Medicare FDR Information
Thank you for your partnership with Health Partners Plans (HPP) to help us provide exceptional service to our Medicare members.
The Centers for Medicare & Medicaid Services (CMS) refers to our contracted partners as First-Tier, Downstream, and Related entities, or FDRs. HPP is required to effectively manage and oversee its FDRs that assist us in providing administrative and/or healthcare services for our Medicare members. Examples of FDRs include field marketing organizations, agents, providers, pharmacies, pharmacy benefit managers, claim administration vendors, fulfillment vendors and other vendors who help us deliver benefits.
HPP maintains the ultimate responsibility for fulfilling the terms and conditions of its contract with CMS. CMS may hold HPP accountable for the failure of its FDRs to comply with Medicare program requirements.
An authorized representative from your organization is required to submit the HPP FDR Compliance Program Attestation on an annual basis. In doing so, you attest to your organization’s compliance with these Medicare Compliance Program requirements.
To help ensure that we meet Medicare program requirements, we provide you with the following:
- Descriptions of First Tier, Downstream, and Related Entity
- Code of Conduct/Compliance Policy/Conflict of Interest
- Medicare Parts C & D Fraud, Waste, and Abuse (FWA) Training and General Compliance Training
- Office of Inspector (OIG)/System for Award Management (SAM) Exclusion Screening
- Reporting FWA and Compliance Concerns
- Offshore Subcontracting Reporting
- Ongoing Monitoring and Auditing
- Downstream Entities
- Important Information
The Medicare Parts C and D General Compliance Training and Combating Medicare Parts C and D Fraud, Waste and Abuse training courses listed below provide separate content for compliance and FWA, and are available as web-based versions that are printable. The training content is generic since various entities (e.g., health plans, labs, hospitals, providers, etc.) use the training.
Medicare Parts C and D General Compliance Training
The Medicare Parts C and D General Compliance Training Web-Based Training (WBT) course available through the Learning Management and Product Ordering System can help you learn:
- How a compliance program operates
- How compliance program violations should be reported
Combatting Medicare Parts C and D Fraud, Waste, and Abuse
The Combatting Medicare Parts C and D Fraud, Waste, and Abuse (FWA) Web-Based Training (WBT) course available through the Learning Management and Product Ordering System can help you learn about:
- The major laws and regulations pertaining to FWA
- Potential consequences and penalties associated with violations
- Methods of preventing FWA
- How to report FWA
- FWA in the Medicare program
- How to correct FWA
Please review the CMS memo for details regarding revisions to the Medicare Parts C and D General Compliance and Fraud, Waste, and Abuse training requirements.
Who must complete the training
While FDRs are required to comply with CMS requirements, including the compliance program training requirements, CMS does not expect an FDR’s entire staff would necessarily be subject to the requirement.
There will be certain FDRs where not every employee needs to take the training based on their duties.
Below are examples of the critical roles within an FDR that should clearly be required to fulfill the training requirements:
- Senior administrators or managers directly responsible for the FDR’s contract with the Sponsor (e.g. Senior Vice President, Departmental Managers, Chief Medical or Pharmacy Officer)
- Individuals directly involved with establishing and administering the Sponsor’s formulary and/or medical benefits coverage policies and procedures
- Individuals involved with decision-making authority on behalf of the Sponsor (e.g. clinical decisions, coverage determinations, appeals and grievances, enrollment/disenrollment functions, processing of pharmacy or medical claims)
- Reviewers of beneficiary claims and services submitted for payment
- Individuals with job functions that place the FDR in a position to commit significant noncompliance with CMS program requirements or health care FWA
Please note, FDRs deemed to have met the FWA training and education certification requirements through enrollment into Parts A or B of the Medicare program or through accreditation as a supplier of DMEPOS are NOT exempt from the general compliance training requirement.
Code of Conduct & Reporting
Reporting non-compliance and FWA within your organization:
- Your manager knows you and your job and can often apply his or her business experience to help you make the right decision
- Contact your organization's compliance department or general counsel
- Use other reporting methods made available to you by your organization
Various mechanisms are in place for reporting concerns directly to HPP, such as:
- Call the Compliance Hotline - 1-866-477-4848. The hotline is answered by a third-party vendor on behalf of HPP, and is available 24/7. Although you may identify yourself within your report, you will also be afforded the right to remain anonymous. At the end of your report, you will be provided with an ID number that you may also use to call back and receive updates on any investigations.
- Email compliance concerns to email@example.com
- Email suspected or actual fraud, waste and abuse concerns to SIUtips@hpplans.com
- Call our Medicare Compliance Officer, Andrew Finkelstein - 215‐991‐4305
- Call our Security and Privacy Officer, Mark Eggleston - 215‐991‐4388
- Call our General Counsel, Johnna Baker - 215‐991‐4051
- HPP Code of Business Conduct (COBC) and Compliance Program
- Reporting Concerns of Actual or Suspected Non-Compliance
- Reporting Concerns of Actual or Suspected Fraud, Waster, or Abuse
Network Providers: Please complete the Provider Compliance Attestation Form.
Delegated Vendors: As a continuing or newly contracted vendor delegated a function to perform on behalf of HPP, please complete the appropriate Delegated Vendor Compliance Attestation Form.
- Provider Compliance Attestation Form
- Delegated Vendor Compliance Attestation Form
- Delegated Vendor Compliance Attestation Form (for newly contracted vendors)
- Offshore Subcontractor Attestation Form
- Downstream Entity Online Form
Frequently Asked Questions
A list of frequently asked questions (FAQs) is available for your reference through the link below. If you have additional questions not addressed by the FAQs, please feel free to contact your appropriate Health Partners Plans representative or email MedicareFDR@hpplans.com.