State Health Insurance Assistance Program (SHIP), Understanding Medicare enrollment periods, medicare.gov/sign-up-change-plans/get-started-with-medicare/join-a-plan/how-can-l-sign-up-for-medicare-and-choose-a-plan, medicare.gov/sign-up-change-plans/types-of-medicare-health-plans/medicare-advantage-plans/how-to-join-a-medicare-advantage-plan, medicare.gov/sign-up-change-plans/get-started-with-medicare/year-1-your-medicare-checklist.
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