As a First Tier, downstream or related entity who provides administrative or healthcare services to Medicare beneficiaries on behalf of HPP, you must at a minimum, provide any new employee, temporary employee, volunteer, consultant, governing body member or delegated vendors Fraud, Waste, and Abuse training and General Compliance training within 90 days of initial hiring and annually thereafter.
Full Answer
What is a first tier/downstream/related entity?
First Tier, Downstream, and Related Entities (FDRs) are defined by CMS as any party that enters into a written arrangement with a Medicare Advantage organization or Part D plan sponsor to provide administrative services or healthcare-related services.
What is a first tier entity for Medicare?
First Tier Entity: any party that enters into a written arrangement, acceptable to CMS, with an MAO or Part D plan sponsor or applicant to provide administrative services or health care services to a Medicare eligible individual under the MA program or Part D program. (See 42 C.F.R. § 423.501).
What is a downstream entity in healthcare?
These written arrangements continue down to the level of the ultimate provider of both health and administrative services (See, 42 C.F.R. §, 423.501). A Downstream Entity could include the following: Hospital within a health system that has entered into a system level agreement Who are Related Entities?
Is compliance training required for Medicare Advantage plan sponsors?
The Centers for Medicare & Medicaid Services (“CMS”) recently enacted a Final Rule removing certain compliance training requirements previously applicable to first tier, downstream and related entities (“FDRs”) of Medicare Advantage and Part D Plan Sponsors (“Plan Sponsors”).
What is a first tier downstream entity?
First Tier, Downstream, and Related Entities (FDRs) are defined by CMS as any party that enters into a written arrangement with a Medicare Advantage organization or Part D plan sponsor to provide administrative services or healthcare-related services.
What is a first tier entity Medicare?
The term first tier entity means any party that enters into a written arrangement with an MA organization or contract applicant to provide administrative services or health care services for a Medicare eligible individual.
What is first tier entity Medicare Advantage?
First Tier Entity is any party that enters into a written arrangement, acceptable to CMS, with a Medicare Advantage Organization or Part D plan sponsor or applicant to provide administrative services or healthcare services to a Medicare eligible individual under the Medicare Advantage program or Part D program.
Which is an example of a first tier entity?
First Tier Entity – any party that enters into a written arrangement, acceptable to CMS, with a Medicare Advantage (MA) Organization (MAO) or Part D plan sponsor or applicant to provide administrative services or health care services to a Medicare eligible individual under the MA program or Part D program (refer to 42 ...
What is a downstream provider?
downstream provider means an entity or individual that is contracted by a First Tier Entity to provide services to Enrollees. A Downstream Provider includes, but is not limited to physicians, ancillary providers, and other health care providers.
What does downstream agreement mean?
Downstream Contracts means all contracts or arrangements to which Working Interest Owner (or any Person acting on behalf of Working Interest Owner) is a party that provide for or relate to the gathering, transportation, treatment, processing, marketing or sale of Subject Hydrocarbons.
What are MA organizations?
MA organization means a public or private entity organized and licensed by a State as a risk-bearing entity (with the exception of provider-sponsored organizations receiving waivers) that is certified by CMS as meeting the MA contract requirements.
What is FDR compliance?
First Tier, Downstream and Related Entity (FDR) Compliance Attestation. CMS requires any organization or individual that contracts with Health Partners Plans (HPP) to provide administrative or health care service functions on behalf of HPP comply with various CMS program requirements.
What is a delegated entity CMS?
CMS* considers delegation a business relationship between the organization and a first-tier entity to perform certain functions that otherwise would be the responsibility of the organization to perform.
What is a Medicare Advantage sponsor?
CMS uses the term “plan sponsor” to describe an organization that has an approved, active contract with the federal government to offer Medicare Advantage plans, prescription drug plans, and 1876 cost plans. A plan sponsor can be an employer, a union, or a health insurance carrier.
Does Managed Medicare follow Medicare guidelines?
Medicare Advantage Plans Must Follow CMS Guidelines In the United States, according to federal law, Part C providers must provide their beneficiaries with all services and supplies that Original Medicare Parts A and B cover.
What is a FDR in Medicare?
First tier, downstream and related entities (FDR’s) are the providers, vendors and related entities that contract with Providence Health Assurance (PHA) to support Medicare members.
Is Providence Medicare a compliance program?
Providence Medicare Advantage Plans is committed to a culture of compliance. As part of our contract with The Centers for Medicare & Medicaid Services (CMS), we have developed and adopted an effective compliance program. Our compliance program reinforces our commitment to high ethical standards and conduct, and establishes our expectation that all Providence Medicare Advantage Plan caregivers, governing board, FDR’s and members conduct themselves in an ethical and lawful manner and comply with all federal, state and local laws and regulations.
First-Tier, Downstream and Related Entities (FDR) Compliance
As a CareFirst BlueCross BlueShield Medicare Advantage (CareFirst) partner, we know you will embrace the core values that drive our success and culture. We also expect you to respect the following tenets, which are central to how we conduct ourselves and everything we do:
Are you an FDR?
CareFirst abides by the Centers for Medicare and Medicaid Services (CMS) FDR definition. This means that if your organization provides an administrative or healthcare service for our members relating to our Medicare contracts on our behalf, we consider you to be an FDR.
What is a first tier entity?
First-tier entity is any party that enters into a written arrangement, acceptable to CMS, with a Medicare Advantage Organization or Part D plan sponsor or applicant to provide administrative services or healthcare services to a Medicare eligible individual under the Medicare Advantage program or Part D program.
What is downstream entity?
Downstream entity is any party that enters into a written arrangement, acceptable to CMS, with persons or entities involved with the Medicare Advantage benefit or Part D benefit, below the level of the arrangement between a Medicare Advantage Organization or applicant or a Part D plan sponsor or applicant and a first tier entity.
Why do we need annual attestation from FDRs?
We obtain an annual attestation from FDRs to ensure they are in compliance with applicable compliance program requirements. An authorized individual from each first-tier entities must attest that its organization and any of its downstream and/or related entities are in compliance with requirements relating to the following:
What should an MA organization do before contracting with CMS?
Before an MA organization contracts with an entity to perform functions that are otherwise the responsibility of the MA organization under its contract with CMS, the MA organization should develop, implement, and maintain policies and procedures for assessing contracting provider groups' administrative and fiscal capacity to manage financial risk prior to delegating MA-related risk to these groups. Suggested policies and procedures include:
How long do you have to give CMS notice?
The organization must give CMS notice at least 90 days before the intended date of termination which specifies the reasons the MA organization is requesting contract termination.
Who audits MA contracts?
DHHS, the Comptroller General, or their designees may audit, evaluate, or inspect any books, contracts, medical records, patient care documentation, and other records of the MA organization or relating to the MA organization's MA contract. DHHS, the Comptroller General, or their designees may audit, evaluate, or inspect any books, contracts, medical records, patient care documentation, and other records of the related entity, contractor, subcontractor, or its transferee that pertain to any aspect of services performed, reconciliation of benefit liabilities, and determination of amounts payable under the contract, or as the Secretary may deem necessary to enforce the MA contract.
Does CMS enter into a contract with an entity?
Unless an organization has a minimum enrollment waiver as explained below, CMS does not enter into a contract with an entity unless it meets the following minimum enrollment requirements:
What is an FDR contract with HPP?
As an FDR that contracts with HPP, you must ensure that compliance is maintained by your organization as well as your downstream and related entities that provide administrative or healthcare services to HPP’s Medicare business. To ensure ongoing compliance with State and Federal regulations, your organization must perform ongoing oversight to ensure that your organization and your downstream and related entities, if applicable, comply with the above stated requirements and any additional regulations related to the services you/ they provide to HPP.
Can Medicare be paid for services furnished by an excluded provider?
Medicare payment may not be made for items or services furnished or prescribed by an excluded provider or entity. HPP is responsible for ensuring that we do not use federal funds to pay for services, equipment or drugs prescribed or provided by a provider, supplier, employee or FDR excluded by the OIG or SAM.
Does HPP take Medicare compliance seriously?
We at HPP, Inc. take compliance concerns and suspected or actual violations related to the Medicare program very seriously. As an FDR that contracts with HPP, you must ensure that all of your employees and those of any of your downstream and related entities are informed of how to report compliance concerns and suspected misconduct. HPP will perform an internal investigation of each concern after your organization reports any incidents.
Is compliance training required for CMS?
However, compliance training is still required of Plan Sponsors, and Plan Sponsors remain obligated under their contracts with CMS to conduct routine monitoring, auditing and oversight of their FDRs.
Does Medicare Advantage require compliance training?
Specifically, beginning in plan year 2019, health care providers that participate in Medicare Advantage and Part D are no longer required by CMS to complete CMS-issued general compliance and fraud, waste and abuse training. However, Plan Sponsors will still have discretion to include compliance training requirements in their provider contracts.
Does CMS require FDRs to complete CMS training?
Beginning January 1, 2019, CMS will no longer require Plan Sponsors to ensure that their FDRs complete CMS-published training modules. CMS’s stated goal is to reduce administrative burden and to provide each Plan Sponsor with flexibility to oversee FDR compliance as it sees fit.
What Are First Tier, Downstream, and Related Entities (Fdrs)?
How to Determine Whether An Entity Is A Fdr
- Below are some factors to consider in determining whether an entity is a FDR: 1. The function to be performed by the delegated entity 2. Whether the function is something the sponsor is required to do or to provide under its contract with CMS, the applicable federal regulations or CMS guidance 3. To what extent the function directly impacts enrollees 4. To what extent the delegat…
Compliance Program Requirements For First Tier, Downstream, and Related Entities
- All FDRs participating in Medicare Advantage are required to maintain certain compliance requirements – even any of your vendors who are considered FDRs. As a provider organization, non-compliance with you or your FDRs could result in a Corrective Action Plan, retraining, or even termination of your contract with the Medicare Advantage plan adminis...