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Handouts - 2017 - National - Managed Care

Sunday, January 29

SESSION

SPEAKER

P1: Compliance Program Makeover: From Good to Great

  • This session will assist the attendees in understanding effortless ways to ignite their compliance program by giving it a makeover, while identifying and mitigating risk.
  • Attendees will become familiar with key strategies to take their compliance programs from “good to great” while creating a valuable compliance brand with limited resources.
  • The session will provide creative case scenarios that include positive instructions on “how to” influence attitudes and behaviors in a challenging environment.

Presentation (2 slides/page)
Presentation (3 slides/page)

Deborah Johnson, Senior Director Compliance and Internal Audit, Peach State Health Plan

Nicole Huff, Chief Compliance & Privacy Officer, St. Luke’s University Health Network


P2: How to Engage Your Business Partners to Embrace Compliance?

  • Building effective partnership with boundaries
  • Know your audience
  • Creative strategies

Presentation (2 slides/page)
Presentation (3 slides/page)

Jennifer Del Villar, Director of Medicare Compliance/Medicare Compliance Officer, Cambia Health Solutions

 


P3: Going on the Offensive: Managed Care Strategies for Investigating, Combating, and Affirmatively Litigating Against Fraud

  • Although managed care entities are just as frequently the victims of fraud and abuse, the federal government’s enforcement efforts sweep by default outside the private/public insurer boundary.
  • The panelists, who are current and former high-level healthcare Fraud prosecutors with the Department of Justice, will discuss how managed care organizations can effectively conduct their own fraud and abuse investigations.
  • They will advise on how such private investigations can best be presented to federal and state Law enforcement to maximize the dedication of government resources.
  • Finally, the panelists will relate how managed care organizations can go on the offensive and bring affirmative litigation, including civil RICO claims, against the worst offenders.

Presentation (2 slides/page)
Presentation (3 slides/page)

Jonathan Phillips, Attorney, Gibson, Dunn & Crutcher LLP

Benton Curtis, Senior Counsel, Broad and Cassel


P4: Simplifying Healthcare Compliance: CareSource’s Experience with Integrated GRC

  • With the highly evolving regulatory landscape, healthcare payers are facing numerous compliance challenges and stringent regulatory scrutiny.
  • Mitigating risks of non-compliance with evolving regulations is a top priority in the industry today, making healthcare organizations move towards adopting GRC solutions.
  • A comprehensive GRC solution can enable healthcare payers to consistently meet compliance objectives, successfully manage regulatory changes, and better align its GRC programs with its business strategy.

Presentation (2 slides/page)
Presentation (3 slides/page)

Kurt Lenhart, Vice President of Corporate Compliance, CareSource

Margaux Frazee, Director, Corporate Compliance, CareSource

Sean Woodson, GRC System Implementation Lead, CareSource


P5: Ensuring Your Vendors Are Ready When You Receive an Audit Notice

  • Coordinate and Educate: Logistically speaking — protocols and procedures
  • Communicate and Motivate: Pass it on — inspiring partnership
  • Evaluate: It’s not over til it’s over

Presentation (2 slides/page)
Presentation (3 slides/page)

Jaima Binzer, External Audit and Delegated Oversight, DST Health Solutions

Mary Menard, Compliance Solutions Executive, DST Health Solutions


P6: Connecting with Compliance: Creative Training and Education Methods

  • Attend this session to learn creative ideas to increase the success of your compliance program through engaging trainings in an environment where new leadership is in place, expectations are growing and compliance budgets are shrinking.
  • The presentation will include creative methods and out-of-the-box efforts designed to connect with varying levels of the organization.
  • With expectations changing from “document that it happened” to “prove it is effective”, this session includes ways to measure effectiveness of trainings and the overall compliance program, without adding staff or significantly increasing efforts.

Presentation (2 slides/page)
Presentation (3 slides/page)

Angela Keenan, Manager of Compliance, Network Health

Jessica Vander Zanden, Director of Compliance and Culture, Network Health


P7: Managing a SIU in a Managed Care World

  • Establishing a SIU department and staffing challenges
  • Managing workloads both reactive and proactive to meet regulatory requirements
  • Coordinating the referral process, coordinating with regulators and law enforcement, and reporting

Presentation (2 slides/page)
Presentation (3 slides/page)

Christopher Horan, Vice President of Corporate Compliance Investigations, WellCare


P8: Star Wars: Avoiding the Dark Side — One Plan’s Approach to Legislative/Regulatory Oversight and Implementation

  • We will review our role within the business structure, types of legislative and regulatory materials we review, and our process for implementation.
  • We will provide our evolution from a one dimensional tracking system into a multi-dimensional system for implementation. We will discuss what this system does, how it was implemented and will provide examples of the system and leadership tracking reports.
  • We will discuss challenges and best practices for cultural change and moving to a tracking system that requires additional documentation to be audit ready. We will have a collaborative group discussion to share audience best practices.

Presentation (2 slides/page)
Presentation (3 slides/page)

Michaela Monaghan, Director, Program Oversight - Government Programs, HCSC

 

Monday, January 30

SESSION

SPEAKER

GENERAL SESSION: False Claims Act Enforcement in the Managed Care Space: Recent Trends and Proactive Compliance Tips

  • A brief False Claims Act (FCA) primer, including a discussion of the implied certification theory of liability, the recently-finalized 60-day rule, and a discussion of how the DOJ investigates an FCA case
  • A discussion regarding the government’s use of the FCA in the managed care space, including common topics and themes present in these types of matters, and actual examples of FCA managed care cases
  • Tips on how to build an effective compliance program in order to avoid creating whistleblowers and facing FCA liability, including a discussion of internal audits/investigations and self-reporting conduct to the government

Presentation (2 slides/page)
Presentation (3 slides/page)

Scott Grubman, Partner, Chilivis, Cochran, Larkins & Bever

Thomas Clarkson, Assistant U.S. Attorney, U.S. Attorney’s Office, Southern District of Georgia


GENERAL SESSION: “I am your Board Member. Please listen to me as to what Compliance education I need in order to serve as an effective Board Member.”

  • From the viewpoint of a Board Member, what initial and continuing education is needed?
  • From the viewpoint of a Board Member, what degree of transparency do I need from the MCO regarding compliance issues?
  • From the viewpoint of a Board Member, what do I need when a major compliance storm rolls in, including a DOJ investigation or CIA?

Presentation (2 slides/page)
Presentation (3 slides/page)

Mark Chilson, EVP General Counsel, CareSource

Jeffrey McFadden, Partner, Stradley Ronon Stevens & Young, LLP

Craig Brown, Board Member, CareSource


101: Medical Loss Ratio Audits: We Were Expecting You

  • Understand Medical Loss Ratio (MLR) reporting basics
  • Learn strategies to navigate through an MLR audit
  • Understand risk areas and prepare for a MLR audit before the audit notice

Presentation (2 slides/page)
Presentation (3 slides/page)

Handout

Steve Bunde, Vice President - Integrity & Compliance and Internal Audit, HealthPartners

Stephanie Moscetti, Program Manager - Integrity & Compliance, HealthPartners


102:

 


103: Fostering a Culture of Compliance

  • Engaging associates in compliance in an interesting way helps to reinforce the culture of compliance
  • Offering supplemental training opportunities to facilitate additional development and national certification help to build compliance infrastructure
  • Incorporating compliance into core business fundamentals, just as goals and/or vision, creates a solid foundation for a culture of compliance

Presentation (2 slides/page)
Presentation (3 slides/page)

Maggie Perritt, Senior Director, Corporate Compliance: Delegation Oversight, WellCare Health Plans


201: Tools and Techniques for Effective Monitoring and Auditing of Sales Agents: Insights from a New Medicare Advantage Plan

  • Sales are the life blood of a Medicare Advantage Organization and agents need to understand the guidelines to sell in a compliant manner.
  • This presentation will provide background, tools and tips for compliance staff to conduct effective and timely audits of sales staff. Attendees will also discover essential techniques to oversee large numbers of agents with limited resources.
  • Medicare Advantage Organizations that fail to have a robust sales oversight program could experience increases in grievances and CMS Complaint Tracking Module (CTM) issues that adversely impact a plans Medicare Star Rating.

Presentation (2 slides/page)
Presentation (3 slides/page)

Handout 1
Handout 2
Handout 3
Handout 4
Handout 5

Thomas Wilson, Director Medicare Compliance, CareSource

Megan Saunders, Manager, Corporate Compliance, CareSource

 


202: Helpful Tips for Value Based Payment (VBP) Compliance Programs

  • Identifying the Compliance Program nuances under various VBP Programs (i.e., MSSP ACO, DSRIP, Bundle Payments)
  • Tips on leveraging your existing Compliance Program to compliment the VBP Compliance Program requirements
  • How Best to Engage Participants and Providers to participate in VBP Compliance Programs

Presentation (2 slides/page)
Presentation (3 slides/page)

Handout (.docx)

Greg Radinsky, Vice President and Chief Corporate Compliance Officer, Northwell Health

Aaron Lund, Director of Compliance and Privacy Officer, Northwell Health

 


203: Mobile Health (mHealth) Applications in a Health Care Environment

  • Legal and Privacy implications regarding the expansion of mobile health applications in combination with patient-centric care
  • HIPAA and the liability for clinical providers in a world of Smartphones, Tablets, and Smartwatches
  • Discussion of the oversight process for health apps, including FDA, FCC, and other federal regulations

Presentation (2 slides/page)
Presentation (3 slides/page)

Brandon Goulter, Facility Compliance Professional, Dignity Health

Steven Baruch, Service Area Compliance Director, Dignity Health

 


301: Surviving Your Managed Medicaid External Quality Review

  • What is the purpose of the External Quality Review?
  • How to successfully complete an External Quality Review in Managed Medicaid
  • Lessons learned from a completed External Quality Review (EQR) and the role of Internal Audit in preparing you for — and to respond to — an EQR announcement

Presentation (2 slides/page)
Presentation (3 slides/page)

Beau Colvin, Medicaid and Government Programs Compliance Manager, SelectHealth

Greg Newton, Program Manager, Intermountain Healthcare


302: Managing the MCO-Provider Relationship: It’s More Than Just PHI

  • From accurate provider directories to updated control interest statement forms, the MCO compliance-provider relationship is more than just PHI being faxed to the wrong provider. Acquire strategies to increase provider engagement and compliance.
  • Learn how the Medicaid Mega-Reg is impacting the MCO-Provider relationship, and take home tools and strategies which will ensure compliance with these new regulations.
  • Take home ideas and techniques for maintaining a collaborative relationship with providers, to collectively manage risk areas, and ensure compliance with regulatory requirements.

Presentation (2 slides/page)
Presentation (3 slides/page)

Scott Garnick, Transaction Contract Associate Manager, Accenture

Polina Blinderman, LCSW, Northwestern Medicine Warren Wright Adolescent Program

 


303: Managing Privacy and Security with a Mobile Workforce

  • Understand and address the unique privacy and security challenges that a mobile workforce presents to the managed care organization
  • Learn how to strike an effective balance involving compliance, business needs, and workforce practices in protecting the privacy and security of information
  • Develop effective auditing and monitoring processes that enable the effective identification of risk areas to help mitigate risks to privacy and security

Presentation (2 slides/page)
Presentation (3 slides/page)

Frank Ruelas, Facility Compliance Professional, St. Joseph’s Hospital and Medical Center/Dignity Health

 


401: How Narrow is Too Narrow? Regulators Respond to Narrow Network Health Plans

  • Across managed care markets, provider networks are narrowing. This presentation will explain the reasons for this trend and the reasons why so many people outside the industry are concerned by this trend.
  • At the state and federal levels, regulators are responding with new requirements and new modes of oversight. Survey recent regulatory actions and discuss how health plans can respond to increasing scrutiny.
  • See trends in provider size and composition based on newly available data from CMS’s machine readable provider directories, and see how health plans measure up to new requirements and each other.

Presentation (2 slides/page)
Presentation (3 slides/page)

Handout 1

Michael Adelberg, Senior Director, Faegre Baker Daniels

Deborah Schreiber, Network Compliance Officer, UnitedHealthcare

Aaron Wesolowski, Senior Research Scientist, Health Care, NORC at the University of Chicago

 


402: Mental Health Parity: Ensuring Compliance in the Era of a Rx Drug Abuse Epidemic

  • MHP: Mental Health & Substance Abuse — A Growing National Concern
  • MHP: Current Laws and Regulations — An Overview
  • MHP Compliance: Areas of Focus and Effective Monitoring

Presentation (2 slides/page)
Presentation (3 slides/page)

Kate Woods, Corporate and ACA Compliance Officer, Capital BlueCross

Laura Gargiulo, Senior Counsel, Capital BlueCross

 


403: Effectively Managing Corrective Actions

  • What factors constitute a meaningful Corrective Action Plan?
  • What level of detail is required to meet a Regulator’s (CMS) corrective action plan expectations?
  • Demonstrating how you will prevent flagged items from happening again

Presentation (2 slides/page)
Presentation (3 slides/page)

Jennifer Del Villar, Director of Medicare Compliance/Medicare Compliance Officer, Cambia Health Solutions

Deneil Patterson, Director of Compliance, Cambia Health Solutions

 

Tuesday, January 31

SESSION

SPEAKER

GENERAL SESSION: CMS Audit Policy, Strategy, and Enforcement

Presentation (2 slides/page)
Presentation (3 slides/page)

Vikki Ahern, Medicare Parts C and D Oversight and Enforcement Group, Centers for Medicare & Medicaid Services


GENERAL SESSION: What Every Leader Should Know About Compliance Officers and Compliance Programs

Presentation (2 slides/page)
Presentation (3 slides/page)

Roy Snell, CEO, SCCE/HCCA


501: Lessons Learned and Insights Gained from Undergoing a CMS Audit

No presentation available

Vikki Ahern, Medicare Parts C and D Oversight and Enforcement Group, Centers for Medicare & Medicaid Services

Shirley Qual, Compliance Officer, UnitedHealthcare

Gail Blacklock, Compliance Officer, Inter Valley Health Plan

Michelle Coberly, Manager, Medicare Compliance & Quality,Priority Health

 


502: Hospital Owned Health Plans: Tips for Effectively Managing Compliance in a Health Plan and Provider Environment

  • Outline of compliance program framework for two separate, yet combined, health care entities
  • Suggestions for managing issues and developing compliance efficiencies, while keeping operations separate
  • Various techniques and tips that are useful when reporting to health plan and hospital stakeholders

Presentation (2 slides/page)
Presentation (3 slides/page)

Handout 1
Handout 2

Catie Heindel, Vice President, Strategic Management Services

Cathy Bodnar, Chief Compliance and Privacy Officer, Cook County Health & Hospitals System

Ryan Lipinski, Compliance Officer, Cook County Health & Hospitals System, CountyCare


503: Value Added Compliance Program Effectiveness Review: A Health Plan’s Journey

  • Discuss how to define the scope and objectives that will add value to the health plan. Pros and cons of using the CMS audit protocol only or following the core elements and digging into the integration of compliance into operations.
  • Discuss how to engage key organizational leaders to solicit support for the process and the final deliverable.
  • Now you have the deliverable, how does it add value and how to approach support for remediation of identified opportunities.

Presentation (2 slides/page)
Presentation (3 slides/page)

Handout (.docx)

Kelly Nueske, Executive Consultant, Pinnacle Healthcare Consulting

Carolyn Barton, Carolyn Barton, Chief Compliance & Ethics Officer, Group Health Cooperative


601: Surviving a CMS-Mandated Independent Validation Audit (IVA): 150 Days and counting

  • Key considerations when determining “clean period” and managing 150 calendar deadline to start IVA
  • Managing first tier entities and downstream entities involved in the IVA
  • How to incorporate lessons learned from Plans who have been through IVAs

Presentation (2 slides/page)
Presentation (3 slides/page)

Anne Crawford, Deputy Director, ATTAC Consulting Group

Elizabeth Lippincott, Managing Member, Strategic Health Law

 


602: Ethical Implications of Bundled Payments and Value Based Purchasing

  • Payment for episodes of care and rewards for measurable improvement in patient outcome raise quality of care compliance issues that have not been seen since the early days of managed care.
  • Capitation arrangements in the ’80s and early ’90s motivated some payors to tie provider panel participation to nondisclosure agreements that left patients in the dark about the financial incentives offered for effective management of utilization.
  • As with those earlier contracting models, health maintenance compensation structures can create ethical challenges for payors and providers, related to disclosure obligations and peer review of specialist referral practices.

Presentation (2 slides/page)
Presentation (3 slides/page)

Handout 1 (.docx)
Handout 2
Handout 3
Handout 4
Handout 5 
Handout 6

David N. Hoffman, Chief Compliance Officer, Physician Affiliate Group of New York, P.C.

 


603: Putting It All Together: Integrating Procurement, Risk Management, and Compliance Oversight

  • Discuss the interdependencies between procurement, risk management, and the compliance oversight for contracted entities
  • Review a collaborative model outlining participant roles and functions and their timing
  • Learn about the experience of Blue Cross and Blue Shield of Kansas implementing a program with limited resources

Presentation (2 slides/page)
Presentation (3 slides/page)

Dan Roehler, Manager Regulatory Compliance, Blue Cross and Blue Shield of Kansas

Christopher English, Regulatory Compliance Analyst, Blue Cross and Blue Shield of Kansas

 


701: The Compliance Challenges Inherent in Risk Adjustment’s Continued Evolution and Expansion

  • Understand the different ways risk adjustment operates in Medicare-Advantage, Medicaid, and Marketplace products
  • Review critical court cases and administrative actions that target risk adjusted health plans and provider groups
  • How to design the necessary oversight policies and procedures for delegated physician-groups, revenue management vendors, and in-house risk adjustment teams

Presentation (2 slides/page)
Presentation (3 slides/page)

Richard Lieberman, Chief Data Scientist, Mile High Healthcare Analytics, LLC

 


702: Compliance with Managed Care Contracts: You Signed It — Now You Have to Live with It

  • Learn the basic elements of managed care contracts
  • Become aware of relationships between contracts and Managed Care Organizations’ manuals, policies and protocols
  • Distinguish contractual compliance with regulatory compliance

Presentation (2 slides/page)
Presentation (3 slides/page)

George Eichhorn, General Counsel/Director of Compliance, ChildServe, Inc.


703: Root Cause Q&A: Complete and Consistent Resolution of Issues Causing Compliance Concerns

  • Erin Heckethorn, Director of Compliance, FirstCarolinaCare Insurance Company
  • The questions everyone asks, and the additional questions you should be asking when conducting a Root Cause Analysis.
  • How to know when you have reached the real root cause — keep digging, you’ll get there!
  • Measuring and monitoring — what happens next? Avoid the black hole of monitoring without a plan for closure.

Presentation (2 slides/page)
Presentation (3 slides/page)

Erin Heckethorn, Director of Compliance, FirstCarolinaCare Insurance Company


801: Deep Dive on DIR: CMS’ 2017 Focus on Enforcement for One-Third Financial Audits and Your Rebates

  • CMS uses the one-third financial audit program to examine health plan internal controls over financial records and processes. New in the 2017 Call Letter, CMS noted instances of noncompliance from these audits may become potential enforcement actions.
  • Take a deep dive on the direct and indirect remuneration (DIR) process, and errors that commonly occur that you may not have uncovered at your health plan.

Presentation (2 slides/page)
Presentation (3 slides/page)

Derek Frye, Audit & Technology Leader, Burchfield Group

Sonya Henderson, Senior Vice President of Corporate Compliance & Government Programs, FirstCare Health Plans

 


802: Ethics in the Age of The Affordable Care Act and SEPs

  • A Brief Overview of the ACA and Its Special Enrollment Periods
  • The Use of Analytics for the Identification of Potential Red Flags
  • Ethical Case Scenarios and Discussion

Presentation (2 slides/page)
Presentation (3 slides/page)

Kate Woods, Corporate and ACA Compliance Officer, Capital BlueCross

Ras Sowers, Director, IT Audit and ERM, Capital BlueCross

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