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Medicare Advantage and Part D Plans Require Providers/Pharmacies to Complete Training on Fraud, Waste and Abuse by December 31, 2009

(December 22, 2009)

Medicare Advantage (MA) plans, Medicare Part D plans and their Prescription Benefit Managers (PBMs) are sending statements, contractual amendments and/or requests for attestations to their network of health care providers requiring that providers’ employees undergo fraud, waste and abuse (FWA) training. Such notices generally are requiring the training of providers’ employees be completed by December 31, 2009.

In regulations that became effective January 1, 2009, the Centers for Medicare & Medicaid Services (CMS) required MA and Part D plan sponsors to provide “effective training and education between the [plan’s] compliance officer and the…[plan’s]…employees, managers and directors, and the…[plan’s]…first tier, downstream, and related entities. The regulations are found in 42 C.F.R. § 422.503(b)(4)(vi) and 42 C.F.R. §423.504(b)(4)(vi) for MA and Part D plans, respectively. Network providers of health services, including infusion pharmacies, are considered “downstream entities.”

On October 22, 2009, proposed MA and Part D technical change rules were published that included proposals from CMS on the FWA training. Specifically, the proposed rules if adopted would mean downstream entity providers enrolled in Medicare would be deemed to have satisfied the FWA training requirements when contracted with MA plans. However, because downstream entities contracted with Part D plans are not always enrolled in Medicare, CMS welcomed comments but did not propose similar deeming. Comments were due on December 8.

NHIA strongly supports CMS’ efforts to reduce fraud, waste and abuse and agrees with CMS’ general principle that providers should be educated and trained to comply with Medicare laws, regulations and other requirements. We recommended that CMS deem downstream entities which are enrolled in Medicare that contract with Part D plans as having met the FWA training requirement. Most home infusion therapy providers are enrolled in Medicare. Our comments included a number of additional points.

• Click here to read NHIA’s comments to CMS.
• What more has CMS communicated? What are MA and Part D Plans Communicating? What actions can you take?
  • NHIA Members: click here and look for the NHIA member advisory issued December 10 for more information on this matter.
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