January 27 - 30, 2019
2019 Managed Care Compliance Conference
Orlando, FL, United StatesSunday, January 27
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08:00 AM - 09:30 AMP01 - Compliance, Privacy, and Security Program Assessment Best Practices Bret Bissey, Vice President, Chief Compliance Officer, Gateway Health Kelly McLendon, Managing Partner, CompliancePro Solutions - Ideas for conducting a compliance program review to ultimately reduce overall organizational compliance risk - How to utilize the elements of the DHHS OIG Model Compliance Program(s) to develop a work plan to perform this assessment - The content of - and tips for performing - HIPAA privacy and security assessments in order to impress OCR and facilitate a high level of compliance which ultimately reduces organizational riskGeneral Compliance
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08:00 AM - 05:30 PMPre Conference Pre Conference100
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09:45 AM - 11:15 AMP02 - Lessons Learned on the Frontlines of Network Compliance Enforcement Deborah Schreiber, Functional Compliance Officer, UnitedHealthcare Niki Jo Kurtis, Pharmacy Compliance Officer, UnitedHealthcare - Regulatory requirements and expectations for provider and pharmacy networks - Lessons learned from current regulatory auditing, monitoring, and reporting requirements for provider networks - Why regulators consider network directory data accuracy issues to be a potential access issue and an important beneficiary/consumer protection focus area - and how to apply lessons learned topharmacy networksGeneral Compliance
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12:30 PM - 02:00 PMBreakout Sessions#P03P03 - Viewing Investigations from a Different Angle: Understanding the Varying Perspectives of Counsel, Compliance Officer, and Prosecutor to Improve Your Internal Investigation Process Heather Fields, Shareholder, Chair - Hospital/Health Systems Practice, Reinhart Boerner Van Deuren s.c. Lisa Estrada, Senior Vice President and Chief Compliance Officer, Fresenius Medical Care North America James Sheehan, Chief, Charities Bureau, NY Attorney General
- Yates/Sessions focus on individual liability in DOJ corporate investigations - how attorney ethical duties, compliance officer ethical guidelines, and Yates cooperation credit requirements impact interviews and investigation process and documentation
- Different planning approaches of compliance officer, legal counsel, and prosecutor/regulator to compliance reviews, investigations, and reporting - through case studies and interaction
- Practical strategies to address investigation challenges and optimize your organization’s ability to achieve the best possible outcome in government investigations or litigation
General Compliance#P04P04 - Compliance 101 Shawn DeGroot, President, Compliance Vitals Jenny O'Brien, Retired, Chief Compliance Officer- Factors to consider when developing and implementing a compliance program -The elements and keys to maintain an effective compliance programn
- Introduction of tools and techniques
General Compliance -
02:15 PM - 03:45 PMBreakout Sessions#P05P05 - Building an SIU That's Nimble, Effective, and Audit Ready! Marita Janiga, Vice President, Investigations, Kaiser Permanente Tamara Neiman, Executive Director, Nat'l Special Investigations Unit, Kaiser Permanente Mark Horowitz, Sr. Manager National Special Investigations Unit, Kaiser Permanente
- The key components of building and leading an effective SIU
- A "best practice" process for responding to CMS memos and issuances
- The steps to take in preparing for a CMS Compliance Program Effectiveness Audit
General Compliance#P06P06 - Build a Managed Care Compliance Audit and Remediation Plan Nicole Huff Deborah Johnson, Vice President, Compliance, IlliniCare Health PlanBest practices on how to review and audit risk adjustments
How to correlate compliance risk assessments and ongoing audit work
- Tracer summaries, including internal controls, remediation activity, documented outcomes, and remediation effectiveness for a compliance scenario
General Compliance - The key components of building and leading an effective SIU
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04:00 PM - 05:30 PMBreakout Sessions#P07P07 - I Can Hear You - But Am I Listening? Jennifer Del Villar, Dir Gov Pgms Compliance, Cambia Health Solutions, Inc. Gail Blacklock, Compliance Officer , Inter Valley Health Plan
- When our members call, are we fulfilling all their needs? Appeals, determinations, grievances and inquiries
- CMS call log universes - the who, where, what, why, and how
- Monitoring and auditing using call logs universes - both the business area and compliance
General Compliance#P08P08 - Let’s Talk Shop: Changes in MA and Part D Compliance Requirements for 2019 Kate McDonald, Partner, McDermott Will & Emery John Tanner, VP Compliance, Medicare Compliance Officer, Molina Healthcare, Inc. Annie Shieh, Sr Compliance Counsel, Central Health Plan of California- Understand and prepare for CMS’s encounter data monitoring efforts
- Reconsider your approach to FDR training in light of CMS changes
- Implement best practices for preclusion list screenings, new MLR reporting requirements, and other compliance-related changes in 2019
General Compliance
Monday, January 28
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09:45 AM - 10:45 AMBreakout Sessions#101101- Managed Care Expansion in Medicaid and Medicare: Benefits, Challenges,and Compliance Denise Leard, Attorney, Brown & Fortunato, P.C. Pam Colbert, Attorney, Brown & Fortunato, P.C. Angela Brice-Smith, Recently retired Regional Administrator for Dallas & Atlanta Regional Offices, CMS
- Understanding managed care private insurance plans vs. Medicare/Medicaid government plans
- Challenges and benefits for beneficiaries and providers in managed care plans for Medicare/Medicaid.
- The culture clashes of government programs and private insurers
General Compliance#102102 - Detecting and Preventing Fraud, Waste, and Abuse Christina Matsiga, Compliance and Risk Director, Inovalon- Review of requirements for providers participating in federal and/or state-funded health care programs to detect and prevent fraud, waste, and abuse.
- Examples of what constitutes fraud, waste, and abuse; and a look at some case studies
- Possible strategies to identify - as well as prevent - fraud, waste, and abuse
General Compliance#103103 - Not for the Faint of Heart: Preparing CMS Tracer Case Summaries Anne Crawford, Director, ATTAC Consulting Group LLC Thomas Wilson, VP Compliance Officer, Health Team Advantage Mary Ann McLean, Vice President, Compliance, Baylor Scott & White Health- Key considerations when developing a tracer case summary, including a model template
- Successful strategies for engaging business owners in presenting tracers
- How to incorporate lessons learned from Plans that have been through a CMS CPE Program Audit
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11:00 AM - 12:00 PMBreakout Sessions#201201 - How Adequate Is Your Provider Network? Applying and Measuring Managed Care Provider Network Compliance Against the New 2018 Requirements Jennifer Tryder, Program Director, Integrity Management Services, Inc. Michael Walsh, Senior Auditor, Integrity Management Services, INc. Kimberly Hornik, VP Compliance & Administration, Integrity Management Services, Inc
- Key transition strategies; moving forward from the 2002 Network Access Rule
- Understanding CMS protocols, EQR requirements and state exceptions for evaluating Network Adequacy standards -Best practice recommendations for evaluating and following network adequacy requirements under government approved auditing standards
General Compliance#202202 - Crisis Management for Really Busy People: Learn How to Implement an Efficient and Effective Crisis Management Program in Six Easy Steps Ahmed Salim, Director of Ethics and Integrity, Adjunct Professor DePaul Law School, iRhythym Lee Painter, Principal, CliftonLarsonAllen LLP- Putting a crisis management plan in place doesn’t have to be difficult
- Six straightforward steps to prepare for crisis events
- Specific implementation and execution recommendations, including how to overcome obstacles and potential risks to success
General Compliance#203203 - Panel - Hot Topics in Managed Care Compliance Ann Kinsella, VP Compliance & Privacy, Medica Sarah Lorance, SVP & Chief Compliance Officer, Anthem, Inc. Ann Greenberg, Executive Director, Compliance Officer, Presbyterian Health Plan- What’s on the Priority List for Compliance Officers
- Program Strategies in a Time of Transformation in the Industry
- Sharing Best Practices and Lessons Learned
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01:15 PM - 02:15 PMBreakout Sessions#301301 - Engaging Members through Advocacy and Outreach: Addressing Social and Clinical Needs to Minimize Health Disparities Joynicole Martinez, CEO, The Alchemist Agency
- The unique programmatic structure for effective advocacy and outreach to hard-to-reach and hard-to-engage populations
- Methods to connect members to culturally relevant and socially constructive resources and assist them as they navigate the system
- Staff and multidisciplinary resources that are the most efficient
General Compliance#302302 - Risk Adjustment Compliance and Operations: Building Meaningful Communications Nicole Martin, Director Risk Adjustment, Coding, Quality, RCM, Neighbor MD Dorothy DeAngelis, Senior Managing Director, Ankura Consulting- Bridging the gap between organizational compliance and risk adjustment compliance
- Understanding and collaborating with risk adjustment operations in your organization; an example using PPO member to PCP attribution
- Physician risk adjustment education compliance, internal planning vs external sharing, where do we draw the line?
General Compliance#303303 - Are You Ready for a Department of Labor Audit? Amy Christen, Member, Dykema- Tips for health insurance issuers on how to prepare for a DOL audit of a group health plan -Tips for a health insurance issuer on how to work with the DOL and the group health plan sponsor to ensure the completeness of audit responses
- Trends in DOL audits, including areas of focus under PPACA; HIPAA privacy issues that arise in the context of DOL audits; a checklist to track responses
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02:30 PM - 03:30 PMBreakout Sessions#401401 - Managed Models: The Future of FDR Delegation - Service Delivery, Service Responsibility, and Service Ability Richard Golfin, Chief Compliance & Privacy Officer, Alameda Alliance for Health
- Managed care in California, the nation’s largest Medicaid population
- In California, health plans delegate clinical delivery and clinical services to non-administrative entities
- Large Medicaid populations require innovative approaches to integrated delivery and population management
General Compliance#402402 - Federally Facilitated Exchange (FFE) Audits: Do You Know the Risk Areas? Steve Bunde, VP Integrity & Compliance & Internal Audit, HealthPartners Dawn Stocker, Prog Mgr, Hlth Care Reform Compliance, Geisinger Health Plan- Understand the FFE audit process and areas of focus
- Learn about the FFE audit process
- Identify FFE risk areas and remediation strategies
General Compliance#403403 - A Phish Tale: Lessons Learned from a Successful Phishing Attack in a Managed Care Organization Jessica VanderZanden, VP, Compliance and Culture, Network Health Angela Keenan, Director, Compliance & Privacy, Network Health- A Medicare Advantage Plan’s incident-response approach to a phishing attack that resulted in a HIPAA breach of over 500 individuals; lessons learned during and after the investigation
- The obligations and complexities of the overall investigation; reporting to other entities such as the media, OCR, and CMS; the facets of an OCR breach investigation
- Creative and effective post-breach training and communication strategies used by the plan, designed to reduce the likelihood of future breaches
General Compliance
Tuesday, January 29
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10:45 AM - 11:45 AMBreakout Sessions#501501 - Regulators Mount Up: How an Insurance Department Ensures Compliance with Managed Care Plans Rachel Chandler, Director, Office of Rural Health & Primary Care, Mississippi State Health Department
- What a Network Adequacy review for a Managed Care Plan entails
- DOs and DON’Ts and PROs and CONs when submitting a Network Adequacy plan for review
- Managed Care Compliance from the perspective of a State agency regulator
General Compliance#502502 - The WHO, WHY, and HOW of Delegation Oversight Christian Puff, Attorney, Hall Render Killian Heath & Lyman P.C. Hayley Ellington-Buckles, Chief Compliance Office, Davis Vision Inc- WHO qualifies as an FDR and how to tell
- WHY perform oversight; rules and regulations
- HOW to do it; steps and best practices
General Compliance#503503 - Stress is Stressful Cathy Bodnar, Chief Compliance and Privacy Officer, Cook County Health Lauren Tockey, Admissions Counselor, Gateway Foundation Alcohol- Recognize and acknowledge that working in Compliance is incredibly challenging
- Key strategies to identify and interpret work-tasks, the work environment, and the impact on self
- Revitalize your compliance "mission" to strengthen your health plan’s compliance program
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12:45 PM - 01:45 PMBreakout Sessions#601601- Medicare Advantage Risk Adjustment Compliance DOs and DON'Ts: How to Effectively Deploy Limited Resources on Emerging Risk Areas Jason Christ, Member, Epstein Becker & Green PC Julie Nielsen, Managing Director, Berkley Research Group Teresa Mason, Attorney, EBG Law
- The current regulatory and enforcement landscape related to Medicare Risk Adjustment, including government areas of focus such as: retrospective chart review and targeted interventions/ in-home assessments
- Effective and appropriate measures to ensure the integrity of risk adjustment data being provided to CMS, including applicable auditing and monitoring best practices
- Methods for conducting thoughtful and effective internal investigations protected by attorney-client privilege
General Compliance#602602 - Don't Freak Out! You Can Survive Multiple CMS Audits at the Same Time - Here’s How Ryan Hayden, Partner, PricewaterhouseCoopers Rohit Gupta, V.P. - Compliance & Medicare Compliance Officer, Molina Healthcare, Inc Rezarta Molla, VP Of Compliance, Harvard Pilgrim- Payers can gain value from being better prepared and more productive, and can uncover greater operational insights when multiple audits occur at the same time
- Payers can lower their risks by understanding how the same set(s) of data may impact multiple audits; scenario planning these impacts is a valuable activity
- Payers can improve their performance by understanding how overlapping audits impact one another under the Medicare program
General Compliance#603603 - Are You Just Checking the Box or Creating Effective Compliance Training? Leah Yoder, Performance Results Consultant, Leah Yoder Consulting, LLC Shelley Segal, Principal, Medicare Compliance Solutions- CMS’s expectations of effective training
- Components of effective training
- Catalysts for caring about training
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02:00 PM - 03:00 PMBreakout Sessions#701701 - The State of Play for Mental Health Parity Tricia Beckmann, Director, Faegre Drinker Amy Finley, Senior Counsel, Highmark Inc.
- Discerning the state of Mental Health Parity and Addiction Equity Act enforcement under the Trump Administration and avoiding traps for the unwary
- The 21st Century Cures Act of 2016 called for stepped up enforcement and additional guidance; taking stock of what has been done to date, what’s missing, and what might be to come in terms of both state and federal responses
- The intersections between mental health parity law and othercoverage mandates and federal nondiscrimination rules
General Compliance#702702 - How to Prepare for 2019 CMS Rule Change to Marketing Materials: ANOCs, EOCs, Summary of Benefits - Issues, Impact, Disclosures and Audits Debbie Mabari, CEO, Cody Consulting Group, Inc. Hannah LaMere, Director, Special Projects, Cody Consulting Group Mike Turrell, CEO, Ultimate Health Plans, Inc.- CMS Expectations: Plans must verify that accurate and complete data is represented on materials; identify benefit changes year-to-year; reduce/eliminate erratas
- Regulatory Changes: Allowing for e-materials means that plans need to be diligent on data presented to members; CMS’s distinguishing between e-communication and e-marketing materials may lead to more focus and scrutiny on these required materials
- Audits and Best Practices: Audit issues; disclosed issues to CMS tied to CPE audit and pre-audit issue summary; beneficiary impact; tracer sample
General Compliance#703703 - The Importance of Automating Your Monitoring and Auditing Pamela Cleveland, Chief Compliance Officer, Sidecar Health Megan Grifa, Sr Director, Compliance, Sidecar Health- Do you know where your compliance risk is hiding?
- How do you move your organization to complete risk identification without adding staff?
- Why is a central compliance management solution critical for managing and mitigating risk?
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03:15 PM - 04:15 PMBreakout Sessions#801801 - Understanding Recent Legislative Changes to Coordination of Benefits Practices for Medicaid and CHIP Programs Kristen Ballantine, VP, State and Federal Government Relations, HMS
- An overview of recent and upcoming changes - due to legislative and regulatory activity at the federal and state levels - which will impact coordination of benefits function for Medicaid and CHIP programs and plans
- Plan requirements, with a focus on operational compliance and impact on stakeholders
General Compliance#802802 - The Rise of the Virtual Workforce: Compliance Role in Robotic Automation Governance Deana Rhoades, Principal, Automation | Health Plan Consulting, NTT DATA John Wells, Executive Director, Compliance, Johns Hopkins HealthCare Sherrie Hentz, Compliance & Security Sr. Advisor, NTT DATA Services- With Operations and IT teams collaborating on an automation strategy, the role of Compliance in governance cannot be ignored
- Robotic Process Automation is creating a team of virtual workers - and an additional layer of oversight requirements
- How Compliance can join Business and IT in development of a proper governance strategy
General Compliance