1. Building the Foundation
for
Effective FDR Oversight
Presented By:
Miss Tamani D. Guy, MPH
Manager of FDR Oversight
Compliance Department
Peoples Health Network
Metairie, Louisiana

2. Peoples Health Network (PHN)
 Established in 1994
 Locally Owned and Operated in State of Louisiana
 Chief Executive Officer- Ms. Carol A. Solomon
 Headquarters and Home Office in Metairie, LA
 Offers Medicare and Commercial Plans
 Primary Line of Business -Medicare Plans
 -HMO, HMO-POS, HMO Dual SNP, and EGWPs (# of
parishes
 CY 2015-Statewide with Dual-SNP plan (all 64 parishes)
 (#) of Medicare lives currently in all Medicare plans
 12 different Medicare products offered for CY 2015
 You can find us at www.peopleshealth.com

3. Peoples Health Network (PHN)-
Compliance Department and FDR Oversight
 The information and recommendations in this presentation are PHN’s
interpretation and implementation of the CMS guidance in reference to
FDR Oversight, in particular with the CMS’ release of Chapter 9/21,
Compliance Program Chapter and the CMS Audit Protocols.
 Although PHN’s FDR Oversight Program has not yet undergone and
been tested by CMS under its new audit program and protocols, PHN’s
Compliance Department has implemented processes and operations
within the department and throughout the plan’s operations in response
to meeting CMS’s FDR Oversight requirements.
 In response to these requirements, the FDR Oversight Program was
sectioned out as a separate team within the Compliance Department in
2012.
 Our company strategy and goal is to be “Audit-Ready” at all times.

4. Peoples Health Network (PHN)

5. Overall Responsibility for FDR
Oversight
• It is important to remember, per CMS requirements as indicated in
Chapter 9/21 Section 40, that the plan sponsor is ultimately responsible
for the compliance and oversight of FDRs.
• The next slides are to provide information and recommendations on
how a plan sponsor can implement processes in its FDR Oversight
Program for pre-contract review and pre-delegation activities when
contracting with a prospective FDR.
• Our experience has indicated that “FDR Oversight”
begins at PRE-CONTRACTING and PRE-
DELEGATION.

6. Pre-Contracting and
Pre-Delegation Activities
• Collaboration of Internal Departments
– Legal
– Compliance
– Business Owner
• It is important to have Compliance Department involvement in
pre-contractual discussions as there may be regulatory and
FDR Oversight requirements that need to be further
considered and explained to the Business Owner and the
Entity from a Compliance prospective when it involves the
plan contracting out Medicare core functions and/or regulated
activities.

7. Pre-Contracting and
Pre-Delegation Activities
• Component # 1-Identify your FDR
– Implement a process for how your organization identifies or categorizes the prospective
entity as an FDR (Chapter 21 Section 40).
– Obtain the Business Owner’s input on the proposed activities of the entity so they are
correctly categorized.
• Component #2- Compliance Department Specific Activities
– Start discussions on the regulatory requirements the FDR will be subject being
contracted with a Medicare plan. (i.e, Compliance & FWA training, Self-reporting,
Monitoring and Auditing, Responding to Corrective Actions) (Chapter 21 Sections 50.3 ,
50.6.6, 50.4.2, 50.6.6 , 50.7.1)
– Start reviewing the draft contract to determine your oversight activities for the FDR
based upon your internal risk assessment and integrating them into your auditing and
monitoring workplans (Chapter 21 Section 50.6.1-50.6.3)
– Review the entity against the federal Exclusions Lists monitoring prior to contracting
and implement your ongoing review of them into your monthly process (Chapter 21
Section 50.6.8)
– Start Pre-Delegation Audit Review (Chapter 11, Section 110.2)

8. Pre-Contracting and
Pre-Delegation Activities
• Component #3- Start Collaborations Early with the FDR
– Begin now building relationships and collaborations with the FDR.
– Establish early on a Compliance contact at the FDR who can be Point of
Contact with the plan’s Compliance contact. This person will help in
facilitating communications and requests better between the plan and the FDR.
– Distribute and provide information on the plan’s Compliance Program, how to
access it, and discuss how they intend to meet the Compliance Program
requirements either by adopting the plan’s program (in whole or part) or by
utilizing their own internal program. (Chapter 21, Section 50.1.3).
– Discuss the Pre-Delegation Audit Review and deliverables required for the
audit. The audit should include a review of the entity’s Compliance Program to
ensure they have a comparable program that meets the CMS requirements.
– Discuss the plan’s Monitoring and Oversight Activities to ensure operational
and compliance program requirements are being met.
– Any Required Reporting or CMS-required Submissions that will be required to
be submitted on their behalf.

9. Pre-Contracting and
Pre-Delegation Activities
• Component #4- Pre-Delegation Audit Review
-The Compliance Department must conduct a “pre-audit” of the entity’s
operational and Compliance Program to ensure they can meet the proposed
contracted or delegated activities.
-Share and Communicate the pre-delegation audit review results with the Business
Owner as well as the entity and any recommendations.
• Component#5- Discussion of Inclusion of Contractual Language for
Compliance and FDR Oversight Activities
– It is recommended that the contract include specific regulatory language in
reference to Medicare compliance and FDR Oversight activities. (in addition to
the Chapter 11 required language).
– This will take a collaboration and agreement with the plan’s Compliance,
Legal, the Business Owner, and the Entity and their stakeholders.
• Component #6-Compliance Department Agreement
– It is recommended that the pre-contract/pre-delegation process includes a sign-
off process of Compliance’s review and agreement with the contract prior to its
execution.

10. Pre-Contracting and
Pre-Delegation Activities-
• The FDR should understand PRIOR TO contracting what requirements it
will be subject to when it contracts to administer the Medicare core function
or regulated activity for the plan.
• Keep in mind that all entities may not perform Medicare or healthcare as
their primary line of business. The plan must take responsibility to educate
the FDR on the plan’s requirements under Medicare and what the FDR is
subject to being contracted with a Medicare plan.
• Success in your FDR Oversight Program integrating Compliance in the
beginning of the contracting process and start to develop a collaborative
relationship and establishing open lines of communication between the plan
and the FDR so that you both are working toward the same goals for better
outcomes for our Medicare beneficiaries.

11. Contact Information
• Miss Tamani D. Guy, MPH
– Manager of FDR Oversight
Compliance Department
Tamani.Guy@peopleshealth.com
Peoples Health Network
Three Lakeway Center
3838 N. Causeway Blvd, Suite 2200
Metairie, LA 70002
Toll free: 1-800-631-8443 x8581
Direct Line: 504.681.8581
Fax: 504-849-6930