Welcome to
2011
Medicare Compliance Training
for External Parties
(2011 – PowerPoint Version)
"CIGNA Medicare Services" is a service mark, and the "Tree of Life" logo is a registered service mark, of CIGNA
Intellectual Property, Inc., licensed for use by CIGNA Corporation and its operating subsidiaries. All products and services
are provided exclusively by operating subsidiaries, including Connecticut General Life Insurance Company and CIGNA
HealthCare of Arizona, Inc., both of which are Medicare Advantage Organizations with a federal Medicare contract, and not
by CIGNA Corporation.
“CIGNA Government Services" mean CIGNA Government Services, LLC, an affiliate of Connecticut General Life Insurance
Company, Part B and DME Contracted Carrier for the Centers for Medicare & Medicaid Services.
Confidential property of CIGNA. Do not duplicate or distribute. All examples and fact patterns used herein are fictitious.
© Copyright 2011 by CIGNA
Introduction
The 2011 Medicare Compliance Training will cover the following topics:
Introduction
Overview of
Programs
Introduction
Overview Rules
of
Medicare
Programs
•
•
•
•
•
•
Overview of CIGNA’s Medicare Programs
What Rules Must CIGNA Medicare Comply With?
Key Elements of a Compliance Program
Policies and Procedures
Protecting Personal Health Information (PHI)
Conclusion
Key
Elements
Medicare
Rules
Training Requirements
Agent/Broker
Policies &
Oversight
Procedures
CIGNA has contracted with the Centers for Medicare & Medicaid Services (CMS) to offer multiple
benefits to Medicare enrollees. As part of those contracts, CIGNA requires their employees who
have direct or indirect involvement with the Medicare program to complete a Compliance training
course.
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
Protecting PHI
Conclusion
Additionally, per the Federal Register Notice CMS-4124-FC, CMS clarifies that the training
and communication requirements apply to all entities we partner with.
Therefore, CIGNA is making this training available in the event you do not have your own
Medicare Compliance Training program established.
Introduction
Overview of
Programs
Medicare Rules
Agent/Broker
Oversight
Key Elements
Policies &
Procedures
Protecting PHI
Conclusion
Lesson One
Overview of Medicare Programs
Overview of CIGNA’s Medicare Programs
Introduction
Overview of
Programs
Introduction
Overview Rules
of
Medicare
Programs
Introduction
The government offers four different types of Medicare programs
Medicare Part A covers
Hospital Care
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
Protecting PHI
Conclusion
Medicare Part B covers
Medical Services
Medicare Part C covers
Medical Services for
Medicare Advantage
plans, like HMO, PPO,
Private Fee for Service
Medicare Part D covers
Prescription Drug Plans
Overview of CIGNA’s Medicare Programs
Introduction
Overview of
Programs
Introduction
Introduction
CIGNA offers three types of Medicare programs
CIGNA Medicare Part D
Prescription Drug
Program (PDP) Medicare D
Overview Rules
of
Medicare
Programs
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
CIGNA Government
Services (CGS) Medicare B
Protecting PHI
Conclusion
CIGNA Medicare Select
(HMO) - a Medicare
Advantage Prescription
Drug (MA-PD) Plan
available in Arizona
(Maricopa and Pinal
counties)
Overview of CIGNA’s Medicare Programs
Introduction
Overview of
Programs
Introduction
Overview Rules
of
Medicare
Programs
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
Protecting PHI
Conclusion
CIGNA Government Services (CGS)
CGS has offices located in Nashville, TN, and Highpoint, NC and contracts with the
Centers for Medicare & Medicaid Services (CMS).
CGS administers the Medicare Part B contract for NC and ID. This contract covers
physician services, outpatient hospital care, and some other medical services (e.g.
physical and occupational therapists) that Part A (hospital, hospice and skilled
nursing home coverage) does not cover.
CGS has also been awarded the Durable Medical Equipment Regional Contract
(DME MAC) for Region C, which encompasses 15 states in the southern United
States. The DME contract covers equipment such as hospital beds, wheelchairs,
oxygen, and diabetic supplies used by the beneficiaries in their homes.
On both contracts (Part B and DME MAC) services include claim payment, provider
inquiry medical review and appeals processing. The Part B contract also includes the
Provider Enrollment process for the covered states.
Overview of CIGNA’s Medicare Programs
Introduction
Overview of
Programs
Introduction
Overview Rules
of
Medicare
Programs
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
Protecting PHI
Conclusion
CIGNA Government Services (CGS)
CGS Awarded A/B MAC Contract
On July 9, 2010, CGS was awarded the Medicare Part A/B MAC contract for
Jurisdiction 15 which includes the states of Ohio and Kentucky. This contract covers
physician services, outpatient hospital care, and some other medical services (e.g.
physical and occupational therapists) as well as Part A services (hospital, hospice
and skilled nursing home coverage).
The Jurisdiction 15 award also includes Home Health and Hospice workloads for
Colorado, Delaware, District of Columbia, Iowa, Kansas, Maryland, Missouri,
Montana, Nebraska, North Dakota, Pennsylvania, South Dakota, Utah, Virginia,
West Virginia and Wyoming.
Overview of CIGNA’s Medicare Programs
CIGNA HealthCare of AZ offers two benefit plans
Introduction
Overview of
Programs
Introduction
Overview Rules
of
Medicare
Programs
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
Protecting PHI
Conclusion
CIGNA Medicare Select Plus Rx (HMO)
CIGNA Medicare Select Plus Rx – Dual (HMO SNP)
The CIGNA Medicare Select plans are located in Phoenix, AZ, and are contracted with
the Centers for Medicare & Medicaid Services to offer Medicare Advantage Prescription
Drug (MA-PD) benefits to Medicare eligible beneficiaries. Through this arrangement,
Medicare pays CIGNA a set amount of money every month to provide medical and
prescription drug coverage to Medicare beneficiaries.
What is CIGNA Medicare Select Plus Rx?
CIGNA Medicare Select Plus Rx is a MA-PD Health Maintenance Organization (HMO) plan
that provides medical and prescription drug coverage. CIGNA Medicare Select Plus Rx
customers must receive services from network and/or contracted providers, except for
emergent or urgent care, which may be obtained worldwide.
Medicare eligible beneficiaries who reside in Maricopa County or the Cities of Apache
Junction or Queen Creek in Pinal County, do not have end stage renal disease, and have
Medicare Parts A and B coverage are eligible for this plan.
Overview of CIGNA’s Medicare Programs
CIGNA HealthCare of AZ offers two benefit plans
Introduction
Overview of
Programs
Introduction
Overview Rules
of
Medicare
Programs
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
CIGNA Medicare Select Plus Rx (HMO)
CIGNA Medicare Select Plus Rx – Dual (HMO SNP)
What is CIGNA Medicare Select Plus Rx – Dual (HMO SNP)?
CIGNA Medicare Select Plus Rx – Dual (HMO SNP) is an MA-PD
Health Maintenance Organization (HMO) Special Needs Plan
(SNP) which offers medical and prescription drug coverage to
beneficiaries who have dual coverage, such as Medicaid and
Medicare benefits.
CIGNA Medicare Select Plus Rx – Dual or CIGNA Medicare
Select beneficiaries must receive services from the CIGNA
Medicare Select network of providers. Emergent or urgent care
may be obtained anywhere within the United States.
Protecting PHI
Conclusion
Dual-eligible beneficiaries may join the CIGNA Medicare
Select Plus Rx – Dual (HMO SNP) plan at any time throughout
the year if the beneficiary resides in Maricopa County or
the cities of Apache Junction or Queen Creek in Pinal
County, does not have end stage renal disease, has
Medicare Parts A and B and maintains their dual-eligible
status.
Overview of CIGNA’s Medicare Programs
CIGNA Medicare Part D Prescription Drug Program (PDP)
Introduction
Overview of
Programs
Introduction
Overview Rules
of
Medicare
Programs
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
Protecting PHI
Conclusion
CIGNA’s PDP program encompasses many offices with the core staff located in
Bloomfield, CT and contracts with the Centers for Medicare & Medicaid Services
(CMS) to provide:
•
Individual prescription drug benefits for Medicare beneficiaries and
•
Employer-sponsored prescription drug plans.
Employer-sponsored prescription drug plans include:
•
Employer Retiree Drug Subsidy – Employers or unions with prescription drug
coverage that is at least as good as Medicare’s can apply to the Centers for
Medicare & Medicaid Services (CMS) to receive a tax-free retiree subsidy.
•
Employer-Specific PDP – The employer makes special arrangements with
entities offering Part D Medicare plans (like, Connecticut General Life
Insurance Company, CGLIC) to provide a retiree prescription drug plan that
integrates the basic Part D individual coverage with the supplemental
coverage (i.e., coverage for classes of prescription drugs not covered under
Part D, such as coverage for Barbiturates and Benzodiazepines).
Introduction
Overview of
Programs
Medicare Rules
Agent/Broker
Oversight
Key Elements
Policies &
Procedures
Protecting PHI
Conclusion
Lesson Two
What Rules Must CIGNA Medicare
Comply With?
Medicare Rules
What rules must CIGNA Medicare comply with?
Introduction
Overview of
Programs
Introduction
Overview Rules
of
Medicare
Programs
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
Protecting PHI
As a Medicare contractor, we must comply with numerous regulations. Listed below are
several important links to these regulations and guidance issued by CMS.
Centers for Medicare & Medicaid Services (CMS):
http://www.cms.hhs.gov
Annual Part C and Part D Application link:
http://www.cms.hhs.gov/PrescriptionDrugCovContra/04_RxContracting_ApplicationGuidance.asp#
TopOfPage
Call Letter link:
http://www.cms.gov/MedicareAdvtgSpecRateStats/Downloads/Announcement2011.pdf
Medicare Part D Manuals link:
http://www.cms.hhs.gov/PrescriptionDrugCovContra/12_PartDManuals.asp#TopOfPage
Medicare Part C Manuals link:
http://www.cms.hhs.gov/Manuals/IOM/itemdetail.asp?filterType=none&filterByDID=99&sortByDID=1&sortOrder=ascending&itemID=CMS019326&intNumPerPage=10
Instructions issued by the Centers for Medicare & Medicaid Services (CMS) via the Health
Plan Management System (HPMS) link:
http://www.cms.hhs.gov/PrescriptionDrugCovContra/HPMSGH/list.asp#TopOfPage
Conclusion
Code of Federal Regulations (CFR) applicable to the Medicare link:
http://www.access.gpo.gov/nara/cfr/cfr-table-search.html#page1
Pharmacies contracted with Medicare Sponsors (such as CIGNA), must comply with
numerous regulations, for example:
Pharmacy specific instructions can be found at:
http://www.cms.hhs.gov/center/pharmacist.asp
Medicare Rules
Introduction
Overview of
Programs
Introduction
Overview Rules
of
Medicare
Programs
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
Protecting PHI
Conclusion
What rules must CIGNA Medicare comply with?
CIGNA and its contractors must comply with all applicable Medicare laws and
regulations and any regulation deviations must be approved by Medicare. Through our
contractual arrangements with the Centers for Medicare & Medicaid Services
(CMS), CIGNA has agreed to adhere to all Medicare laws and regulations.
The Centers for Medicare & Medicaid Services (CMS) regulations outline their
expectations and CIGNA utilizes these regulations to develop our health plan
operations, workflows, and internal processes to ensure we meet our contractual
requirements.
CIGNA subcontractors must also ensure processes are in place to comply with
regulations and develop applicable policies and procedures.
Introduction
Overview of
Programs
Medicare Rules
Agent/Broker
Oversight
Key Elements
Policies &
Procedures
Protecting PHI
Conclusion
Lesson Three
CMS Key Elements of a
Compliance Program
Key Elements of a Compliance Program
Key Elements of a Medicare Compliance Program
Introduction
Overview of
Programs
Introduction
Overview Rules
of
Medicare
Programs
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
According to the Centers for Medicare & Medicaid Services (“CMS”) the key
elements of an effective compliance program are:
•
•
•
•
•
Key Elements
Protecting PHI
•
•
Policies &
Conclusion
Procedures
•
Protecting PHI
Written Policies and Procedures
Designation of a Compliance Officer and a Compliance Committee
Conducting an Effective Training and Education Program
Development of Effective Lines of Communication
Enforcement through Publicized Disciplinary Guidelines and Policies that deal
with Ineligible Persons
Auditing and Monitoring
Responding to Detected Offenses, Developing Corrective Action Initiatives and
Reporting to Government Authorities
Plan to Detect, Correct, and Prevent Fraud, Waste and Abuse
CMS requires plan sponsors to have written Standards of Conduct. One way that
CIGNA satisfies this requirement is through our Code of Ethics.
Conclusion
We are responsible for knowing, understanding and complying with
CIGNA's Code of Ethics as well as the policies and procedures that apply to the
work we do.
Key Elements of a Compliance Program
Introduction
I. Written Policies and Procedures
Overview of
Programs
Introduction
CMS requires plan sponsors to have written Standards of Conduct. One way that
CIGNA satisfies this requirement, is through our Code of Ethics.
Overview Rules
of
Medicare
Programs
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
The Code of Ethics and related policies reflect CIGNA’s commitment to integrity,
ethical conduct and legal/regulatory compliance.
A few of the policies you can find within CIGNA’s Code of Ethics are:
•
Conflict of Interest
•
CIGNA Assets
Key Elements
Protecting PHI
•
Gifts and Entertainment
Policies &
Conclusion
Procedures
•
Control, Accounting and Reporting
Protecting PHI
•
Information Protection and Privacy
Conclusion
•
Communications and Fair Disclosure
All entities contracted to perform work related to Medicare programs must
review CIGNA’s Code of Ethics policies and procedures or have appropriate
policies and procedures to address Code of Conduct policies, as well as
Fraud, Waste and Abuse.
Key Elements of a Compliance Program
Introduction
Overview of
Programs
Introduction
Overview Rules
of
Medicare
Programs
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
Protecting PHI
Conclusion
I. Written Policies and Procedures
CIGNA’s Code of Ethics can be accessed by external contracted entities and
individuals working on CIGNA’s behalf at this website address:
http://cigna.com/about_us/governance/index.html. CMS requires entities not having
their own Code of Ethics (Code of Conduct) policies to view CIGNA’s Code of Ethics
training.
Corporate Governance: The Code of Ethics is located at www.cigna.com on the
Corporate Governance page. Here, the Code of Ethics is available for clients,
customers and other stakeholders who want to learn more about CIGNA’s commitment
to integrity, ethical conduct and legal and regulatory compliance.
Key Elements of a Compliance Program
Introduction
Overview of
Programs
Introduction
Overview Rules
of
Medicare
Programs
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
Protecting PHI
Conclusion
II. Compliance Officer and Compliance Committee
The Medicare Part D Compliance Committee is led by the CIGNA Medicare
Services Compliance Officer Rich Appel.
Members of the Committee are comprised of:
•
CIGNA Senior Care President
•
•
•
•
•
•
•
CIGNA Senior Care Operations Director
CIGNA Senior Care Sales Director
CHC-AZ MA-PD Operations Director
CIGNA Special Investigations Unit Director
CIGNA Legal Counsel
CIGNA Pharmacy Management Clinical Director
CIGNA Product Director
•
CIGNA Pharmacy Management Network Director
The Arizona Medicare Compliance Officer is David Hu. David also leads the
Arizona Medicare Operations Compliance and Quality Committee (MOCQC).
The Arizona Compliance Committee is comprised of:
•
Vice President of AZ Medicare Operations
•
Regional/Local Quality Mgt
•
Delegated Oversight Mgt
•
Provider Network and Contracting Mgt
•
Cigna Medical Group Operations Directors and Mgt
•
Pharmacy Services Administration Mgt
•
Sales and Enrollment Mgt.
•
Appeal, Call Center, Claims, and Credentialing Mgt
Key Elements of a Compliance Program
Introduction
Overview of
Programs
Introduction
Overview Rules
of
Medicare
Programs
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
Protecting PHI
Conclusion
III. Disciplinary Guidelines
Compliance with CIGNA’s Code of Ethics and related policies as well as applicable
Medicare Policies and Procedures Manuals (which incorporate legal and contractual
requirements), is an ongoing performance objective for all CIGNA Medicare Services
contractors.
Disciplinary actions are discussed within CIGNA’s Code of Ethics at
http://cigna.com/about_us/governance/index.html.
On a case-by-case basis, the severity of the disciplinary action will be determined by
the CIGNA Medicare Services Compliance Officer.
Violation of CIGNA’s Code of Ethics and related policies and/or CIGNA’s operational
policies and procedures may result in disciplinary action, up to and including contract
termination.
Key Elements of a Compliance Program
Introduction
IV. Auditing & Monitoring
CIGNA Audit Programs include:
Overview of
Programs
Introduction
•
Risk Assessment
•
CIGNA conducts an annual risk assessment, supplemented by a quarterly
enterprise risk assessment, to evaluate functional areas of the organization
to assess potential business or control risk. Results of the assessment are
scored and those areas identified as the highest risk are considered when
developing the internal audit plan. Other factors are considered in the risk
assessment such as areas at risk of not meeting the Centers for Medicare &
Medicaid Services (CMS) standards.
•
Internal Audits
•
The CIGNA Medicare Services Compliance Officer will coordinate with
management to implement the internal audit plan. Audits will be performed
to ensure adherence to the Centers for Medicare & Medicaid Services
(CMS) requirements and CIGNA’s internal policies and procedures.
•
Corrective action plans will be developed and implemented in areas where
processes do not meet the requirements.
•
External Entity Oversight
•
CIGNA Medicare Services is also subject to audits from external parties
such as the Centers for Medicare & Medicaid Services (CMS) and the Office
of Inspector General (OIG).
•
Corrective action plans for any deficiencies or findings reported during
external audits will be developed and implementation will be monitored to
ensure processes are strengthened and regulations are followed.
Overview Rules
of
Medicare
Programs
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
Protecting PHI
Conclusion
Key Elements of a Compliance Program
Introduction
Overview of
Programs
Introduction
Overview Rules
of
Medicare
Programs
V. Responding to Detected Offenses
Violations of the:
•
•
•
•
Compliance Program,
federal and state statutes,
rules and regulations, or
any other types of misconduct
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
Protecting PHI
Conclusion
Will be investigated by the CIGNA Medicare Services Compliance Officer or
designee.
Key Elements of a Compliance Program
V. Responding to Detected Offenses
Introduction
Overview of
Programs
Introduction
Overview Rules
of
Medicare
Programs
Key
Elements
Medicare
Rules
Reporting of detected criminal violations
•
Reporting Obligation
•
It is the obligation of every employee and individual working on CIGNA’s behalf who knows of
or reasonably suspects a violation of CIGNA's Code of Ethics to promptly report it.
•
Unless a specific policy states otherwise, the report may be oral or written, and made to:
Ethics Help Line at 1.800.472.8348 or https://cignaethicshelpline.alertline.com/gcs/welcome or
through the CIGNA Medicare Services Compliance Officer or Arizona Medicare Compliance
Officer, as applicable.
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
Protecting PHI
Conclusion
If you know of, or reasonably suspect, a misappropriation of CIGNA assets or any other
violation of law, ethical or business policies you must report the matter
Non-Retaliation
•
CIGNA will not discriminate or retaliate against anyone who, in good faith, reports violations of
laws or regulations, the Code of Ethics, or other company policies, whether those violations
are by a CIGNA company, another employee or agent. In addition, employees are protected
by federal law against any retaliation for taking action under the federal False Claims Act.
Compliance is Everyone’s Business…and it begins with you!
Key Elements of a Compliance Program
Introduction
Overview of
Programs
Introduction
Overview Rules
of
Medicare
Programs
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
Protecting PHI
Conclusion
V. Responding to Detected Offenses
CIGNA’s Ethics Help Line
•
To facilitate confidential and retribution-free reporting of violations and requests for
information about CIGNA’s Code of Ethics, CIGNA has a toll-free, 24-hour Ethics
Help Line (1.800.472.8348). Calls can be made anonymously at your discretion, or
you can email https://cignaethicshelpline.alertline.com/gcs/welcome.
CIGNA's Fraud Hot Line
•
To facilitate confidential and retribution-free reporting of suspected fraud and
requests for information about CIGNA's Fraud, Waste and Abuse policies, or to
report possible fraud, CIGNA has a a toll-free 24-hour Fraud Hotline
(1.800.667.7145) and email box at specialinvestigations@cigna.com.
CIGNA’s Privacy Office
•
All information reported by CIGNA employees, enrollees, individuals working on
CIGNA’s behalf or others shall be kept confidential by CIGNA to the extent
reasonably possible during any resulting investigation; however, it is possible that
such individual’s name may become known or may have to be revealed in certain
instances when governmental authorities intercede, or as may be otherwise
required by law. If you have questions related to CIGNA’s Privacy Policy you can
contact CIGNA’s Privacy Office at CIGNAHealthCarePrivacyOffice@CIGNA.com.
Information and Data Security
•
CIGNA’s Information Protection Policy outlines safeguards and activities needed to
protect proprietary information and avoid unintended disclosures. If you witness an
act that looks like a policy violation or puts CIGNA information at risk, tell your
manager, HR representative, contact CIGNA Medicare Services Compliance Officer,
or call 1.800.4SAFEPC.
Key Elements of a Compliance Program
Introduction
Overview of
Programs
Introduction
Overview Rules
of
Medicare
Programs
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
Protecting PHI
Conclusion
V. Responding to Detected Offenses
Developing Corrective Action Initiatives
•
Reports of suspected misconduct will be investigated and if a violation of
applicable law or regulation is found to exist, CIGNA will take steps to
correct the problem which may include:

Development of a corrective action initiative, or, if material,

Immediate referral to criminal and/or civil law enforcement
authorities, and

Disclosure to CIGNA senior management and the appropriate
governmental authority, where appropriate.
Reporting to the Government
•
CIGNA shall report to appropriate governmental authorities, such as the
Centers for Medicare & Medicaid Services (CMS) and the Department of
Health & Human Services’ Office of Inspector General (OIG), credible
information of material violations of the law by CIGNA, subcontractors,
providers or enrollees for a determination as to whether any criminal, civil, or
administrative action may be appropriate.
Key Elements of a Compliance Program
Introduction
Overview of
Programs
Introduction
Overview Rules
of
Medicare
Programs
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
Protecting PHI
Conclusion
VI. Plan to Detect, Correct, and Prevent Fraud, Waste, and Abuse
The Centers for Medicare & Medicaid Services (CMS) requires all Medicare
sponsors to develop a comprehensive program to detect, correct and prevent
Fraud, Waste and Abuse (FWA).
Entities contracted with CIGNA should also have appropriate policies and
procedures to address fraud, waste, and abuse
To reflect CIGNA’s commitment to the Medicare
program, CIGNA’s Special Investigations Unit:
• Administers required annual anti-fraud training
for key employees;
• Detects, deters and investigates suspicious
claims;
• Provides methods to report suspicious activity;
• Maintains a process for receiving and
documenting complaints of internal and external
fraudulent activity;
• Files reports and quarterly documentation
regarding fraud, waste and abuse to the
Centers for Medicare & Medicaid Services
(CMS); and
• Assists CMS and state and federal law
enforcement in investigational activity.
Key Elements of a Compliance Program
VI. Plan to Detect, Correct, and Prevent Fraud, Waste, and Abuse
Introduction
Overview of
Programs
Introduction
Overview Rules
of
Medicare
Programs
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
FWA Detection - the Special Investigations Unit (SIU) uses a variety of means to
help employees detect suspicious claims:
•
•
•
•
•
•
Referrals from claim processors and customer service representatives
Red Flags Job Aids
- Medical – Medicare Part C
- Pharmacy – Medicare Part D
A dedicated phone line and email box for reporting suspected FWA
Data mining
CIGNA Pharmacy Management’s (CPM) Audit Vendor Program
CIGNA’s Narcotic Therapy Management Program
Policies &
Conclusion
Procedures
CIGNA’s SIU communicates with other SIUs, law enforcement, regulatory agencies, the
Protecting PHI
Centers for Medicare & Medicaid Services (CMS), Medicare Drug Integrity Contractors
(MEDIC) and trade groups to identify schemes and/or suspect pharmacies.
Conclusion
Key Elements of a Compliance Program
Introduction
Overview of
Programs
Introduction
Overview Rules
of
Medicare
Programs
VI. Plan to Detect, Correct, and Prevent Fraud, Waste, and Abuse
FWA Investigation
The Special Investigations Unit (SIU) gathers information and evidence by:
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
Auditing claims
Interviewing members and providers
Reviewing medical records and prescriptions
Protecting PHI
Conclusion
Data mining
Documenting findings
Key Elements of a Compliance Program
Introduction
VI. Plan to Detect, Correct, and Prevent Fraud, Waste, and Abuse
Overview of
Programs
Introduction
FWA Investigation
Overview Rules
of
Medicare
Programs
The Centers for Medicare & Medicaid Services (CMS) has contracted with
certain companies to be Medicare Drug Integrity Contractors (MEDIC).
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
Protecting PHI
Conclusion
The Special Investigations Unit (SIU) will refer cases of suspected FWA to the
MEDIC for investigation.
The MEDIC’s activities include:
•
•
•
Data analysis to identify potential Part D fraud;
Investigation of potential Part D fraud for referral to law enforcement;
Liaison to law enforcement/sponsors for Part D issues; and audits of
sponsor and subcontractor Part D operations.
Key Elements of a Compliance Program
Introduction
VI. Plan to Detect, Correct, and Prevent Fraud, Waste, and Abuse
Overview of
Programs
Introduction
FWA Prosecution
Overview Rules
of
Medicare
Programs
CIGNA takes appropriate action against fraud offenders by:
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
Protecting PHI
Conclusion
•
•
•
•
•
Stopping payments to providers;
Referring cases to state and federal law enforcement for legal action;
Partnering with state insurance departments, fraud bureaus and
professional organizations;
Pursuing sanctions through state licensing boards; and
Within 30 days of identifying a suspicion of fraud or the
documentation of fraud, the Special Investigations Unit (SIU) will
make a referral to the Medicare Drug Integrity Contractor (MEDIC)
and the appropriate state Department of Insurance.
Key Elements of a Compliance Program
Introduction
Overview of
Programs
Introduction
Overview Rules
of
Medicare
Programs
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
Protecting PHI
Conclusion
VI. Plan to Detect, Correct, and Prevent Fraud, Waste, and Abuse
FWA Restitution
CIGNA’s Special Investigations Unit tries to recover losses incurred due to
fraud by:
•
•
•
Pursuing and recovering damages;
Pursuing civil remedies; and
Pursuing criminal charges.
Key Elements of a Compliance Program
Introduction
VI. Plan to Detect, Correct, and Prevent Fraud, Waste, and Abuse
Overview of
Programs
Introduction
FWA Prevention
Overview Rules
of
Medicare
Programs
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Increased fraud awareness is created by:.
Key Elements
Protecting PHI
•
Policies &
Conclusion
Procedures
Protecting PHI
Conclusion
•
•
•
Requiring training programs for key CIGNA employees, vendors and
partners;
Maintaining anti-fraud policies and procedures;
Communicating new fraud schemes with CIGNA employees; and
Identifying control weaknesses.
Key Elements of a Compliance Program
Introduction
Overview of
Programs
Introduction
VI. Plan to Detect, Correct, and Prevent Fraud, Waste, and Abuse
Reporting suspected Fraud, Waste and Abuse
Overview Rules
of
Medicare
Programs
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
Protecting PHI
Conclusion
Please refer all suspicious claims to specialinvestigations@cigna.com
Calls pertaining to Medicare FWA should be directed to the Fraud Hot Line
at 1.800.667.7145
Introduction
Overview of
Programs
Medicare Rules
Agent/Broker
Oversight
Key Elements
Policies &
Procedures
Protecting PHI
Conclusion
Lesson Four
Policies and Procedures
Policies and Procedures
Introduction
Overview of
Programs
Introduction
Overview Rules
of
Medicare
Programs
Key
Elements
Medicare
Rules
Policies with provisions of special relevance to Medicare
include but are not limited to:
Conflict of Interest
OIG/GSA Exclusion Review
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
Record Retention
Anti-Kickback
Protecting PHI
Conclusion
False Claims
Policies and Procedures
Conflict of Interests
Introduction
Overview of
Programs
Introduction
Overview Rules
of
Medicare
Programs
Conflicts of interest can arise if you have a direct or indirect financial, business or
personal involvement with a current or potential supplier, competitor, customer, or
employee of CIGNA.
In addition, outside financial or business involvement by members of your immediate
family, or by persons with whom you have a close personal relationship, may create a
possible conflict of interest for you. As an individual working on CIGNA’s behalf:
Key
Elements
Medicare
Rules
•
Agent/Broker
Policies &
Oversight
Procedures
You must not take part in any transaction in which you have a personal
interest if there is, or might appear to be, a conflict between your interest
and the interests of CIGNA.
•
You must not take part in any business transaction in which you have a
personal interest if your participation is in any way related to information
you received, or a relationship you developed, as an employee or
director.
•
You should not show preferential treatment to any provider or supplier
regardless of their relationship with CIGNA. If you become aware of a
situation involving preferential treatment to providers or suppliers, you
should notify the CIGNA Medicare Services Compliance Officer
immediately.
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
Protecting PHI
Conclusion
Each provider or entity that contracts with CIGNA will require its managers,
officers and directors responsible for the administration or delivery of Part D
benefits to sign a conflict of interest statement, attestation, or certification at the
time of hire and annually thereafter certifying that the manager, officer or
director is free from any conflict of interest in administering or delivering Part D
benefits.
Policies and Procedures
Introduction
Overview of
Programs
Introduction
Overview Rules
of
Medicare
Programs
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
Protecting PHI
Conclusion
OIG/GSA Exclusion Review
Office of Inspector General (OIG) and General Services Administration (GSA)
Exclusion Review
CIGNA will not knowingly hire any individual or contract with any person or entity for it Medicare
program who has been convicted of a criminal offense related to health care or who is listed by a
federal agency as debarred, excluded, or otherwise ineligible for participation in a federal health care
program.
CIGNA will review the Department of Health & Human Services Office of Inspector General (OIG) and
General Services Administration (GSA) exclusion lists to ensure that its Medicare employees and
subcontractors are not included on such lists. Primary source is NPDB for initial credentialing and
re-credentialing, and CAQH for ongoing monitoring.
If CIGNA learns that an employee or contracted provider is on an OIG/GSA list, CIGNA will notify the
individual and remove the individual from any work directly or indirectly related to Federal healthcare
programs. CIGNA will also take appropriate corrective actions, which will include payment recovery for
sanctioned and excluded providers.
If CIGNA learns that an individual is charged with a criminal offense related to health care or proposed
for exclusion or debarment, the individual shall be removed from direct responsibility for or involvement
in all such Medicare activities until resolution of such charges or proposed debarment or exclusion.
During the contracting process, CIGNA requires all contracted entities to attest that they
(i) have policies and procedures which ensure that any employee or manager responsible
for administering or delivering Medicare services or benefits, is not excluded from Federal
health care programs and (ii) review the OIG and GSA exclusions lists. The OIG and GSA lists
will be checked upon initially hiring and annually thereafter. Additionally, if an employee is
identified to be on such lists, that employee will immediately be removed from any work related
directly or indirectly to all Federal health care programs and the entity will take appropriate
corrective actions.
Policies and Procedures
Record Retention
Introduction
Overview of
Programs
Introduction
Overview Rules
of
Medicare
Programs
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Unless specific conditions apply, all relevant Medicare Part C & D records will be
maintained for 10 years from the end of the final contract period or completion of an
audit, whichever is later.
CMS has authority under section 1860D–12(b)(3)(c) of the Act and §422.504(e)(2) and
§423.505(e)(2) to inspect and audit any books, contracts, and records of a Part D
sponsor or MA organization and its first tier, downstream, and related entities that
pertain to any aspect of services performed, reconciliation of benefit liabilities, and
determination of accounts payable under the contract or as the Secretary may deem
necessary to enforce the contract.
Key Elements
Protecting PHI
All records created in the course of business are the property of CIGNA and will be
maintained in compliance with all legal, regulatory, and/or government contract
requirements.
Policies &
Conclusion
Procedures
Unauthorized disposal or removal of records from CIGNA is prohibited.
Protecting PHI
Only official records should be retained and they should be accurate and
complete.
Conclusion
Policies and Procedures
Anti-Kickback
Introduction
Overview of
Programs
Introduction
Overview Rules
of
Medicare
Programs
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
Protecting PHI
Conclusion
It is CIGNA’s policy to strictly comply with all laws that regulate government
contracting.
You must not offer, give, request, or receive anything of value for free or below fair
market price in connection with the sale or recommendation of, or referral to, any
benefit plan, product or service paid partly or fully by any government program.
To ensure compliance with this policy, contracts or other business arrangements
between CIGNA and any health care provider or supplier (including pharmaceutical
companies), and between CIGNA and any government agency or program, must be in
writing and must be reviewed and approved by the member of CIGNA's legal
department assigned to the relevant business division.
Policies and Procedures
Introduction
Anti-Kickback Examples
Examples of potential violations would include:
Overview of
Programs
Introduction
•
Overview Rules
of
Medicare
Programs
•
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
Protecting PHI
Conclusion
•
•
A medical provider group compensates a referral coordinator for channeling
members to their practice.
A pharmacy’s waiving of Medicare co-payments in order to encourage enrollees to
fill their prescriptions there.
A Medicare Part D plan sponsor’s acceptance of a pharmaceutical manufacturer’s
offer of a free disease management program in return for encouraging Medicare
enrollees to use the manufacturer’s products.
A drug manufacturer’s provision of a free trip to an employee of a Medicare Part D
plan sponsor in return for the plan sponsor’s decision to place the manufacturer’s
drug in the preferred tier of the plan’s Medicare formulary.
Policies and Procedures
False Claims
Introduction
Overview of
Programs
Introduction
Overview Rules
of
Medicare
Programs
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
Protecting PHI
Conclusion
Making a false statement, or the submission of false claims, is among the government’s
highest fraud and abuse concerns. Such actions can result in criminal prosecution, up
to 5 years imprisonment and/or a fine of up to $500,000.
Examples of False Claims
Anyone who participates in submitting a false or fraudulent claim to the United States
government for payment, including Medicare or Medicaid claims, can be held personally
liable. Examples of prohibited conduct include, but are not limited to:
• Filing a claim for services that were never provided, were medically unnecessary, or
were described inaccurately;
• Inflating the number of claims processed or failing to process any claims; and
• Falsifying data entered into a reimbursement-related database, cost reports, Medicare
enrollee satisfaction data, or audit-related documents.
Policies and Procedures
Introduction
False Claims
As an individual working on behalf of CIGNA, you must:
Overview of
Programs
Introduction
Overview Rules
of
Medicare
Programs
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
Protecting PHI
Conclusion
•
Ensure the integrity of the product or service provided, and of the related submissions
made to the government.
•
Never falsify a document or knowingly submit misleading information. Exercise due care
and due diligence by verifying the accuracy of all data on which the certification is to be
made.
•
Take every submission of information to the government seriously and review the
underlying requirements associated with certifications.
•
Report any false, inaccurate, or altered requests for payment or claims to a CIGNA
Medicare Services Compliance Officer, CIGNA’s Chief Compliance, Ethics & Privacy
Officer, CIGNA Legal Counsel or contact CIGNA’s Ethics Help Line (1.800.472.8348).
Employees and subcontractors are protected from retaliation for False Claims Act
complaints under 31 U.S.C. § 3730(h) and other applicable anti-retaliation protections.
Introduction
Overview of
Programs
Medicare Rules
Agent/Broker
Oversight
Key Elements
Policies &
Procedures
Protecting PHI
Conclusion
Lesson Five
Protecting Personal Health Information
(PHI)
Protecting PHI
Introduction
Overview of
Programs
Introduction
Overview Rules
of
Medicare
Programs
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
Protecting PHI
Conclusion
Protecting Individually Identifiable Health Information (PHI): High Level
Overview of the HIPAA Privacy & Security Rules
The HIPAA Privacy and Security Rules protect Individually Identifiable Health
Information, referred to as Protected Health Information (PHI), held or transmitted by a
Covered Entity (Health Care Professionals, Health Plans, Health Care Clearinghouse)
and their Business Associates (entities that complete functions on the Covered Entity’s
behalf, such as Medicare subcontractors).
PHI includes information that identifies the individual or could reasonably be used to
identify the individual. PHI is information, including demographic data, which relates to
the:
• Individual’s past, present or future physical or mental health or condition;
• Health care provided to the individual; or
• Past, present, or future payment for health care provided to the individual.
The HIPAA Privacy Rule protects all PHI in any form or media, whether electronic, paper
or oral. The HIPAA Security Rule applies only to electronic PHI (e-PHI). In general, this
rule requires a Covered Entity to adopt additional safeguards for e-PHI ensuring the
confidentiality and availability of all it creates, receives, uses, maintains, or transmits.
The Health Information Technology for Economic and Clinical Health (HITECH) Act
expands certain HIPAA Privacy and Security requirements to cover Business Associates
and to provide individuals with additional rights to access and control the use of their
PHI, among other things.
As you can see, PHI is a critical concept that you must be familiar with.
Protecting PHI
Protecting Individually Identifiable Health Information (PHI)
Introduction
Overview of
Programs
Introduction
Overview Rules
of
Medicare
Programs
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
All of the elements in this chart could be PHI either alone or if combined in a way that would allow for an
individual to be identified. Let’s look at a couple of examples of information CIGNA holds as a Medicare
subcontractor.
– Zip code alone would not be PHI, but this data element combined with address and phone
number would be PHI. This is because the combination of these data elements could be
used to identify an individual.
– Birth date alone would not be PHI, but coupled with SSN and claim numbers could result in
identification of an individual and would be considered PHI.
– Social Security Number (SSN) alone would be PHI as this data element can be used to
identify an individual.
So, it is important to remember that the context and combination of information elements will determine
whether information is PHI. If you have any questions about what is or is not PHI, always check with the
CIGNA Privacy Office.
Examples of Protected Health Information (PHI)
Zip Code
Address
Name
Telephone and/or Fax
Numbers
Medical Record
Number
Health Plan
Beneficiary Numbers
Vehicle Identifiers and
Serial Numbers
Birth Date
Names of Relatives
and Employers
Certificate/License
Numbers
Social Security
Number (SSN)
Benefit Coverage
Information
Account Number
Finger and Voice
Prints
E-mail and IP
(Internet Protocol)
Address
Alternative Member
Identifier (AMI)
Device Identifiers
URL (Uniform
Resource Locator) or
web address
Full Face Photo
Date of Service
Medical Information
(Medical Records,
Lab Values, Health
Risk Assessments
Claim Numbers/Data
Eligibility/Enrollment
Data
X-Rays
Employer’s Name
Protecting PHI
Conclusion
Protecting PHI
Introduction
Overview of
Programs
Introduction
Overview Rules
of
Medicare
Programs
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
Protecting PHI
Conclusion
Protecting Individually Identifiable Health Information (PHI)
Additional Requirements
Safeguarding Protected Health Information – Members of the workforce must employ the
appropriate administrative, technical and physical safeguards to protect the privacy of protected health
information.
Use & Disclosure of Information: PHI Confidential information cannot be disclosed to others without
the individual’s written authorization except for the purposes of treatment (providing care), payment
(claim payment) or health plan operations (examples include, but are not limited to: audits and fraud
and abuse detection).
Minimum Necessary – When collecting, accessing, using or disclosing PHI, or when requesting PHI
to perform job functions, members of the workforce must make reasonable efforts to limit the use and
disclosure to the minimum necessary to accomplish the intended purposes of the use or request.
Verification – Members of the workforce must follow CIGNA's procedures to verify the identity of a
person requesting PHI and the authority of any such person to have access to PHI.
Notice of Privacy Practices: Individuals must receive and have access to a “Notice of Privacy
Practices” which describes how their health information may be used or disclosed by CIGNA and what
individual rights they have in relation to this information.
Individual Privacy Rights – The HIPAA Privacy Rule provides individuals with certain rights related to
their PHI. These rights include: they can have access to their PHI; request amendment to their PHI;
obtain an accounting of disclosures of their PHI; request restrictions on the use and disclosure of their
PHI; and request alternate means of communicating with them, such as sending materials to an
alternative address or location; and lodge a complaint if they believe there has been a violation of their
privacy rights.
Protecting PHI
Protecting Individually Identifiable Health Information (PHI)
Introduction
Overview of
Programs
Introduction
Overview Rules
of
Medicare
Programs
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
Protecting PHI
Conclusion
Frequently Asked Questions regarding transmitting PHI:
PHI via the “Internet” – Even when transmitting PHI for permitted or required purposes (e.g., based
on an individual’s authorization), it is NEVER acceptable to transmit PHI via e-mail over the internet
unless the email is encrypted through the use a SecureMessage process. You MUST utilize a
“SecureMessage” process.
Additionally, CIGNA's IT department has provided a secure electronic transmission solution for
Medicare Part D and PFFS business with our subcontractors NationsHealth and Accenture. As a
result, email sent to the following email extensions is secure:
NationsHealth (email addresses ending with @uspgi.com, @nationshealth.com, and @nhrx.com) and
Accenture (email addresses ending with @accenture.com).
We do not have a secure connection with the Centers for Medicare & Medicaid Services (CMS).
These are email addresses ending with @cms.hhs.gov.
Important note: Even if CMS inadvertently transmits PHI, we should never reply or forward the email
without removing the PHI or securing the message appropriately by using the SecureMessage
solution.
PHI via fax – Prior to faxing PHI, you should ensure the receiving fax machine is attended and an
authorized person is waiting to receive the fax.
For more information on any of CIGNA’s privacy practices, please see:
http://www.cigna.com/privacy/index.html.
Protecting PHI
Protecting Individually Identifiable Health Information (PHI)
Introduction
Overview of
Programs
Introduction
If a member of the workforce (including a contractor) or a subcontractor becomes aware of
any potential violation of the HIPAA Privacy or Security Rules, HITECH Act or CIGNA's
Privacy Policies and Procedures, they should take the following steps:
Overview Rules
of
Medicare
Programs
Report the issue either orally or in writing to any manager, the CIGNA Medicare Services
Compliance Officer, or to CIGNA’s Privacy Office.
Key
Elements
Medicare
Rules
CIGNA Medicare Services Compliance Officer – Rich Appel – 860.226.7696
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
Protecting PHI
Conclusion
CIGNA Arizona Medicare Compliance Officer – David Hu – 602.371.2429
CIGNA Privacy Office – via e-mail to - CIGNAHealthCarePrivacyOffice@CIGNA.com
Instances of potential non-compliance with the Privacy & Security
Rules, HITECH Act and CIGNA's Privacy Policies and Procedures
will be investigated and appropriate disciplinary action will be taken
as needed.
Protecting PHI
Introduction
Overview of
Programs
Introduction
Overview Rules
of
Medicare
Programs
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
Policies &
Conclusion
Procedures
Protecting PHI
Conclusion
Protecting Individually Identifiable Health Information (PHI)
Reporting Privacy Policy Incidents
Report privacy complaints and incidents promptly so that appropriate action can be
taken.
All employees, managers, contractors, and subcontractors will immediately notify
the CIGNA Medicare Services Compliance Officer or the CIGNA Privacy Office of any
incident involving a potential violation of the HIPAA Privacy or Security Rules, HITECH
Act or CIGNA's Privacy Policies and Procedures.
Protecting PHI
Protecting Individually Identifiable Health Information (PHI)
Introduction
Overview of
Programs
Introduction
Overview Rules
of
Medicare
Programs
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Key Elements
Protecting PHI
The Health Information Technology for Economic and Clinical Health Act
(HITECH)
HITECH enhanced the existing HIPAA Privacy & Security Rules. The fundamental intention of
HITECH is to promote the establishment and use of Electronic Health Records (“EHRs”). An
EHR is an electronic record of health-related information about an individual that is created,
gathered, managed, and consulted by authorized health care clinicians and staff.
HITECH also established new rules for the use and protection of PHI, and defined
requirements for the identification, notification, and reporting of a breach - the unauthorized
acquisition, access, use, or disclosure of PHI which compromises the security or privacy of
such information, except where an unauthorized person to whom such information is disclosed
would not reasonably have been able to retain such information.
Policies &
Conclusion
Procedures
Under HITECH, more severe civil and criminal penalties may be imposed on Covered Entities,
Business Associates and individuals for violations of HIPAA.
Protecting PHI
Now more than ever, it will be important for you to notify the appropriate area within
CIGNA (CIGNA Medicare Services Compliance, CIGNA Privacy Office, CIGNA Business
Lead) of any inappropriate access, acquisition, misuse, or loss of PHI.
Conclusion
Introduction
Overview of
Programs
Conclusion
Medicare Rules
Agent/Broker
Oversight
Key Elements
Policies &
Procedures
Protecting PHI
Conclusion
Thank you for your time and attention.
Please carefully read the certification on the
following slide. Contracted entities can print,
sign, and date the certification and retain to
support completion of the annual Medicare
Compliance Training requirement
Certification
Introduction
Overview of
Programs
Introduction
Overview Rules
of
Medicare
Programs
Key
Elements
Medicare
Rules
Agent/Broker
Policies &
Oversight
Procedures
Completion of CIGNA’s 2011 Medicare Compliance Training
Certification
I hereby certify that I have received, read and understand the written standards of
conduct related to Medicare Compliance, including the laws and regulations
related to Fraud, Waste and Abuse, that I have been trained on such standards,
and that I understand my responsibility to comply with the requirements of such
standards.
Key Elements
Protecting PHI
Signature: ____________________________________________________
Policies &
Conclusion
Procedures
Date: ___________________________
Protecting PHI
Retain for your records.
Conclusion
Confidential property of CIGNA. Do not duplicate or distribute. All examples and fact
patterns used herein are fictitious.
© Copyright 2011 by CIGNA