Centers for Medicare and Medicaid Services---
Compliance Agency is the Office of Inspector General
Health Insurance Compliance
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Medicaid-
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Billing Guides: See examples for WA or Arizona will help you stay in compliance
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State Role
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Medicare (no state role)
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Medicaid Managed Care
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Private Insurance
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Compliance Training: HCCA Certification
Resources
2017
OIG Compliance Basics: Presentation to Great Plains Tribes
OIG, November 2014 "Caution on Use of Medicaid and Medicare Funds."
OIG / HCCA Compliance Program Elements (January 2017):
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Standards, Policies, and Procedures
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Compliance Program Administration
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Screening and Evaluation of Employees, Physicians, Vendors and other Agents
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Communication, Education, and Training on Compliance Issues
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Monitoring, Auditing, and Internal Reporting Systems
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Discipline for Non‐Compliance
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Investigations and Remedial Measures
What are common non-compliance issues?
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Medicaid billing
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Mental Health
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CD/SUD
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Credentialing
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Contracting with MCOs (Managed care Medicaid, Exchange Plans)
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Culturally based care uncertainty
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No uncertainty by tribes that it is valuable and effective
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Uncertainty about what is billable
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History of fraud investigations helps and hurts
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How does management imperative to innovate and grow reconcile compliance imperative to work to the rule?
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Indepence of Compliance staff
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Chain of Command
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Goals of Organization
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Privileged position of the status quo regulaltion vs. desire to innovate of organizations
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Where does Compliance Officer 'fit'
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When is compliance at odds with management need to direct and guide performance?
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Communication: The right to monitor, receive reports, and file reports is not the right to manage
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Compliance should support good management, but cannot set vision, goals or methods of management.
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