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Modelo de Cuidado de MCS

Adiestramiento anual para proveedores y entidades delegadas 2019

(This is a text version of the Training. Click Here for the print version)

Requisitos de CMS

Pagina 2
  • Los Centros de Servicios de Medicare & Medicaid (CMS, por sus siglas en inglés) requieren que todo el personal de MCS, entidades delegadas y sus proveedores reciban el adiestramiento relacionado al Modelo de Cuidado de los Planes de Necesidades Especiales al momento de comenzar funciones y anualmente.
  • CMS requiere que MCS asegure el 100% de cumplimiento con el adiestramiento inicial y anual de todos los empleados, entidades delegadas y proveedores.

Objetivos

Pagina 3
  • Memorizar los cuatro (4) elementos que componen el Modelo de Cuidado
  • Describir el Modelo de Cuidado que MCS ofrece a los afiliados de elegibilidad dual con necesidades especiales (D-PNE)
  • Nombrar los Equipos de Cuidado Interdisciplinario para la población D-PNE
  • Explicar el rol integral que tienen los empleados y proveedores en el Modelo de Cuidado de MCS.

Definiciones

Pagina 4
  • CAHPS (Consumer Assessment of Healthcare Providers and Systems): Encuesta que reúne, evalúa y reporta sobre la experiencia (percepción) de los afiliados en relación a los servicios recibidos por parte de las aseguradoras y proveedores.
  • CHRA (Comprehensive Health Risk Assessment): Evaluación realizada por personal clínico para identificar necesidades y factores de riesgo en el afiliado.
  • CM (Care Management): Programa de Manejo de Cuidado/Manejador de Cuidado
  • HCC (Hierarchy Condition Category): Sistema de clasificación basado en el estado de salud (datos de diagnóstico) y las características demográficas (tales como la edad y el sexo) de un beneficiario para calcular las puntuaciones de riesgo.
  • HOS (Health Outcomes Survey): Encuesta que reúne datos válidos y clínicamente significativos sobre el bienestar mental y físico del paciente.

Definiciones

Pagina 5
  • ICP (Individualized Care Plan): Plan de Cuidado Individualizado creado para el afiliado
  • ICT (Interdisciplinary Care Team): Equipo de Cuidado Interdisciplinario responsable del desarrollo del plan de cuidado, coordinación de cuidado, entre otros
  • PCP (Primary Care Physician): Médico primario responsable del cuidado principal del afiliado bajo el Modelo de Cuidado
  • RAPS (Risk Adjustment Processing System): Proceso que permite que CMS otorgue al plan médico el pago de prima correspondiente de acuerdo al riesgo de salud del beneficiario

Trasfondo de los Planes de Necesidades Especiales

Pagina 6 2003
  • Bajo el Medicare Modernization Act, el Congreso de Estados Unidos desarrolló los planes de necesidades especiales (PNE) como requisito para los planes Medicare Advantages (MA).
  • Los PNEs se clasificaron en tres categorías:
    • Eligibilidad Dual (D-PNE)
    • Condiciones Crónicas (C-PNE)
    • Individuos Institucionalizados (I-PNE)
2012
  • El Affordable Care Act enmienda la sección 1856(f)(7) del “Social Security Act”
  • Requiere que todos los planes MA que ofrezcan planes PNEs sometan a CMS un Modelo de Cuidado (MOC) para la evaluación y aprobación del National Committee for Quality Assurance (NCQA) que asegure el cumplimiento con las guías establecidas por CMS.
La regulación 42 CFR §422.101(f) de CMS requiere que toda organización MA implemente un Modelo de Cuidado para sus afiliados con necesidades especiales, de manera que se puedan satisfacer sus necesidades de salud y mejorar su calidad de vida.

MCS Classicare Platino

Trasfondo de los Planes de Necesidades Especiales con Elegibilidad Dual (D-PNE)

Pagina 7

Definición: Plan de salud para personas elegibles a Medicare Parte A+B y Medicaid.

Medicare A+B + Medicaid = D-PNE

MCS Advantage, Inc tiene contrato con Medicare y ASES para ofrecer planes Platino a sus beneficiarios con elegibilidad dual.

Modelo de Cuidado (MOC)

Pagina 8

CMS describe el Modelo de Cuidado como una herramienta vital de mejoramiento de calidad que integra componentes para asegurar que las necesidades únicas de cada beneficiario se identifiquen y sean atendidas. El MOC provee la infraestructura necesaria para promover la calidad, el manejo de cuidado y procesos de coordinación de cuidado para los asegurados PNEs.

  • El departamento de Calidad de MCS es el responsable de vigilar, monitorear y evaluar las acciones pertinentes al Modelo de Cuidado.
D-PNE
  • Acceso a servicios
  • Manejo de Cuidado
  • Coordinación de Cuidado
  • Mejorar resultados de salud
  • Garantizar la calidad en los servicios

Componentes que apoyan al MOC

Pagina 9
  • El MOC de MCS cuenta con la estructura necesaria para comunicar y satisfacer las necesidades de nuestros afiliados PNEs.
  • Comunica con regularidad al afiliado y su PCP el manejo médico, cognitivo, mental, psicosocial y funcional de sus afiliados e incluye al cuidador cuando es necesario.
  • Las iniciativas facilitan los procesos de preautorización, transición de cuidado, seguimiento a condiciones crónicas y comunicación entre proveedores.
  • El desempeño del MOC y sus componentes se evalúan regularmente para garantizar el cumplimiento con las guías de CMS.
MOC
  • Afiliado
  • CHRA
  • ICT
  • ICP
  • Red De Proveedores
  • Guías Clínicas
  • Evaluación de Desempeño
  • MOC Taskforce

Modelo de Cuidado (MOC) - 4 elementos que lo componen

Pagina 10
  • MOC 1 Descripción de la Población PNE
  • MOC 2 Coordinación de Cuidado Protocolo de Transición de Cuidado
  • MOC 3 Red de Proveedores
  • MOC 4 Medidas de Calidad y Mejoramiento de Desempeño

MCS Classicare Platino Planes 2019

Pagina 11

En el 2019, MCS cuenta con 6 planes Platino para la población PNE.

Nombre de producto Número de contrato de MCS Número de grupo de MCS
Platino Ideal (OSS PNE) H5577-002 (Renovación) 850614
Platino Progreso (OSS PNE) H5577-017 (Renovación 850717
Platino Cómodo (OSS PNE H5577-027 (Renovación) 850721
Platino Clásico (OSS PNE) H5577-028 (Renovación) 850722
Platino Más Ca$h (OSS PNE) H5577-029 (Renovación) 850723
Platino OTC (OSS PNE H5577-036 (Nuevo) 850724
A enero del 2018, la población total D-PNE de MCS era de 95,471 afiliados.

MOC 1

Pagina 12

Descripción de la Población PNE

MOC 1: Descripción de la Población PNE (Población más vulnerable)

Pagina 13

Población total PNE - MCS Classicare Platino

La población PNE más vulnerable es parte de la población total MCS Classicare Platino identificada con riesgos de salud complejos que requieren intervención de parte de un Manejador de Cuidado para asistirle en sus necesidades.

  • PNE - Población general (95,471 afiliados)
  • PNE - Población más vulnerable (14,007 afiliados)

MOC 1: Descripción de la Población PNE

Pagina 14
  • El 30% es menor de 65 años
  • El 57% de la población son féminas
  • El 46% reside en zona rural
  • El 53% reportan requerir de
  • un cuidador
  • Los tres diagnósticos principales identificados en la población PNE son: 1. diabetes mellitus 2. hipertensión y 3. depresión mayor recurrente.
  • El 68% de la población tiene sobrepeso/obesidad.
  • El 11.6% de los afiliados no visitó a su PCP durante 2017
  • En el CHRA, 37% de los encuestados refiere tener una buena calidad de vida.
  • El 30% no completó la escuela superior
  • El 99% refieren ser hispanos
  • El 99.72% prefieren el uso de español como idioma principal
Datos importantes para describir la población:
  • Elegibilidad
  • Factores sociales, cognitivos y ambientales
  • Condiciones de vida
  • Comorbilidades
  • Condiciones de salud física y mental
  • Características específicas identificadas en la población

MOC 2

Pagina 15

Coordinación de Cuidado Protocolo de Transición de Cuidado

MOC 2: Coordinación de Cuidado

Pagina 16
  • La regulaciones 42 CFR §422.101(f)(ii)-(v) y 42 CFR §422.152(g)(2)(vii)-(x) requieren que todos los SNPs coordinen y evalúen la efectividad de la prestación de servicios contemplados en el MOC.
  • La coordinación de cuidado asegura que todas las necesidades de salud y preferencias en servicio de los asegurados PNEs sean cubiertas.
  • Además asegura que se comparta la información médica entre los profesionales de salud maximizando la efectividad, la eficiencia, la alta calidad en los servicios y mejorando los resultados de salud de los afiliados.
  • El MOC describe los roles, responsabilidades y vigilancia del personal clínico y no clínico.
  • Establece un plan de contingencia que asegura la continuidad de funciones críticas dentro de la operación de MCS durante una emergencia.
  • Además requiere que todo el personal esté adiestrado sobre el MOC al momento de comenzar en el empleo y anualmente.

MOC 2: Coordinación de Cuidado Rol integral de los empleados

Pagina 17
  • Asegurar el cumplimiento con los requisitos de CMS para el MOC
  • Participar en el adiestramiento inicial y anual del MOC
  • Asistir a los afiliados y a los proveedores para satisfacer sus necesidades de servicio
  • Apoyar iniciativas para cumplir con las metas del MOC

MOC 2: Coordinación de Cuidado

Pagina 18
  • Estructura del personal
    • Personal Clínico
      • Requiere credenciales
    • Personal No Clínico
      • Personal de apoyo
    • MCS provee adiestramiento del MOC inicial y anual a todos sus empleados y contratistas
  • Evaluación de Riesgo de Salud
    • CHRA
      • Inicial –se realiza dentro de los 90 días a la fecha de afiliación del afiliado.
      • Anual –se realiza dentro de los 12 meses a partir del último CHRA
  • Plan de Cuidado
    • El Plan de Cuidado - Se realiza basado en las necesidades identificadas en la evaluación de riesgo (CHRA)
  • Grupo Interdisciplinario
    • Equipos de Cuidado Interdisciplinarios de MCS
      • Estándar
      • Complejo
  • Transición de Cuidado
    • Tipos de Transiciones
      • Planificada
      • No planificada

MOC 2: Coordinación de Cuidado - Evaluación de Riesgo de Salud CHRA

Pagina 19
  • El Comprehensive Health Risk Assessment (CHRA) es una herramienta diseñada para recopilar todos los elementos que ayuden a identificar las necesidades de nuestros afiliados.
  • Es una evaluación de riesgo realizada por un personal clínico durante los primeros 90 días de afiliación y anualmente antes del vencimiento de los 12 meses del CHRA anterior.
  • Las secciones del CHRA son cuidadosamente seleccionadas por el Equipo de Cuidado Interdisciplinario (ICT, por sus siglas en inglés) para evaluar posibles riesgos y necesidades en el afiliado, tanto clínicas como no clínicas.
  • En caso de que el afiliado sufra algún cambio en su estado de salud, el CHRA o Estimado General (GA) debe actualizarse.

MOC 2: Coordinación de Cuidado - Evaluación de Riesgo de Salud identificados en el CHRA

Pagina 20
  • Médicas
  • Psicosociales
  • Funcionales
  • Salud mental
  • Cognitivas

MOC 2: Coordinación de Cuidado - Evaluación de Riesgo de Salud CHRA 2019

Pagina 21
  • Sección de información clínica
  • Sección de información no clínica

Las necesidades identificadas en el CHRA determinan el nivel de riesgo de salud del afiliado PNE en una de las siguientes tres categorías: leve-moderado-severo

MOC 2: Coordinación de Cuidado - Evaluación de Riesgo de Salud CHRA

Pagina 22

Logística de Niveles de Salud basado en la puntuación obtenida en el CHRA

  • Leve > 65 puntos
    • Requiere Plan de Cuidado Individualizado Estándar. (anual)
  • Moderado - Entre 20 a 65 puntos
      Requiere Plan de Cuidado Individualizado Estándar. (anual)
  • Severo < 20 puntos
      Requiere Plan de Cuidado Individualizado Complejo e intervención de Manejo de Cuidado. (cada 6 meses)

MOC 2: Coordinación de Cuidado - Planes de Cuidado Individualizados

Pagina 23

Un Equipo de Cuidado Interdisciplinario (ICT) altamente cualificado desarrolla los Planes de Cuidado Individualizados (ICP, por sus siglas en inglés) de acuerdo al riesgo de salud del afiliado identificado en el CHRA.

  • Estratificación del afiliado
    • ICT Estándar
      • Leve
      • Moderado
    • ICT Complejo Unidad de Manejo de Cuidado
      • Complejo (Población más vulnerable)

MOC 2: Coordinación de Cuidado

Pagina 24

Las intervenciones y recomendaciones establecidas en los Planes de Cuidado se basan en los siguientes criterios:

  • ICT Estándar Nivel de Riesgo: Leve o Moderado
    • Cuidado preventivo por edad y género
      • Mujer
        • < 65 años
        • > 65 años
      • Hombre
        • < 65 años
        • > 65 años
    • Condiciones crónicas presentes
      • Cardiovascular
      • Diabetes
      • Enfermedad respiratoria
      • Enfermedad renal
      • Artritis
      • Osteoporosis
      • Hepatitis C
      • VIH/SIDA
      • Depresión
      • Trastorno del Estado Anímico
      • Alzheimer
      • Hipotiroidism
  • ICT Complejo Nivel de Riesgo: Severo
    • Estimado de necesidades individuales
      • Realizado por Manejador(a) de Cuidado para establecer intervenciones específicas que atiendan el estado de salud del afiliado

MOC 2: Coordinación de Cuidado - Fuentes de información y proceso para generar Planes de Cuidado Individualizados

Pagina 25 Fuente Inicial de referido
  • CHRA
  • RAPS
  • HCC
  • Niveles de riesgo de salud de acuerdo a diagnósticos reportados y datos demográficos
    • Afiliados con nivel de riesgo: Leve o moderado
      • Plan de Cuidado preliminar basado en edad, género y diagnósticos encontrados en las fuentes de referido
    • Afiliados con nivel de riesgo: Severo
      • Referido a Manejo de Cuidado
      • Evaluación de riesgo individual por un Manejador (a) de Cuidado
      • Se establece un plan de cuidado individualizado tomando en consideración las respuestas al Estimado General y a la edad, género y diagnósticos identificados por el MC

MOC 2: Coordinación de Cuidado

Pagina 26

El formato del Plan de Cuidado Individual incluye:

  • Encabezado
    • Nombre del afiliado
    • Número de contrato
    • Nombre del médico primario
  • Situación
    • Edad y género
    • Condiciones crónicas del afiliado
  • Intervenciones
    • Recomendaciones de autocuidado preventivo por edad, género y condiciones crónicas
    • Intervenciones de apoyo
      • Intervenciones que MCS lleva a cabo para promover el cuidado de la salud del afiliado
    • Intervenciones del médico primario
      • Para la evaluación y manejo de la salud del afiliado

MOC 2: Coordinación de Cuidado - Proceso de comunicación y actualización del Plan de Cuidado

Pagina 27
  • Leves y moderados
    • Plan de Cuidado al menos una vez al año.
    • Se modifica el Plan de Cuidado si se reporta un nuevo CHRA y se encuentran cambios en niveles de riesgos y/o diagnósticos.
    • Se genera carta con la información del plan de cuidado del afiliado. Se comparte con el afiliado y con su PCP, y se incluye en la aplicación de MC.
  • Severos
    • Plan de Cuidado es revisado y discutido con el afiliado según sea necesario y se envía al menos cada 6 meses, modificado de acuerdo a necesidades de salud del afiliado durante su participación en el Programa de Manejo de Cuidado.
    • Se evalúa cumplimiento con las metas y se documentan los resultados de cada intervención en la aplicación de CM. Se genera una carta con el Plan de Cuidado al afiliado, al médico primario y se incluye en la herramienta electrónica de CM.
    • El Plan de Cuidado está disponible para el ICT a través de la aplicación de CM.

*Todo envío de cartas y Plan de Cuidado se realiza por correo postal al afiliado y PCP.

MOC 2: Coordinación de Cuidado - Estrategias que apoyan la recolección de datos y diseminación del Plan de Cuidado

Pagina 28
  • Con afiliados
    • Intervenciones individuales de manejo de cuidado en afiliados de riesgo severo
    • Recordatorios de cuidado preventivo y manejo de condiciones crónicas
    • Cartas de alerta de manejo clínico
    • Campañas educativas
    • Envío de material educativo y guías de autocuidado
    • Talleres de manejo de condiciones crónicas
    • Charlas de salud
    • Revista Cuídate
    • Rutinas de ejercicios a través de MCS Salud Paso a Paso
  • Con médicos primarios
    • Entrega y discusión de reporte de medidas de calidad por médico primario
    • Cartas de alerta de manejo clínico
    • Intervenciones educativas clínicas acreditadas con educación continua
    • Campañas educativas
    • Llamadas de coordinación de cuidado clínico a afiliados de riesgo severo
    • Adiestramiento anual del Modelo de Cuidado de MCS

MOC 2: Coordinación de Cuidado - Equipos de Cuidado Interdisciplinarios

Pagina 29

El Equipo de Cuidado Interdisciplinario (ICT) provee la estructura y los procesos necesarios para ofrecer y coordinar los servicios para el cuidado de la salud de nuestros afiliados del plan de necesidades especiales, de acuerdo al estado de salud y necesidades de salud identificadas.

  • Equipo de Cuidado Interdisciplinario Estándar
    • Afiliado/Cuidador
      • Médico Primario (PCP)
        • Manejador de Cuidado RN
        • Trabajador(a) Social
        • Farmacia
        • Educadora en salud
        • Salud mental
        • Manejo de utilización
        • Manejo de información
  • Equipo de Cuidado Interdisciplinario Complejo
    • Afiliado/Cuidador
      • Médico Primario (PCP)
        • Manejador de Cuidado RN
        • Gerente de Manejo de Cuidado RN
        • Director de Manejo de Cuidado RN
        • Trabajador(a) Social
        • Farmacia
        • Salud mental
        • Consultores de MCS
        • Otros miembros *”Ad Hoc”

MOC 2: Coordinación de Cuidado - Transición de Cuidado

Pagina 30
  • Cuando un afiliado sufre un cambio en su estado de salud y requiere trasladarse de un escenario de salud a otro para mantener su cuidado, nos referimos a una Transición de Cuidado.
  • Transición de Cuidado para bajar de nivel:
    • Ejemplo: Del hospital a una facilidad de rehabilitacion y luego al hogar del afiliado
  • Transición de Cuidado para subir de nivel:
  • Ejemplo: Del hogar del afiliado al hospital

MOC 2: Coordinación de Cuidado - Transición de Cuidado

Pagina 31
  • Transición NO planificada
    • Visita a sala de emergencia que conlleva admisión al hospital
  • Transición planificada
    • Cirugías electivas o procedimientos planificados
    • Admisión a un Centro de Cuidado Diestro de Enfermería (SNF, por sus siglas en inglés)
    • Agencias de servicios de Salud en el Hogar (HHA, por sus siglas en inglés)

MCS cuenta con diferentes protocolos de Transición de Cuidado para facilitarle a nuestros afiliados el cambio de escenario de salud según sus necesidades.

MOC 2: Coordinación de Cuidado - Transición de Cuidado

Pagina 32 Durante el proceso de Transición de Cuidado, educamos a nuestros afiliados mediante:
  • Carta de Transición de Cuidado al afiliado y a su PCP
  • Medilínea 24/7
  • Material educativo de autocuidado (Revista Cuídate, recordatorios preventivos sobre diabetes, condiciones cardiovasculares, entre otros)
  • Llamada telefónica por un profesional de enfermería

MOC 3 - Red de Proveedores

Pagina 33

MOC 3: Red de Proveedores

Pagina 34
  • Proveedores
    • Médicos primarios
    • Médicos especialistas
      • Medicina interna
      • Endocrinología
      • Cardiología
      • Entre otras
    • Expertos en servicios de salud mental
      • Entre otros
  • Adiestramientos
    • MCS ofrece adiestramiento inicial y anual sobre el Modelo de Cuidado a todos sus Proveedores
      • Participantes
      • No participantes
    • Entidades Delegadas:
      • FHC
      • Eye Management
      • TNPR
      • TeleMedik
      • Entre otras
  • Guías Clínicas y Protocolos de Transición de Cuidado
    • MCS adopta, revisa y comparte guías clínicas para ayudar al médico y afiliado en la toma de decisiones del cuidado apropiado de salud.
    • Transición de Cuidado
        Continuidad de Cuidado
    • Ejemplo de guías clínicas:
      • Diabetes
      • Asma
      • Cáncer
    • MCS asegura a través de protocolos de transición la continuidad de cuidado a nuestros afiliados.

MOC 3: Red de Proveedores - Rol del médico primario y especialistas

Pagina 35
  • Participar en la planificación del cuidado del paciente
  • Proveer el cuidado médicamente necesario
  • Proveer educación de la condición al paciente o cuidador
  • Ofrecer cuidado preventivo y dirigir al afiliado a llevar un estilo de vida saludable
  • Fomentar entre los pacientes la participación en su proceso de cuidado

MOC 3: Red de Proveedores - Rol del médico primario y especialistas

Pagina 36
  • Participar en las reuniones del equipo de cuidado interdisciplinario
  • Mantener comunicación con el manejador de cuidado, con el equipo de cuidado interdisciplinario o cuidador y colaborar en el plan de cuidado individualizado
  • Proveer el acceso e integrar otros médicos o proveedores dentro del manejo de cuidado, de ser necesario
  • Utilizar las guías de práctica clínica adoptadas por MCS (disponibles en Provinet)
  • Revisar y actualizar el Plan de Cuidado y responder a las preocupaciones o preferencias del afiliado
  • Asegurar la continuidad de cuidado o servicios y ofrecer seguimiento al tratamiento del afiliado

MOC 3: Red de Proveedores - Rol del médico primario y especialistas

Pagina 37
  • Proveer el cuidado médicamente necesario
  • Integrar al médico primario en el cuidado del afiliado
  • Notificar al plan médico cualquier barrera que afecte el acceso a los servicios o el proceso de transición de cuidado
  • Fomentar la participación de los pacientes en su proceso de cuidado
  • Proveer servicios a tiempo, efectivamente y garantizando la calidad

MOC 3: Red de Proveedores

Pagina 38

Provinet: herramienta para proveedores

MOC 3: Red de Proveedores

Pagina 39

Asistencia al PCP para coordinar el cuidado del afiliado (Brecha en Cuidado)

  • Medidas HEDIS
    • El proveedor puede evaluar el cumplimiento de su paciente en cuidados preventivos y medidas HEDIS usando Provinet

MOC 3: Red de Proveedores

Pagina 40 Guías Clínicas adoptadas por MCS Advantage, accesibles a los proveedores
  • Las Guías Clínicas están disponibles en Provinet
  • Algunos ejemplos son:
    • Asma
    • Cáncer
    • Entre otras

MOC 3: Red de Proveedores

Pagina 41 Adiestramiento del MOC accesible al proveedor a través de Provinet

Nuestros proveedores pueden acceder a los adiestramientos del MOC a través de Provinet

MOC 3: Red de Proveedores

Pagina 42 Referido para los Programas de Manejo de Cuidado
  • Referido para afiliados potenciales a los Programas de Manejo de Cuidado
    • Enviar al fax: 787.620.1336
    • Documento disponible en Provinet

MOC 4

Pagina 43 Medidas de Calidad y Mejoramiento de Desempeño

MOC 4: Medidas de Calidad y Mejoramiento de Desempeño

Pagina 44
  • MOC
    • BOD
    • UMC
    • QIC
    • MOC Taskforce
  • El MOC actual de MCS tiene una vigencia de 3 años (2018-2020).
  • Requiere la aprobación anual del la Junta de Directores de MCS, Comité de Utilización y Comité de Calidad.
  • El equipo de trabajo MOC Taskforce, compuesto por gerenciales de las áreas impactadas por el MOC incluyendo las entidades delegadas, se reúnen al menos 6 veces al año para discutir y monitorear el cumplimiento operacional con los requisitos del MOC e incluyen medidas alineadas a STARS, HEDIS, CAHPS, HOS y aquellas propias del departamento.

MOC 4: Medidas de Calidad y Mejoramiento de Desempeño

Pagina 45
  • A. Plan para Medidas de Calidad y Mejoramiento de Desempeño
    • Fuentes de datos:
    • Aplicaciones de MC, CHRA, PMHS
    • Participación de líderes de MCS en el proceso de calidad interna
  • B. Metas Cuantificables y Resultados de Salud
    • Indicadores de Medidas
    • STARS
    • HEDIS
    • Reportes regulatorios
    • Reportes operacionales
  • C. Midiendo la experiencia de Cuidado del afiliado
    • Encuestas de Satisfacción
    • CAHPS
    • HOS
    • Encuestas internas de satisfacción de afiliados
    • Grupos focales
  • D. Mejora continua del desempeño y evaluación del MOC
    • Monitorea y analiza los indicadores de calidad para identificar oportunidades de mejoramiento
    • Efectúa reuniones de grupos de trabajo del MOC
    • El MOC se presenta para Evaluación del Programa en el Comité de Calidad de MCS
  • E. Comunicación del desempeño del MOC de los PNE
    • MCS comunica la información obtenida a:
    • Junta de Directores
    • Empleados
    • Proveedores
    • Entre otros

¡GRACIAS POR SU COMPROMISO

Pagina 46 con mejorar la calidad de vida de nuestros afiliados!

Referencias

Pagina 47
  • MCS SNPs (2018) Model of Care Description
  • Medicare Managed Care Manual-Chapter 16-B: Special Needs Plans (Rev.123, Issued: 08-19-16)
  • Medicare Managed Care Manual-Chapter 5 - Quality Assessment (Rev. 117, 08-08-14)
  • MOC Scoring Guidelines CY (2019)

¡ESTAMOS PARA SERVIRLE!

Pagina 48

Cualquier información adicional se puede dirigir a:

To review the training material below, place your mouse over the training material to enable the scrolling feature (if you are on a mobile device, touch the training material to enable the scrolling feature).

Modelo de Cuidado para Planes de Necesidades Especiales FY 2019

(This is a text version of the Training. Click Here for the print version)

Objetivos

Pagina 2
  • Conocer el trasfondo histórico de las leyes y regulaciones del Modelo de Cuidado (MOC).
  • Identificar los planes y criterios de un Plan de Necesidades Especiales (SNP).
  • Identificar los componentes básicos de los Planes de Necesidades Especiales (SNP).

Objetivos

Pagina 3
  • Aprender los elementos del Modelo de Cuidado vigente para el año 2019.
  • Entender los Modelos de Cuidado de MMM y PMC.

Adiestramiento del Modelo de Cuidado

Pagina 4

Es obligatorio que todos los planes MAO provean y documenten el adiestramiento del Modelo de Cuidado para los planes SNP para todos los empleados, contratistas y proveedores:

  • Adiestramiento inicial y anual

Adiestramiento del Modelo de Cuidado

Pagina 5

Metodología puede ser:

  • En persona.
  • Interactivo (vía web, audio/vídeo conferencia).
  • Estudio independiente (material impreso, medio electrónico).

Trasfondo Histórico del Modelo de Cuidado

Pagina 6
  • 2003: Medicare Modernization Act (MMA) establece los SNP.
  • 2008: Ley de Mejoras para Pacientes y Proveedores (MIPPA, por sus siglas en inglés), PL110-275 establece requisito para todos los planes SNP de presentar para revisión un Modelo de Cuidado basado en evidencia durante el ciclo de aplicación para los planes MA.

Trasfondo Histórico del Modelo de Cuidado

Pagina 7

2008: Ley de Mejoras para Pacientes y Proveedores (MIPPA, por sus siglas en inglés). Se estableció el requisito de realizar una Evaluación de Salud (HRA, por sus siglas en inglés), plan de cuidado, equipo interdisciplinario del cuidado para beneficiarios y evaluar la efectividad del cuidado.

Trasfondo Histórico del Modelo de Cuidado

Pagina 8
  • 2008: “Call Letter” Carta de llamada estableció adiestramientos para los proveedores.
  • 2008-2010: Los planes de salud están obligados a cumplir con los requisitos establecidos por el Comité Nacional de Garantía de Calidad (NCQA, por sus siglas en inglés).

Trasfondo Histórico del Modelo de Cuidado

Pagina 9

Tras la promulgación en el 2011, de la Ley de Protección al Paciente y Cuidado de Salud Asequible se amplió el programa para los planes SNP al 31 de diciembre de 2013, y se encomendó además realizar cambios en los SNP como:

  • Requerir a todos los SNP a presentar para revisión un Modelo de Cuidado (MOC) que cumpla con un proceso de aprobación basado en los estándares de CMS; los cuales son revisados y aprobados por NCQA a partir del 1 de enero de 2012.

Trasfondo Histórico del Modelo de Cuidado

Pagina 10
  • 2013 “CMS Memo” (Febrero): CMS emitió una notificación clarificando las expectativas para los Planes de Necesidades Especiales basado en auditorías independientes realizadas en el 2012.
  • 2013 “CMS Memo” – (Abril): CMS emitió notificación indicando el Protocolo de Auditoría para el Modelo de Cuidado (MOC) 2013.

Trasfondo Histórico del Modelo de Cuidado

Pagina 11

El 5 de marzo de 2014, los Centros de Servicios de Medicare y Medicaid (CMS), y su grupo para la vigilancia y ejecución para Medicare Partes C y D (MOEG), fueron responsables de llevar a cabo auditorías a los planes “Medicare Advantage” (MA) y Parte D, para garantizar el cumplimiento de los requisitos de CMS, promulgar los documentos y protocolos del proceso de auditoría del 2014 que se utilizarán para medir los resultados en las siguientes áreas.

Trasfondo Histórico del Modelo de Cuidado

Pagina 12
  • Parte D - Formulario y Administración de Beneficio.
  • Parte D - Determinación de Cubiertas, Apelaciones y Agravios.
  • Parte C - Determinación de Cubiertas, Apelaciones y Agravios.
  • Planes de Necesidades Especiales (SNP) – Modelo de Cuidado (MOC).
  • Partes C y D - Efectividad del Programa de
  • Cumplimiento.

Planes de Necesidades Especiales (SNP)

Pagina 13

Proveer un plan para las personas que requieren servicios de salud adaptados a sus necesidades y condiciones específicas.

  • Vulnerables
  • Más vulnerables

Planes de Necesidades Especiales (SNP)

Pagina 14
  • Los planes están disponibles para los beneficiarios que tienen enfermedades crónicas, severas o que están discapacitados.
  • También ofrece servicios a aquellos beneficiarios que tienen Medicare y cubierta de Medicaid, y que viven en ciertos tipos de instituciones (ejemplo, hogares de ancianos).

Planes de Necesidades Especiales (SNP)

Pagina 15

Plan Dual (D-SNP)

  • Plan de necesidades especiales elegibles a los beneficiarios que tienen derecho a Medicare (Título XVIII) y asistencia médica de un plan estatal bajo el título XIX (Medicaid). Ofrece la oportunidad de mejorar aquellos beneficios disponibles al combinar Medicare y Medicaid.

Planes Duales 2019

  • MMM Diamante Platino
  • MMM Relax Platino
  • MMM Completo Platino
  • PMC Premier Platino

Planes de Necesidades Especiales (SNP)

Pagina 16

Condiciones Crónicas MMM Supremo (C-SNP) - Certificación médica

  • Diabetes
  • Fallo Cardiaco Congestivo
  • Condiciones Cardiovasculares

Requisito C-SNP

  • CMS brinda un periodo de 60 días para evidenciar las condiciones del beneficiario. Del afiliado no evidenciar el padecimiento de una de las condiciones elegibles a la cubierta quedará desafiliado del MA

MMM SNP para condiciones crónicas

Pagina 17

MMM SUPREMO - Se recomienda a beneficiarios con condiciones crónicas:

  • Cardiovasculares
  • Diabetes
  • Fallo cardíaco congestivo
  • Que no tienen Medicaid

MMM/PMC SNP para Elegibles Duales

Pagina 18

MMM

  • MMM Diamante Platino
  • MMM Relax Platino
  • MMM Completo Platino

PMC Medicare Choice

  • PMC Premier Platino

Se recomienda a beneficiarios:

  • Que tienen Parte A y Parte B de Medicare.
  • Que tienen plan Medicaid certificado.

Modelo de Cuidado SNP 2019

Pagina 19

Un resultado mínimo de 70% es considerado aprobación del MOC y resultados de 75% o más son considerados para la aprobación de varios años; dos o tres años. Los resúmenes pretenden ofrecer un panorama amplio de cada SNP MOC y brindar al lector una visión general de cómo cada SNP aborda necesidades beneficiarias.

Los MOC de MMM y PMC fueron aprobados por un termino de 3 años.

Elementos del MOC

Pagina 20
  • MOC 1: Descripción de la Población SNP
  • MOC 2: Coordinación de Cuidado
  • MOC 3: Red de proveedores
  • MOC 4: Medición de calidad y mejoramiento del desempeño del MOC

MOC 1: Descripción de la Población SNP

Pagina 21
  • Se enfoca en población del SNP.
  • Incluye a toda la población así como a la población más vulnerable.
  • Se centra en las necesidades únicas de todos los beneficiarios, incluyendo los más vulnerables.

MOC 2: Coordinación de Cuidado

Pagina 22
  • Asegurar que las necesidades de los beneficiarios y su información es compartida con el personal de servicios de salud y las facilidades.
  • Coordinar la prestación de servicios y beneficios especializados que abarcan las necesidades de la población mas vulnerable.

MOC 2: Coordinación de Cuidado

Pagina 23
  • Requisito de Evaluación de Riesgo de Salud (HRA, por sus siglas en inglés), Plan de Cuidado Individualizado (ICP, por sus siglas en inglés) y Equipo Interdisciplinario (ICT, por sus siglas en inglés).

MOC 2: Coordinación de Cuidado

Pagina 24

Incluye los siguientes elementos claves:

  • Evaluación de Riesgo de Salud (HRA)
    • Inicial
    • Anual
  • Plan de Cuidado Individualizado (ICP)
    • Inicial
    • Anual/Cambios en estado de salud
  • Equipo de Cuidado Interdisciplinario (ICT)
    • "Steering"
    • Virtual
    • Ronda clínica
  • Transiciones de Cuidado

MOC 2: Coordinación de Cuidado Evaluación de Riesgo de Salud (HRA)

Pagina 25

MIPPA 2008 establece que es obligatorio que los planes SNP lleven a cabo una evaluación de riesgo de salud inicial y anual a CADA beneficiario.

    El "HRA" evalúa las necesidades médicas, psicosociales, cognitivas, funcionales de los beneficiarios de planes SNP. El "HRA" es realizado por teléfono y pudiese ser realizado en persona o papel.

MOC 2: Coordinación de Cuidado Evaluación de Riesgo de Salud (HRA)

Pagina 26
  • MMM/PMC utiliza el instrumento de Health Risk Assessment (HRAT) llamado MSO’s Health Risk Assessment , que es un instrumento desarrollado por el Comité Directivo del Equipo de Cuidado Interdisciplinario.
  • El "HRA" es realizado en los primeros 90 días a partir de la fecha de afiliación, a los 365 días a partir del último "HRA" y/o cuando hayan cambios en el estado de salud del beneficiario.

MOC 2: Coordinación de Cuidado Evaluación de Riesgo de Salud (HRA)

Pagina 27
  • Los resultados clasifican al afiliado en diversas categorías de riesgos. De esta manera se generan los referidos automáticos a los programas de Manejo de Cuidado.
  • Los resultados son comunicados a beneficiarios, equipo de cuidado interdisciplinario de cuidado y el médico habitual del beneficiario.

MOC 2: Coordinación de Cuidado Plan de Cuidado Individualizado (ICP)

Pagina 28
  • MMM/PMC desarrolla un "ICP" para cada beneficiario SNP.
  • El "ICP" asegura que las necesidades sean atendidas, se hagan evaluaciones regulares y coordinación de servicios y beneficios para las necesidades únicas de los beneficiarios.
  • Desarrollado para cada beneficiario por su equipo de cuidado interdisciplinario y las necesidades de los afiliados identificados en el HRA.

MOC 2: Coordinación de Cuidado Plan de Cuidado Individualizado (ICP)

Pagina 29
  • El ICP es comunicado a cada beneficiario y/o cuidador primario y proveedor.
  • Revisado anualmente o cuando haya cambios en el estado de salud.
  • Mantener un registro de los planes de cuidado para asegurar el acceso de todos los miembros del equipo de cuidado interdisciplinario.

MOC 2: Coordinación de Cuidado Equipo de Cuidado Interdisciplinario (ICT)

Pagina 30

MIPPA establece obligatorio que un plan SNP debe asignar a CADA beneficiario a un equipo de cuidado interdisciplinario.

  • El "ICT" de MMM/PMC está compuesto pero no se limita a manejador de casos, trabajadora social, nutricionista, médico habitual del beneficiario o médico primario y beneficiario o su cuidador primario.

MOC 2: Coordinación de Cuidado Equipo de Cuidado Interdisciplinario (ICT)

Pagina 31

Este equipo es responsable de:

  • Analizar los resultados de las evaluaciones de riesgo de salud iniciales y anuales.
  • Colaborar para desarrollar un "ICP" para cada beneficiario.
  • Manejar las necesidades médicas, cognitivas, psicosociales y funcionales del beneficiario.
  • Mantenerse en comunicación constante para coordinar el plan de cuidado del beneficiario.

MOC 2: Coordinación de Cuidado Equipo de Cuidado Interdisciplinario (ICT)

Pagina 32

El ICT tiene 3 enfoques distintos para discutir y manejar las necesidades de los afiliados y están son a través de la Ronda Clínica, ICT virtual y "Steering" ICT.

MOC 2: Care Coordination Care Transitions

Pagina 33
  • Transición es un movimiento de un afiliado de un nivel de cuidado a otro, según su estado de salud cambie.

Ejemplo: Mover de hospital a hogar.

  • Ejemplo: Mover de hospital a hogar.

MOC 2: Care Coordination Care Transitions

Pagina 34
  • MMM/PMC tiene personal disponible en su Programa de Manejo de Cuidado para coordinar transiciones de cuidado y facilitar la comunicación entre facilidades de cuidado, médico habitual del afiliado y afiliado o cuidador primario.
  • El "ICP" del afiliado es compartido entre niveles de cuidado cuando una transición ocurre.

MOC 3: Red de Proveedores SNP

Pagina 35

MMM/PMC se asegura:

  • Que la red de proveedores esté compuesta por especialistas clínicos que abarquen la población SNP.
  • Del uso de Guías Clínicas y Protocolos de Transición de Cuidado.
  • De educar a la red de proveedores de SNP y proveedores fuera de la red del Modelo de Cuidado del Plan.

MOC 4: Medición de calidad y mejoramiento del desempeño

Pagina 36
  • Hay establecido un plan de mejoramiento de la calidad y desempeño específico para los planes SNP.
  • MMM/PMC evalúa metas y resultados de salud para los planes SNP.
  • MMM/PMC evalúa la satisfacción de los afiliados SNP.

MOC 4: Medición de calidad y mejoramiento del desempeño

Pagina 37
  • Apoyo al mejoramiento continuo del MOC.
  • Anualmente los resultados del mejoramiento de la calidad y el desempeño del SNP MOC son comunicados a:
    • afiliados, empleados, proveedores, Junta de Directores y al público.

Para clarificar preguntas relacionadas al Modelo de Cuidado para Planes de Necesidades Especiales 2019 (MOC), comunícate con tu supervisor directo.

Pagina 38

Gracias

To review the training material below, place your mouse over the training material to enable the scrolling feature (if you are on a mobile device, touch the training material to enable the scrolling feature).

Adiestramiento a Proveedores Modelo de Cuidado para Planes de Necesidades Especiales (SNP-MOC)

(This is a text version of the Training. Click Here for the print version)

Objetivos

Pagina 2
  • Explicar los requisitos de CMS (Centers for Medicare and Medicaid Services) para el Modelo de Cuidado (MOC).
  • Nombrar los productos que ofrece Triple-S Advantage (TSA)
  • para la población de necesidades especiales (SNPs).
  • Definir los elementos, objetivos y componentes básicos del MOC.
  • Explicar el rol y las responsabilidades de los proveedores de
  • salud.

Regulaciones de CMS

Pagina 3

Los Centros de Servicios para Medicare y Medicaid (CMS, por sus siglas inglés) establecen que todo plan Medicare Advantage tiene como requisito adiestrar sobre el Modelo de Cuidado a todos sus empleados, personal contratado y red de proveedores.

Adiestramiento inicial al momento de la contratación y luego anualmente.

Trasfondo de los SNP’s

Pagina 4
  • Como parte de la Ley de Modernización de Medicare de 2003 (MMA), el Modelo de Cuidado fue creado para brindar atención especifica a las personas con necesidades especiales.
  • En 2012, el “Patient Protection and Affordable Care Act (ACA)” reforzó la importancia del MOC como un componente fundamental para los SNP’s.
  • El Comité Nacional para la Garantía de Calidad (NCQA) ejecuta la revisión y aprobación del SNP-MOC basado en normas y criterios de puntuación establecidos por CMS.

¿Qué son los SNP’s?

Pagina 5

Los SNP’s son Planes Medicare Advantage diseñados para atender grupos específicos de la población que requieren servicios especiales para el cuidado de su salud.

  • Limitan la membresía a personas con enfermedades o características específicas.
  • Ajustan los beneficios, opciones de proveedores y listas de medicamentos cubiertos para satisfacer las necesidades específicas de los grupos a los que brindan servicios.

CMS ha definido tres tipos de SNP’s:

Pagina 6
  • D-SNP: Individuos que cualifican para las Partes A y B de Medicare y Medicaid
  • C-SNP: Individuos con condiciones crónicas o severas
  • I-SNP*: Individuos que están institucionalizados o son elegibles a cuidado de enfermería en el hogar
*TSA no provee este tipo de SNP

Productos Triple-S Advantage

Pagina 7

Durante este año 2019, TSA cuenta con cinco productos SNP’s:

Nombre del Producto Tipo de Plan
Platino Plus HMO – D-SNP
Platino Ultra HMO – D-SNP
Platino Advance HMO – D-SNP
Platino Blindao HMO – D-SNP
Vital Plus HMO – C-SNP

¿Qué es el Modelo de Cuidado?

Pagina 8
  • Es una herramienta fundamental en el mejoramiento de la calidad de los servicios ofrecidos.
  • Es un componente importante para asegurar que las necesidades específicas de cada paciente afiliado a un SNP’s, sean debidamente identificadas y manejadas.

¿Cuáles son los objetivos del MOC?

Pagina 9 Mejorar:
  • el acceso a los servicios de salud física, salud mental y servicios sociales
  • el acceso a un cuidado médico asequible
  • la coordinación de cuidados a través de un punto de contacto identificado
  • las transiciones de cuidado a través de los distintos proveedores de salud
  • el acceso a los servicios de salud preventiva
  • los resultados de salud de los beneficiarios
Asegurar:
  • la utilización adecuada de los servicios
  • una prestación de servicios rentable

Elementos del MOC

Pagina 10
  • MOC 1: Descripción de la población
  • MOC 2: Coordinación de Cuidado
  • MOC 3: Red de Proveedores
  • MOC 4: Medición de la Calidad y Mejoramiento del Desempeño

MOC 1. Descripción de la Población

Pagina 11

Factores o características que identifican la población de SNP’s:

Población general: Población más vulnerable
Edad Múltiples admisiones en hospital
Género Alta utilización de medicamentos
Barreras significativas en el acceso a los servicios asociadas con el estatus socioeconómico Combinación de dos o más factores demográficos que afecten adversamente la salud
Incidencia y prevalencia de condiciones crónicas Condiciones de vivienda

MOC 1. Servicios ofrecidos a la población SNP’s:

Pagina 12
  • Programa Transición de Cuidado
  • Programa de Cuidado Coordinado
  • Programa de Manejo de Condiciones
  • Programa de Manejo de Terapia de Medicamentos (MTM)
  • Programa Gero-Social
  • Transportación no emergente
  • Tele-consulta

MOC 2. Cuidado Coordinado

Pagina 13
  • Cuidado Coordinado
    • Estructura del Personal
    • Evaluación de Riesgo de Salud (HRA)
    • Plan de Cuidado Individualizado (ICP)
    • Equipo de Cuidado Interdisciplinario (ICT)
    • Protocolos de Transición de Cuidado

MOC 2. Cuidado Coordinado

Pagina 14
  • Estructura del Personal
    • Desempeño de funciones administrativas y clínicas.
    • Todo el personal de TSA es adiestrado sobre el MOC al momento de la contratación y luego anualmente.

MOC 2. Cuidado Coordinado

Pagina 15
  • Evaluación de Riesgo de Salud (HRA)
    • Se lleva a cabo para identificar las necesidades y riesgos de salud médica, psicosocial, cognitivas.
    • El HRA inicial se debe completar dentro de los primeros 90 días de la afiliación y luego, anualmente se reevalúa el estado de salud del paciente.
    • Los resultados del HRA se utilizan en el plan de cuidado y se comparten con su médico primario.
    • La entidad delegada para llevar acabo esta evaluación es AxisPoint.
    • Los médicos primarios pueden completar la evaluación de forma electrónica a través del Electronic Patient Assessment Solution Suite (ePASS) de Inovalon.

MOC 2. Cuidado Coordinado

Pagina 16 Plan de Cuidado Individualizado (ICP)
  • Se desarrolla con los resultados obtenidos del HRA.
  • Participan todos los profesionales de la salud responsables del cuidado del paciente.
  • El paciente y/o cuidador participan en el desarrollo del ICP.
  • Incluye: metas, objetivos, servicios y beneficios específicos, preferencias del afiliado y resultados medibles.
  • El paciente recibe educación específica de su condición y el progreso de las metas en su ICP.

MOC 2. Cuidado Coordinado

Pagina 17

Equipo de Cuidado Interdisciplinario (ICT)

El equipo de TSA colabora de forma integral con todos los miembros del ICT en la coordinación del ICP.

  • Paciente
    • Proveedor de Salud Mental
    • Trabajador Social
    • Educador en Salud
    • Familiares
    • Otros
    • Medico Primario
    • Manejador de Caso
    • Especialista

MOC 2. Cuidado Coordinado

Pagina 18

Responsabilidades del ICT:

  • Desarrolla metas específicas para cada paciente.
  • Desarrolla intervenciones que mejoren los resultados de salud.
  • Identifica y anticipa problemas de salud.
  • Actúa como enlace entre el paciente y su médico primario.
  • Identifica y coordina los servicios necesarios.
  • Educa y orienta a los pacientes sobre sus condiciones de salud para una buena toma de decisiones.

MOC 2. Cuidado Coordinado

Pagina 19

Protocolos de Transición de Cuidado Aseguran la continuidad de los servicios y Se maneja la coordinación de transición de cuidado de un nivel a otro

  • Cuidado en el Hogar
  • Hospital
  • Centros de Rehabilitación
  • Centros de Enfermería Diestra (SNF)

MOC 2. Cuidado Coordinado

Pagina 20

Protocolos de Transición de Cuidado

  • Prevención
    • Asegurar cuidado de seguimiento luego de altas hospitalarias para evitar readmisiones.
    • Comunicarle al ICT cualquier cambio en la severidad de la condición de un paciente para modificar su ICP.
  • Identificación
    • Coordinar con las facilidades para asistir a los beneficiarios SNP’s en el hospital o en un centro de enfermería especializada para acceder a la atención en el nivel apropiado.
    • Trabajar con la facilidad y el beneficiario en el desarrollo de un plan de alta adecuado.
  • Manejo
    • Notificar al médico primario sobre la transición de cuidado, la fecha esperada de alta y el plan de alta establecido.
    • Los pacientes SNP’s son orientados acerca del cuidado de su salud luego de su alta.

MOC 3. Red de Proveedores

Pagina 21

El compromiso de TSA es:

  • Mantener una amplia red de proveedores.
  • Adiestrar a sus proveedores y grupos médicos sobre el MOC.
  • Asegurar una red de proveedores competente mediante un proceso formal de credencialización y re- credencialización.
  • Asegurar la adecuacidad y acceso de la red.

MOC 4. Medición de la Calidad y Mejoramiento de Desempeño

Pagina 22

TSA tiene como objetivo mejorar la capacidad de los SNP’s para ofrecer servicios y beneficios de atención médica de alta calidad a los pacientes.

  • Plan de Evaluación
  • Objetivos Medibles
  • Experiencia del Paciente
  • Evaluación de Mejoramiento Continuo
  • Comunicación de Resultados

MOC 4. Plan de evaluación para el Mejoramiento de la Calidad en TSA

Pagina 23
Quality Improvement Project (QIP) Chronic Care Improvement Program (CCIP)
  • Monitorea la medida de prevención de readmisiones en pacientes con enfermedad de obstrucción pulmonar crónica Chronic Obstructive Pulmonary Disease (COPD)/Asma
  • Supervisa los resultados de salud
  • Supervisa la implementación del MOC
  • Identifica a los pacientes con diagnóstico de diabetes, hipertensión e hipercolesterolemia
  • Controla sus condiciones
  • Promueve la adherencia a sus medicamentos

MOC 4. Objetivos Medibles y Resultados de Salud

Pagina 24
  • Recopilar e identificar datos que se evalúan anualmente para garantizar si se han alcanzado las metas.
  • Esto se evalúa, entre otros indicadores, con las medidas HEDIS® (Healthcare Effectiveness Data and Information Set).
    • Detección de Cáncer Colorectal
    • Control de la Presión Arterial Alta
    • Manejo de Osteoporosis en mujeres que han sufrido fracturas
    • Reconciliación de medicamentos posteriores al alta
    • Otras

MOC 4. Experiencia de Cuidado del Paciente

Pagina 25

Se identifican áreas de oportunidad, mediante encuestas de satisfacción a los afiliados.

  • CAHPS® (Consumer Assessment of Healthcare Providers and Systems)
    • Evalúa la experiencia del paciente en relación a su cuidado de salud.
  • HOS (Health Outcomes Survey)
    • Recopila datos de salud válidos, confiables y clínicamente significativos del programa Medicare Advantage.

MOC 4. Evaluación de Mejoramiento Continuo

Pagina 26 Objetivos de TSA:
  • Mejorar el acceso a los servicios de salud física y mental y servicios sociales.
  • Mejorar la red de proveedores especializados.
  • Mejorar y garantizar el acceso a servicios asequibles.
  • Mejorar la coordinación de cuidado a través de un punto de contacto identificado. Mejorar la coordinación y la efectividad del cuidado para la población mas vulnerable.
  • Mejorar la transición de cuidado entre los distintos escenarios de cuidado de salud.
  • Mejorar el acceso a servicios preventivos.

MOC 4. Comunicación de resultados sobre la evaluación de la calidad

Pagina 27
  • TSA ha establecido que el foro para discutir los temas identificados y para evaluar tendencias y patrones será el Comité de Calidad Clínica.
  • Los resultados se comunican a la Junta de Directores, Equipo Gerencial, Empleados, Proveedores, otros.

¿Cuál es el rol del Proveedor de Salud?

Pagina 28
  • Facilitar que el paciente pueda obtener las atenciones médicas necesarias.
  • Hacer partícipe a sus pacientes del proceso de cuidado.
  • Completar la evaluación inicial y anual de riesgos de salud (HRA)

¿Cuál es el rol del Proveedor de Salud?

Pagina 29

Comunicarse con el ICT y colaborar con el Plan de Cuidado Individualizado (ICP).

  • Revisar el plan y responder a las preocupaciones
  • Participar de las reuniones del equipo interdisciplinario cuando sea posible

Asegurar que la información necesaria esté en el expediente médico

  • Historial médico, tratamiento, consulta e informes de diagnóstico, ICP

Expectativas del Modelo de Cuidado

Pagina 30
  • Fortalecer la colaboración entre proveedores de salud para el beneficio de cada uno de los pacientes.
  • Mejorar la comunicación entre pacientes, cuidadores, proveedores y empleados de Triple-S Advantage.
  • Tener un alcance interdisciplinario ante las necesidades especiales de nuestros pacientes.
  • Proveer un cuidado comprensivo y apoyar las preferencias de los pacientes en su plan de cuidado.

Referencias

Pagina 31

  • Capítulo 5 del Medicare Managed Care Manual Title 42, Part 422, Subpart D, 422.152
  • https://www.cms.gov/Medicare/Health-Plans/SpecialNeedsPlans/index.html
  • Model of Care Scoring Guidelines CY 2015
  • Chapter 16B Special Needs Plans of the Medicare Managed Care Manual
  • Portal de Auto Servicios al Proveedor: https://providers.sssadvantage.com/

To review the training material below, place your mouse over the training material to enable the scrolling feature (if you are on a mobile device, touch the training material to enable the scrolling feature).

Therapy Network of Puerto Rico

2019 Supplemental Fraud, Waste, and Abuse and Compliance Training

(This is a text version of the presentation. Click Here for the print version)

Overview

This Supplemental FWA Training is being provided in conjunction with the following CMS training presentations

  • Combating Medicare Parts C and D Fraud, Waste, and Abuse Web-Based Training Course (January 2019)
  • Medicare Parts C and D General Compliance Training Web-Based Training Course (January 2019)
  • This supplemental training is intended to provide you with the methods for reporting Compliance, Ethics, and Fraud Waste and Abuse violations (suspected or confirmed).
  • You can report these violations to TNPR directly, the Federal Government, or to the affected Health Plan(s).
  • The methods for reporting to TNPR and the affected Health Plan(s) are contained in the remaining slides of this presentation.
    • The methods for reporting to the Federal Government are contained in the CMS training presentations.

TNPR Contact Information

Fraud, Waste, and Abuse Hotline

866-321-5550 (Toll-Free)
You can also file an anonymous report, if you want.

MAIL your report to:

Marjorie Henderson
Special Investigative Unit
2001 S. Andrews Avenue
Fort Lauderdale, Florida 33316

FAX your report to:

Attention: Marjorie Henderson
(866)276-3667
This is a dedicated Compliance line

E-MAIL your report to:

SIU@healthsystemone.com

Humana Contact Information

Special Investigations Referral Department:

800-614-4126 (Toll-Free)

MAIL your report to:

Humana
Special Investigative Unit (SIU)
1100 Employers Blvd
Green Bay, WI 54344

Fax your report to:

Attention: Humana SIU
(920)339-3673

E-MAIL your report to:

SIUReferrals@Humana.com

Ethics Help Line:

877-5-THE-KEY (Toll-Free)
877-584-3539
www.ethicshelpline.com

MCS Contact Information

How can you report FWA to MCS internally?

  • Any person who has suspicion or knowledge of FWA must report it. The MCS Code of Conduct emphasizes on the importance of reporting guarantees that no retaliation will be taken against those individuals who report in good faith.
  • Once reported, the Compliance Department, through the Special Investigations Unit, will conduct investigations to take the necessary actions, including the referral to applicable agencies.
  • These mechanisms are accessible for employees, contractors, delegated entities, providers, and beneficiaries.

ACTRight Hotline:

1-877-627-0004
(Toll-Free)

In Person:

Special Investigative Unit (SIU)/ Compliance Department

Online:

www.mcs.com.pr

Email

MCSCompliance@medicalcardsystem.com

How can you report FWA internally? In addition to the reporting mechanisms indicated previously, you may report situations through:

  • Your Supervisor, Manager, Director or Vice-President;
  • Chief Compliance Officer: Maité Morales, Esq.;
  • Special Investigations Unit Director: Mrs. Elizabeth Roussel;
  • MCS Compliance Department;
  • MCS Human Resources Department;
  • MCS Legal Department.

For any questions related to MCS, contact:

Elizabeth Roussel, CAMS, CFE
SIU Director
787-758-2500 x 2071
Elizabeth.Roussel@medicalcardsystem.com

MMM Contact Information

Informa violaciones eticas, de cumpliento, fraude, perdida u abuso, de manera confidencial, accediendo

1-877-307-1211

Myra Plumey - Oficial de Cumplimiento MMM y PMC

El Oficial de Cumplimiento tiene la responsabilidad total de los asuntos de cumplimiento y reporta directamente al Dr. Rick Shinto, Principal Oficial Ejecutivo (CEO) y al Lcdo. Orlando González, Presidente.

Triple S Advantage (TSA) Contact Information

Ethics Point:

866-384-4277 (Toll-Free)
www.ethicspoint.com

TSA Compliance Officer:

Jenny D Cárdenas
JennyCar@sssadvantage.com
787-620-1919 extension 4183

TSA Compliance Email:

tsacompliance@ssspr.com



Combating Medicare Parts C and D Fraud, Waste, and Abuse Web-Based Training Course

TABLE OF CONTENTS

  • ACRONYMS - 3
  • TITLE - 4
  • INTRODUCTION - 5
  • LESSON 1: WHAT IS FWA? - 12
  • LESSON 2: YOUR ROLE IN THE FIGHT AGAINST FWA - 32
  • POST-ASSESSMENT - 55
  • APPENDIX A: RESOURCES - 66
  • APPENDIX B: JOB AIDS - 68

ACRONYMS

The following acronyms are used throughout the course.

ACRONYM DEFINITION
CFR Code of Federal Regulations
CMS Centers for Medicare & Medicaid Services
EPLS Excluded Parties List System
FCA False Claims Act
FDRs First-tier, Downstream, and Related Entities
FWA Fraud, Waste, and Abuse
HIPAA Health Insurance Portability and Accountability Act
LEIE List of Excluded Individuals and Entities
MA Medicare Advantage
MAC Medicare Administrative Contractor
MLN Medicare Learning Network®
NPI National Provider Identifier
OIG Office of Inspector General
PBM Pharmacy Benefits Manager
WBT Web-Based Training

INTRODUCTION

INTRODUCTION PAGE 1

The Combating Medicare Parts C and D Fraud, Waste, and Abuse course is brought to you by the Medicare Learning Network®

INTRODUCTION PAGE 2

The Medicare Learning Network® (MLN) offers free educational materials for health care professionals on the Centers for Medicare & Medicaid Services (CMS) programs, policies, and initiatives. Get quick access to the information you need.

INTRODUCTION PAGE 3

This training assists Medicare Parts C and D plan Sponsors' employees, governing body members, and their first-tier, downstream, and related entities (FDRs) to satisfy their annual fraud, waste, and abuse (FWA) training requirements in the regulations and sub- regulatory guidance at:

Sponsors and their FDRs are responsible for providing additional specialized or refresher training on issues posing FWA risks based on the employee's job function or business setting.

INTRODUCTION PAGE 4

Why Do I Need Training?

Every year billions of dollars are improperly spent because of FWA. It affects everyone—including you. This training will help you detect, correct, and prevent FWA. You are part of the solution.

Combating FWA is everyone's responsibility! As an individual who provides health or administrative services for Medicare enrollees, every action you take potentially affects Medicare enrollees, the Medicare Program, or the Medicare Trust Fund.

INTRODUCTION PAGE 5

Training Requirements: Plan Employees, Governing Body Members, and First-Tier, Downstream, or Related Entity (FDR) Employees

Certain training requirements apply to people involved in Medicare Parts C and D. All employees of Medicare Advantage Organizations (MAOs) and Prescription Drug Plans (PDPs) (collectively referred to in this course as “Sponsors”) must receive training for preventing, detecting, and correcting FWA.

FWA training must occur within 90 days of initial hire and at least annually thereafter.

More information on other Medicare Parts C and D compliance trainings and answers to common questions is available on the CMS website.

Learn more about Medicare Part C

Medicare Part C, or Medicare Advantage (MA), is a health insurance option available to Medicare beneficiaries. Private, Medicare-approved insurance companies run MA programs. These companies arrange for, or directly provide, health careservices to the beneficiaries who enroll in an MA plan.

Learn more about Medicare Part D

Medicare Part D, the Prescription Drug Benefit, provides prescription drug coverage to Medicare beneficiaries enrolled in Part A and/or Part B who enroll in a Medicare Prescription Drug Plan (PDP) or an MA Prescription Drug (MA-PD) plan. Medicare approved insurance and other companies provide prescription drug coverage to individuals living in a plan’s service area.

INTRODUCTION PAGE 6

Navigating and Completing This Course

Anyone providing health or administrative services to Medicare enrollees must satisfy general compliance and FWA training requirements. You may use this WBT course to satisfy the FWA requirements.

Visit the Resources page for disclaimers, a glossary, and frequently asked questions (FAQs). You may find this information useful as you proceed through this course.

INTRODUCTION PAGE 8

Course Objectives

When you complete this course, you should correctly:

  • Recognize FWA in the Medicare Program
  • Identify the major laws and regulations pertaining to FWA
  • Recognize potential consequences and penalties associated with violations
  • Identify methods of preventing FWA
  • Identify how to report FWA
  • Recognize how to correct FWA

Select the “MAIN MENU” button to return to the Main Menu. Then, select “Lesson 1: What Is FWA?”

LESSON 1: WHAT IS FWA?

LESSON 1 PAGE 1

Lesson 1: Introduction and Learning Objectives

This lesson describes fraud, waste, and abuse (FWA) and the laws that prohibit it. It should take about 10 minutes to complete. Upon completing the lesson, you should be able to correctly:

  • Recognize FWA in the Medicare Program
  • Identify the major laws and regulations pertaining to FWA
  • Recognize potential consequences and penalties associated with violations
LESSON 1 PAGE 2

Fraud

Fraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program.

The Health Care Fraud Statute makes it a criminal offense to knowingly and willfully execute a scheme to defraud a health care benefit program. Health care fraud is punishable by imprisonment up to 10 years. It is also subject to criminal fines up to $250,000.

In other words, fraud is intentionally submitting false information to the Government or a Government contractor to get money or a benefit.

LESSON 1 PAGE 3

Waste and Abuse

For the definitions of fraud, waste, and abuse, refer to Section 20, Chapter 21 of the Medicare Managed Care Manual and Chapter 9 of the Prescription Drug Benefit Manual on the Centers for Medicare & Medicaid Services (CMS) website.

Waste includes practices that, directly or indirectly, result in unnecessary costs to the Medicare Program, such as overusing services. Waste is generally not considered to be caused by criminally negligent actions but rather by the misuse of resources.

Abuse includes actions that may, directly or indirectly, result in unnecessary costs to the Medicare Program. Abuse involves paying for items or services when there is no legal entitlement to that payment, and the provider has not knowingly or intentionally misrepresented facts to obtain payment.

LESSON 1 PAGE 4

Examples of FWA

Examples of actions that may constitute Medicare fraud include:

  • Knowingly billing for services not furnished or supplies not provided, including billing Medicare for appointments the patient failed to keep
  • Billing for nonexistent prescriptions
  • Knowingly altering claim forms, medical records, or receipts to receive a higher payment

Examples of actions that may constitute Medicare waste include:

  • Conducting excessive office visits or writing excessive prescriptions
  • Prescribing more medications than necessary for treating a specific condition
  • Ordering excessive laboratory tests

Examples of actions that may constitute Medicare abuse include:

  • Unknowingly billing for unnecessary medical services
  • Unknowingly billing for brand name drugs when generics are dispensed
  • Unknowingly excessively charging for services or supplies
  • Unknowingly misusing codes on a claim, such as upcoding or unbundling codes
LESSON 1 PAGE 5

Differences Among Fraud, Waste, and Abuse

There are differences among fraud, waste, and abuse. One of the primary differences is intent and knowledge. Fraud requires intent to obtain payment and the knowledge the actions are wrong. Waste and abuse may involve obtaining an improper payment or creating an unnecessary cost to the Medicare Program but do not require the same intent and knowledge.

LESSON 1 PAGE 6

Understanding FWA

To detect FWA, you need to know the law.

The following pages provide high-level information about the following laws:

  • Civil False Claims Act, Health Care Fraud Statute, and Criminal Fraud
  • Anti-Kickback Statute
  • Stark Statute (Physician Self-Referral Law)
  • Exclusion from all Federal health care programs
  • Health Insurance Portability and Accountability Act (HIPAA)

For details about specific laws, such as safe harbor provisions, consult the applicable statute and regulations.

LESSON 1 PAGE 7

Civil False Claims Act (FCA)

The civil provisions of the FCA make a person liable to pay damages to the Government if he or she knowingly:

  • Conspires to violate the FCA
  • Carries out other acts to obtain property from the Government by misrepresentation
  • Conceals or improperly avoids or decreases an obligation to pay the Government
  • Makes or uses a false record or statement supporting a false claim
  • Presents a false claim for payment or approval

For more information, refer to 31 United States Code (USC) Sections 3729–3733.

Damages and Penalties

Any person who knowingly submits false claims to the Government is liable for three times the Government's damages caused by the violator plus a penalty.

A Medicare Part C plan in Florida:

  • Hired an outside company to review medical records to find additional diagnosis codes it could submit to increase risk capitation payments from CMS
  • Was informed by the outside company that certain diagnosis codes previously submitted to Medicare were
  • undocumented or unsupported
  • Failed to report the unsupported diagnosis codes to Medicare
  • Agreed to pay $22.6 million to settle FCA allegations

The owner-operator of a medical clinic in California:

  • Used marketers to recruit individuals for medically unnecessary office visits
  • Promised free, medically unnecessary equipment or free food to entice individuals
  • Charged Medicare more than $1.7 million for the scheme
  • Was sentenced to 37 months in prison
LESSON 1 PAGE 8

Civil FCA (continued)

Whistleblowers

A whistleblower is a person who exposes information or activity that is deemed illegal, dishonest, or violates professional or clinical standards.

Protected: Persons who report false claims or bring legal actions to recover money paid on false claims are protected from retaliation.

Rewarded: Persons who bring a successful whistleblower lawsuit receive at least 15 percent, but not more than 30 percent, of the money collected.

LESSON 1 PAGE 9

Health Care Fraud Statute

The Health Care Fraud Statute states, “Whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice to defraud any health care benefit program … shall be fined under this title or imprisoned not more than 10 years, or both.”

Conviction under the statute does not require proof the violator had knowledge of the law or specific intent to violate the law. For more information, refer to 18 USC Sections 1346–1347.

A Pennsylvania pharmacist:

  • Submitted claims to a Medicare Part D plan for non-existent prescriptions and drugs not dispensed
  • Pleaded guilty to health care fraud
  • Received a 15-month prison sentence and was ordered to pay more than $166,000 in restitution to the plan

The owner of multiple Durable Medical Equipment (DME) companies in New York:

  • Falsely represented themselves as one of a nonprofit health maintenance organization’s (that administered a
  • Medicare Advantage plan) authorized vendors
  • Provided no DME to any beneficiaries as claimed
  • Submitted almost $1 million in false claims to the nonprofit; $300,000 was paid
  • Pleaded guilty to one count of conspiracy to commit health care fraud
LESSON 1 PAGE 10

Criminal Health Care Fraud

Persons who knowingly make a false claim may be subject to:

  • Criminal fines up to $250,000
  • Imprisonment for up to 20 years

If the violations resulted in death, the individual may be imprisoned for any term of years or for life. For more information, refer to 18 USC Section 1347

LESSON 1 PAGE 11

Anti-Kickback Statute

The Anti-Kickback Statute prohibits knowingly and willfully soliciting, receiving, offering, or paying remuneration (including any kickback, bribe, or rebate) for referrals for services that are paid, in whole or in part, under a Federal health care program (including the Medicare Program).

For more information, refer to 42 USC Section 1320a-7b(b).

Damages and Penalties

Violations are punishable by:

  • A fine up to $25,000
  • Imprisonment up to 5 years

For more information, refer to the Social Security Act (the Act), Section 1128B(b).

EXAMPLE

From 2012 through 2015, a physician operating a pain management practice in Rhode Island:

  • Conspired to solicit and receive kickbacks for prescribing a highly addictive version of the opioid Fentanyl
  • Reported patients had breakthrough cancer pain to secure insurance payments
  • Received $188,000 in speaker fee kickbacks from the drug manufacturer
  • Admitted the kickback scheme cost Medicare and other payers more than $750,000

The physician must pay more than $750,000 restitution and is awaiting sentencing.

LESSON 1 PAGE 12

Stark Statute (Physician Self-Referral Law)

The Stark Statute prohibits a physician from making referrals for certain designated health services to an entity when the physician (or a member of his or her family) has:

  • An ownership/investment interest or
  • A compensation arrangement

Exceptions may apply. For more information, refer to 42 USC Section 1395nn.

Damages and Penalties

Medicare claims tainted by an arrangement that does not comply with the Stark Statute are not payable. A penalty of around $24,250 can be imposed for each service provided. There may also be around a $161,000 fine for entering into an unlawful arrangement or scheme.

For more information, visit the Physician Self-Referral webpage and refer to the Act, Section 1877.

EXAMPLE

A California hospital was ordered to pay more than $3.2 million to settle Stark Law violations for maintaining 97 financial relationships with physicians and physician groups outside the fair market value standards or that were improperly documented as exceptions.

LESSON 1 PAGE 13

Civil Monetary Penalties (CMP) Law

The Office of Inspector General (OIG) may impose civil penalties for several reasons, including:

  • Arranging for services or items from an excluded individual or entity
  • Providing services or items while excluded
  • Failing to grant OIG timely access to records
  • Knowing of and failing to report and return an overpayment
  • Making false claims
  • Paying to influence referrals

For more information, refer to 42 USC 1320a-7a and the Act, Section 1128A(a).

Damages and Penalties

The penalties can be around $15,000 to $70,000 depending on the specific violation. Violators are also subject to three times the amount:

  • Claimed for each service or item or
  • Of remuneration offered, paid, solicited, or received

EXAMPLE

A California pharmacy and its owner agreed to pay over $1.3 million to settle allegations they submitted unsubstantiated claims to Medicare Part D for brand name prescription drugs the pharmacy could not have dispensed based on inventory records.

LESSON 1 PAGE 14

Exclusion

No Federal health care program payment may be made for any item or service furnished, ordered, or prescribed by an individual or entity excluded by the OIG. The OIG has authority to exclude individuals and entities from federally funded health care programs and maintains the List of Excluded Individuals and Entities (LEIE).

The U.S. General Services Administration (GSA) administers the Excluded Parties List System (EPLS), which contains debarment actions taken by various Federal agencies, including the OIG. You may access the EPLS on the System for Award Management (SAM) website.

When looking for excluded individuals or entities, check both the LEIE and the EPLS since the lists are not the same. For more information, refer to 42 USC Section 1320a-7 and 42 Code of Federal Regulations (CFR) Section 1001.1901

EXAMPLE

A pharmaceutical company pleaded guilty to two felony counts of criminal fraud related to failure to file required reports with the U.S. Food and Drug Administration concerning oversized morphine sulfate tablets. The pharmaceutical firm executive was excluded based on the company’s guilty plea. At the time the unconvicted executive was excluded, there was evidence he was involved in misconduct leading to the company’s conviction.

LESSON 1 PAGE 15

Health Insurance Portability and Accountability Act (HIPAA)

HIPAA created greater access to health care insurance, strengthened the protection of privacy of health care data, and promoted standardization and efficiency in the health care industry.

HIPAA safeguards deter unauthorized access to protected health care information. As an individual with access to protected health care information, you must comply with HIPAA.

For more information, visit the HIPAA webpage.

Damages and Penalties

Violations may result in Civil Monetary Penalties. In some cases, criminal penalties may apply.

EXAMPLE

A former hospital employee pleaded guilty to criminal HIPAA charges after obtaining protected health information with the intent to use it for personal gain. He was sentenced to 12 months and 1 day in prison.

LESSON 1 PAGE 16

Lesson 1 Summary

There are differences among fraud, waste, and abuse (FWA). One of the primary differences is intent and knowledge. Fraud requires the person have intent to obtain payment and the knowledge his or her actions are wrong. Waste and abuse may involve obtaining an improper payment but not the same intent and knowledge.

Laws and regulations exist that prohibit FWA. Penalties for violating these laws may include:

  • Civil Monetary Penalties
  • Civil prosecution
  • Criminal conviction, fines, or both
  • Exclusion from all Federal health care program participation
  • Imprisonment
  • Loss of professional license
LESSON 1 PAGE 17

Lesson 1 Review

Now that you completed Lesson 1, let's do a quick knowledge check. Your Post-Assessment score is unaffected by the following questions.

LESSON 1 PAGE 18

Knowledge Check

Select the correct answer.

Which of the following requires intent to obtain payment and the knowledge the actions are wrong?

  1. Fraud
  2. Abuse
  3. Waste

Correct Answer (A)

LESSON 1 PAGE 19

Knowledge Check

Select the correct answer.

Which of the following is NOT potentially a penalty for violation of a law or regulation prohibiting fraud, waste, and abuse (FWA)?

  1. Civil Monetary Penalties
  2. Deportation
  3. Exclusion from participation in all Federal health care programs

Correct Answer (B)

LESSON 1 PAGE 20

You completed Lesson 1: What Is FWA?

Now that you have learned about FWA and the laws and regulations prohibiting it, let's look closer at your role in the fight against FWA.

LESSON 2: YOUR ROLE IN THE FIGHT AGAINST FWA

LESSON 2 PAGE 1

Lesson 2: Introduction and Learning Objectives

This lesson explains the role you can play in fighting against fraud, waste, and abuse (FWA), including your responsibilities for preventing, reporting, and correcting FWA. It should take about 10 minutes to complete. Upon completing the lesson, you should correctly:

  • Identify methods of preventing FWA
  • Identify how to report FWA
  • Recognize how to correct FWA
LESSON 2 PAGE 2

Where Do I Fit In?

As a person providing health or administrative services to a Medicare Part C or Part D enrollee, you are likely an employee of a:

  • Sponsor (Medicare Advantage Organization [MAO] or a Prescription Drug Plan [PDP])
  • First-tier entity (Examples: Pharmacy Benefit Management [PBM]; hospital or health care facility; provider group; doctor's office; clinical laboratory; customer service provider; claims processing and adjudication company; a company that handles enrollment, disenrollment, and membership functions; and contracted sales agents)
  • Downstream entity (Examples: pharmacies, doctor's office, firms providing agent/broker services, marketing firms, and call centers)
  • Related entity (Examples: Entity with common ownership or control of a Sponsor, health promotion provider, or SilverSneakers®)
LESSON 2 PAGE 3

Where Do I Fit In? (continued)

I am an employee of a Part C Plan Sponsor or an employee of a Part C Plan Sponsor's first-tier or downstream entity.

The Part C Plan Sponsor is a CMS Contractor. Part C Plan Sponsors may enter into contracts with FDRs. This stakeholder relationship flow chart shows examples of functions relating to the Sponsor's Medicare Part C contracts. First-tier and related entities of the Medicare Part C Plan Sponsor may contract with downstream entities to fulfill their contractual obligations to the Sponsor.

Examples of first-tier entities may be independent practices, call centers, health services/hospital groups, fulfillment vendors, field marketing organizations, and credentialing organizations. If the first-tier entity is an independent practice, then a provider could be a downstream entity. If the first-tier entity is a health service/hospital group, then radiology, hospital, or mental health facilities may be the downstream entity. If the first-tier entity is a field marketing organization, then agents may be the downstream entity. Downstream entities may contract with other downstream entities. Hospitals and mental health facilities may contract with providers.

I am an employee of a Part D Plan Sponsor or an employee of a Part D Plan Sponsor's first-tier or downstream entity.

The Part D Plan Sponsor is a CMS Contractor. Part D Plan Sponsors may enter into contracts with FDRs. This stakeholder relationship flow chart shows examples of functions that relate to the Sponsor's Medicare Part D contracts. First-tier and related entities of the Part D Plan Sponsor may contract with downstream entities to fulfill their contractual obligations to the Sponsor.

Examples of first-tier entities include call centers, PBMs, and field marketing organizations. If the first-tier entity is a PBM, then the pharmacy, marketing firm, quality assurance firm, and claims processing firm could be downstream entities. If the first-tier entity is a field marketing organization, then agents could be a downstream entity.

LESSON 2 PAGE 4

What Are Your Responsibilities?

You play a vital part in preventing, detecting, and reporting potential FWA, as well as Medicare noncompliance.

  • FIRST, you must comply with all applicable statutory, regulatory, and other Medicare Part C or Part D requirements, including adopting and using an effective compliance
  • SECOND, you have a duty to the Medicare Program to report any compliance concerns and suspected or actual violations of which you may be
  • THIRD, you have a duty to follow your organization's Code of Conduct that articulates your and your organization's commitment to standards of conduct and ethical rules of
LESSON 2 PAGE 5

How Do You Prevent FWA?

  • Look for suspicious activity
  • Conduct yourself in an ethical manner
  • Ensure accurate and timely data and billing
  • Ensure coordination with other payers
  • Know FWA policies and procedures, standards of conduct, laws, regulations, and CMS' guidance
  • Verify all received information
LESSON 2 PAGE 6

Stay Informed About Policies and Procedures

Know your entity's policies and procedures.

Every Sponsor and First-Tier, Downstream, and Related Entity (FDR) must have policies and procedures that address FWA. These procedures should help you detect, prevent, report, and correct FWA.

Standards of Conduct should describe the Sponsor's expectations that:

  • All employees conduct themselves in an ethical manner
  • Appropriate mechanisms are in place for anyone to report noncompliance and potential FWA
  • Reported issues will be addressed and corrected

Standards of Conduct communicate to employees and FDRs compliance is everyone's responsibility, from the top of the organization to the bottom.

LESSON 2 PAGE 7

Report FWA

Everyone must report suspected instances of FWA. Your Sponsor's Code of Conduct should clearly state this obligation. Sponsors may not retaliate against you for making a good faith effort in reporting.

Report any potential FWA concerns you have to your compliance department or your Sponsor's compliance department. Your Sponsor's compliance department will investigate and make the proper determination. Often, Sponsors have a Special Investigations Unit (SIU) dedicated to investigating FWA. They may also maintain an FWA Hotline.

Every Sponsor must have a mechanism for reporting potential FWA by employees and FDRs. Each Sponsor must accept anonymous reports and cannot retaliate against you for reporting.

Review your organization's materials for the ways to report FWA.

When in doubt, call your Compliance Department or FWA Hotline.

LESSON 2 PAGE 8

Reporting FWA Outside Your Organization

If warranted, Sponsors and FDRs must report potentially fraudulent conduct to Government authorities, such as the Office of Inspector General (OIG), the U.S. Department of Justice (DOJ), or CMS.

Individuals or entities who wish to voluntarily disclose self-discovered potential fraud to OIG may do so under the Self-Disclosure Protocol (SDP). Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a Government- directed investigation and civil or administrative litigation.

Details to Include When Reporting FWA

When reporting suspected FWA, include:

  • Contact information for the information source, suspects, and witnesses
  • Alleged FWA details
  • Alleged Medicare rules violated
  • The suspect's history of compliance, education, training, and communication with your organization or other entities

WHERE TO REPORT FWA

HHS Office of Inspector General:

  • Phone: 1-800-HHS-TIPS (1-800-447-8477) or TTY 1-800-377-4950
  • Fax: 1-800-223-8164
  • Email: HHSTips@oig.hhs.gov
  • Online: Forms.OIG.hhs.gov/hotlineoperations/index.aspx

For Medicare Parts C and D:

  • Investigations Medicare Drug Integrity Contractor (I MEDIC) at 1-877-7SafeRx (1-877-772-3379)

For all other Federal health care programs:

  • CMS Hotline at 1-800-MEDICARE (1-800-633-4227) or TTY 1-877-486-2048

Medicare beneficiary website

LESSON 2 PAGE 9

Correction

Once fraud, waste, or abuse is detected, promptly correct it. Correcting the problem saves the Government money and ensures your compliance with CMS requirements.

Develop a plan to correct the issue. Ask your organization's compliance officer about the development process for the corrective action plan. The actual plan is going to vary, depending on the specific circumstances. In general:

  • Design the corrective action to correct the underlying problem that results in FWA program violations and to prevent future noncompliance.
  • Tailor the corrective action to address the particular FWA, problem, or deficiency identified. Include timeframes for specific actions.
  • Document corrective actions addressing noncompliance or FWA committed by a Sponsor's employee or FDR's employee, and include consequences for failure to satisfactorily complete the corrective
  • Monitor corrective actions continuously to ensure

Corrective Action Examples

Corrective actions may include:

  • Adopting new prepayment edits or document review requirements
  • Conducting mandated training
  • Providing educational materials
  • Revising policies or procedures
  • Sending warning letters
  • Taking disciplinary action, such as suspension of marketing, enrollment, or payment
  • Terminating an employee or provider
LESSON 2 PAGE 10

Indicators of Potential FWA

Now that you know about your role in preventing, reporting, and correcting FWA, let's review some key indicators to help you recognize the signs of someone committing FWA.

The following pages present potential FWA issues. Each page provides questions to ask yourself about different areas, depending on your role as an employee of a Sponsor, pharmacy, or other entity involved in delivering Medicare Parts C and D benefits to enrollees.

LESSON 2 PAGE 11

Key Indicators: Potential Beneficiary Issues

  • Does the prescription, medical record, or laboratory test look altered or possibly forged?
  • Does the beneficiary's medical history support the services requested?
  • Have you filled numerous identical prescriptions for this beneficiary, possibly from different doctors?
  • Is the person receiving the medical service the beneficiary (identity theft)?
  • Is the prescription appropriate based on the beneficiary's other prescriptions?
LESSON 2 PAGE 12

Key Indicators: Potential Provider Issues

  • Are the provider's prescriptions appropriate for the member's health condition (medically necessary)?
  • Does the provider bill the Sponsor for services not provided?
  • Does the provider write prescriptions for diverse drugs or primarily for controlled substances?
  • Is the provider performing medically unnecessary services for the member?
  • Is the provider prescribing a higher quantity than medically necessary for the condition?
  • Does the provider's prescription have their active and valid National Provider Identifier on it?
  • Is the provider's diagnosis for the member supported in the medical record?
LESSON 2 PAGE 13

Key Indicators: Potential Pharmacy Issues

  • Are drugs being diverted (drugs meant for nursing homes, hospice, and other entities being sent elsewhere)?
  • Are the dispensed drugs expired, fake, diluted, or illegal?
  • Are generic drugs provided when the prescription requires dispensing brand drugs?
  • Are PBMs billed for unfilled or never picked up prescriptions?
  • Are proper provisions made if the entire prescription is not filled (no additional dispensing fees for split prescriptions)?
  • Do you see prescriptions being altered (changing quantities or Dispense As Written)?
LESSON 2 PAGE 14

Key Indicators: Potential Wholesaler Issues

  • Is the wholesaler distributing fake, diluted, expired, or illegally imported drugs?
  • Is the wholesaler diverting drugs meant for nursing homes, hospices, and Acquired Immune Deficiency Syndrome (AIDS) clinics, marking up the prices, and sending to other smaller wholesalers or pharmacies?
LESSON 2 PAGE 15

Key Indicators: Potential Manufacturer Issues

  • Does the manufacturer promote off-label drug usage?
  • Does the manufacturer knowingly provide samples to entities that bill Federal health care programs for them?
LESSON 2 PAGE 16

Key Indicators: Potential Sponsor Issues

  • Does the Sponsor encourage or support inappropriate risk adjustment submissions?
  • Does the Sponsor lead the beneficiary to believe the cost of benefits is one price, when the actual cost is higher?
  • Does the Sponsor offer beneficiaries cash inducements to join the plan?
  • Does the Sponsor use unlicensed agents?
LESSON 2 PAGE 17

Lesson 2 Summary

  • As a person providing health or administrative services to a Medicare Part C or D enrollee, you play a vital role in preventing fraud, waste, and abuse (FWA). Conduct yourself ethically, stay informed of your organization's policies and procedures, and keep an eye out for key indicators of potential
  • Report potential FWA. Every Sponsor must have a mechanism for reporting potential FWA. Each Sponsor must accept anonymous reports and cannot retaliate against you for
  • Promptly correct identified FWA with an effective corrective action
LESSON 2 PAGE 18

Lesson 2 Review

Now that you completed Lesson 2, let's do a quick knowledge check. Your Post-Assessment score is unaffected by the following questions.

LESSON 2 PAGE 19

Knowledge Check

Select the correct answer.

A person drops off a prescription for a beneficiary who is a “regular” customer. The prescription is for a controlled substance with a quantity of 160. This beneficiary normally receives a quantity of 60, not 160. You review the prescription and have concerns about possible forgery. What is your next step?

  1. Fill the prescription for 160
  2. Fill the prescription for 60
  3. Call the prescriber to verify the quantity
  4. Call the Sponsor's compliance department
  5. Call law enforcement

Correct Answer (C)

LESSON 2 PAGE 20

Knowledge Check

Select the correct answer.

Your job is to submit a risk diagnosis to the Centers for Medicare & Medicaid Services (CMS) for the purpose of payment. As part of this job, you use a process to verify the data is accurate. Your immediate supervisor tells you to ignore the Sponsor's process and to adjust or add risk diagnosis codes for certain individuals. What should you do?

  1. Do what your immediate supervisor asked you to do and adjust or add risk diagnosis codes
  2. Report the incident to the compliance department (via compliance hotline or other mechanism)
  3. Discuss your concerns with your immediate supervisor
  4. Call law enforcement

Correct Answer (B)

LESSON 2 PAGE 21

Knowledge Check

Select the correct answer.

You are in charge of paying claims submitted by providers. You notice a certain diagnostic provider (“Doe Diagnostics”) requested a substantial payment for a large number of members. Many of these claims are for a certain procedure. You review the same type of procedure for other diagnostic providers and realize Doe Diagnostics' claims far exceed any other provider you reviewed. What should you do?

  1. Call Doe Diagnostics and request additional information for the claims
  2. Consult with your immediate supervisor for next steps or contact the compliance department (via compliance hotline, Special Investigations Unit [SIU], or other mechanism)
  3. Reject the claims
  4. Pay the claims

Correct Answer (B)

LESSON 2 PAGE 22

Knowledge Check

Select the correct answer.

You are performing a regular inventory of the controlled substances in the pharmacy. You discover a minor inventory discrepancy. What should you do?

  1. Call local law enforcement
  2. Perform another review
  3. Contact your compliance department (via compliance hotline or other mechanism)
  4. Discuss your concerns with your supervisor
  5. Follow your pharmacy's procedures

Correct Answer (E)

LESSON 2 PAGE 23

You completed Lesson 2: Your Role in the Fight Against FWA

Now that you have learned how to fight FWA, it's time to assess your knowledge.

POST-ASSESSMENT

POST-ASSESSMENT PAGE 1

Post-Assessment

This brief Post-Assessment asks 10 questions and should take about 10 minutes. Select the "NEXT" button to begin the Post-Assessment.

POST-ASSESSMENT PAGE 2

Question 1 of 10

Select the correct answer.

Once a corrective action plan is started, the corrective actions must be monitored annually to ensure they are effective.

  1. True
  2. False
POST-ASSESSMENT PAGE 3

Question 2 of 10

Select the best answer.

Ways to report potential fraud, waste, and abuse (FWA) include:

  1. Telephone hotlines
  2. Mail drops
  3. In-person reporting to the compliance department/supervisor
  4. Special Investigations Units (SIUs)
  5. All of the above
POST-ASSESSMENT PAGE 4

Question 3 of 10

Select the correct answer.

Any person who knowingly submits false claims to the Government is liable for five times the Government's damages caused by the violator plus a penalty.

  1. True
  2. False
POST-ASSESSMENT PAGE 5

Question 4 of 10

Select the correct answer.

These are examples of issues that should be reported to a Compliance Department: suspected fraud, waste, and abuse (FWA); potential health privacy violation; unethical behavior; and employee misconduct.

  1. True
  2. False
POST-ASSESSMENT PAGE 6

Question 5 of 10

Select the correct answer.

Bribes or kickbacks of any kind for services that are paid under a Federal health care program (which includes Medicare) constitute fraud by the person making as well as the person receiving them.

  1. True
  2. False
POST-ASSESSMENT PAGE 7

Question 6 of 10

Select the correct answer.

Waste includes any misuse of resources, such as the overuse of services or other practices that, directly or indirectly, result in unnecessary costs to the Medicare Program.

  1. True
  2. False
POST-ASSESSMENT PAGE 8

Question 7 of 10

Select the correct answer.

Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly or intentionally misrepresented facts to obtain payment.

  1. True
  2. False
POST-ASSESSMENT PAGE 9

Question 8 of 10

Select the correct answer.

Some of the laws governing Medicare Parts C and D fraud, waste, and abuse (FWA) include the Health Insurance Portability and Accountability Act (HIPAA), the False Claims Act, the Anti-Kickback Statute, and the Health Care Fraud Statute.

  1. True
  2. False
POST-ASSESSMENT PAGE 10

Question 9 of 10

Select the correct answer.

You can help prevent fraud, waste, and abuse (FWA) by doing all of the following:

  • Look for suspicious activity
  • Conduct yourself in an ethical manner
  • Ensure accurate and timely data and billing
  • Ensure you coordinate with other payers
  • Keep up to date with FWA policies and procedures, standards of conduct, laws, regulations, and the Centers for Medicare & Medicaid Services (CMS) guidance
  • Verify all information provided to you
  1. True
  2. False
POST-ASSESSMENT PAGE 11

Question 10 of 10

Select the best answer.

What are some of the penalties for violating fraud, waste, and abuse (FWA) laws?

  1. Civil Monetary Penalties
  2. Imprisonment
  3. Exclusion from participation in all Federal health care programs
  4. All of the above

APPENDIX A: RESOURCES

RESOURCES PAGE 1 OF 1

Disclaimers

This Web-Based Training (WBT) course was current at the time it was published or uploaded onto the web. Medicare policy changes frequently so links to the source documents have been provided within the course for your reference.

This course was prepared as a service to the public and is not intended to grant rights or impose obligations. This course may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents.

The Medicare Learning Network® (MLN)

The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department of Health & Human Services (HHS).

Glossary

For glossary terms, visit the Centers for Medicare & Medicaid Services Glossary.

Centers for Medicare & Medicaid Services Glossary

APPENDIX B: JOB AIDS

Job Aid A: Applicable Laws for Reference


Job Aid B: Resources


Job Aid C: Where to Report Fraud, Waste, and Abuse (FWA)

HHS Office of Inspector General:

  • Phone: 1-800-HHS-TIPS (1-800-447-8477) or TTY 1-800-377-4950
  • Fax: 1-800-223-8164
  • Email: HHSTips@oig.hhs.gov
  • Online: Forms.OIG.hhs.gov/hotlineoperations/index.aspx

For Medicare Parts C and D:

  • Investigations Medicare Drug Integrity Contractor (I MEDIC) at 1-877-7SafeRx (1-877-772-3379)

For all other Federal health care programs:

  • CMS Hotline at 1-800-MEDICARE (1-800-633-4227) or TTY 1-877-486-2048

HHS and U.S. Department of Justice (DOJ): Medicare.gov/forms-help-and-resources/help-fight-medicare-fraud



Medicare Parts C and D General Compliance Training Web-Based Training Course

TABLE OF CONTENTS

  • ACRONYMS - 3
  • TITLE - 4
  • INTRODUCTION - 5
  • LESSON: COMPLIANCE PROGRAM TRAINING - 12
  • APPENDIX A: RESOURCES - 44
  • APPENDIX B: JOB AIDS - 46

ACRONYMS

The following acronyms are used throughout the course.

  • CFR — Code of Federal Regulations
  • CMS — Centers for Medicare & Medicaid Services
  • FDR — First-tier, Downstream, and Related Entity
  • FWA — Fraud, Waste, and Abuse
  • HHS — U.S. Department of Health & Human Services
  • MA — Medicare Advantage
  • MAO — Medicare Advantage Organization
  • MA-PD — MA Prescription Drug
  • MLN — Medicare Learning Network®
  • OIG — Office of Inspector General
  • PDP — Prescription Drug Plan

TITLE

Medicare Parts C and D General Compliance Training

INTRODUCTION PAGE 1

INTRODUCTION

The Medicare Parts C and D General Compliance Training course is brought to you by the Medicare Learning Network®

INTRODUCTION PAGE 2

The Medicare Learning Network® (MLN) offers free educational materials for health care professionals on the Centers for Medicare & Medicaid Services (CMS) programs, policies, and initiatives. Get quick access to the information you need.

INTRODUCTION PAGE 3

This training assists Medicare Parts C and D plan Sponsors' employees, governing body members, and their first-tier, downstream, and related entities (FDRs) to satisfy their annual general compliance training requirements in the regulations and sub-regulatory guidance at:

Completing this training in and of itself does not ensure a Sponsor has an “effective Compliance Program.” Sponsors and their FDRs are responsible for establishing and executing an effective compliance program according to the CMS regulations and program guidelines.

INTRODUCTION PAGE 4

Why Do I Need Training?

Every year, billions of dollars are improperly spent because of fraud, waste, and abuse (FWA). It affects everyone—including you. This training helps you detect, correct, and prevent FWA. You are part of the solution.

Compliance is everyone's responsibility! As an individual who provides health or administrative services for Medicare enrollees, every action you take potentially affects Medicare enrollees, the Medicare Program, or the Medicare Trust Fund.

INTRODUCTION PAGE 5

Training Requirements: Plan Employees, Governing Body Members, and First-Tier, Downstream, or Related Entity (FDR) Employees

Certain training requirements apply to people involved in Medicare Parts C and D. All employees of Medicare Advantage Organizations (MAOs) and Prescription Drug Plans (PDPs) (collectively referred to in this course as “Sponsors”) must receive training about compliance with CMS program rules.

You may need to complete FWA training within 90 days of your initial hire. More information on other Medicare Parts C and D compliance trainings and answers to common questions is available on the CMS website. Please contact your management team for more information.

Learn more about Medicare Part C

Medicare Part C, or Medicare Advantage (MA), is a health insurance option available to Medicare beneficiaries. Private, Medicare-approved insurance companies run MA programs. These companies arrange for, or directly provide, health care services to the beneficiaries who enroll in an MA plan.

MA plans must cover all services Medicare covers with the exception of hospice care. They provide Part A and Part B benefits and may also include prescription drug coverage and other supplemental benefits.

Learn more about Medicare Part D

Medicare Part D, the Prescription Drug Benefit, provides prescription drug coverage to Medicare beneficiaries enrolled in Part A and/or Part B who enroll in a Medicare Prescription Drug Plan (PDP) or an MA Prescription Drug (MA-PD) plan. Medicareapproved insurance and other companies provide prescription drug coverage to individuals living in a plan’s service area.

INTRODUCTION PAGE 6

Navigating and Completing This Course

Anyone who provides health or administrative services to Medicare enrollees must satisfy general compliance and FWA training requirements. You may use this course to satisfy the general compliance training requirements.

This course consists of one lesson and a Post-Assessment. Successfully completing the course requires completing the lesson and scoring 70 percent or higher on the Post-Assessment. After successfully completing the Post-Assessment, you'll get instructions to print your certificate. If you

do not successfully complete the course, you can review the course material and retake the Post-Assessment.

This course uses cues at various times to provide additional information and functionality. For more information on using these cues, adjusting your screen resolution, and suggested browser settings, select “HELP”.

You do not have to complete this course in one session; however, you must complete the lesson before exiting the course. You can complete the entire course in about 25 minutes. After you successfully complete this course, you receive instructions on how to print your certificate.

Visit the Resources page for disclaimers, a glossary, and frequently asked questions (FAQs). You may find this information useful as you proceed through this course.

INTRODUCTION PAGE 7

Course Objectives

After completing this course, you should correctly:

  • Recognize how a compliance program operates
  • Recognize how compliance program violations should be reported

LESSON: COMPLIANCE PROGRAM TRAINING

LESSON PAGE 1

Introduction and Learning Objectives

This lesson outlines effective compliance programs. It should take about 15 minutes to complete. After completing this lesson, you should correctly:

  • Recognize how a compliance program operates
  • Recognize how compliance program violations should be reported
LESSON PAGE 2

Compliance Program Requirement

The Centers for Medicare & Medicaid Services (CMS) requires Sponsors to implement and maintain an effective compliance program for its Medicare Parts C and D plans. An effective compliance program must:

  • Articulate and demonstrate an organization's commitment to legal and ethical conduct
  • Provide guidance on how to handle compliance questions and concerns
  • Provide guidance on how to identify and report compliance violations
LESSON PAGE 3

What Is an Effective Compliance Program?

An effective compliance program fosters a culture of compliance within an organization and, at a minimum:

  • Prevents, detects, and corrects non-compliance
  • Is fully implemented and is tailored to an organization's unique operations and circumstances
  • Has adequate resources
  • Promotes the organization's Standards of Conduct
  • Establishes clear lines of communication for reporting non-compliance

An effective compliance program is essential to prevent, detect, and correct Medicare non-compliance as well as fraud, waste, and abuse (FWA). It must, at a minimum, include the seven core compliance program requirements.

LESSON PAGE 4

Seven Core Compliance Program Requirements

CMS requires an effective compliance program to include seven core requirements:

  1. Written Policies, Procedures, and Standards of Conduct

    These articulate the Sponsor’s commitment to comply with all applicable Federal and State standards and describe compliance expectations according to the Standards of Conduct.

  2. Compliance Officer, Compliance Committee, and High-Level Oversight

    The Sponsor must designate a compliance officer and a compliance committee accountable and responsible for the activities and status of the compliance program, including issues identified, investigated, and resolved by the compliance program.

    The Sponsor's senior management and governing body must be engaged and exercise reasonable oversight of the Sponsor's compliance program.

  3. Effective Training and Education

    This covers the elements of the compliance plan as well as preventing, detecting, and reporting FWA. Tailor this training and education to the different employees and their responsibilities and job functions.
LESSON PAGE 5

Seven Core Compliance Program Requirements (continued)

  1. Effective Lines of Communication

    Make effective lines of communication accessible to all, ensure confidentiality, and provide methods for anonymous and good- faith compliance issues reporting at Sponsor and first-tier, downstream, or related entity (FDR) levels.

  2. Well-Publicized Disciplinary Standards

    Sponsor must enforce standards through well-publicized disciplinary guidelines.

  3. Effective System for Routine Monitoring, Auditing, and Identifying Compliance Risks

    Conduct routine monitoring and auditing of Sponsor's and FDR's operations to evaluate compliance with CMS requirements as well as the overall effectiveness of the compliance program.

    NOTE: Sponsors must ensure FDRs performing delegated administrative or health care service functions concerning the Sponsor's Medicare Parts C and D program comply with Medicare Program requirements.

  4. Procedures and System for Prompt Response to Compliance Issues

    The Sponsor must use effective measures to respond promptly to non-compliance and undertake appropriate corrective action.

LESSON PAGE 6

Compliance Training: Sponsors and Their FDRs

CMS expects all Sponsors will apply their training requirements and “effective lines of communication” to their FDRs. Having “effective lines of communication” means employees of the Sponsor and the Sponsor's FDRs have several avenues to report compliance concerns.

LESSON PAGE 7

Ethics: Do the Right Thing!

As part of the Medicare Program, you must conduct yourself in an ethical and legal manner. It's about doing the right thing!

  • Act fairly and honestly
  • Adhere to high ethical standards in all you do
  • Comply with all applicable laws, regulations, and CMS requirements
  • Report suspected violations
LESSON PAGE 8

How Do You Know What Is Expected of You?

Now that you've read the general ethical guidelines on the previous page, how do you know what is expected of you in a specific situation?

Standards of Conduct (or Code of Conduct) state the organization's compliance expectations and their operational principles and values. Organizational Standards of Conduct vary. The organization should tailor the Standards of Conduct content to their individual organization's culture and business operations. Ask management where to locate your organization's Standards of Conduct.

Reporting Standards of Conduct violations and suspected non-compliance is everyone's responsibility.

An organization's Standards of Conduct and Policies and Procedures should identify this obligation and tell you how to report suspected non-compliance.

LESSON PAGE 9

What Is Non-Compliance?

Non-compliance is conduct that does not conform to the law, Federal health care program requirements, or an organization's ethical and business policies. CMS identified the following Medicare Parts C and D high risk areas:

  • Agent/broker misrepresentation
  • Appeals and grievance review (for example, coverage and organization determinations)
  • Beneficiary notices
  • Conflicts of interest
  • Claims processing
  • Credentialing and provider networks
  • Documentation and Timeliness requirements
  • Ethics
  • FDR oversight and monitoring
  • Health Insurance Portability and Accountability Act (HIPAA)
  • Marketing and enrollment
  • Pharmacy, formulary, and benefit administration
  • Quality of care

For more information, refer to the Compliance Program Guidelines in the Medicare Prescription Drug Benefit Manual and Medicare Managed Care Manual.

Know the Consequences of Non-Compliance

Failure to follow Medicare Program requirements and CMS guidance can lead to serious consequences, including:

  • Contract termination
  • Criminal penalties
  • Exclusion from participating in all Federal health care programs
  • Civil monetary penalties

Additionally, your organization must have disciplinary standards for non-compliant behavior. Those who engage in noncompliant behavior may be subject to any of the following:

  • Mandatory training or re-training
  • Disciplinary action
  • Termination
LESSON PAGE 10

NON-COMPLIANCE AFFECTS EVERYBODY

Without programs to prevent, detect, and correct non-compliance, we all risk:

Harm to beneficiaries, such as:

  • Delayed services
  • Denial of benefits
  • Difficulty in using providers of choice
  • Other hurdles to care

Less money for everyone, due to:

  • High insurance copayments
  • Higher premiums
  • Lower benefits for individuals and employers
  • Lower Star ratings
  • Lower profits
LESSON PAGE 11

How to Report Potential Non-Compliance

Employees of a Sponsor

  • Call the Medicare Compliance Officer
  • Make a report through your organization’s website
  • Call the Compliance Hotline

First-Tier, Downstream, or Related Entity (FDR) Employees

  • Talk to a Manager or Supervisor
  • Call your Ethics/Compliance Help Line
  • Report to the Sponsor

Beneficiaries

  • Call the Sponsor’s Compliance Hotline or Customer Service
  • Make a report through the Sponsor’s website
  • Call 1-800-Medicare

Don't Hesitate to Report Non-Compliance

When you report suspected non-compliance in good faith, the Sponsor can't retaliate against you.

Each Sponsor must offer reporting methods that are:

  • Anonymous
  • Confidential
  • Non-retaliatory
LESSON PAGE 12

What Happens After Non-Compliance Is Detected?

Non-compliance must be investigated immediately and corrected promptly. Internal monitoring should ensure:

  • No recurrence of the same non-compliance
  • Ongoing CMS requirements compliance
  • Efficient and effective internal controls
  • Protected enrollees
LESSON PAGE 13

What Are Internal Monitoring and Audits?

Internal monitoring activities include regular reviews confirming ongoing compliance and taking effective corrective actions.

Internal auditing is a formal review of compliance with a particular set of standards (for example, policies, procedures, laws, and regulations) used as base measures.

LESSON PAGE 14

Lesson Summary

Organizations must create and maintain compliance programs that, at a minimum, meet the seven core requirements. An effective compliance program fosters a culture of compliance.

To help ensure compliance, behave ethically and follow your organization's Standards of Conduct. Watch for common instances of non-compliance, and report suspected non-compliance.

Know the consequences of non-compliance, and help correct any non- compliance with a corrective action plan that includes ongoing monitoring and auditing.

Compliance Is Everyone's Responsibility!

  • Prevent: Operate within your organization’s ethical expectations to prevent non-compliance!
  • Detect & Report: Report detected potential noncompliance!
  • Correct: Correct non-compliance to protect beneficiaries and save money
LESSON PAGE 15

Lesson Review

Now that you completed the lesson, let's do a quick knowledge check. The Post-Assessment course score is unaffected by answering the following questions.

LESSON PAGE 16

Knowledge Check

Select the correct answer.

You discover an unattended email address or fax machine in your office receiving beneficiary appeals requests. You suspect no one is processing the appeals. What should you do?

  1. Contact law enforcement
  2. Nothing
  3. Contact your compliance department (via compliance hotline or other mechanism)
  4. Wait to confirm someone is processing the appeals before taking further action
  5. Contact your supervisor

Answer (C)

LESSON PAGE 17

Knowledge Check

Select the correct answer.

A sales agent, employed by the Sponsor's first-tier, downstream, or related entity (FDR), submitted an application for processing and requested two things: 1) to back-date the enrollment date by one month, and 2) to waive all monthly premiums for the beneficiary.

What should you do?

  1. Refuse to change the date or waive the premiums but decide not to mention the request to a supervisor or the compliance department
  2. Make the requested changes because the sales agent determines the beneficiary's start date and monthly premiums
  3. Tell the sales agent you will take care of it but then process the application properly (without the requested revisions)—you will not file a report because you don't want the sales agent to retaliate against you
  4. Process the application properly (without the requested revisions)—inform your supervisor and the compliance officer about the sales agent's request
  5. Contact law enforcement and the Centers for Medicare & Medicaid Services (CMS) to report the sales agent's behavior

Answer (D)

LESSON PAGE 18

Knowledge Check

Select the correct answer.

You work for a Sponsor. Last month, while reviewing a Centers for Medicare & Medicaid Services (CMS) monthly report, you identified multiple individuals not enrolled in the plan but for whom the Sponsor is paid. You spoke to your supervisor who said don't worry about it. This month, you identify the same enrollees on the report again. What should you do?

  1. Decide not to worry about it as your supervisor instructed—you notified your supervisor last month and now it's his responsibility
  2. Although you know about the Sponsor's non-retaliation policy, you are still nervous about reporting—to be safe, you submit a report through your compliance department's anonymous tip line to avoid identification
  3. Wait until the next month to see if the same enrollees appear on the report again, figuring it may take a few months for CMS to reconcile its records—if they are, then you will say something to your supervisor again
  4. Contact law enforcement and CMS to report the discrepancy
  5. Ask your supervisor about the discrepancy again

Answer (B)

LESSON PAGE 19

Knowledge Check

Select the correct answer.

You are performing a regular inventory of the controlled substances in the pharmacy. You discover a minor inventory discrepancy. What should you do?

  1. Call local law enforcement
  2. Perform another review
  3. Contact your compliance department (via compliance hotline or other mechanism)
  4. Discuss your concerns with your supervisor
  5. Follow your pharmacy's procedures

Answer (E)

LESSON PAGE 20

You've completed the lesson!

Now that you have learned about compliance programs, it's time to assess your knowledge.

POST-ASSESSMENT

POST-ASSESSMENT PAGE 1

Post-Assessment

This brief Post-Assessment asks 10 questions and should take about 10 minutes.

Choose an answer for each question by selecting the button next to your answer. You must select an answer before advancing to the next question. You can only move forward in the Post-Assessment, and you can only try each question once. You may change your answer for a question until you select the “SUBMIT ANSWER” button. After you submit your answer, feedback for the question and the “NEXT” button will appear. Select the “NEXT” button to continue. Do not select the “X” button in the right-hand corner of the window as this will cause you to exit the course without recording your progress.

You may print your score when you finish the Post-Assessment. After successfully completing the course, you can print a certificate. Successfully completing the course includes finishing all lessons, scoring 70 percent or higher on the Post-Assessment, and completing the course evaluation. Instructions on printing your certificate are available after you pass the Post-Assessment.

Select the “NEXT” button to begin the Post-Assessment.

POST-ASSESSMENT PAGE 2

Question 1 of 10

Select the correct answer.

Compliance is the responsibility of the Compliance Officer, Compliance Committee, and Upper Management only.

  1. True
  2. False
POST-ASSESSMENT PAGE 3

Question 2 of 10

Select the correct answer.

Ways to report a compliance issue include:

  1. Telephone hotlines
  2. Report on the Sponsor's website
  3. In-person reporting to the compliance department/supervisor
  4. All of the above
POST-ASSESSMENT PAGE 4

Question 3 of 10

Select the correct answer.

What is the policy of non-retaliation?

  1. Allows the Sponsor to discipline employees who violate the Code of Conduct
  2. Prohibits management and supervisor from harassing employees for misconduct
  3. Protects employees who, in good faith, report suspected non-compliance
  4. Prevents fights between employees
POST-ASSESSMENT PAGE 5

Question 4 of 10

Select the correct answer.

These are examples of issues that can be reported to a Compliance Department: suspected fraud, waste, and abuse (FWA); potential health privacy violation, and unethical behavior/employee misconduct.

  1. True
  2. False
POST-ASSESSMENT PAGE 6

Question 5 of 10

Select the correct answer.

Once a corrective action plan begins addressing non-compliance or fraud, waste, and abuse (FWA) committed by a Sponsor's employee or first-tier, downstream, or related entity's (FDR's) employee, ongoing monitoring of the corrective actions is not necessary.

  1. True
  2. False
POST-ASSESSMENT PAGE 7

Question 6 of 10

Select the correct answer.

Medicare Parts C and D plan Sponsors are not required to have a compliance program.

  1. True
  2. False
POST-ASSESSMENT PAGE 8

Question 7 of 10

Select the correct answer.

At a minimum, an effective compliance program includes four core requirements.

  1. True
  2. False
POST-ASSESSMENT PAGE 9

Question 8 of 10

Select the correct answer.

Standards of Conduct are the same for every Medicare Parts C and D Sponsor.

  1. True
  2. False
POST-ASSESSMENT PAGE 10

Question 9 of 10

Select the correct answer.

Correcting non-compliance _____.

  1. Protects enrollees, avoids recurrence of the same non-compliance, and promotes efficiency
  2. Ensures bonuses for all employees
  3. Both A. and B.
POST-ASSESSMENT PAGE 11

Question 10 of 10

Select the correct answer.

What are some of the consequences for non-compliance, fraudulent, or unethical behavior?

  1. Disciplinary action
  2. Termination of employment
  3. Exclusion from participating in all Federal health care programs
  4. All of the above

APPENDIX A: RESOURCES

RESOURCES PAGE 1 OF 1

Disclaimers

This Web-Based Training (WBT) course was current at the time it was published or uploaded onto the web. Medicare policy changes frequently so links to the source documents have been provided within the course for your reference.

This course was prepared as a service to the public and is not intended to grant rights or impose obligations. This course may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents.

The Medicare Learning Network® (MLN)

The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department of Health & Human Services (HHS).

Glossary

For glossary terms, visit the Centers for Medicare & Medicaid Services Glossary.

APPENDIX B: JOB AIDS

Job Aid A: Seven Core Compliance Program Requirements

The Centers for Medicare & Medicaid Services (CMS) requires that an effective compliance program must include seven core requirements:

  1. Written Policies, Procedures, and Standards of Conduct

    These articulate the Sponsor's commitment to comply with all applicable Federal and State standards and describe compliance expectations according to the Standards of Conduct.

  2. Compliance Officer, Compliance Committee, and High-Level Oversight

    The Sponsor must designate a compliance officer and a compliance committee to be accountable and responsible for the activities and status of the compliance program, including issues identified, investigated, and resolved by the compliance program.

    The Sponsor's senior management and governing body must be engaged and exercise reasonable oversight of the Sponsor's compliance program.

  3. Effective Training and Education

    This covers the elements of the compliance plan as well as prevention, detection, and reporting of fraud, waste, and abuse (FWA). This training and education should be tailored to the different responsibilities and job functions of employees.

  4. Effective Lines of Communication

    Effective lines of communication must be accessible to all, ensure confidentiality, and provide methods for anonymous and good- faith reporting of compliance issues at Sponsor and first-tier, downstream, or related entity (FDR) levels.

  5. Well-Publicized Disciplinary Standards

    Sponsor must enforce standards through well-publicized disciplinary guidelines.

  6. Effective System for Routine Monitoring, Auditing, and Identifying Compliance Risks

    Conduct routine monitoring and auditing of Sponsor's and FDR's operations to evaluate compliance with CMS requirements as well as the overall effectiveness of the compliance program.

    NOTE: Sponsors must ensure FDRs performing delegated administrative or health care service functions concerning the Sponsor's Medicare Parts C and D program comply with Medicare Program requirements.

  7. Procedures and System for Prompt Response to Compliance Issues

    The Sponsor must use effective measures to respond promptly to non-compliance and undertake appropriate corrective action.

Job Aid B: Resources

To review the training material below, place your mouse over the training material to enable the scrolling feature (if you are on a mobile device, touch the training material to enable the scrolling feature).

Guia Basica a Proveedores al Brindar Servicios de Salud a Beneficiarios LGBTT+

(This is a text version of the presentation. Click Here for the print version)

Certificación de cumplimiento ASES 19-0305

Descarga Certificacion

Guia Basica a Proveedores al Brindar Servicios de Salud a Beneficiarios LGBTT+

La Administración de Seguros de Salud del Gobierno de Puerto Rico (en adelante la ASES) fue creada en virtud de la Ley Numero 72 de 7 de septiembre de 1993, según enmendada (en adelante Ley 72), como "una corporación pública con plena capacidad para desarrollar las funciones que la ley le encomienda. Particularmente, se le delega "la responsabilidad de implantar, administrar y negociar, mediante contratos con aseguradores, y/u organizaciones de servicios de salud, [...] un sistema de seguros de salud que eventualmente le brinde a todos las residentes de la Isla acceso a cuidados medico hospitalarios de calidad, independientemente de la condición económica y capacidad de pago de quien las requiera."

Los poderes, deberes y funciones por las cuales queda investida la ASES en virtud de la Ley 72 incluyen, entre otros: implantar planes de servicios médico-hospitalarios basados en seguros de salud; negociar y contratar con aseguradores públicos y privados, y organizaciones de servicios de salud, cubiertas de seguros médico-hospitalarios, según se definen en la Ley 72; establecer en las contratos que suscriba con las aseguradoras o con los proveedores participantes, y organizaciones de servicios de salud asuntos tales coma la garantía del pago y la atención médico-hospitalaria que reciban sus beneficiarios, aunque la misma se preste fuera del área de salud donde las beneficiarios residan, par razón de emergencia o necesidad imperiosa y las mecanismos de evaluación y de cualquier otra naturaleza que garanticen todos las aspectos que afecten, directa o indirectamente, la accesibilidad, calidad, control de costos y de utilización de los servicios, así coma la protección de los derechos de los beneficiarios y proveedores participantes.

Además, el Plan de Reorganización Núm. 3 de 29 de julio de 2010 facultada y autoriza a la ASES para administrar, negociar, contratar y gestionar los beneficios de salud para los retirados y empleados públicos conforme a la Ley de Beneficios de Salud para Empleados Públicos (Ley Núm. 95 del 29 de junio de 1963, según enmendada; en adelante Ley 95) y su Reglamento.

El Boletín Administrativo Orden Ejecutiva-2017-037 (en adelante OE), emitido por el Gobernador de Puerto Rico, Honorable Ricardo Rosselló Nevares, reitera como política pública del Gobierno de Puerto Rico la prohibición al discrimen en todas sus manifestaciones, incluyendo el discrimen por identidad de género, expresión de genera u orientación sexual real o percibida. Por lo tanto, y siendo la ASES el organismo gubernamental designado por ley para negociar y contratar las cubiertas de servicios de salud del Plan de Salud del Gobierno Vital, Medicare Platino y el plan de Salud de los Empleados Públicos del Gobierno de Puerto Rico, así como la fiscalización en todos sus componentes para garantizar de servicios de salud de calidad, ASES reafirma la política pública establecida por el Gobierno.

Como parte de los esfuerzos anti-discrimen y en aras de que toda persona reciba servicios de salud de manera digna y sensible, la ASES emite esta Guía básica a proveedores para manejo sensible y adecuado al brindar servicios de salud a beneficiarios LGBTT+, como pautas mínimas a considerar y seguir al momento de proveer servicios de salud a nuestros beneficiarios de la población lésbica, gay, bisexual, transgénero, transexual (LGBTT+).

La orientación sexual, expresión de genera e identidad de género son conceptos muy distintos, pero en muchas ocasiones usados como sinónimos. El ser humano es la combinación de estos elementos: sexo biológico, identidad y expresión de género, y orientación sexual. Se trata de características independientes, que juntas, nos define. Reconocer la diferencia entre ellas y entender sus posibles combinaciones, es extremamente importante para poder construir una sociedad más tolerante y comprensiva, en la que todas las personas puedan desarrollarse y expresarse plenamente, redundando en una sana convivencia.

Uno de los obstáculos que las personas parte de la población LGBTT+ pueden enfrentar es que los servicios de salud que reciben pudieran estar marcados por discrimen, señalamientos o expresiones innecesarias hacia su persona, mancillando su integridad.

El propósito de este documento es que sirva como educación y protocolo de trabajo básico de provisión de servicios de salud sensibles y adecuados, dirigido a todos los proveedores de servicios de salud contratados por alguna aseguradora asociada a ASES, al momento de proporcionar sus servicios a nuestros beneficiarios que a su vez son parte de la población LGBTT+. Si su práctica o institución cuenta con un protocolo de trabajo a los efectos que se pretende satisfacer con este documento, no está en la obligación de usar el mismo. El recibo de este documento y educación sobre esta guía o el protocolo existente debe constar en el expediente de las personas que laboran en alguna oficina o entidad que se dedica a proveer de salud a beneficiarios de las líneas de salud contratadas por ASES. Aunque este documento detalla un protocolo de trabajo con guías mínimas, siéntase en la libertad de ampliarlo si las necesidades de la practica especifica así lo requieren, pero sin disminuir los parámetros aquí establecidos.

Asexual: Orientación sexual de una persona que no siente atracción erótica hacia otras personas. Puede relacionarse afectiva y románticamente. No implica necesariamente no tener libido, o no practicar sexo, o no poder sentir excitación.

Bifobia: Rechazo, discriminación, invisibilizacion, burlas y otras formas de violencia basadas en prejuicios y estigmas hacia las personas bisexuales o que parecen serlo. Puede derivar en otras formas de violencia como los crímenes de odio por bifobia, aun cuando cabe aclarar que ese hecho delictivo todavía no se encuentra legalmente tipificado. Supone, además, que todas las personas deben limitar su atracción afectiva y sexual a las mujeres o a los hombres exclusivamente, esto es, a uno solo de los géneros, y si no lo hacen así se les considera "en transición", como inestables o indecisas.

Binarismo de género: Concepción, prácticas y sistema de organización social que parte de la idea de que solamente existen dos géneros en las sociedades, femenino y masculino, asignados a las personas al nacer, como hombres (biológicamente: machos de la especie humana) y como mujeres (biológicamente: hembras de la especie humana), y sobre los cuales se ha sustentado la discriminación, exclusión y violencia en contra de cualquier identidad, expresión y experiencia de genero diversas.

Bisexualidad: Capacidad de una persona de sentir una atracción erótica afectiva por personas de un género diferente al suyo y de su mismo género, así como la capacidad de mantener relaciones íntimas y sexuales con ellas. Esto no implica que sea con la misma intensidad, al mismo tiempo, de la misma forma, ni que sienta atracción por todas las personas de su mismo género o del otro.

Características sexuales: Se refiere a las características físicas o biológicas, cromosómicas, gonadales, hormonales y anatómicas de una persona, que incluyen características innatas, tales como los órganos sexuales y genitales, y/o estructuras cromosómicas y hormonales, así como características secundarias, tales como la masa muscular, la distribución del pelo, los pechos o mamas.

Discriminación: Toda distinción, exclusión, restricción o preferencia que, por acción u omisión, con intención o sin ella, no sea objetiva, racional ni proporcional, y tenga por objeto o resultado obstaculizar, restringir, impedir, menoscabar o anular el reconocimiento, goce o ejercicio de los derechos humanos y libertades, cuando se base en uno o más de los siguientes motivos: el origen étnico o nacional, el color de piel, la cultura, el sexo, el género, la edad, las discapacidades, la condición social, económica, de salud o jurídica, la religión, la apariencia física, las características genéticas, la situación migratoria, el embarazo, la lengua, las opiniones, la orientación sexual, la identidad de género, la expresión de género, las características sexuales, la identidad o filiación política, el estado civil, la situación familiar, las responsabilidades familiares, el idioma, los antecedentes penales o cualquier otro motivo.

Diversidad sexual y de género: Hace referencia a todas las posibilidades que tienen las personas de asumir, expresar y vivir su sexualidad, así como de asumir expresiones, preferencias u orientaciones e identidades sexuales. Parte del reconocimiento de que todos los cuerpos, todas las sensaciones y todos los deseos tienen derecho a existir y manifestarse, sin más límites que el respeto a los derechos de las otras personas.

Equidad de género: se refiere a la imparcialidad y la justicia en la distribución de beneficios y responsabilidades entre hombres mujeres. El concepto reconoce que el hombre y la mujer tienen distintas necesidades y gozan de distinto poder, y que esas diferencias deben determinarse y abordarse con miras a corregir el desequilibrio entre los sexos.

Estereotipo: Son las preconcepciones, generalmente negativas y con frecuencia formuladas inconscientemente, acerca de los atributos, características o roles asignados a las personas, por el simple hecho de pertenecer a un grupo en particular, sin considerar sus habilidades, necesidades, deseos y circunstancias individuales.

Estigma: Es la desvalorización o desacreditación de las personas de ciertos grupos de población, atendiendo a un atributo, cualidad o identidad de las mismas, que se considera inferior, anormal o diferente, en un determinado contexto social y cultural, toda vez que no se ajusta a lo socialmente establecido.

Expresión de género: Es la manifestación del género de la persona. Puede incluir la forma de hablar, manierismos, modo de vestir, comportamiento personal, comportamiento o interacción social, modificaciones corporales, entre otros aspectos. Constituye las expresiones del género que vive cada persona, ya sea impuesto, aceptado o asumido.

Gay: Hombre que se siente atraído erótico afectivamente hacia otro hombre. Es una expresión alternativa a "homosexual" (de origen medico). Algunos hombres y mujeres, homosexuales o lesbianas, prefieren el termino gay, por su contenido político y uso popular.

Género: Se refiere a los atributos que social, histórica, cultural, económica, política y geográficamente, entre otros, han sido asignados a los hombres ya las mujeres. Se utiliza para referirse a las características que, social y culturalmente, han sido identificadas como "masculinas" y "femeninas", las cuales abarcan desde las funciones que históricamente se le han asignado a uno u otro sexo (proveer vs. cuidar), las actitudes que por lo general se les imputan (racionalidad, fortaleza, asertividad vs. emotividad, solidaridad, paciencia), hasta las formas de vestir, camina, hablar, pensar, sentir y relacionarse.

Heteronormatividad: Expectativa, creencia o estereotipo de que todas las personas son, o deben ser, heterosexuales, o de que esta condición es la única natural, normal o aceptable; esto es, que solamente la atracción erótica afectiva heterosexual y las personas heterosexuales, o que sean percibidas como tales, viven una sexualidad valida éticamente, o legitima, social y culturalmente.

Heterosexual: Capacidad de una persona de sentir atracción erótica afectiva por personas de un genera diferente al suyo, así como la capacidad de mantener relaciones íntimas y sexuales con ellas.

Homofobia: Rechazo, discriminación, invisibilización, burlas y otras formas de violencia basadas en prejuicios, estereotipos y estigmas hacia la homosexualidad o hacia las personas con orientación o preferencia homosexual, o que son percibidas como tales. Puede derivar en otras formas de violencia como la privación de la vida y el delito de homicidio, que puede ser tipificado como crimen de odio por homofobia. Su uso se ha extendido al rechazo hacia las orientaciones sexuales e identidades de genera no hegemónicas en general; sin embargo, esto ha contribuido a invisibilizar las distintas formas de violencia que viven lesbianas, personas trans, bisexuales e intersexuales.

Homosexualidad: Capacidad de cada persona de sentir una atracción erótica afectiva por personas de su mismo genera, así como la capacidad de mantener relaciones íntimas y sexuales con estas personas. El Comité para la Eliminación de Todas las Formas de Discriminación contra la Mujer (Comité CEDAW) observa una tendencia a reivindicar el uso y referencia a los términos lesbiana y lesbiandad, para hacer referencia a la homosexualidad femenina.

Identidad de género: Vivencia interna e individual del genera, tal coma cada persona la siente, misma que puede corresponder o no con el sexo asignado al nacer. Incluye la vivencia personal del cuerpo, que podría o no involucrar la modificación de la apariencia o funcionalidad corporal a través de tratamientos farmacológicos, quirúrgicos o de otra índole, siempre que la misma sea libremente escogida. También incluye otras expresiones de genera coma la vestimenta, el modo de hablar y los modales. Es un constructo social.

lgualdad de género: Es la ausencia de discriminación basada en las identidades de la persona en materia de oportunidades, asignación de recursos y beneficios o acceso a los servicios. Política Pública se fundamenta en la Ley.

Lesbiana: Mujer que se siente atraída erótica y afectivamente por mujeres. Es una expresión alternativa a "homosexual", que puede ser utilizada por las mujeres para enunciar o reivindicar su orientación sexual.

LGBTT+: Siglas para referirse a las personas lesbianas, gays, bisexuales, transgeneros, transexuales, queers, intersexuales y asexuales, entre otros. Aunque el termino no abarca todas las pequeñas comunidades de diversas sexualidades, igual están representadas y aceptan a sus integrantes.

Orientación sexual: Capacidad de cada persona de sentir una atracción erótica afectiva por personas de un genera diferente al suyo, o de su mismo genera, o de más de un genera o de una identidad de genera, así coma la capacidad de mantener relaciones íntimas y sexuales con estas personas.

Pansexual: Capacidad de una persona de sentir atracción erótica afectiva hacia otra persona, con independencia del sexo, genera, identidad de genera, orientación sexual o roles sexuales, así como la capacidad de mantener relaciones íntimas y/o sexuales con ella.

Prejuicios: Percepciones generalmente negativas, o predisposición irracional a adoptar un comportamiento negativo, hacia una persona en particular o un grupo poblacional, basadas en la ignorancia y generalizaciones erróneas acerca de tales personas o grupos, que se plasman en estereotipos.

Queers: Las personas queer, o quienes no se identifican con el binarismo de genera, son aquellas que además de no identificarse y rechazar el genera socialmente asignado a su sexo de nacimiento, tampoco se identifican con el otra genera o con alguno en particular. Dichas personas pueden manifestar, masque identidades fijas, expresiones y experiencias que: 1) se mueven entre un genera y otra alternativamente; 2) se producen por la articulación de los dos generas socialmente hegemónicos; 3) formulan nuevas alternativas. de identidades, por lo que no habría, en sentido estricto, una transición que partiera de un sitio y buscara llegar al polo opuesto, como en el caso de las personas transexuales. Las personas queer usualmente no aceptan que se les denomine con las palabras existentes que hacen alusión a hombres y mujeres, por ejemplo, en casos como "todos" o "todas", "nosotros" o "nosotras", o profesiones u oficios (doctoras o doctores), entre otras situaciones; sino que demandan en el caso del idioma español que en dichas palabras, la última vocal (que hace referencia al genera) se sustituya por las letras "e" o "x", por ejemplo, "todes" o "todxs", "nosotrxs", "doctorxs", etc.

Salud sexual: Estado de bienestar físico, mental y social en relación con la sexualidad. Requiere un enfoque positivo y respetuoso de la sexualidad y de las relaciones sexuales, así como la posibilidad de tener experiencias sexuales placenteras y seguras, libres de toda coacción, discriminación y violencia. Para que la salud sexual se logre, es necesario que los derechos sexuales de las personas se reconozcan y se garanticen. Requiere de un enfoque positivo y respetuoso de las distintas formas de expresión de la sexualidad y las relaciones sexuales, así como de la posibilidad de ejercer y disfrutar experiencias sexuales placenteras, seguras, dignas, libres de coerción, de discriminación y de violencia.

Sexo: Referencia a los cuerpos sexuados de las personas; esto es, a las características biológicas (genéticas, hormonales, anatómicas y fisiológicas) a partir de las cuales las personas son clasificadas como machos o hembras de la especie humana al nacer, a quienes se nombra como hombres o mujeres, respectivamente.

Transexuales: Las personas transexuales se sienten y se conciben a sí mismas como pertenecientes al género y al sexo opuestos a los que social y culturalmente se les asigna en función de su sexo de nacimiento, y que pueden optar por una intervención médica - hormonal, quirúrgica o ambas - para adecuar su apariencia física y corporalidad a su realidad psíquica, espiritual y social.

Transgeneros: Las personas transgéneros se sienten y se conciben a sí mismas como pertenecientes al género opuesto al que social y culturalmente se asigna a su sexo de nacimiento, y quienes, por lo general, solo optan por una reasignación hormonal - sin llegar a la intervención quirúrgica de los órganos pélvicos sexuales internos y externos para adecuar su apariencia física y corporalidad a su realidad psíquica, espiritual y social.

Travestis: Las personas travestis, en términos generales, son aquellas que presentan de manera transitoria o duradera una apariencia opuesta a la del género que socialmente se asigna a su sexo de nacimiento, mediante la utilización de prendas de vestir, actitudes y comportamientos.

Atributos del Buen Servicio

  1. Un buen servicio debe cumplir con ciertos atributos relacionados con la expectativa que la persona tiene sobre sí misma. Como mínimo, el servicio debe ser:
    1. Respetuoso: Los seres humanos esperan ser reconocidos y valorados sin que se desconozcan nuestras diferencias.
    2. Amable: Cortes pero también sincero.
    3. Confiable: Como está previsto en las normas y con resultados certeros.
    4. Empático: El proveedor de servicios de salud percibe lo que la persona siente y se pone en su lugar.
    5. Incluyente: De calidad para todas las personas sin distinciones, ni discriminaciones.
    6. Oportuno: En el momento adecuado, cumpliendo los términos acordados con la persona.
    7. Efectivo: Cumpliendo siempre con las leyes y normativas aplicables.

    El buen servicio va más allá de la simple respuesta a la solicitud de la persona: esto supone comprender sus necesidades, lo que a su vez exige escucharlo e interpretar bien sus necesidades.

  2. Las personas necesitan información y aprecian que esta les sea dada de manera oportuna, clara y completa. Respuestas como "No sé ...", o "Eso no me toca a mí ..." son vistas por la persona como un mal servicio. Los proveedores de servicios de salud y sus empleados, entonces, deben:
    • Informarse sobre los formatos, plantillas o guiones de atención definidos para el beneficiario y su situación particular.
    • Conocer los trámites inherentes y necesarios.
    • Seguir el procedimiento -el conducto regular- con aquellos temas que no pueda solucionar: ante alguna dificultad para responder por falta de información, información incompleta o errada, debe acudirse a su supervisor y/o aseguradora correspondiente.
    • Y siempre: Se debe atender a las personas como nos gustaría que nos atendieran a nosotros.

Actitud

Según la Real Academia Española de la Lengua, la actitud es la disposición de ánimo de una persona, expresada mediante diferentes formas como la postura corporal, el tono de voz o los gestos.

Los proveedores de servicios de salud deben mostrar una buena actitud de servicio, entendida como su disposición de escuchar al otro, ponerse en su lugar y entender sus necesidades y peticiones; no se trata tanto de pensar en la persona sino como la persona, ser conscientes de que cada persona tiene una visión y unas necesidades diferentes, que exigen un trato responsable. En este sentido, el proveedor de servicio y sus empleados deben:

  • Anticipar y entender las necesidades de la persona. Escucharlo y evitar interrumpirlo mientras habla.
  • Ir siempre un paso más allá de lo esperado en la atención. Comprometerse únicamente con lo que pueda cumplir.
  • Ser creativo para dar a la persona una experiencia de buen servicio.

La persona se llevara una buena impresión si el proveedor de servicios:

  • Entiende sus problemas.
  • Es respetuoso.
  • Lo orienta con claridad y precisión. Lo atiende con calidez y agilidad.

Por el contrario, se formara una impresión negativa cuando:

  • Lo trata de manera altiva, desinteresada o con falsa amabilidad.
  • Lo hace esperar innecesariamente o sin ofrecer una explicación por las demoras.
  • No tiene la información o el conocimiento necesario para atender su solicitud.

Lenguaje

Por medio del lenguaje los seres humanos expresan sus necesidades y experiencias. Estas son algunas recomendaciones para una comunicación efectiva:

  • El lenguaje para hablar con las personas debe ser respetuoso, claro y sencillo; frases amables como: "con mucho gusto, en que le puedo ayudar?" siempre son bien recibidas.
  • Evitar el uso de siglas, abreviaturas, extranjerismos, regionalismos o tecnicismos que puedan resultar incomprensibles. Si es imprescindible usarlos, hay que explicar su significado.
  • Evitar respuestas a la persona o utilizar términos confianzudos como " mi amor", "corazón", etc.
  • Para dirigirse a la persona encabezar la frase con "usted".
  • Evitar respuestas cortantes del tipo "Si", "No", ya que se pueden interpretar como frías y de afán. Dejar· hablar a la persona. El mejor interlocutor no es el que habla mucho, sino el que sabe escuchar.
  • Reconocer la identidad de la persona: "Como quiere que se llame?"

En la comunicación escrita se debe tener en cuenta:

  • La mejor estrategia para responder claramente a una persona es ponerse en su lugar. La persona no necesita un tratado filosófico, ni un inventario de normas, sino una respuesta clara, precisa y corta (4 o 5 párrafos es el ideal). Por lo tanto, en el primer párrafo se debe responder claramente la pregunta, y a continuación citar las normas que la sustenten, si es necesario.
  • Se debe escribir para comunicar, no para "impactar". El uso de palabras sencillas en una comunicación no reduce la calidad del escrito; por el contrario, se gana credibilidad y confianza en el lector.
  • No se deben utilizar siglas, abreviaturas, extranjerismos, regionalismos ni tecnicismos que puedan resultar incomprensibles. Si es imprescindible usarlos, hay que explicar su significado.
  • Lo ideal es poner en práctica aquella regla elemental del orden en la redacción: sujeto, verbo y complemento.
  • No se debe escribir todo en mayúsculas, pues complica la lectura y es agresivo para quien lee el texto. Lo ideal es combinar minúsculas y mayúsculas, en los casos que se requiera.
  • Es importante que el lector identifique la parte clave de la respuesta o las ideas más importantes. Por lo tanto, se aconseja resaltar estas ideas, subrayarlas o utilizar un tipo de letra distinto al resto del texto. Un escrito piano es monótono y dificulta la comprensión.
  • Revisar ortografía, puntuación y redacción. Esto también afecta la imagen no solo de quien escribe sino de la entidad que representa.

Atención a la persona

En muchas ocasiones al solicitar servicios de salud llegan personas inconformes, confundidas, ofuscadas o furiosas, a veces por desinformación. En estos casos, se recomienda:

  • Mantener una actitud amigable y mirar al interlocutor a los ojos; no mostrar agresividad verbalmente, ni con los gestos, ni con la postura corporal.
  • Dejar que la persona se desahogue, escucharle atentamente, no interrumpirle ni entablar una discusión con ella.
  • Evitar calificar su estado de ánimo.
  • No tomar la situación como algo personal: las personas se quejan de un servicio, no de quien la atiende.
  • No perder el control; si el proveedor de servicios de salud conserva la calma es probable que la persona también se calme.
  • Cuidar el tono de la voz: muchas veces no cuenta tanto que se dice, sino como se dice.
  • Usar frases como "lo comprendo", "que pena", "claro que sí". Estas demuestran que el proveedor de servicios es consciente del malestar de la persona.
  • Dar alternativas de solución, si es que las hay y comprometerse solo con lo que se pueda cumplir.
  • Si el mismo problema ocurre con otra persona, informar al supervisor o supervisora para dar una solución de fondo.

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Cultural Competency Training for Providers

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Purpose of Training

  • Cultural competency training programs are developed to increase cultural awareness, knowledge, and skills, leading to changes in staff behavior and member-staff interactions.
  • Training provides a way to redirect problems stemming from the cultural mismatches that result whenever members and staff do not share a common subculture and mutual understanding of each other’s health beliefs.

Provider Network

  • An Annual Population Assessment reviews Quality Improvement Referrals, Provider Satisfaction results, and Translator service request to identify any opportunities related to providing a sufficient provider network to support the linguistic, race, ethnicity, and gender needs of the patient/ beneficiary population.
  • The Organization does not discriminate against employees, patients / beneficiaries, or providers, based on age, race, sex, religion, sexual preference/orientation, or any protected status.

Culture

  • An integrated pattern of learned beliefs and behaviors that can be shared among groups.
  • It includes thoughts, style of communication, language, ways of interacting, views on roles and relationships, values, practices, and customs13

Cultural Competence in Health Care

The ability of systems to provide care to members with diverse values, beliefs, and behaviors, including tailoring delivery to meet the members social, cultural, and linguistic needs.13

Health Literacy

Health literacy is the degree to which individuals have the capacity to obtain, process and understand basic health information needed to make appropriate health decisions.

Members health literacy may be affected if they have:

  • Health care providers who use words that members don’t understand
  • Low educational skills
  • Cultural barriers to health care
  • Limited English Proficiency (LEP)17

National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care

  • In 2000, the U.S. Department of Health and Human Services, Office of Minority Health first published the National Standards for Culturally and Linguistically Appropriate Services in Health Care6
  • Principal Standard: Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs16
  • A significant number of states including Florida are actively implementing the National CLAS Standards by integrating the National CLAS Standards into their strategic plans6

Beliefs

How does culture impact the outcome of treatment?

  • How is the illness perceived
  • Community environment
  • Behavior / habits
  • A Members attitude about Providers & Health care can have an impact on compliance with treatment

Communication

Communication is vital for the patient to receive adequate care

  • Limited English Proficiency (LEP) - describes someone who has limited or inability to speak, read, write, or understand the English language

Communication (continued)

Patients with LEP may not understand health information concerning their care

  • A translation service will be used for patients unable to speak English, if the enrollee’s spoken language is outside of organizations in-house capabilities, which include: Spanish, Creole, and French.
  • The UM staff will notify providers and patients of the availability of oral interpretation services and inform them how to access oral interpretation services, regardless of whether an Enrollee speaks a language that meets the threshold of a prevalent non-English language. There will be no charge to the member for translation services
  • TTY/TDD services are available

Positive Communication

Patient: If they tell you they forgot their glasses, because they are ashamed they can’t read well.

Response from provider: Give clear instructions in different ways. Use “teach back” method.

Patient: I am more comfortable with a female doctor

Response from provider: Office staff should confirm preferences during appointment scheduling20

Emotional Intelligence

  • Emotional intelligence (EQ) is the ability to identify, use, understand, and manage your own emotions in positive ways to relieve stress, communicate effectively, empathize with others, overcome challenges and defuse conflict.18
  • By understanding your emotions and how to control them, you’re better able to express how you feel and understand how others are feeling.
  • This allows you to communicate more effectively and forge stronger relationships, with patients.18

Emotional Intelligence at work

You are a manager in an organization or practice owner that is trying to encourage respect for racial and ethnic diversity. You overhear someone telling a racist joke. What do you do?

Speak up on the spot, saying that such jokes are inappropriate and will not be tolerated in your organization.

The most effective way to create an atmosphere that welcomes diversity is to make clear in public that the social norms of your organization do not tolerate such expressions. Confronting the behavior privately lets the individual know the behavior is unacceptable, but does not communicate it to the team. Instead of trying to change prejudices (a much harder task), keep people from acting on them.

Tools

Teach back method is a way of confirming the patient understands by asking the patient to state in their own words what they need to know or do about their health, which:

  • Improves patient understanding and adherence
  • Decrease call backs & cancelled appointments
  • Improve outcomes and satisfaction
  • Use clear plain language when talking to patients19

Subcultures

  • A subculture is an ethnic, regional, economic, or social group
  • Cross-cultural health care teaches people in the health care industry how to relate to people of different sections of society

Cultural differences, it is important to understand and respect the values, beliefs, and customs, norms, and traditions of different people

  • Consider the person’s cultural views concerning
  • Eye contact
  • Personal space
  • Respect for authority

Seniors & People with Disabilities

Ask a person with a disability first before providing assistance like holding their arm to help them out of a chair. When dealing with seniors, consider the possible challenges and impairments:

  • Hearing
  • Visual
  • Cognitive
  • Physical
  • Taking multiple medications
  • Dependent on care givers

Possible Barriers to Cultural Competency

  • Lack of diversity in leadership
  • System not designed to meet the needs of a diverse population
  • Poor communication between providers and patients of different cultural backgrounds

Benefits of Cultural Competency

Healthcare experts identified a connection between cultural competence and quality improvement, and the elimination of racial and ethnic disparities.

LGBTT+ Cultural Competence training

Handling with sensibility the LGBTT population when requesting health care related services.

Objectives

  • To know the regulatory and legal basis that supports anti-discrimination efforts based on sexual orientation and gender identity
  • To distinguish among sexual orientation and gender identity
  • To know a basic guideline which provides tools to handle with sensibility the LBGTT+ population when requesting health care services.

Laws and Regulations

Section 1557 is the nondiscrimination provision of the Affordable Care Act (ACA). The law prohibits discrimination on the basis of race, color, national origin, sex, age, or disability in certain health programs or activities. This Section prohibits health insurers to design a health coverage which includes benefits that can be discriminatory for transgender persons. The OCR (Office of Civil Rights)has been enforcing this provision since it was enacted.

Laws and Regulations

Section 1557 is the nondiscrimination provision of the Affordable Care Act (ACA). The law prohibits discrimination on the basis of race, color, national origin, sex, age, or disability in certain health programs or activities. This Section prohibits health insurers to design a health coverage which includes benefits that can be discriminatory for transgender persons. The OCR (Office of Civil Rights)has been enforcing this provision since it was enacted.

Puerto Rico Plans

The Governor of Puerto Rico issued an Administrative Bulletin "Orden Ejecutiva 2017-037", indicating that Puerto Rico’s public policy prohibit any kind of discrimination including gender identity, gender expression or individual’s real or perceived sexual orientation.

Amended Normative Letter 19-0305

ASES reaffirms the public policy established by the Puerto Rico Government to ensure strict compliance with the anti-discrimination efforts, when beneficiaries of the Lesbian, Gay, Bisexual, Transgender and Transsexual population seeks for health care services.

Sexual Orientation and Gender Identity are two different concepts

Sexual Orientation: tells you how a person characterizes their sexual and emotional attraction to others.

Gender Identity: is a person’s internal sense of being a man, woman, both, neither, or another gender. Most people have a gender identity that is the same as the sex they were assigned at birth. However, some people have a gender identity that does not correspond to the sex they were assigned at birth. The term transgender is used to describe these individuals.

Common words to describe sexual orientation

  • Heterosexual: (straight) is a sexual orientation that describes women who are emotionally and sexually attracted to men, and men who are emotionally and sexually attracted to women.
  • Gay: Gay is a sexual orientation that describes a person who is emotionally and sexually attracted to people of their own gender. It is more commonly used to describe men.
  • Lesbian: Lesbian is a sexual orientation that describes a woman who is emotionally and sexually attracted to other women.
  • Bisexual: Bisexual is a sexual orientation that describes a person who is emotionally and sexually attracted to people of their own gender and people of other genders.

Gender Identity describes a wide range of people, including the following:

  • Transgender: A umbrella term describing the state of a person’s gender identity which does not necessarily match the gender they were assigned at birth. Transgender people may or may not decide to alter their bodies hormonally and/or surgically.
  • Transsexuals: They identify themselves with a gender which does not match the gender they were assigned at birth. Transsexual people decide to alter their bodies hormonally and surgically to match the gender they identify with.

Barriers when receiving health care services

  • There are different reasons why LGBTT+ people may have difficulty accessing health care services, among those are: Discrimination and/or unnecessary expressions toward them.
  • In some cases, health care services could be denied to them, which can cause serious and catastrophic consequences to their health.

Basic guidelines to handle with sensibility the LGBTT population when they request health care related services

Cultural Competence and Sensibility

  • Cultural Competence is about being respectful and receptive towards the beliefs, practices, and needs of the diverse groups of the population being able to interact effectively with the different groups that composed our society.
  • Diversity is what makes us unique. Which aspects are included on diversity?
  • Race, color, religion, age, socio-economic status, sexual orientation, gender, identity, nationality, disability among others.

Resource: Us Department of Health and Human Services

What can you do to render a service with sensibility?

  • Respect diversity. Make others feels safe in a comfortable and open environment.
  • Treat others with courtesy.
  • Be inclusive, give equal services to all people without distinctions or discriminatory attitudes.
  • Listen carefully to all client’s needs, when they call or visit the office.
  • Give the extra mile when attending the person.
  • Don’t promise what you can’t accomplish.
  • Be creative so you can be able to offer a good service, by making sure that you follow the established policies and procedures.
  • Do not make assumptions about people's gender identity or sexual orientation.
  • Be flexible and non judgmental
  • Familiarize with LGBTT+ concepts
  • Do not make unnecessary questions, ask yourself before asking any questions if the requested information is important to provide health care services.
  • Keep in mind that different gender identity or sexual orientation expressions exist.
  • Do not demonstrate surprise or disapproval to an affiliate’s sexual orientation or gender identity.

Cultural Competency's Mission

  • When we create an environment free of discrimination, everything around us becomes more sensible and inclusive by making people feel more comfortable when asking for health care related services without any fear of being judged or rejected by others.
  • Health System One, complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

Reporting

If a person believes that Health System One has failed to provide these services or discriminated in another way on the basis of race, color national origin, age, disability, or sex, you can file a grievance:

  1. Organization Compliance Hotline: 866-321-5550 (Toll-Free)
  2. File an anonymous report
  3. You can mail your report to: Marjorie Dorcely 2001 S. Andrews Avenue Fort Lauderdale, Florida 33316
  4. You can fax your report attention: Marjorie Dorcely (866)276-3667 (This is a dedicated Compliance line)
  5. You can email your report to: Compliance@healthsystemone.com

Any person can also file a civil rights complaint with the US Department of Health and Human Services, Office of Civil Rights electronically through the Office of Civil Rights Complaint Portal, available at:

  • https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
  • U.S. Department of Health and Human Services
    200 Independence Avenue SW
    Room 509F-HHH Building
    Washington, DC 20201,
  • 1-800-368-1019
  • 1-800-537-7697 (TDD).

References

  • Weinick, R.M., Zuvekas, S.H., Cohen, J.W. (2000). Racial and ethnic differences in access and use of health care services, 1977-1996. Medical Care Research and Review, 57 (supplement 1), 36-54.
  • United States Department of Health and Human Services, Agency for Healthcare Research and Quality. 2004 National Healthcare Disparities Report. Available online at http://qualitytools.ahrq.gov/disparitiesreport/documents/nhdr2004.pdf.
  • Brach, C. & Fraserirector, I. (2000).Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Medical Care Research and Review, 57 (supplement 1), 181-217.
  • Assuring Cultural Competence in Health Care: Recommendations for National Standards and an Outcomes-Focused Research Agenda. (1999). Part I: Recommendations for National Standards: Office of Minority Health.
  • Ross, H. (2001). Office of Minority Health publishes final standards for cultural and linguisticcompetence: Office of Minority Health.
  • National Standards for Culturally and Linguistically Appropriate Services in Health Care. (2001, March). Retrieved May 15, 2005, from ttp:// www.omhrc.gov/omh/programs/ 2pgprograms/finalreport.pdf
  • Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989). Towards a culturally competent system of care (Vol. 1). Washington, D.C.: Georgetown University Child Development Center, CASSP Technical Assistance Center.
  • Saha, S., Taggart, S. H., Komarony, M., & Bindman, A. B. (2000). Do patients choose physicians
  • of their own race? Health Affairs, 19(4), 76-83.
  • State of New Jersey 211th Legislature. Senate No. 144 and Senate Substitute for Assembly No 492. Adopted March 29 2004. http:// njleg. state.nj.us/2004/Bills/ S0500/144_R2.htm. Accessed 11/21/2005
  • Health Resources and Services Administration (HRSA), American Public Human Services Association (APHSA). Bridging Cultures and Enhancing: Approaches to Cultural and Linguistic Competency in Managed Care. May 30 2002:1-3 http://www.hrsa.gov/financeMC/ bridgingcultures/. Accessed 11/30/2005.
  • Gilbert MJ, ed. Principles and Recommended Standards for Cultural Competence Education of Health Care Professionals-2003. Available online at: http://www.calendow.org/reference/publications/cultural_competence.stm. Accessed 10/13/05.
  • Doutrich, Dawn and Marni Storey. “Education and Practice: Dynamic Partners for Improving Cultural Competence in Public Health.” Family Community Health, Vol. 27, No. 4, 2004, pp. 298-307.
  • Joseph R. Betancourt, A. R. (2002). Cultural Competence In Health Care: Emerging Frameworks And Practical Approaches. Field Report, 1-24.
  • http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/healthlittoolkit2-tool5.html
  • http://www.floridahealth.gov/about-the-department-of-health/_documents/state-health-improvement-plan.pdf
  • https://www.thinkculturalhealth.hhs.gov/pdfs/enhancednationalclasstandards.pdf
  • http://www.hrsa.gov/publichealth/healthliteracy/
  • http://www.helpguide.org/articles/emotional-health/emotional-intelligence-eq.htm
  • http://www.teachbacktraining.com/
  • http://www.iceforhealth.org/library/documents/ICE_C_L_Cultural_Competency_Provider_Training_Final(1).pdf
  • https://www.psychologytoday.com/basics/emotional-intelligence
  • http://www.talentsmart.com/about/emotional-intelligence.php
  • Gulliford, R. (2003). CDHS Research Foundation of SUNY BSC. Retrieved July 2016, from Emotional Intelligence: How Your Emotions Influence Your Life at Work and at Home: www.bsc-cdhs.org
  • http://healthvermont.gov/family/toolkit/tools%5CF-6%20Cultural%20Differences%20in%20Nonverbal%20Communic.pdf
  • https://www.mindtools.com/pages/article/cross-cultural-mistakes.htm
  • Triple-S, Inc. LGBTT+ Cultural Competence training

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Health, Safety, Wellness, Financial Exploitation, Abuse, Neglect, and Human Trafficking Training

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What is Financial Exploitation?

The fraudulent or otherwise illegal, unauthorized, or improper act , that uses the resources of an elder for monetary or personal benefit, profit, or gain, or that results in depriving an elder the rightful access to, or use of, benefits, resources, belongings, or assets.

https://elder.findlaw.com/elder-abuse/elder-financial-abuse-and-exploitation.html

What is abuse

  • Non-accidental infliction of physical and/or emotional harm.
  • Sexual abuse upon a disabled adult or an elderly person by a relative, caregiver, household member or any other person.
  • Active encouragement of any person by a relative, caregiver or household member to commit an act that inflicts or could reasonably be expected to result in physical or psychological/emotional injury to a disabled adult or an elderly person.

Physical abuse

Physical abuse Infliction of physical pain or injury to an older person.

Physical abuse of patient Non-accidental use of force that results in bodily injury, pain or impairment, including, but not limited to, being slapped, burned, cut, bruised or improperly physically restrained.

Signs and Symptoms of Physical Abuse

  • Sprains, dislocations, fractures or broken bones.
  • Bruises, welts or discolorations
  • Burns from cigarettes, appliances or hot water.
  • Abrasions on arms, legs or torso that resemble rope or strap marks.
  • Cuts, lacerations or puncture wounds.
  • Fractures of long bones and ribs.
  • Internal injuries evidenced by pain, difficulty with normal functioning of organs and bleeding from body orifices.
  • A history of similar injuries and/or numerous or suspicious hospitalizations.
  • Injuries healing through secondary intention indicating that the member did not receive appropriate treatment
  • A history of member being brought to different medical facilities for treatment to prevent medical practitioners from observing patterns.
  • Delays between the onset of injury and seeking of medical care.
  • Signs of confinement (e.g., member is locked in his or her room).

Sexual Abuse

  • Includes unwanted touching, fondling, sexual threats, sexually inappropriate remarks or other sexual activity with an adult with disabilities.
  • Touching, fondling, sexual threats, sexually inappropriate remarks or other sexual activity with an older person when the older person is unable to understand, unwilling to consent, threatened or physically forced to engage in sexual activity.

Signs and Symptoms of Sexual Abuse

  • Bruises on external genitalia, inner thighs, abdomen or pelvis.
  • Difficulty walking or sitting not explained by other physical conditions.
  • Stained or bloody underclothing.
  • Sexually transmitted diseases.
  • Urinary tract infections.
  • Inappropriate sex role relationships between victims and suspects.
  • Inappropriate, unusual or aggressive sexual behavior.
  • Signs of psychological trauma, including excessive sleep, depression or fearfulness.

verbal or Emotional Abuse

Verbal abuse Includes, but is not limited to, name calling, intimidation, yelling and swearing. May also include ridicule, coercion and threats.

Emotional abuse Verbal assaults, threats of maltreatment, harassment or intimidation intended to coerce the older person to engage in conduct that he or she wishes and has a right to abstain from, or to refrain from conduct the older person wants to do and has a right to do.

Psychological Abuse

  • Berating, ignoring, ridiculing or cursing.
  • Threats of punishment or deprivation.
  • Significant weight loss or gain that cannot be attributed to other causes.
  • Stress-related conditions including elevated blood pressure.

Isolation by perpetrator:

  • Berating, ignoring, ridiculing or cursing.
  • Threats of punishment or deprivation.
  • Significant weight loss or gain that cannot be attributed to other causes.
  • Stress-related conditions including elevated blood pressure.

Neglect

Neglect: Repeated conduct or a single incident of carelessness that results or could reasonably be expected to result in serious physical or psychological/emotional injury or substantial risk of death.

Neglect of customer: The failure of another individual to provide an adult with disabilities with, or the willful withholding from an adult with disabilities of the necessities of life including, but not limited to, food, clothing, shelter or medical care.

Self-neglect: Individual neglects to attend to his/her own basic needs, such as personal hygiene, appropriate clothing, feeding or tending appropriately to medical conditions.

Passive neglect: A caregiver’s failure to provide an eligible adult with the necessities of life including, but not limited to, food, clothing, shelter or medical care. This definition does not create a new affirmative duty to provide support to eligible adults; nor shall it be construed to mean that an eligible adult is a victim of neglect because of health care services provided or not provided by licensed health care professionals.

Signs and symptoms of neglect

  • Weight loss that cannot be explained by other causes.
  • Lack of toileting that causes incontinence.
  • Member sits in own urine and feces.
  • Increased falls and agitation.
  • Indignity and skin breakdown.
  • Uncommon pressure ulcers.
  • Evidence of inadequate or inappropriate use of medication.
  • Personal hygiene is neglected; emotionally withdrawn.
  • Lack of assistance with eating, drinking, walking, bathing and participating in activities.
  • Little or no response to requests for personal assistance.

Exploitation

Exploitation is the act of a person who stands in a position of trust and confidence with a disabled adult or an elderly person and knowingly by deception, intimidation or force:

  • Obtains control over the person’s funds, assets or property.
  • Deprives the person of the use, benefit or possession of funds, assets or property. This intentional action can be temporary or permanent.
  • Uses the person’s funds, assets or property for the benefit of someone other than the disabled adult or elderly person.

Types of Exploitation

Exploitation of customer: The illegal use of assets or resources of an adult with disabilities. It includes, but is not limited to, misappropriation of assets or resources of the alleged victim by undue influence, by breach of fiduciary relationship, by fraud, deception, extortion or in a manner contrary to law.

Financial exploitation: The misuse or withholding of an older person’s resources by another person to the disadvantage of the older person or the profit or advantage of a person other than the older person.

Indicators of exploitation

  • Visitors ask the member to sign documents the member does not understand.
  • Unpaid bills,  Despite adequate financial resources, bills remain unpaid by the caregiver or other party.
  • Lack of affordable amenities for the member, such as personal grooming items or appropriate clothing.
  • New "best friends" who take an interest in the member’s finances.
  • Legal documents, such as powers of attorney, which the member did not understand at the time he/she signed them.
  • Unusual activity in the member’s bank accounts. Includes large, unexplained withdrawals, frequent transfers between accounts or other activity that the member cannot explain.
  • Caregiver expresses excessive interest in the amount of money being spent on the member.
  • Belongings or property are missing.
  • Suspicious signatures on checks or other documents. Includes signatures not matching the member’s. Includes signatures and other writing by a member who cannot write.
  • Absence of documentation about financial arrangements.
  • Implausible explanations about the member’s finances are given by the member or the caregiver.
  • Member is unaware of or does not understand financial arrangements that have been made for him/her.

Family and caregivers:

  • Do not provide an opportunity for the member to speak for himself/herself.
  • See others who could impact a member’s situation without the presence of the member.
  • Have an attitude of indifference or anger toward the member.
  • Blame the member for the member’s condition. For example, accusation that incontinence is a deliberate act.
  • Show aggressive behavior toward the member, Threaten, Insult, or Harass

Abandonment

Abandonment is defined as the desertion of a person by an individual who has assumed responsibility for providing care or has custody.

Signs and symptoms of abandonment

  • The desertion of a person in a hospital, nursing facility or other similar institution
  • The desertion of a person at a shopping center or other public location
  • Report of being abandoned

Increased risk factors or traits of Abuse

Likelihood of abuse, neglect or exploitation occurring increases for members in the presence of one or more risk factors. These include:

  • Dependency on others for personal care.
  • Dependency on others for financial management.
  • Isolation from information about own rights and health.
  • Diminished mental capacity.
  • Serious health problems.
  • Taking medications that affect cognitive status.
  • Depression, anxiety or fearfulness.
  • Recent losses, including the loss of a spouse, home or friend.

Increased risk factors or traits of Abuse

Problems and contributing factors exhibited by caregivers who are at risk to abuse, neglect or exploit include:

  • Alcoholism
  • Mental illness
  • Stress
  • Chronic fatigue
  • Frequent medical consultation
  • History of marital violence and/or child abuse
  • Previous relationship difficulties
  • Conflicting demands of other family members
  • Problems with housing, finances and/or employment
  • Lack of support; lack of respite
  • The presence of a single risk factor or caregiver contributing factor does not by itself indicate that abuse or neglect is occurring or is likely to occur. It may, however, indicate the need for measures to be taken to reduce the potential for abuse or neglect in the future.
  • Plan care managers, providers (including participant direct employees) and other staff having contact with members or caregivers should be trained to recognize the risk factors for abuse and neglect, including how and when to contact Adult Protective Services.

Human sex trafficking

Human sex trafficking: The recruitment, harboring, transportation, provision or obtaining of a person for a commercial sex act in which a commercial sex act is induced by force, fraud or coercion, or in which the person induced to perform such an act has not attained 18 years of age.

Physical signs of adult sex trafficking

  • Multiple or recurrent STIs
  • Abnormally high number of sexual partners
  • Trauma to vagina and/or rectum
  • Signs of physical trauma
  • Somatization symptoms (recurring headaches, abdominal pain, etc.)
  • Suspicious tattoos or branding

Behavioral Signs of adult sex trafficking

  • Depressed mood/flat affect
  • Anxiety/hypervigilance/panic attacks
  • Affect dysregulation/irritability
  • Frequent emergency care visits
  • Unexplained/conflicting stories
  • Using language from "the life"
  • Signs of drug or alcohol abuse

Labor trafficking

The recruitment, harboring, transportation, provision or obtaining of a person for labor or services through the use of force, fraud or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage or slavery.

Physical signs of Labor trafficking

  • Musculoskeletal and ergonomic injuries
  • Malnutrition/dehydration
  • Lack of routine screening and preventive care
  • Poor dental hygiene
  • Untreated skin infections/inflammations
  • Injuries or illness from exposure to harmful chemicals/unsafe water
  • Ophthalmology issues or vision complaints
  • Somatization

Behavioral Signs of Labor trafficking

  • Anxiety/panic attacks (for example, shortness of breath, chest pain)
  • Unexplained/conflicting stories
  • Overly vigilant or paranoid behavior
  • Inability/aversion to make decisions independent of employer
  • Inability/aversion to speak with out an interpreter
  • Affect dysregulation/irritability

Reporting Human trafficking

Mandated reporting warranted or the patient wishes to report

  • Report to designated contacts and/or contact the NHTRC Hotline 1-888-373-7888

Reporting not warranted and the patient does not wish to report

  • Provide referrals and contact the NHTRC Hotline (1-888-373-7888)

Prevention Steps

  • When a provider suspects there is a risk of abuse, neglect or exploitation, he/she should work with the Health Plan
  • The health plan determines if a member is at-risk for abuse or neglect, if the patient does not display signs or symptoms, the health plan will include in the plan-of-care specific interventions to reduce the member’s risk.

Prevention Steps (Cont.)

Interventions may be tailored to the member’s particular risk factor(s) and may include, one or more of the following:

  • Increased frequency of care coordination face-to-face visits to monitor for potential abuse, neglect or exploitation.
  • Education of the member on the types, risks factors, associated traits and symptoms of abuse, neglect and exploitation, as well as options for reporting abuse and neglect, including through the care manager or through support agencies, such as Adult Protective Services.
  • Alert the member’s providers, including home and community-based services providers, of the need for heightened vigilance and surveillance, and review of the procedures for notifying the care manager of suspected abuse or neglect.
  • Seek arrangements for respite for unpaid caregivers, to be provided for in the plan-of-care.
  • Increase informal social support for member through use of community activities or resources, e.g., senior centers, support group or worship attendance.
  • Refer member, family or caregiver to mental health/substance abuse treatment.
  • Refer member to social service agency if family resources are severely limited.

When identifying abuse situations, utilize these handle with care measures

Recognize risk factors of abuse, neglect and exploitation.

  • Potential risk
  • Signs and symptoms

Assess each situation

  • Presence of possible problems or factors that might contribute to tendencies.
  • Observation and inquiry (subject to privacy rights and level of cooperation).

Prevention

  • If risk is determined, include specific plan-of-care interventions to reduce risk.
  • Intervention
  • Reporting

Report of abuse, neglect or exploitation

Although the law requires all persons to report suspected abuse, neglect and/or exploitation, certain professionals have a specific responsibility to report. These include, but are not limited to:

  • Physicians, osteopaths, medical examiners, chiropractors, nurses or hospital personnel engaged in the admission, examination or care and treatment of elderly or disabled adults.
  • Health and mental health professionals not listed above.
  • Nursing home staff, adult-living facility staff, adult day-care-center staff, social worker, or other professional adult-care, residential or institutional staff.
  • State, county or municipal criminal justice employees or law enforcement officers.
  • Human Rights Advocacy Committee (HRAC) and Long-Term-Care Ombudsman Council (LTCOC) members.
  • Banks, savings and loan or credit union officers, trustees or employees.

Mandated Reporter

A mandated reporter is an individual who is required by law to

  • report situations immediately in which he/she suspects an adult may have been abused, neglected or exploited or is at risk of being abused, neglected or exploited.

Rights of mandated reporters

Most states allow for:

  • Immunity from civil and criminal liability unless the report was made in bad faith or with malicious intent.
  • Identity protection; your consent must be given to reveal your identify.
  • The court may order the identity of the reporter revealed. The court can then release confidential information without penalty.

General reporting requirements (states may differ)

  • Can you identify the person being abused? If known, provide address and/or location.
  • What is the approximate age of the adult?
  • Does an emergency exist?
  • Can you describe the circumstances of the alleged abuse, neglect or exploitation?
  • What are the names and relationships of other members of the adult household, if applicable?
  • Is the adult incapacitated?
  • Do you know the name and address of the caregiver if applicable?
  • Do you know the name and relationship of the alleged perpetrators?
  • Are there other people who may have knowledge of the adult?
  • Do you know the name of the adult’s physicians?
  • What is your name, address, phone number? (You can report anonymously.)

Important reporting processes

  • Provider must report any suspected abuse, neglect or exploitation to the appropriate state agency. Provider must also report suspected abuse, neglect or exploitation to the Health Plan.
  • The Health Plan will also report the suspected abuse, neglect or exploitation to the appropriate state agency.

Reporting Requirements Florida

  • Briefly consult on the appropriateness of a referral.
  • If the member is in immediate danger, dial 911 or local police.
  • Immediately contact the appropriate agency: Telephone: 1-800-96-ABUSE (1-800-962-2873), Press 2 to report suspected abuse, neglect or exploitation of the elderly or a vulnerable adult. Florida Abuse Hotline toll-free number is available 24/7.
  • TTY (Telephone Device for the Deaf): 1-800-453-5145
  • Fax a detailed written report with your name and contact telephone to:1-800-914-0004
  • Website: https://reportabuse.dcf.state.fl.us

Reporting

If you suspect Abuse, Neglect, Financial Exploitation, or Human Trafficking, please contact your manager.

References

  • Prevention and Detection of Financial Exploitation Special Investigations Unit- MCS Training Presentation
  • Humana Health, Safety and Welfare Education Training
  • Simply Abuse, neglect, exploitation and human trafficking provider training

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