PACE of Southwest Michigan has adopted a Fraud, Waste, and Abuse (FWA) Compliance Program to affirm our commitment to complying with all applicable laws and to meet the requirements for Medicare Part D Prescription Drug Plan.
Our FWA Program:
- articulates our commitment to detecting, correcting, and preventing fraud, waste, and abuse in the administration of our Prescription Drug Plan (PDP);
- describes standards of conduct and compliance expectations that employees, and first tier, downstream, and related entities (“FDRs”) of PACE are expected to adhere to;
- outlines procedures that PACE follows in monitoring and auditing for fraud, waste and abuse, with respect to the prescription and in investigating and resolving any potential improper conduct when identified;
- provides guidance for our employees and FDRs in reporting compliance issues and addressing questions relating to fraud, waste and abuse in the organization’s PDP; and
- Identifies specific risk areas for us that merit attention and monitoring.
Components of PACE of Southwest Michigan’s Fraud, Waste and Abuse Program
- Compliance Coordinator-Lauren Metzger (Quality and Utilization Manager)
- Compliance Committee – Lauren Metzger (Quality and Utilization Manager), Sherry Simpson (Nurse Practitioner), Ken Welch (CFO), Emily Bashaw (Pharmacist), Allison Laz (Strategic Account Executive, OptumRx), Anna Bautista (Senior Script Account Manager, OptumRx)
- Risk Assessment – annually our compliance coordinator conducts a FWA Risk Assessment to identify: possible FWA risk areas; the safeguards in place to manage those risks; and any areas where additional safeguards might be appropriate.
- Risk Area Monitoring and Audits – we conduct regular monitoring and auditing activities to detect and prevent potential FWA and to ensure compliance with all applicable federal and state laws, the FWA Program, and Organization’s policies and procedures. The Compliance Officer has an audit work plan outline which includes a schedule of planned auditing and monitoring activities for each year. Monitoring and/or auditing extends to all areas of PACE including:
- Operations of third-party contractors;
- Claims processing;
- Pricing, rebates and other price concessions;
- Marketing and enrollment violations;
- Agent/broker misrepresentation;
- Enrollment/disenrollment noncompliance;
- Quality assessment;
- Appeals and grievance procedures;
- Utilization management;
- Audit Reports and Corrective Actions – PACE of Southwest Michigan’s Board of Directors receives the outcome of compliance audits and corrective action plans.
- Exclusion – PACE of Southwest Michigan screens all employees, contractors (including FDRs) and members of the Board of Directors against the Office of Inspect General List of Excluded Individuals/Entities and the General Services Administration (“GSA”) Exclusion List Check, and/or any state exclusion lists maintained by state Medicaid programs, at the time of initial hire/contract/appointment/election, and at least monthly thereafter. Employees and contractors found to be excluded will be removed immediately from employment with PACE of Southwest Michigan.
- Disciplinary Guidelines-PACE employees and FDRs are expected to comply with all organization policies related to compliance, including but not limited to this FWA Program, as a condition of employment or contract. We expects our employees and FDRs to meet the highest ethical standards, and comply with all applicable laws. Failure to do so may result in appropriate disciplinary action, up to and including termination of the contract.
- Monitoring and Safeguards – to ensure the truth and accuracy of data submitted to CMS, and to identify areas where data collection and submission practices could be improved, PACE of Southwest Michigan periodically monitors the following:
- Prescription Data Event (“PDE”) information;
- Cost data;
- Diagnoses information reported through Risk Adjustment Processing Data System (“RAPS”);
- Information reported to CMS;
- Enrollment and disenrollment data;
- Submission of claims under the appropriate reimbursement program (e.g., Medicare Part B claims vs. Medicare Part D claims); and
- All other information required to be reported, including information about vaccines; generic drug utilization; overpayments; pharmaceutical manufacturer rebates, discounts and other price concessions; and long-term care (“LTC”) rebates.
Your Roles in Compliance and Monitoring of Fraud, Waste and Abuse
– Please use any of our reporting mechanisms to report compliance and fraud, waste and abuse concerns.
- Fill out the box below. Your request will be anonymous.
- Call the main line (269) 408-4322 Monday-Friday 8:00- 4:30 and ask to speak with a member of the Compliance Team.