1. Fy18-19 Compliance Plan Review & Board Member Training
Mid-State Health Network

2. Compliance PROGRAM Requirements
The Medicaid Managed Specialty Supports and Services Contract with MDHHS, requires that the PIHP have:
An established process for carrying out corporate compliance activities
Policy that specifies procedures and standards of conduct
A designated Compliance Officer
A Compliance Committee
Established Process Includes:
Compliance Plan, Compliance Officer, Compliance Committee, Policies, Procedures, Monitoring and Oversight of Providers
MSHN Compliance Committee:
CEO, Deputy Director, CIO, CFO, Chief Clinical Director, and Director of CS/Compliance/QI and the Director of Provider Network Management Systems

3. Compliance PROGRAM Requirements
The Medicaid Managed Specialty Supports and Services Contract with MDHHS, requires that the PIHP have: Con’t
Training for all employees and board members related to compliance standards
A process for internal monitoring and auditing
Procedures for prompt response to identified problems and development of corrective actions
Monitoring and Auditing:
Post payment reviews of paid claims
Assure standards are enforced
Identify other high-risk compliance areas
Identify where improvements must be made
Corrective Action:
Can include restitution of payments, reporting to other governmental entities, or system changes

4. Board Members role in Compliance
MSHN’s Board of Directors Responsibility:
Review and approval of:
Compliance Plan
Compliance related policies
Annual Compliance Report
Matters related to the Compliance Program
Having the highest level of oversight of the Compliance Program
Reporting suspected fraud, waste and abuse

5. Board Members role in Compliance
MSHN’s Board of Directors Responsibility: Con’t
Abiding by the Standards of Conduct in performing activities
Assisting in establishing a workplace culture
Receiving training on the Compliance Plan and Standards of Conduct
Workplace Culture:
Promotes prevention, detection and resolution of conduct that does not conform with laws

6. Board Members role in Compliance
MSHN’s Board of Directors Responsibility: Con’t
Code of Conduct
Inclusive of confidentiality
Drug free and weapon free work environment
Free from harassment/bullying
Avoiding conflict of interest
Reporting suspected fraud and abuse
Conducting business in a honest and legal manner, promoting ethical behavior, etc.
All of these standards are included in MSHN’s Personnel Manual

7. Reporting and Investigation
All suspected violations, misconduct and fraud and abuse are required to be reported to the MSHN Compliance Officer
If it is suspected that Compliance Officer has a conflict of interest in the matter being reported, then the report is made to the Chief Executive Officer
If the suspected violation involves the Chief Executive Officer, then the report will be made to the Compliance Officer or the Board Chairperson/ Executive Committee

8. Reporting and investigation: con’t
The MSHN Compliance Officer will report all suspected fraud and abuse to the MDHHS Office of Health Services Inspector General
All reports of wrongdoing will be investigated promptly and investigations will be kept confidential. (prompt means action taken within 15 days of receipt of complaint)
When an investigation substantiates a violation, corrective action will be required that can include restitution of overpayment amounts, notifying government agencies, a corrective action plan and implementing system changes

9. Summary of Recommended Changes for FY18-19 Compliance Plan
Most changes/revisions to the plan are minor and were made to reflect our current processes
New/additional requirements of the Office of Inspector General
Preliminary investigations are to be completed prior to reporting to OIG
Quarterly Reporting to the OIG includes:
Tips/grievances received
Data mining and analysis of paid claims, including audits performed based on the results
Data Mining/Algorithms – Program Integrity scenarios (programs, formulas, queries, etc.) applied to claims data to identify providers or consumers to review/investigate for potential fraud, waste, or abuse.

10. Summary of Recommended Changes for FY17-18 Compliance Plan, Con’t
Quarterly Reporting to the OIG to include: Con’t
Compliance Activities (28 elements to report for each activity)
Audits performed
Overpayments collected
Identification and investigation of fraud, waste and abuse
Corrective action plans implemented
Annual Reporting of:
Provider disenrollments
Contract terminations