3D Compliance for Managed Care

1. 3D Compliance for Managed Care Vickie McCormick Integrity Officer - UnitedHealth Group Mamie Segall Vice President, Compliance Operations - Medica Health Care Compliance Institute The Compliance Evolution: Revealing the Opportunities

2. Introduction Three Dimensions to Building and Sustaining Compliance Organization Compliance Tools Partner/Vendor/Provider (�Extender�) Organizations

3. Compliance Organization Model #1 -- Compliance Oversight Operational/functional department primarily responsible for: identifying compliance obligations implementing operational processes to promote compliance Compliance primarily responsible for: providing coordination, resources and facilitation notifying operational/functional departments of compliance obligations when identified facilitating cross-departmental issues conducting monitoring/auditing creating/maintaining metrics of functional departments� compliance

4. Compliance Organization Model #2 -- Compliance Implementation Compliance is primarily responsible for: identifying compliance obligations implementing operational processes to promote compliance facilitating cross-departmental issues conducting monitoring/auditing creating/maintaining metrics of functional departments� compliance

5. Compliance Organization Model #3 -- Compliance Oversight and Implementation Compliance works in conjunction with functional/operational departments to: identify compliance obligations implement operational processes to promote compliance Compliance function: facilitates cross-departmental issues conducts monitoring/auditing creates/maintains metrics of functional departments� compliance

6. Compliance Tools Periodic Reporting on Compliance Activities Confirming compliance organization structure Compliance Officer Compliance Committee Identifying compliance-related activities Regulatory compliance Risk Analysis/Controls Training Human Resource/Organizational Development Product Department Regulatory and Miscellaneous Compliance Monitoring and Auditing Programs Corrective Action, including discipline

7. Compliance Tools Compliance Intranet Description of compliance office responsibilities and staff Code of Conduct Policies Q&A Compliance Hotline Information Compliance Notices/Articles/Newsletters Compliance Resources and Tools

8. Compliance Tools Accountability and Obligation Tracking Define Mission Define Job Profile Create Intake Method Create Implementation Process Flow Track Assessments Monitor Obligation Summaries

9. Compliance Tools Software Solutions Goldmine Lotus Notes/Excell/Access/Web Database PricewaterhouseCoopers Compliance Office Ernst & Young Compliance Saver

10. Compliance Tools Tool Box UnitedHealth Group Quarterly Integrity and Compliance Reports Sample Organization Charts Intranet Site Content Outline Regulatory Filing Tracking Tools

11. Extender Organizations MCO Accountability for Extender Organization Compliance OIG Guidance M+C Organizations responsible for provider organization compliance HCFA and State Regulators MCO can not avoid compliance obligation through delegation to extender organizations, including providers and IPAs New York DOI position that MCOs are ultimately responsible for actions (an inaction) of IPAs Maryland DOI decision regarding UnitedHealthCare of the Midland�s obligation to pay claims not paid by capitated IPAs

12. Extender Organizations Standard MCO Extender Organizations Medical Providers and Suppliers Providing medical services and supplies Information source (encounter data, special status, etc.) Delegated Administrative Services/Clinical Services Claims Pharmacy Benefit Management Credentialing Utilization Management Quality Information Systems Standard Business Vendors/Suppliers

13. Extender Organizations Agreement Provisions Regarding Compliance General compliance with all laws clause no longer sufficient Addressing compliance in agreements with extender organizations Standard 7 compliance program elements Flow-through to sub-contractors Consider excluded provider issue Extender organization reporting compliance issues to MCO External organization attorney/client privilege issues Joint Defense Agreement? MCO obligation to report to regulators/customers Violation of performance standards MCO right/obligation to audit extender organization compliance program