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Medicare Compliance and
Quality Improvement Committee

The structure, composition, independence, and operation of the Medicare Compliance and Quality Improvement Committee "MCC"), and the implementation and operation of the required Fraud, Waste, and Abuse Control Program, are integral to the implementation and operation of a Medicare Advantage program. Without a properly structured and functioning Compliance Committee, and Fraud, Waste, and Abuse Program, the entire program is at jeopardy. This is particularly critical since CMS has the right to submit inquiries and conduct audits of a provider's program.

The firm advises providers in such key areas as:

  • Job description and reporting lines for Medicare Compliance Officer
  • Charter, operating procedures, composition, and reporting lines for Medicare Compliance Committee
  • Policies and Procedures
  • Standards for education and training
  • Review of Audit procedures
  • Reporting of findings and recommendations

Medicare Compliance Officer

The Medicare Compliance Officer ("MCO") is required to have adequate authority and independence to perform his/her functions, and report directly to the Board of Directors. The MCO must report to the Board on the effectiveness and operations of the compliance program.

The MCO is primarily and personally responsible for:

  • Developing Policies and Procedurs
  • Receive reports to MCO as required by Policies and Procedures
  • Overseeing internal audits
  • Overseeing subcontractual relationships (e.g., Third Party Administrators)
  • Reporting to CMS
  • Remedial and corrective action

The Committee and the Medicare Compliance Officer must report directly to the CEO of the Company and the Board of Directors.

Medicare Compliance Committee

The Medicare Compliance Officer, and the Medicare Compliance Committee, are charged with the responsibility for developing, operating, and monitoring the Fraud, Waste, and Abuse Program.

  • Providing support for the MCO
  • Review of internal audits
  • Corrective and remedial action
  • Must meet at least quarterly
  • Reports directly to the Board of Directors
  • Ensures a non-retaliative atmosphere for the provider's operations, including operation of the Fraud, Waste, and Abuse Program

Policies and Procedures

The firm will assist the Company in preparation of Policies and Procedures that assure proper education and training of the responsible individuals, proper monitoring and auditing of the operations, enforcement of disciplinary actions to address violations found, incentives to discourage fraud and abuse, preventive measures to minimize fraud, waste, and abuse, and reporting necessary information to the MCC.