Sunday, January 26
08:00 AM - 09:30 AMEthics and Compliance Work Plan Essentials that Effectively Mitigate Risk Andrea Share, Exec Director, Ethics/Compliance Strategy & Ops, Kaiser Permanente Shakeya McDow, Vice President, Strategy, Intelligence, and Operat, Kaiser Foundation Health Plan - Explain the importance of conducting an ethics and compliance risk assessment and the relevance of risk assessments in an integrated care setting - Describe the key components of a risk assessment, how to conduct a risk assessment, and the role of work planning for effective mitigation - Introduce a “simple six step” approach to conducting a risk assessment, review a framework for defining risk, and discuss key takeaways for how the connection between risk assessment and work planning delivers business value
08:00 AM - 05:30 PMPre Conference Pre Conference
09:45 AM - 11:15 AMCyber Threats and Compliance Challenges: How to Manage Technology Risk Jennifer Griveas, Chief Human Resources Officer & General Counsel, Eliza Jennings Senior Care Network Michael Gray, Eliza Jennings - Identify biggest security threats to healthcare organizations - Identify the value of integration of knowledgeable IT personnel into high-level operations team as a means to ensure compliance and effective risk mitigation - Describe how best to implement technology solutions to enhance efficiency and productivity without sacrificing organizational security
12:30 PM - 02:00 PMBreakout Session 1#P03The A to Zs of FDR, Delegate, and Subcontractor Oversight Steve Bunde, VP Integrity & Compliance & Internal Audit, HealthPartners Laurena Lockner, Sr Mgr Monitoring & Compliance, HealthPartners Rebecca Fuller, Corporate Compliance Officer, PrimeWest Health
General Compliance#P04Compliance 2020: Compliance and Business Roles in Today’s Complex Regulatory Environment James Taylor, Manager, PricewaterhouseCoopers Christopher Schroeder, Director, PricewaterhouseCoopers Taline Avakian, Director of Compliance, Harvard Pilgrim Health Care
- Prevent: Learn about CMS and state requirements for FDR, delegate, and subcontractor oversight and areas of audit focus
- Detect: Understand due diligence, contracting, risk assessment, and auditing and monitoring strategies - including key partnerships
- Correct: Discover what to do when issues are identified and how to incorporate those into the correct CMS Program Audit Universe
- Key developments and trends across the healthcare industry related to the evolving role of compliance and the role of business units
- How compliance has helped define the role of meeting regulatory requirements
- An understanding of embedded compliance support and/or performance/program support teams/units, and how risk ownership is driving the role of business units
02:15 PM - 03:45 PMBreakout Session 2#P05Effectively Managing Internal Investigations and Regulatory Disclosures Anne Crawford, Director, ATTAC Consulting Group LLC Emily Moseley, Strategic Health Law Annie Shieh, Sr Compliance Counsel, Central Health Plan of California
General Compliance#P06Compliance Goals in Risk Adjustment Coding Dana Brown, 503-658-7274, Reimbursement Mgmt Consultants, Inc. Dott Campo, Risk Adjustment Auditor, Reimbursement Mgmt Consultants, Inc.
- Methods to determine if communication infrastructure supports prompt identification of potential issues
- Strategies for initiating timely investigations that determine beneficiary and organizational impacts
- Common themes and regulatory disclosure approaches when deciding whether self-reporting to regulators is required or advisable
- Attorney-client privilege and litigation risk-management strategies
- Overview of Risk Adjustment reimbursement in the MA and ACA models
- Review of Risk Adjustment coding, HCC code capture accuracy, review of coding guidelines, rules & regulations
- In-depth review of most common compliance issues in coding in an RA environment, isolating the issues and giving tools to analyze them and make good compliant decisions
04:00 PM - 05:30 PMBreakout Session 3#P07Special Supplemental Benefits and the FDRs that Provide Them - Unique Monitoring Challenges They Pose Jennifer Del Villar, Dir Gov Pgms Compliance, Cambia Health Solutions, Inc. Gail Blacklock, Compliance Officer , Inter Valley Health Plan
General Compliance#P08Establishing a Best-Practice Approach for Your Compliance, Privacy, and Security Programs Bret Bissey, Vice President, Chief Compliance Officer, Gateway Health Kelly McLendon, Managing Partner, CompliancePro Solutions
- Unique monitoring challenges with unique FDRs
- Monitoring the member match - right member to the right supplemental benefit
- Tracking & monitoring health outcomes
- Learn how to utilize, in detail, the elements of the DHHS OIG Model Compliance Program(s) to develop a best practice for your compliance efforts
- Learn how to utilize the HIPAA Privacy and Security regulations and conduct a program assessment to create a best practice standard in your organization.
- Learn how best to formulate security, privacy, and compliance education programs in your organization, including a focus on being compliant at the top of the organization, by utilizing market knowledge to stimulate learning.
Monday, January 27
09:45 AM - 10:45 AMBreakout Session 1#101The Compliance Officers Guide to a Successful Audit Michelle Rigby, Director, BluePeak Advisors, LLC Wendy Edwards, President, ATRIO Health Plans, Inc
General Compliance#102Exclusions v. Preclusions — Insights,Analytics, and Monitoring Best Practices after 1 Year of Releases Annie Shieh, Sr Compliance Counsel, Central Health Plan of California Michael Rosen, Co-Founder, ProviderTrust, Inc
- What can you do today to be prepared for an audit tomorrow?
- What resources does a compliance officer use to help identify gaps and prioritize issues in a lean organization with competing priorities?
- Consultants, a compliance officer’s best friend to support mitigation efforts, staffing augmentation, audit prep, and audit support
General Compliance#103Implementing a GRC Solution to Manage and Enhance Auditing & Monitoring Natalie Ramello, Vice President Chief Compliance & Risk Officer, CommunityCare Rebecca Blades, Manager, Internal Audit
- Trends, analytics, and learnings from the first year of monitoring & implementation
- Learn the crossover between the CMS Preclusion List and Federal and State Medicaid Exclusion Lists
- Predictive insights and future considerations for your provider network operations and SIU teams
- A roadmap for implementing a comprehensive GRC solution within their organization including how to make GRC successful and how to make it CMS compliant
- Best practices for adoption of a GRC model for auditing and monitoring
- An understanding of how to tie risks, policies and controls to your auditing and monitoring activities
11:00 AM - 12:00 PMBreakout Session 2#201Dual Products and MMP: Navigating State and Federal Oversight Anjenette Fenske, Compliance Officer, UnitedHealthcare Deanna Simonds, Compliance Officer, UnitedHealthcare
General Compliance#202How Bias and Perception Impact Compliance Ahmed Salim, Deloitte Walter Johnson, Senior Advisor, Compliance Stategists LLC
- The Bipartisan Budget Act of 2018 sets forth requirements for increased integration for Dual Special Needs Plans (DSNPs) by 2021. These unprecedented requirements will impact the landscape of duals products.
- This panel will provide insight on best practice, challenges, and the future state of dual products from both compliance officers from multiple managed care plans.
- The audience will hear perspectives from several seasoned compliance professionals overseeing different fully integrated dual products.
General Compliance#203Navigating Compliance Challenges for Integrated Payor-Provider Systems Randi Seigel, Partner, Manatt, Phelps & Phillips, LLP Annie Miyazaki, SVP, Chief Compliance & Privacy Officer, Visiting Nurse Service of New York
- Breaking down why people make bad decisions
- Understanding how risk perception and inherent tendencies negatively impact compliance
- Utilizing tools to identify bias to increase compliance within your organization
- Key regulatory considerations relevant to intercompany arrangements, patient/member consent, and other documentation
- Tips for balancing plan versus provider regulatory frameworks and referral source/community partner needs
- Risks and opportunities in data sharing among affiliates under HIPAA and other privacy laws
01:15 PM - 02:15 PMBreakout Session 3#301Managed Care Plan Network Adequacy and Accuracy Methods of Review An Industry Comparative Analysis Deborah Schreiber, Network Compliance Officer, UnitedHealthcare
General Compliance#302Proactive vs Reactive in Risk Management - "Ring the Bell!" Fredy Rocha, Senior Compliance Manager, IlliniCare Health Tiffany Lewis, Manger, Vendor Oversight Compliance, Centene Corporation - IlliniCare Health
- Review and discuss results of a critical/comparative analysis of multiple regulator reviews and research studies from 2013 to present
- Assess effectiveness of methods used and potential issues with review methodologies
- Recommend best practices and emerging trends
General Compliance#303Rx Data Driven Compliance Monitoring: Opioid Prescribing, Dispensing, and Utilization Francis Grabowski, Mgr Digital Risk Solutions, PwC Ben Wright, Director, PricewaterhouseCoopers Sandhi Ton, Mgr Special Investigations Unit & Analytics, SCAN Health Plan
- Identify challenges and explore practical experiences for conducting an effective risk assessment while building a proactive monitoring and auditing plan
- Identify proactive risk management, which consists of mitigating the risks of threat events before these might possibly occur and negatively impact the organization
- Identify reactive risk management, which consists of responding to risk events as they occur to mitigate negative impacts to the organization
- Regulators are increasing focus on how plans are responding to the opioid crisis and compliance has a growing role in developing the strategy and controls related to provider prescribing practices, pharmacy dispensing, and member drug utilization.
- Incorporating insights gained through the fact-based analysis of trends and outliers is a solid base from which to launch an aggressive attack on the crisis.
- Advanced analytics, such as network analysis, can further help plans understand overlap between providers, pharmacies, and members, allowing the identification of unexpected connections and potential bad actors.
02:30 PM - 03:30 PMBreakout Session 4#401Expert Auditing and Monitoring Practices to Measure Quality of Care and Performance Improvement Strategies in Medicaid Managed Care Michael Walsh, Senior Auditor, Integrity Management Services, INc. Jennifer Tryder, Program Director, Integrity Management Services, Inc.
General Compliance#402A Compliance Program Facelift: Sculpting a Program from Good to Great Nicole Huff, Chief Compliance & Privacy Officer, St. Luke's Univ Health Network Deborah Johnson, Vice President, Compliance, IlliniCare Health Plan
- Understanding MCO performance measurement data and what is required to be produced and reported
- Best practices on performing and selecting Medicaid audits in order to effectively measure quality of care standards and performance
- Examples of MCO policies and procedures that assure the provisions and quality of care are actively monitored and remediated on an ongoing basis, and that the results are used to improve performance
General Compliance#403Adjusting the Risk for Medicare Advantage: Recent Enforcement Trends and Litigation Involving Medicare Advantage Risk Adjustment Practices Brandon Moss, Attorney, Wiley Rein
- Address increasing state and federal regulatory requirements and enforcement activities
- Discuss strategies to move your compliance program from “Good to Great” with limited resources
- Case scenarios describing how to build partnerships and influence positive outcomes
- Attacks on Medicare Advantage plans’ practices with respect to auditing or reviewing risk adjustment scoring are growing both more complex and popular.
- While the government has been handed some serious setbacks in the last year, cases involving risk adjustment continue to be brought (both civilly and criminally).
- This panel will discuss recent trends in civil and criminal enforcement actions, where courts are lining up on interpreting key regulations, and what all this means for Medicare Advantage providers looking to navigate this high-stakes and ever-changing landscape.
Tuesday, January 28
10:45 AM - 11:45 AMBreakout Session 1#501FWA Oversight for a Small- to Mid-Size Plan Yvonne Zachman Fiedler, Consultant, The Burchfield Group, Inc.
General Compliance#502Process Optimization, Organizational Structure, and Best Practices to Boost Appeals & Grievances Outcomes and Compliance Richard Merino, Managing Director, FTI Consulting, Inc Diane Ramey, Senior Director, Ankura Consulting Nancy Waltermire, Senior Director, Ankura Consulting
- Helping small- to mid-size plans build and maintain an effective FWA program
- How to utilize delegates to provide assistance in an FWA program
- How to prep for a CMS program audit and demonstrate an effective FWA program
General Compliance#503Compliance Effectiveness through Channels of Communication and Investigations Andrew Finkelstein, Vice President, Compliance; and Medicare Compliance Officer, Health Partners Plans, Inc.
- Prevention of common audit finding “pitfalls”, and industry best practices for remediation, including compliance with new regulations and updates
- OIG Report: How best to identify high overturn rates in your appeals, identifying gaps to increase accuracy and lower overturn rates
- Tackling an end-to-end ODAG process evaluation, developing process improvements, development of effective organization structure, workflows and monitoring workplan on your appeals and grievances.
- Learn effective strategies, best practices, and challenges when establishing communication procedures and investigatory practices
- Identify key metrics for your compliance program to measure the effectiveness of organizational communication and oversight
- Case studies: A look at the compliance framework in action after issues are reported to compliance and acted upon
12:45 PM - 01:45 PMBreakout Session 2#601Mental Health Parity: Are You Compliant? Leigh Anne Hodge, Partner, Bradley Arant Boult Cummings Rhea Garrett, CHSPSC,LLC
General Compliance#602Fraud, Waste, and Abuse Program Audits Are Coming to an SIU Near You - Are You Ready? Jala Attia, President, Jala Attia Jessica Gay
- This presentation will provide an overview of the Mental Health Parity and Addition Equity Act (the “MHPAEA”). The presentation will cover the requirements of the MHPAEA, application of parity laws and rules under the MHPAEA, state parity laws, and state report cards.
- The presentation will address agency auditing activity and the types of violations that are garnering attention from regulators.
- Finally, the presentation will address recent trends in MHPAEA litigation, with a focus on wilderness therapy and Applied Behavioral Analysis (“ABA”) cases.
General Compliance#603How to Identify and Handle a Contracted Over-Prescriber Mark Horowitz, Pharmacy Audit and Compliance, Kaiser Permamente Joaquin Basauri, Senior Investigator, Kaiser Permanente Carolyn Barton, VP, Compliance & Regional Compliance Officer, Kaiser Foundation Health Plan of Washington
- Assess your Special Investigations Unit’s compliance against fraud prevention, detection, and recovery requirements by understanding key areas reviewed during typical program audits.
- Identify and discuss critical compliance and reporting elements as well as common pitfalls that arise during the audit process.
- Leverage best practices and proactive measures to maintain ongoing fraud, waste, and abuse compliance within your Special Investigations Unit.
- How to identify an over-prescriber and internally escalate the case with the right health plan disciplines
- How to address patient abandonment concerns and network adequacy
- How to navigate the contract termination, external reporting, and PBM controls processes
02:00 PM - 03:00 PMBreakout Session 3#701Risk Adjustment Compliance: Can You Afford the Risk? Colleen Brennan, Horizon BCBS of NJ Nicole Martin, Manager, Provider Eucation & Field Chart Review, Florida Blue
General Compliance#702Compliance Session - TBAGeneral Compliance#703Driving Compliance: How to Manage Compliant Activities Without Authority Angela Muncy, Medicare Advantage Compliance Officer, Blue Cross Blue Shield of Kansas City Michelle Rigby, Director, BluePeak Advisors, LLC
- The life cycle of the risk adjustment process and member and provider engagement
- Key risks and pitfalls in the risk adjustment process
- How to best coordinate your risk adjustment operational and compliance teams
- Tips, tools, and best practices to manage, communicate, and motivate business owners to drive compliance
- How to prioritize issues and work with areas that are already overwhelmed to drive progress
- When and how to escalate issues internally and externally to get back on track
03:15 PM - 04:15 PMBreakout Session 4#801Compliance in the New Age of Expanded Supplemental Benefits Regan Pennypacker, President, Ancorat Consulting, LLC Elizabeth Browning, National Medicare Compliance Officer, Magellan Health
General Compliance#802Proven Methods to Streamline & Optimize FDR Oversight Christopher Wilde, Senior Manager, Compliance/Auditing/Third Party Oversight, Peach State Health Plan, Centene Corporation Deborah Johnson, Vice President, Compliance, IlliniCare Health Plan
- CMS has finalized a plan to expand the supplemental benefits that chronically ill Medicare Advantage members can access.
- The expansion of benefits, such as meals beyond a limited basis, non-medical transportation, and home environment services, will give way to new vendors like community agencies looking to partner with plans.
- This session will provide you tips on effectively working with agencies new to Medicare Advantage to ensure compliance program requirements are considered prior to implementation.
- Covered entities are ultimately responsible for actions delegated to FDRs
- FDR oversight and monitoring of often overlooked functional areas
- Pharmacy benefits manager (PBM) auditing & monitoring best practices
Agenda subject to change.