For the first time since 1999, the HHS OIG has released Industry Segment-Specific Compliance Program Guidance (“ICPG”) for Medicare Advantage. The guidance is directed towards a wide range of entities and individuals participating in or engaged with Medicare Advantage (“MA Parties”), including Medicare Advantage Organizations (“MAOs”). This guidance does not override the requirements for MAOs set forth in CMS’ Medicare Managed Care Manual. In addition, interested parties should use this new guidance in tandem with OIG’s General Compliance Program Guidance (“GCPG”) and implement OIG’s 7 elements of an effective compliance program.
The new Medicare Advantage ICPG identifies the following subjects as compliance risk areas:
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Access to Care (Network Adequacy and Prior Authorization)
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Marketing and Enrollment
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Risk Adjustment
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Quality of Care
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Oversight of Third Parties
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Compliance Programs within Vertically Integrated Organizations and Other Ownership Structures
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Submission of Accurate Claims
OIG clarifies that the absence of a previously identified risk area or consideration in the new Medicare Advantage ICPG does not signal that a risk no longer exists, has become irrelevant, or is otherwise inapplicable. This means the new ICPG does not automatically invalidate any previous guidance, including the original guidance from 1999. In addition, OIG guidance does not identify the only risk areas relevant to MA Parties. OIG does not intend for the guidance to replace MA Parties’ own compliance efforts, and recommends that they conduct their own individualized risk assessment and mitigation efforts.
Our compliance specialists at Nichols Weitzner Thomas LLP have decades of experience navigating CMS and OIG compliance. Nichols Weitzner Thomas LLP can help tailor comprehensive compliance plans to fit a client’s needs and ensure proper risk mitigation efforts are in place. Contact Nichols Weitzner Thomas LLP today for assistance with healthcare compliance matters.
