December 2016

CMS Compliance Program Training Requirements

Per the CMS Memo 4642 released in January 1, 2016, all Managed Care Organizations (MCOs) and their vendors identified as First Tier, Downstream and Related Entities (FDRs) are required to complete CMS’s compliance trainings.

Trainings

• The trainings must occur within 90 days of initial hiring and annually thereafter.
• The annual training can be completed any time between Jan. 1 – Dec. 31 of any given contract year.

• Attestations demonstrating completion of the appropriate general compliance and Fraud, Waste,and
• Abuse (FWA) trainings are required as evidence of compliance with the training requirement.

Attestations must include language specifying the entity complies with CMS compliance and FWA training requirements and the training provided includes CMS content.

• The format of the attestation may vary depending on the Sponsor.

Upon request, attestations must be provided within 24 hours to the MCO and/or CMS. Failure to produce attestations will result in regulatory noncompliance status with HCSC and may result in an escalation progression, inclusive of contract termination.

What are the Compliance Program Training Requirements?
Sponsors must ensure their FDRs receive general compliance training as well as FWA training. The CMS compliance program training was designed to ensure:

(1) Sponsors’ FDRs have at least a basic knowledge and understanding of compliance program requirements; and,

(2) Sponsors’ FDRs are knowledgeable about compliance and FWA issues and how to appropriately address them. CMS developed a web-based compliance training module, which was recently redesigned. The general compliance and FWA training courses now offer the ability to provider separate content for compliance and FWA, and provide web-based and downloadable versions. The training content is generic since various entities (e.g., health plans, labs, hospitals, etc.) complete the training. A certificate of completion is generated upon passing a short test with a score of 70% or higher at the end of the training module.

Training courses are available on the CMS Medicare Learning Network^® (MLN):
https://learner.mlnlms.com/Default.aspx

Methods for Completing the Training
Sponsors and/or FDRs will have three (3) options for ensuring FDRs have satisfied the general compliance training requirement:

(1) FDRs can complete the general compliance and/or FWA training modules located on the CMS MLN. Once an individual completes the training, the system will generate a certificate of completion. The MLN certificate of completion must be accepted by Sponsors.

(2) Sponsors and FDRs can incorporate the content of the CMS standardized training modules from the CMS website into their organizations’ existing compliance training materials/systems.

(3) Sponsors and FDRs can incorporate the content of the CMS training modules into written documents for providers (e.g. Provider Guides, Participation Manuals, Business Associate Agreements, etc.).

Although the training content cannot be modified, CMS will allow modifications to the appearance of the content (i.e., font, color, background, format, etc.). Additionally, organizations may enhance or wrap around the CMS training content by adding topics specific to their organization or the employee’s job function. At the Sponsor’s request, FDRs must submit an attestation confirming that the organization has completed the appropriate general compliance and FWA training.

Who Must Complete the Training?
Below are examples of (but not limited to) the critical roles within an FDR that should clearly be required to fulfill the training requirements:

Positions/Roles

• Senior administrators or managers directly responsible for the FDR’s contract with the Sponsor (e.g., Senior Vice President, Departmental Managers, Chief Medical or Pharmacy Officer);
• Individuals directly involved with establishing and administering the Sponsor’s formulary and/or medical benefits coverage policies and procedures;
• Individuals involved with decision-making authority on behalf of the Sponsor (e.g., clinical decisions, coverage determinations, appeals and grievances, enrollment/disenrollment functions, processing of pharmacy or medical claims);
• Reviewers of beneficiary claims and services submitted for payment; or,
• Individuals with job functions that place the FDR in a position to commit significant noncompliance with CMS program requirements or health care FWA.

Should you have any questions, contact your Provider Relations Representative for further instructions on fulfilling the CMS Compliance Program Training requirements.