Blue Cross Blue Shield of Michigan Best Compliance Practice for Management of Patient Protection and Affordable Care Act
Reina Navarra Manager, Business Compliance Oversight Office rnavarra@bcbsm.com Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Topics ● Implications of Patient Protection and Affordable Care Act ● BCBSM Compliance Approach ● Best Practice Model ● Compliance Plan ● Business Compliance Oversight Office Key Roles ● Compliance Liaison Council ● Compliance Management Tools and Education
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Implications of PPACA (Patient Protection and Affordable Care Act)
Rapid and Unrelenting Changes Characterize Today’s Environment 1. Multiple regulators: CCIIO - The Center for Consumer Information & Insurance Oversight CMS - Centers for Medicare and Medicaid Services HHS - Department of Health and Human Services DIFS - Department of Insurance and Financial Services
2. Guidance on regulations continues to emerge while development is underway 3. Aggressive timeframes 4. Sweeping volumes of change
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BCBSM Compliance Model
BCBSM PPACA Compliance Oversight Model
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Best Practice - Our Foundation Enables Success
2013 Be=er Prac>ce Model, Internal Audit Associa>on
Liaisons
BCOO
Internal Audit
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PPACA Compliance Plan
• The compliance plan, required to be a Qualified Health Plan, is designed to outline the key roles and responsibilities associated with PPACA compliance management and oversight. • The plan is consistent with current work and compliance liaison charter which breaks compliance oversight into tiers (Compliance Liaisons and the Business Compliance Oversight Office). • Key roles and responsibilities are divided among BCBSM business area staff, Compliance Liaisons, Public Policy/Office of the General Counsel, Office of National Health Reform program management and Business Compliance Oversight Office. • CMS Seven elements of an effective compliance program are incorporated
Written Policies, Procedures, Standards
Compliance Officer, Compliance Committee, High Level Oversight
Effective Training and Education
Effective Lines of Communication
WellPublicized Disciplinary Standards
Effective System for Routine Monitoring, Auditing, Identification of Compliance Risks
Procedures and System for Prompt Response to Compliance Issues
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Business Compliance Oversight Office Key Roles
• Advise and consult with business areas on implementing controls to comply with PPACA regulations • Oversee policies and procedures management • Educate business areas and provide tools for regulatory audit readiness • Maintain deficiency database and track deficiency resolution • Monitor and report on compliance metrics • Own and maintain compliance management system • Apply risk intelligent approach in annual planning and business consulting 7
Health Care Reform Compliance and Empowerment
A Risk Intelligent Approach -‐ Success through Empowerment
Understand the Boundaries
Be Transparent with Decisions and Assign Accountability
ACHIEVE RISK
INTELLIGENCE
• Best prac>ce vs. Evaluate Op%ons sufficiency • Cost and benefits • Impacts and probability Iden%fy the Risk • What uncertain • Compliance risks may consider: event or effects • Member harm • Financial loss could happen • Know the facts • Audit risk • Reputa:on/Market Share 8
Compliance Liaison Council
Others eBig, Appeals
OGC Human Performance
Small Group
PPACA Compliance Medicaid
Medicare
Liaison Council
BCN
Claims
Customer Service
Actuarial And Underwriting
Finance
Health Care Value
Sales & Marketing IBU
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Compliance Management Tools and Training
• Compliance Management Playbook • PPACA Mandate Inventory Log • BCOO Share Point tool • Compliance Liaison and business area formal training Overall Training Results
Future 2014 plans include a computer based training and certification process.
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Questions
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