1. CMS Five Star Best Practice Review Kaiser Foundation Health Plan Marcella Jordan, Vice President Medicare & Compliance Programs September 5, 2012

2. 2 Overview Background Review Process & Protocols Compliance Program Best Practices

3. Background For 2012, four of KFHP’s Medicare health plans were awarded an overall rating of 5 stars –California, Colorado, Hawaii, and Northwest –Combined membership of over 900,000 –Integrated health systems inclusive of health plan, hospitals, and affiliated medical group  Operations largely decentralized  National Compliance Program in place 3

4. Review Process & Protocols: Approach  Formal notification received February 6, 2012  Conducted in two phases  Compliance Program was only area reviewed on- site 4 Phase 1Phase 2 Formulary and Benefit AdministrationAgent/Broker Oversight Part D Coverage Determinations & Appeals Late Enrollment Penalty (LEP) Part C Organization Determinations & Appeals Grievances Part C Access Compliance Program Effectiveness

5. Review Process & Protocols: Timeline 5

6. Review Process & Protocols: Preparation Universe/supporting documentation request included with engagement letter Samples received just a few days in advance or on same day depending on element – Moving forward, sample selection to be provided on day of audit Reviews conducted via webinar – Live “walk-though” of systems All documents uploaded through secure File Transfer Protocol (FTP) 6

7. Review Process & Protocols: Challenges Short turnaround times to produce: – Universes, supporting documentation Coordination (i.e. ensuring right people available at the right times) – Securing necessary information/files from vendors Technical difficulties – Viewing/opening large files via webinar – Navigating complex data systems in real-time – Playing audio recordings (e.g. OEV calls) over webinar 7

8. Review Process & Protocols: Lessons Learned Secure leadership support to ensure adequate resources Have WebEx savvy people available to facilitate meetings Ensure electronic versions of documents are available for quick retrieval and effective archiving All hands on deck! 8

9. Compliance Program Best Practices 9 KFHP passed all eight Compliance Program elements – Seven OIG elements and FDR Compliance Program was previously audited in Fall 2010 Numerous best practices cited by CMS

10. Compliance Program Best Practices Data Mining Analytic team dedicated to data mining Identifies patterns that suggest FWA; refers cases as appropriate Conducts ad-hoc studies based on tips Monitoring of claims paid in CMS- designated “high-risk Counties” 10

11. Compliance Program Best Practices Tracking of FDR Training Training for our Medical Groups: – Offered through web- based modules – Completion tracked at individual level 11

12. Compliance Program Best Practices Compliance Hotline Receives 7,000 calls per year Integrated with case tracking system – System also tracks all CAPs and disciplinary actions – Controls allow for triaging and active monitoring of open cases 12

13. Compliance Program Best Practices New CMS Issuance process Regulatory guidance is reviewed and internally disseminated Implementation of new requirements tracked in a database 13

14. Compliance Program Best Practices Code of Conduct Interactive website that allows employees to add comments or pose questions Site showcases policies, procedures, and compliance toolkits 14

15. Contact Information Marcella Jordan, VP- Medicare & Compliance Programs Kaiser Foundation Health Plan, Inc. 2101 East Jefferson Street, 2W Rockville, MD 20852 Office: (301) 816-7178 Mobile: (202) 744-0233 marcella.jordan@kp.org 15

16. Questions & Answers Thank you! 16