For many organizations it is difficult to know what training to take to ensure compliance with government requirements. Fraud, Waste and Abuse and Corporate Compliance training requirements are often misunderstood.
The Centers for Medicare & Medicare Services (CMS) provided Additional Guidance Compliance Program Training Requirements and Audit Process Update in a 2016 letter to "All Medicare Advantage Organizations and Prescriptions Drug Plan Sponsors." According to the letter:
CMS continues to receive inquiries and concerns from sponsors and first tier, downstream and related entities (FDR) regarding the difficulties with adopting CMS' compliance training module to satisfy the compliance program training requirement. Many Medicare Advantage (Part C) and Part D Sponsors identify most or all of their vendors as FDRs requiring Medicare compliance training. In addition, each of those sponsors has organization or FDR-specific compliance training that they require their contracted entities to take as a term of their contract. Therefore, FDRs are still being subjected to multiple compliance trainings, but now have an additional burden of taking CMS training and reporting completion back to the sponsor or sponsors with whom they contract. Therefore, the industry has indicated that the requirement implemented intending to reduce the training burden has instead potentially increased the burden for some providers and sponsors.
Compliance Program Training Requirements
According to CMS sponsors (e.g. insurance companies) must ensure their FDRs (e.g. healthcare providers) receive general compliance training as well as fraud, waste, and abuse (FWA) training. The CMS compliance program training was designed to ensure: (1) Sponsors' FDRs have at least a basic knowledge and understanding of compliance program requirements; and, (2) Sponsors' FDRs are knowledgeable about compliance and FWA issues and how to appropriately address them. CMS developed a web-based compliance training module, which was recently redesigned.
Further, the general compliance and FWA training courses offer the ability to provide separate content for compliance and FWA, and provide web-based and downloadable versions. The training content is generic since various entities (e.g., health plans, labs, hospitals, etc.) complete the training. A certificate of completion is generated upon passing a short test with a score of 70% or higher at the end of the training module. It's important to note the training content cannot be modified; however, CMS will allow modifications to the appearance of the content.
Sponsors discretion
The guidance from CMS makes it clear: sponsors are ultimately responsible for determining if FDRs have completed required CMS compliance and FWA training requirements:
At the Sponsor's request, FDRs must submit an attestation confirming that the organization has completed the appropriate general compliance and FWA training. Attestations must include language specifying the entity complies with CMS compliance and FWA training requirements and the training provided includes CMS content. The format of the attestation may vary depending on the Sponsor. FDRs should check with Sponsors for options on how to submit attestations, as the sponsor may have a specific process or document to be completed.
Clearing up the confusion
To help clear up any confusion, Healthcare Compliance Pros offers CMS Corporate Compliance training that is unmodified and satisfies CMS requirements. The following will help you determine if CMS Corporate Compliance training should be completed by your practice.
- Does your practice work with Medicare Part A, Part B, Part C or Part D?
- Yes, we work one or more Medicare plans. If you select this option, go to question 2.
- No, we do not work with any Medicare Plans. If you select this option, please see Alternate Training Option below
- Does your practice only work with Medicare Part C and/or Part D?
- Yes, we only work with Part C and/or Part D. If you selected this option, you should complete the CMS Corporate Compliance training module. FWA and general Compliance Training should be completed at the time of hire and at least annually thereafter to ensure compliance with CMS and plan sponsor requirements.
- No, we accept other Medicare plans. If you select this option, go to question 3.
- Does your practice only work with Medicare Parts A or B? Or does your practice work with a combination such as Medicare Parts B, C and D?
- Yes, we only work with Medicare Parts A or B.
- Yes, we work with a combination including Medicare Part B, in addition to Part C and/or Part D.
Deeming Exception: If your organization only works with Medicare Parts A or B, or if your organization works with a combination including Medicare Part B, in addition to Part C and/or Part D, you are deemed to have met the FWA training and education certification requirements through enrollment into Parts A or B of the Medicare program; the same is true through accreditation as a supplier of DMEPOS.
IMPORTANT: you must still complete C and D General Compliance training.
Alternate Training Option
If your organization does not work with Medicare Parts A, B, C or D you may choose to have your employees complete the standard Corporate Compliance training module.
CMS examples of who should be required to fulfill training requirements
The following are examples of critical roles within an FDR that should be required to fulfill training requirements; however, sponsors are responsible for providing the final determination.
Senior administrators or managers directly responsible for the FDR's contract with the Sponsor (e.g. Senior Vice President, Departmental Managers, Chief Medical or Pharmacy Officer);
Individuals directly involved with establishing and administering the Sponsor's formulary and/or medical benefits coverage policies and procedures;
Individuals involved with decision-making authority on behalf of the Sponsor (e.g. clinical decisions, coverage determinations, appeals and grievances, enrollment/disenrollment functions, processing of pharmacy or medical claims);
Reviewers of beneficiary claims and services submitted for payment; or,
Individuals with job functions that place the FDR in a position to commit significant noncompliance with CMS program requirements or health care FWA.
Training must be completed within 90 days of initial hiring and annually thereafter (e.g. between January 1 and December 31 of any given contract year.
Conclusion
If your organization works with Medicare Parts C and D, and you are not enrolled into Parts A or B of the Medicare program or throw accreditation as a supplier of DMEPOS, the entire CMS Corporate Compliance training module, including FWA and general compliance training, should be completed at time of hire and annually thereafter. Because the sponsor has the ultimate say, to ensure compliance, you should have all employees involved with your contract with the plan sponsor, anyone involved with patient care who contributes to a claim being submitted to Medicare, and anyone who may be in noncompliance or potential health care FWA with CMS Medicare requirements.
If your organization only works with Medicare Parts A or B, or if your organization works with a combination including Medicare Part B, in addition to Part C and/or Part D, to ensure compliance we recommend completing the FWA training at the time of hire, or during the first year of enrollment; then at the very least, completing general compliance training at least annually thereafter. You may also opt to complete the entire CMS Corporate Compliance training module to ensure compliance with Sponsor requirements.