CMS requires an effective compliance program to include seven core requirements:
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Written Policies, Procedures, and Standards of Conduct These articulate the Sponsor’s commitment to comply with all applicable Federal and State standards and describe compliance expectations according to the Standards of Conduct.
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Compliance Officer, Compliance Committee, and High-Level Oversight The Sponsor must designate a compliance officer and a compliance committee accountable and responsible for the activities and status of the compliance program, including issues identified, investigated, and resolved by the compliance program. The Sponsor’s senior management and governing body must be engaged and exercise reasonable oversight of the Sponsor’s compliance program.
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Effective Training and Education This covers the elements of the compliance plan as well as preventing, detecting, and reporting FWA. Tailor this training and education to the different employees and their responsibilities and job functions.
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Effective Lines of Communication Make effective lines of communication accessible to all, ensure confidentiality, and provide methods for anonymous and good-faith compliance issues reporting at Sponsor and first-tier, downstream, or related entity (FDR) levels.
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Well-Publicized Disciplinary Standards Sponsor must enforce standards through well-publicized disciplinary guidelines.
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Effective System for Routine Monitoring, Auditing, and Identifying Compliance Risks Conduct routine monitoring and auditing of Sponsor’s and FDR’s operations to evaluate compliance with CMS requirements as well as the overall effectiveness of the compliance program.
NOTE: Sponsors must ensure FDRs performing delegated administrative or health care service functions concerning the Sponsor’s Medicare Parts C and D program comply with Medicare Program requirements. -
Procedures and System for Prompt Response to Compliance Issues The Sponsor must use effective measures to respond promptly to non-compliance and undertake appropriate corrective action.