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Risk assessment and monitoring plansJanuary 2016
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A deep dive
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YOUR DIVERS:Steve Bunde –VP Integrity and Compliance & Internal Audit, HealthPartners
Laurena Lockner –Sr
Manager Monitoring & Compliance, HealthPartners
Stephanie Moscetti –Program Manager, Integrity and Compliance, HealthPartners
AGENDA:
Developing and communicating the risk assessment
Aligning the monitoring plan to the risk assessment
Understanding risk areas
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Risk assessments
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Risk
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Template considerations• DETERMINE risk criteria•
REVIEW risk equation• DETERMINE risk ratings•
ENGAGE leaders• ANALYZE trends • REVIEW process
SHARE
DEVELOP
Risk development
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BOTH
‐Audit guides‐Regulatory guidance
‐Review topics
COMMERCIAL
‐Certification requirements‐CMS FFM compliance priorities
GOVERNMENTPROGRAMS
‐State contracts
Risk process
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MEET with business areasCREATE
and distribute summary document
REVIEW with LeadershipREVIEW
with Compliance Committee
MONITOR periodically
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Align monitoring plans to risk assessment
Resources
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Limited resources
Determine monitoring strategy
Distinguish between auditing & monitoring
Identify all areas
Work plans
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Consider inherent vs. residual risks
Understand business
monitoring and results
Coordinate with internal
teams
Don’t forget FDRs and rotation planning
Align work plan with risks
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Reporting
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DETERMINE
reporting format (up front)
CONSIDER action plans in reports
PRESENT monitoring results to business leaders, compliance and board committees
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Understand commercial and Government Programs risks
Defining high risk
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BOTH
‐Financial risk‐Regulator
focus‐Audit protocol‐New rules
COMMERCIAL
‐False Claims Act
‐Litigation
GOVERNMENTPROGRAMS
‐Beneficiary impact
‐Audit findings‐Delegates
‐New contracts
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GP significant risks
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PART D
DELEGATED ACTIVITIES
COVERAGE/ORG DETERMINATIONS
COMPLIANCE PROGRAM
Commercial significant risks
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GENERALEdge Server, 3Rs, APTC/CSR, MLR/Risk Corridor, Taxes
FFM P&Ps, Provider Directories, Agent/Broker
requirements
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QUESTIONS
?
?
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Contact Information
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Steve [email protected]
Stephanie
[email protected]
Laurena
[email protected]
