Non-compliance is conduct that does not conform to the law, Federal health care program requirements, or an organization’s ethical and business policies. CMS identified the following Medicare Parts C and D high risk areas:
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Agent/broker misrepresentation
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Appeals and grievance review (for example, coverage and organization determinations)
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Beneficiary notices
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Conflicts of interest
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Claims processing
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Credentialing and provider networks • Documentation and Timeliness requirements
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Ethics
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FDR oversight and monitoring
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Health Insurance Portability and Accountability Act (HIPAA)
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Marketing and enrollment • Pharmacy, formulary, and benefit administration
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Quality of care
For more information, refer to the Compliance Program Guidelines in the Medicare Prescription Drug Benefit Manual and Medicare Managed Care Manual.