OIG Releases Compliance Program Guidance for Medicare+Choice Organizations Offering Coordinated Care Plans - Office of Inspector General - Brief Article

Healthcare Financial Management, Dec, 1999

On November 4, the HHS Office of Inspector General (OIG) released final compliance guidance for Medicare Choice organizations that offer coordinated care plans (M CO/CCPs). The document is similar in format to previous OIG guidance for hospitals, home health agencies, and third-party billing companies in that it lists the basic elements of a compliance plan, including risk areas. For M CO/CCPs, risk areas include the election process; benefits and beneficiary protections; quality assessment and performance improvement; cost sharing; solvency, licensure, and other state regulatory issues; claims processing; and appeals and grievance procedures.

HHS Inspector General June Gibbs Brown stressed that the document "will help the managed care industry understand the government's expectations for a well-run, effective compliance program." While Brown continues to assert that use of the compliance guidance documents is strictly voluntary, HCFA's interim final rule implementing the M CO program requires M COs to have an effective compliance plan in place by January 1, 2000. Because HCFA provides minimal operational guidance, organizations are advised to use the OIG's document as a starting point for developing a compliance plan to meet HCFA's requirements.

In the final document, the OIG states that it will be issuing a limited safe harbor to protect capitated managed care organizations (including M COs/CCPs) from sanctions under the antikickback statute for receiving payments from "individuals or entities with which [the managed care organization has] direct contracts to provide or arrange for the provision of items or services." In addition, the compliance guidance provides operational guidance for entities to avoid incurring a civil monetary penalty (CMP) for influencing a "beneficiary's decision to order or receive items or services from a particular" participating provider. The 1996 Health Insurance Portability and Accountability Act created the new CMP, but the OIG has not issued a final rule on this provision. The OIG states, however, that it does not plan to sanction "organizations that provide incentives to enroll in a plan," but it will sanction organizations that "induce a beneficiary to use a particular provider, practitioner, or supplier once the beneficiary has enrolled in a plan."

The full compliance guidance is available to HFMA members at the Association's Web site, www.hfma.org/members/guides/medicarechoice.htm.>

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