1. Prompt response compliance TRAINING
Prompt Response to Issues of Non-Compliance

2. compliance training
This training module ensures VSP ‘s first tier, downstream or related entities (FDR’s), as suppliers, satisfy the general compliance training requirements as outlined by the Office of Inspector General (OIG) and Centers for Medicare and Medicaid Services (CMS).
The training program includes the compliance requirements provided under 42 C.F.R. § (b)(4)(vi)(G) & (b)(4)(vi)(G), Section 50.7 of the Compliance Program Guidelines, Chapter 21 of the Medicare Managed Care Manual.

3. Compliance is EVERYONE’s responsibility.
Why Do I Need Training?
Compliance is EVERYONE’s responsibility.
Your every action potentially affects our enrollees.
As a supplier who has been contracted to provide health or administrative services on behalf of VSP for Medicare and Medicaid enrollees, your every action potentially affects these enrollees and the Medicare and Medicaid Program.
The VSP Corporate Compliance Program is intended to demonstrate in the clearest possible terms the absolute commitment of VSP to the highest standards of ethics and compliance.
The program implements federal and state laws and regulations that govern company business.

4. Training Requirements
VSP Entity
VSP Management is committed to complying with all federal and state regulations, standards and sub-regulatory guidance. When an issue of non-compliance is identified, if you are contracted by VSP in support of our plan clients for Medicare Advantage Organizations (MAOs) and Medicaid, you, must receive training about compliance with CMS’ program rules.
Certain training requirements apply to people involved in performing or delivering the Medicare Parts C and D benefits and other Plans.
Medicare Part C, or Medicare Advantage (MA), is a health plan choice available to Medicare beneficiaries. MA is a program run by Medicare-approved private insurance companies. These companies arrange for, or directly provide, health care services for beneficiaries who elect to enroll in a MA plan.

5. Training Course Content
This course consists of general compliance program training and awareness.
You must satisfy general compliance training on the proper escalation of issues of non-compliance. You must use this course to satisfy general compliance training requirements.
This course should take approximately 15 minutes to complete.
Successfully completing the course will require completing the entire lesson and course evaluation.
Remember: In addition to this training “The Power of Three” – Compliance, HIPAA, Fraud/Waste/Abuse training must all be completed for New suppliers and Annual Compliance Training

6. When you complete this course, you should be able to correctly:
course Objectives
When you complete this course, you should be able to correctly:
Understand VSP’s commitment in conducting a timely, and reasonable inquiry into any evidence of misconduct related to payment or delivery of items or services under contract.
Recognize how VSP conducts appropriate corrective action (for example, repayment of overpayments, disciplinary actions against responsible individuals) in response to potential violations of non-compliance.
Recognize how compliance program violations should be reported.

7. Prompt response training topics
What is a considered an issue of non-compliance?
Does VSP make reasonable inquiry into all compliance incidents/issues to identify potential Fraud, Waste or Abuse (FWA)?
Discuss and define how VSP should promptly respond to identified compliance issues.
Does VSP require and ensure that all inquiries are well documented?
Does VSP require and ensure that all inquiries are initiated as quickly as possible?
Are appropriate corrective actions undertaken to correct and prevent future non-compliance, including conducting a root-cause analysis?

8. What is an issue of non-compliance?
Conduct that doesn’t conform to the law or federal regulatory requirements
Conduct against VSP’s ethical and business policies
A systemic issue impacting enrollee’s from receiving benefits

9. Compliance program
An effective compliance program is essential to prevent, detect and correct Medicare and Medicaid non-compliance as well as Fraud, Waste and Abuse (FWA).
It must, at a minimum, include the Seven Core Compliance Program requirements.
This training covers Requirement #7 – Prompt Response to Issues of Non-Compliance
For more information, refer to:
42 Code of Federal Regulations (CFR) Section (b)(4)(vi) on the internet
42 CFR Section (b)(4)(vi) on the internet
“Medicare Managed Care Manual”, Chapter 21 on the CMS website

10. Overview –element 7/ Prompt response
CMS requires for our health plan clients to operate in compliance with federal/state regulations and report any issues that may be out-of-compliance.
VSP is required to report any issues that may be considered out-of-compliance to the Health Plan Client Compliance Officer immediately upon learning of a reportable issue.
Both VSP (who holds a direct contract with Health Plan) and VSP’s suppliers or downstream (FDRs) that provide administrative services on behalf of VSP to Medicare/Medicaid members must complete this training.
NOTE: All FDR’s (VSP) who performs delegated administrative or health care service functions concerning Medicare Part C plans must comply with Medicare Program requirements.

11. What is Non-compliance?
Conflicts of Interest, Ethics, Agent/Broker Misrepresentation, Documentation and Timeliness Requirements, FDR Oversight & Monitoring
HIPAA, Claims Processing, Appeals and Grievances, Member Notices
Credentialing and Provider Networks; Quality of Care; Benefit Administration
Non-compliance is conduct that does not conform to the law, Federal health care program requirements, or to VSP ethical and business policies.
All areas are affected by Regulatory Compliance Requirements

12. Element 7 – important components
If VSP discovers evidence of misconduct related to payment or delivery of items/services under our contract, VSP must:
Conduct timely, reasonable inquiry into the conduct
Take appropriate corrective action
Have procedures to self-report fraud or misconduct related to our Medicare/Medicaid clients

13. Reasonable inquiry
Potential FWA compliance issues are investigated by the Special Investigation Unit (SIU) in conjunction with the Compliance Officer.
Potential employee misconduct is investigated by HR.
Potential issues of Privacy or Security are investigated by Office of Information Security (OIS), in conjunction with Regulatory Compliance.
Issues of non-compliance related to the administration of the Medicare and Medicaid program is investigated and resolved by the applicable business unit(s)
Non-compliance issues identified by the business unit are to be reported to Regulatory Compliance via an Issue Write-Up Form.
Non-compliance issues identified by Regulatory Compliance are reported to the applicable business unit via a Notice of Non-Compliance.
Non-compliance issues identified by health plan clients, or regulatory agencies and reported to VSP.

14. Promptly respond
Employees are required to report potential non-compliance issues to their department leadership immediately upon knowledge of issue.
Business Unit leadership evaluates the potential issue to determine if an Issue Write-Up Form is required.
If required, complete form and submit to Regulatory Compliance within 5-business days from issue identification.
Regulatory Compliance is responsible for tracking and monitoring all Issue Write-Ups received up to the point of resolution.
For issues of a more urgent nature involving access to care, VSP must initiate an immediate response. The Compliance Department should be notified verbally and by upon identification.
Issue Write-Up is reviewed by the Compliance Officer or designee to determine if potential non-compliance is reportable to client, and/or regulatory agency.

15. Documentation
The Issue Write-Up Form ensures detailed documentation is retained through the following:
Executive Summary of the Issue – short description of what occurred
Requirement – describes the regulatory and/or internal requirement applicable to the issue
Background – summarizes any relevant information needed to understand the issue
Date of issue Identified – the date the non-compliant issue was first identified
Description of Incidence – the Who, What and How of the incident
Impact of Incidence – total members impacted, systems
Root Case Analysis – the Why?
Template provides pre-defined root cause reasons

16. Timely inquiry / investigation
In accordance with VSP Compliance Policy C-0010, Issue Write-ups are submitted and investigated timely:
Submission of Issue Write-Up to Regulatory Compliance within 5-day calendar days of receipt.
Issues impacting member access to care or well-being are escalated to the Compliance Committee should a corrective action fall beyond 30-days.

17. Correct & prevent reoccurrence
Compliance Department reviews corrective action plans and tasks to determine if the deficiency is satisfied and is sustained.
Issues identified are coordinated through Compliance with the applicable Business Unit to revise corrective action plan.

18. Lesson summary
Organizations must create and maintain compliance programs that, at a minimum, meet the seven core requirements.
An effective compliance program fosters a culture of compliance.
To help ensure compliance, behave ethically and follow the VSP Code of Conduct.
Watch for common instances of non-compliance and report suspected non-compliance.
Know the consequences of non-compliance and help correct any non-compliance with a corrective action plan that includes ongoing monitoring and auditing.

19. Reference SEVEN CORE COMPLIANCE PROGRAM REQUIREMENTS
CMS requires that an effective compliance program must include seven core requirements:
Written Policies, Procedures, and Standards of Conduct: These articulate the Sponsor’s commitment to comply with all applicable Federal and State standards and describe compliance expectations according to the Standards of Conduct.
Compliance Officer, Compliance Committee, and High-Level Oversight: The Sponsor must designate a compliance officer and a compliance committee that will be accountable and responsible for the activities and status of the compliance program, including issues identified, investigated, and resolved by the compliance program. The Sponsor’s senior management and governing body must be engaged and exercise reasonable oversight of the Sponsor’s compliance program.
Effective Training and Education: This covers the elements of the compliance plan as well as prevention, detection, and reporting of FWA. This training and education should be tailored to the different responsibilities and job functions of employees.
Effective Lines of Communication: Effective lines of communication must be accessible to all, ensure confidentiality, and provide methods for anonymous and good-faith reporting of compliance issues at Sponsor and First-Tier, Downstream, or Related Entity (FDR) levels.

20. Reference SEVEN CORE COMPLIANCE PROGRAM REQUIREMENTS
CMS requires that an effective compliance program must include seven core requirements (continued):
Well-Publicized Disciplinary Standards: Sponsor must enforce standards through well-publicized disciplinary guidelines.
Effective System for Routine Monitoring, Auditing, and Identifying Compliance Risks: Conduct routine monitoring and auditing of Sponsor’s and FDR’s operations to evaluate compliance with CMS requirements as well as the overall effectiveness of the compliance program. NOTE: Sponsors must ensure that FDRs performing delegated administrative or health care service functions concerning the Sponsor’s Medicare Parts C and D program comply with Medicare Program requirements.
Procedures and System for Prompt Response to Compliance Issues: The Sponsor must use effective measures to respond promptly to non-compliance and undertake appropriate corrective action.

21. Prompt response compliance training
CONGRATULATIONS!
YOU HAVE COMPLETED THE
VSP PROMPT RESPONSE COMPLIANCE AWARENESS TRAINING
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