Federal law and the Centers for Medicare and Medicaid Services (CMS) contracts impose a number of requirements relative to the delegation of functions to downstream entities or partners for Medicare Advantage (MA) organizations and Part D plan sponsors. Each MA organization and Part D plan sponsor is ultimately responsible for adhering to the terms and conditions of their contracts with CMS – notwithstanding any relationships it may have with related entities, contractors, or subcontractors. Some of these CMS requirements are clearly more process-oriented, and these requirements should be embedded in the appropriate contractual documents. The broader and more substantive requirements require active engagement of business leads, documentation and oversight structures.

The best way to make sure that an MA organization or Part D plan sponsor meets both these process-oriented and substantive requirements – and shows its commitment to the government to do so – is to put in place a compliance program that includes the familiar key elements that the government has identified as constituting an effective compliance program. With a robust compliance program containing these key elements, coupled with a strong commitment to creating an organizational culture of compliance, MA organizations and Part D plan sponsors can ensure that they are overseeing their delegated entity relationships in a manner most likely to meet – and, better yet, exceed – the expectations of regulatory authorities.

In addition, the structures, processes, and outcomes principles outlined above have applicability to any health care organization operating in a complex regulatory environment. In this regard, the most critical principle is that work may be delegated – but the delegating organization will still retain responsibility and accountability for performance and outcomes.

A related article from Bloomberg BNA's Health Care Program Compliance Guide will be available to attendees.

Educational Objectives:

• Become aware of the complex web of federal regulation and subregulatory guidance related to delegate oversight is helpful in navigating around potential minefields associated with oversight of delegates in the Medicare context. While work can be delegated from one organization to another, the accountability for that work must not be delegated. This creates a challenging paradox: an organization may be delegating work because it lacks expertise in a particular area – but it still must have enough expertise to oversee the performance of its new business partner.

• Understand the issues associated with creating a program to accomplish this difficult task – that is, overseeing business partners that may have more expertise than the delegating organization – while at the same time meeting regulatory requirements and ensuring that an organization protects its reputation.

Who would benefit from attending the program?

This program will provide information that can help executives, attorneys, and compliance professionals understand the legal framework and make informed decisions about oversight of delegates.

Program Level: Intermediate