General Session: OIG’s Oversight of Expanding Managed Care Programs
Speaker: Megan Tinker
- OIG’s tailored oversight to address the unique risks presented by managed care
- Insights into managed care from OIG’s work
- Trends and upcoming audits and studies
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101 The Inflation Reduction Act’s Overhaul of Medicare Part D
Speakers: Anne Crawford, Elizabeth Lippincott, Sandra Durkin
- Address strategies for amending PBM contracts to address the changes to the drug program
- Understand how the IRA changes Part D and how to approach implementation of the Part D reforms
- Address the impacts of the Part D reforms on Prescription Drug Plan sponsors and their members
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102 A Compliance Officer’s Guide to Successfully Navigating a 2024 CMS Audit: Compliance Program Effectiveness (CPE) Audit Experience and Lessons Learned during 2023 CMS Program Audits
Speakers: Nicholas Kirsch, Tami Geroski, Wendy Edwards
- Manic Monday: Medicare compliance manager’s tips and top priorities to stay calm when selected for a program audit
- Preparing for audit: Highlighting CPE elements and successfully documenting FDR, employee, and board requirements
- 2023 CMS program audit lessons: First-hand details to navigate the audit, tips for success, and best practices
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103 Optimize Compliance Oversight of First Tier, Downstream, and Related Entities (FDRs) with Best Practices
Speakers: Courtney Allen, Megan Allison, Megan Geltman
- Discuss evaluating FDRs for compliance risks, and some typical risks that they may pose
- Learn how to apply the Seven Elements of an Effective Compliance Program to your FDRs
- Review best practices that can be practically applied to bolster FDR compliance
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104 PACE Audits: A New CMS and State Program Audit Frontier
Speakers: Lezlie Teter, Olivia Patton
- What is PACE: Background of the Program of All Inclusive Care for the Elderly (PACE) and insights on the value proposition of this government program for Medicare/Medicaid beneficiaries
- PACE CMS/State Program Audit Model: CMS and state oversight of the integrated managed care and direct provider care program
- Lessons learned in anticipating and responding to a CMS and state program audit to ensure ongoing audit readiness
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105 False Claims Act Risk and the RADV Final Rule
Speakers: Christine Worthen, Gabriel Imperato
- Discuss False Claims Act liability for health plans in connection with risk adjustment practices and reimbursement from federal health programs
- The basis for “risk adjustment” liability and the compliance implications of the recent RADV rule and the development of health plan provider networks and correct coding initiatives
- The anatomy of a False Claims Act case and managing the compliance risk for health plans, including liability for “risk adjustment” and claims to federal health programs
- Review of the RADV Final Rule and best practices and strategies for compliance and alignment with business objectives
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106 Exorcizing Ghost Networks: Tools and Strategies for Compliance Professionals
Speakers: Tricia Beckmann, Zach Snyder
- Understand what is a “ghost network” and the rapidly evolving policy landscape to crack down on this phenomenon
- Stay up to date on the standards for Medicare Advantage, Medicaid managed care, and commercial plan provider directory standards
- Develop different tools and strategies across health plan teams to identify “ghost” providers and consider how to mitigate potential consumer and regulator actions
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107 CMS Program Audit: Tips for Success
Speakers: Laurena Lockner, Stephanie Moscetti, Steve Bunde
- Learn proactive readiness steps
- Identify risk areas based on CMS's Program Audit and Enforcement Report
- Understand tips for successful webinar and CPE weeks
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Handout
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108 How to Leverage the Strengths of Your Market-Based & Enterprise Teams in a Medicaid & Marketplace Regulatory Landscape
Speakers: Allison Reynolds, Cameual Wright, Josslyn Gillard
- Proactive project management approach to audits
- Minimizing the impact of audits on your business operations
- Understanding & communicating the complexities of federal & state level requirements
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109 Building a Strong FWA Compliance Program with a Small Team
Speakers: Britton Whitbeck, Jala Attia
- Understand how a small team can effectively ensure key compliance requirements
- Leverage existing tools and resources to amplify the efforts of the FWA team
- Learn steps that will assist attendees in determining the best starting point for their organization
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110 A Compliance Professional's Tips and Techniques for Proposed, New and Updated Regulations and Guidance
Speakers: Annie Hsu Shieh, Jennifer Del Villar
- Techniques in reviewing and disseminating proposed, new, and updated regulations and guidance
- How to implement regulatory change management and operationalize new requirements within the business
- Collaboration with trusted compliance and internal colleagues - book club anyone?
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EB1 It’s Lonely Being Picked First: CMS Program Integrity Audit Is Not a CMS Program Audit
Speakers: Candice Weatherly, Lauren Chan
- What is a CMS Program Integrity Audit? How is it different from a CMS Program Audit?
- Knowing when to align and distinguish between compliance requirements & separate FWA requirements
- How to demonstrate oversight of PBM Part D FWA investigations to satisfy the auditor
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EB2 Compliance Considerations and Impacts with the Emerging Role of Private Investment Partners in Managed Care
Speakers: Jenny O'Brien, Melanie Sponholz, Samantha Kelen
- Oversight implications in response to the changing landscape in partnerships/collaborations
- Considerations when partnering with healthcare technology companies
- Increasing role of private equity/venture capital in healthcare space
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General Session: The Risk and Opportunities of AI Regarding Managed Care And Other Healthcare Organizations
Speakers: Belinda Luu, Hovannes Daniels
- AI Bills, Regulations, and Acts that will apply to healthcare and managed care entities.
- AI opportunities, use cases and associated data management and governance.
- AI governance and frameworks, employee guidelines, policies and skill development.
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201 Navigating Digital Data and Managing Cybersecurity Compliance
Speakers: Jennifer Griveas, Michael Gray
- Review the legal and regulatory schemes surrounding cybersecurity in healthcare, which underscore the significance of protecting patient information, securing healthcare systems, and mitigating cyber risks
- Learn to identify and triage the top threats to data security, including threats presented by a more mobile workforce and a proliferation of new connected devices in health care
- Tips on the most effective auditing and monitoring strategies to ensure HIPAA and related privacy and security regulation compliance, and best practices and intervention suggestions for managing both external and internal cyber threats
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202 Building the Airplane as You Fly: FDR and Vendor Oversight at a MA Start-Up and What Happens after Wheels Go UP!
Speakers: Aaron Burch, Kenneth Nuñez
- Day 0: Navigate the intimidating world of identifying and negotiating with FDR and delegated vendors before launch date, including issues around contracting, pre-delegation audits, network adequacy, and compliance program effectiveness of partners
- Implementation: The importance of involving compliance in each implementation stage including system configuration, CMS required mailings, call center operations and delegating or retaining A&G
- Go Live and Hair on Fire! Determining who has ultimate responsibility over the FDR and delegate after go-live: Should it be Compliance, Procurement, Operations, or a team-based approach?
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203 The Marriage between Quality and Compliance: How Do They Complement Each Other?
Speaker: Marquitta Massey
- How can compliance professionals use the quality staff to canvas for compliance issues?
- Is there a "right door" for reporting concerns?
- Why it is important to "deputize" all staff with a compliance officer badge
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204 Update on Mental Health Parity Enforcement and Emerging Regulatory Guidance
Speakers: Amanda Brown, Bailey Wendzel
- Discuss recent DOL and CMS work in Mental Health Parity audits and investigations
- Address new and emerging Mental Health Parity and Addiction Equity Act (MHPAEA) regulatory guidance
- Discuss common risk areas, enforcement trends, and lessons learned
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205 Transparency and Tips for Navigating Regulator Relationships
Speakers: Andrew Reitz, Whitney Fitch
- Relationships, relationships, relationships
- Importance of establishing rapport and open communication with regulators
- Integrity, honesty, and vulnerability
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206 New Compliance Leadership: (Re)establishing a Compliance Program in an Integrated Health System/Health Plan
Speakers: Anne Sullivan Daly, Chris Norman
- Strategies for new compliance leadership when starting with a new organization
- External evaluations/understanding what you are working with
- How to organize and prioritize – when to rebuild, and when to remodel
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207 The Three "R"s of Vendor Performance Management & Oversight: Requirements, Roles & Resources
Speakers: Deb Lightner, Kathleen Lewanski
- Requirements: Do your vendor contracts accurately set forth regulatory and other performance expectations? Does your vendor have enough skin in the game if you are subjected to compliance penalties?
- Roles: Who is responsible for vendor performance management and oversight, and do they know it? How is information shared across internal and external stakeholders accountable for vendor performance and oversight?
- Resources: Do your stakeholders have what they need to manage vendor performance?
Presentation
Handout - Onboarding Workflow
Handout - Performance Monitoring
Handout - Reporting Dashboard
Handout - Supplier Accountability Matrix
Handout - Third Party Supplier Contracting Checklist
Handout - Third Party Supplier Offboarding Checklist
Handout - Third Party Supplier Onboarding Checklist
Handout - Vendor Escalation
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208 What's Next for Prior Authorization: From Managed Care to Value Based Care
Speakers: Dorothy DeAngelis, Kathy Roe
- Describe how Congress, DHHS, CMS and the industry are evolving prior authorization requirements and expectations
- Identify underlying themes and trends in all this activity to evolve prior authorization including the use of Artificial Intelligence
- Assess what these changing prior authorization requirements and expectations may mean for Health plans and delegated entities
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Closing General Session: Navigating No Surprise Billing and the Everchanging Regulatory Landscape
Speakers: Lisa Shih, Toni Waldman
- Discuss complexity of compliance with No Surprises Act.
- Discuss regulatory landscape, guidance, and enforcement discretions as well as the impact of ongoing litigation.
- Discuss challenges and risk areas with regard to calculation of the Qualified Payment Amount, post-stabilization care and regulatory audits.
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